Issues and Challenges in the Design of Culturally Adapted Evidence-Based Interventions

ANRV407-CP06-09 ARI 22 February 2010 15:15

Issues and Challenges in theDesign of Culturally AdaptedEvidence-Based InterventionsFelipe Gonzalez Castro,1,2 Manuel Barrera Jr.,1

and Lori K. Holleran Steiker3

1Department of Psychology, Arizona State University, Tempe, Arizona 85287-1104;email: [email protected] Interdisciplinary Research Center, Arizona State University, Phoenix,Arizona 850043School of Social Work, University of Texas at Austin, Austin, Texas 78712

Annu. Rev. Clin. Psychol. 2010. 6:213–39

First published online as a Review in Advance onJanuary 6, 2010

The Annual Review of Clinical Psychology is onlineat clinpsy.annualreviews.org

This article’s doi:10.1146/annurev-clinpsy-033109-132032

Copyright c© 2010 by Annual Reviews.All rights reserved

1548-5943/10/0427-0213$20.00

Key Words

cultural adaptation, adaptation models

AbstractThis article examines issues and challenges in the design of culturaladaptations that are developed from an original evidence-based inter-vention (EBI). Recently emerging multistep frameworks or stage mod-els are examined, as these can systematically guide the developmentof culturally adapted EBIs. Critical issues are also presented regardingwhether and how such adaptations may be conducted, and empiricalevidence is presented regarding the effectiveness of such cultural adap-tations. Recent evidence suggests that these cultural adaptations areeffective when applied with certain subcultural groups, although theyare less effective when applied with other subcultural groups. Generally,current evidence regarding the effectiveness of cultural adaptations ispromising but mixed. Further research is needed to obtain more defini-tive conclusions regarding the efficacy and effectiveness of culturallyadapted EBIs. Directions for future research and recommendations arepresented to guide the development of a new generation of culturallyadapted EBIs.

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Contents

OVERVIEW OF CULTURE ANDINTERVENTIONADAPTATIONS . . . . . . . . . . . . . . . . . . 214

PURPOSE AND SCOPE. . . . . . . . . . . . . 215PERSPECTIVES AND

CHALLENGES IN THEDESIGN OF CULTURALADAPTATIONS . . . . . . . . . . . . . . . . . . 216Concepts of Culture and

Cultural Frameworks . . . . . . . . . . . 216Population Segmentation. . . . . . . . . . . 217Subcultural Groups . . . . . . . . . . . . . . . . 217The Structure of Culture as a

Collection of CulturalElements . . . . . . . . . . . . . . . . . . . . . . . 217

Systemic-Ecological Modelsof Culture . . . . . . . . . . . . . . . . . . . . . . 217

Cultural Change andAcculturative Adaptation . . . . . . . . 218

Cultural Relevance andCultural Adaptation . . . . . . . . . . . . . 218

Terminology for ApproachingCultural Adaptation . . . . . . . . . . . . . 219

PROFESSIONAL CONTEXTSAFFECTING THE DESIGN OFCULTURAL ADAPTATIONS . . . . 220Distinctions Regarding Types of

Evidence-Based Interventions . . . 220FOUR MAJOR ISSUES IN

CULTURAL ADAPTATION. . . . . . 221The Fidelity-Adaptation Dilemma . . 221

CONCERNS OVER EROSIONOF INTERVENTIONEFFECTIVENESS. . . . . . . . . . . . . . . . 221Issue #1: Are Cultural Adaptations of

Evidence-Based TreatmentsJustifiable? . . . . . . . . . . . . . . . . . . . . . . 222

Issue #2: What Procedures ShouldIntervention Developers FollowWhen Conducting a CulturalAdaptation?. . . . . . . . . . . . . . . . . . . . . 225

Issue #3: Is There Evidence thatCultural Adaptations areEffective? . . . . . . . . . . . . . . . . . . . . . . . 228

Issue #4: How Can WideWithin-Group Cultural VariationBe Accommodated in a CulturalAdaptation?. . . . . . . . . . . . . . . . . . . . . 229

APPLYING CULTURALADAPTATION APPROACHES . . . 230Exemplars of Culturally Grounded

Cognitive-BehavioralTreatments . . . . . . . . . . . . . . . . . . . . . 230

Exemplar of a Culturally GroundedSubstance Abuse PreventionIntervention . . . . . . . . . . . . . . . . . . . . 231

ISSUES, ANSWERS, ANDABIDING CHALLENGES. . . . . . . . 232Directions for Future

Development . . . . . . . . . . . . . . . . . . . 233Some Recommendations . . . . . . . . . . . 234

OVERVIEW OF CULTURE ANDINTERVENTION ADAPTATIONS

Clinical psychologists have a deep respectfor scientific principles that have contributedto the development of interventions and thesubstantiation of their effectiveness in relievinghuman suffering and remediating problems inliving. This research tradition has promoteddisciplinary standards of evidence for deter-mining that an intervention is efficacious inproducing one or more targeted outcomes

(Flay et al. 2005). Subsequently, tested-and-effective treatment procedures have beenincorporated into treatment manuals and othermedia to facilitate consistency in treatmentdelivery (Chambless & Hollon 1998).

From the perspective of clinical practice,clinical psychologists have equal respect for anin-depth understanding of the person and ofhuman variation (Sue & Sue 1999). The essenceof the clinical method involves the applicationof nomothetic principles filtered through an

214 Castro · Barrera · Holleran Steiker

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individual case conceptualization and informedby clinical judgment for effectively treatingeach person. Within this duality, a dynamictension has emerged between the standardizednomothetic scientific top-down approach thatdemands fidelity in its implementation and theidiographic casewise bottom-up approach thatdemands sensitivity and responsiveness to eachperson’s unique needs.

This dynamic tension can foment con-troversy, raise contentious issues, and launcha search for common ground. The culturaladaptation of evidence-based interventionsis a specific topic where these two equallyimportant professional values have clashed,particularly as embodied by the fidelity-adaptation dilemma (Castro et al. 2004, Elliott& Mihalic 2004). Within this context, weexamine the literature on treatment andprevention interventions; thus, we use the termevidence-based interventions (EBIs) to refer tointerventions of two types: (a) those developedto treat existing disorders, usually within clin-ical settings, i.e., evidence-based treatments(EBTs) and (b) interventions developed forpreventing disorders within various at-riskpopulations, i.e., evidence-based preventioninterventions (EBPIs).

The cultural adaptation of EBIs has emergedas an intervention strategy and will likely growin prominence as a result of two trends (LaRoche & Christopher 2008, Lau 2006): (a) thegrowing demand for EBIs and (b) the growingdiversification of the American population. Thegrowing demand for EBIs has emerged despiteclinicians’ concerns that it may be prematureand may impose unrealistic constraints on clin-ical practice (Bernal & Scharron-del-Rıo 2001,Norcross et al. 2006).

Division 12 of the American Psychologi-cal Association (APA) has taken a leadershiprole in establishing criteria for determining thata psychological intervention is evidence basedand in maintaining a catalog of interventionsthat meet these criteria (Am. Psychol. Assoc.1995, 2006). Other groups, including the Na-tional Registry of Evidence-Based PreventionPrograms (NREPP) (Schinke et al. 2002), have

created such lists (Subst. Abuse Mental HealthServ. Admin. 2009). This demand has also beendriven by several professional groups, includingclinical researchers and scientist-practitionerswho feel a professional responsibility to developand deliver interventions supported by researchevidence. Other advocates include agencies thatpay for psychological services and civic, com-munity, and governmental organizations thatdemand evidence that limited funds will bespent appropriately on interventions that work(Whaley & Davis 2007).

The second trend involves the growing cul-tural diversity within the United States andthe globalization of intervention disseminations(Iwamasa 1997, Weisman et al. 2006). Unfor-tunately, the infusion of cultural factors intoEBIs and tests of their efficacy with subculturalgroups have not kept pace with these diver-sification trends. In this regard, La Roche &Christopher (2008) note that racial/ethnic mi-nority participants have rarely been includedin samples used for validating the efficacy ofEBIs, including many of those recognized byAPA’s Division 12 in 1995 (Am. Psychol. Assoc.1995). This limitation has changed only mod-erately over the past decade.

PURPOSE AND SCOPE

The purpose of this review is to provide an anal-ysis of issues and challenges involved in the de-sign of cultural adaptations that are developedfrom original EBIs. We do so by pursuing twoaims. First, we review fundamental approachesand frameworks for a deep structure analysis ofculture, as tools for designing cultural adapta-tions of EBIs. Second, we identify and discusscritical issues and challenges in the design ofthese cultural adaptations. The analysis of theseissues is guided by the following four questions:

� Are cultural adaptations developed fromoriginal EBIs justifiable?

� What procedures should intervention de-velopers follow when conducting a cul-tural adaptation?

� What is the evidence that cultural adap-tations are effective?

www.annualreviews.org • Issues in Cultural Adaptations 215

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� How can within-group cultural variationbe accommodated in a cultural adapta-tion?

In our analysis, we take a contemporaryview of clinical psychology science and prac-tice by including evidence from prevention in-terventions and from clinical psychotherapiesfor psychological disorders. We include preven-tion interventions because they also introduceimportant issues involving cultural adaptations(Munoz 1997). Finally, this review presents asummary of what we know about the culturaladaptation of EBIs, examines issues and chal-lenges, and presents suggestions for future re-search along with a few recommendations.

PERSPECTIVES ANDCHALLENGES IN THE DESIGNOF CULTURAL ADAPTATIONS

Several issues and challenges emerge in de-veloping a cultural adaptation of an EBI. Afirst challenge involves the conceptualizationof culture in the design of an adapted EBI thatis tailored to the needs of a particular culturalgroup. Cultural adaptation involves a planned,organized, iterative, and collaborative processthat often includes the participation of personsfrom the targeted population for whom theadaptation is being developed. The culturalcompetence of the investigator and of thecultural adaptation team is also important forconducting a deep structure analysis (Resnicowet al. 2000) of the needs and preferences ofa targeted cultural group. Resnicow and col-leagues (2000) indicate that cultural sensitivityin developing tailored prevention interventionsconsists of two dimensions: surface structureadaptations and deep structure adaptations.According to Resnicow and colleagues, surfacestructure adaptations involve changes in anoriginal EBI’s materials or activities thataddress observable and superficial aspectsof a target population’s culture, such as lan-guage, music, foods, clothing, and relatedobservable aspects. By contrast, deep structureadaptations involve changes based on deeper

cultural, social, historical, environmental, andpsychological factors that influence the healthbehaviors of members of a targeted population.

Concepts of Culture andCultural Frameworks

Culture is a complex construct, as indicatedby over 100 varied definitions of culture thathave been proposed (Baldwin & Lindsley 1994).Fundamentally, culture consists of the world-views and lifeways of a group of people. Munoz& Mendelson (2005) add that human phenom-ena can be construed at three conceptual levels:(a) universal characteristics that tend to applyto all people, (b) group-focused characteristicsand norms that apply to special cultural groups(or subcultural groups), and (c) individualizedcharacteristics that are unique to the individualperson.

A distinct group of people (a tribe, an eth-nic group, professional organization, a nation)can be described as “having a culture,” mean-ing that its members share a collective systemof values, beliefs, expectations, and norms, in-cluding traditions and customs, as well as shar-ing established social networks and standardsof conduct that define them as a cultural group(Betancourt & Lopez 1993). Their cultural her-itage is transmitted from elders to children, andit confers members of this cultural group witha sense of peoplehood, unity, and belonging, acollective identity or ethnicity (McGoldrick &Giordano 1996). Language is a distinct facet ofculture that encodes symbols, meanings, formsof problem solving, and adaptations that alsofacilitate the group’s survival (Harwood 1981,Thompson 1969 as cited by Baldwin & Lindsley1994).

Although culture is a complex construct, itcan nonetheless be applied in the design andcultural adaptation of an original EBI. A chal-lenge in this application involves problems thatemerge when equating culture with ethnicityand/or when using ethnicity or nationality asproxy variables for culture. Culture and ethnic-ity are not synonymous (Betancourt & Lopez1993), and developing a cultural adaptation


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does not necessarily involve the developmentof an ethnic adaptation.

Population Segmentation

An emerging challenge in designing a cul-turally relevant adaptation of an original EBIinvolves reframing this adaptation under a unitof analysis other than ethnicity. In this regard,population segmentation (Balcazar et al. 1995)narrows an otherwise heterogeneous ethnicpopulation or group into a smaller and morehomogeneous subcultural group to avoid eth-nic gloss in planning an intervention (Resnicowet al. 2000, Trimble 1995). As an example ofthis approach, as minority youths are dispro-portionately overrepresented within juvenilejustice settings, being under adjudication canoperate as a salient factor that better definesthe common life experiences of a certainsubcultural group of deviant youths. Thissubcultural group can consist of youths fromdiverse racial/ethnic backgrounds (AfricanAmericans, Latinos, white nonminority) whoshare several common developmental andfamilial experiences (i.e., disrupted families,antisocial conduct, and experiences of incarcer-ation or rehabilitation). Thus, their commondevelopmental trajectories can establish thismultiethnic group of deviant youths as a sub-cultural group of adolescent juvenile offenders.This example illustrates how investigators mayreframe their perspective on culture by address-ing a common cultural identity, such as adjudi-cated youths, as the cultural unit of analysis forthe design of a culturally relevant adaptation, inplace of focusing on the label of ethnicity per se.

Subcultural Groups

In the United States there exists considerableheterogeneity within and between major racial/ethnic groups: Latinos/Hispanics, AfricanAmericans, Asian Americans, NativeAmericans. These racial/ethnic groups rangein population size from about one millionamong Native Americans to over 42.7 millionfor Hispanics/Latinos (U.S. Census Bur. News2006). Within each of these broad racial/ethnic

groups, there exist many homogeneous sub-cultural groups, hidden subpopulations thatcan be defined by population segmentation(Balcazar et al. 1995). This approach canexamine the intersection of cultural elements(Schulz & Mullings 2006) such as nationality,socioeconomic status, religious background,immigration status, gender, and generationalgroup, as well as any special identity or socialstatus, such as being under adjudication. Wediscuss aspects of this segmentation approachlater in this review.

The Structure of Culture as aCollection of Cultural Elements

Chao & Moon (2005) introduced the “culturalmosaic” as a structural framework consisting ofa collage of elements that constitute a person’ssociocultural identity. The identity of each indi-vidual consists of a unique combination of ele-ments (or cultural tiles), including demographic(e.g., age, race, ethnicity, gender), geographic(e.g., urban-rural status, region or country), andassociative (e.g., family, religion, profession). Asan extension of this framework, an ethnic groupconsists of a collective of individuals who sharemany common elements (e.g., a common her-itage, religion, or ethnic identity). Accordingly,members of this group share a common groupidentity, although each individual also differsfrom the others in his or her unique combina-tion of cultural tiles.

This mosaic may appear complex, yet uponcloser inspection it exhibits a coherent andidentifiable structure. This integrative systemicapproach describes the complexities of cul-ture within its natural ecological context andalso captures the perspective of anthropologistsKluckhohn and Murray, who stated that everyperson is like all other people, some other peo-ple, and no other person (Kluckhohn & Murray1948).

Systemic-Ecological Modelsof Culture

Erez & Efrat (2004) proposed a multilevelmodel of culture that features both structural


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and dynamic elements. Structurally, these lev-els of culture range from the most macro(global culture) to the most micro (the in-dividual person). An earlier version of thissystemic model, Bronfenbrenner’s ecodevelop-mental model (Bronfenbrenner 1986) intro-duced the macro, exo, meso, and micro ecolog-ical levels. This model describes how events ateach of these levels can influence an adolescent’sidentity development and behaviors. From a dy-namic perspective, temporal influences on in-dividual behavior and development can also beexamined systemically, e.g., how parents influ-ence a child’s development over time. This mul-tilevel model is similar to other more recentsystemic ecodevelopmental models that havebeen proposed (Castro et al. 2009, Szapocznik& Coatsworth 1999). Erez & Efrat (2004) alsoadvocate for a shift from conceptions of cultureas a stable entity toward a conception of cul-ture as a dynamic entity that exhibits multipleinfluences across time and ecological levels.

Cultural Change andAcculturative Adaptation

A major concept in the analysis of culture andcultural change is acculturation. Acculturationis a worldwide phenomenon that occurs whenindividuals and families migrate from onesociocultural environment to another in questof better living conditions. Early concep-tions of acculturation regarded it as a linear,unidirectional process, although more contem-porary frameworks emphasize two dimensions:an orientation to the new host culture (themainstream culture) and an orientation to thenative culture (the ethnic culture) (Oetting& Beauvais 1990–1991). This two-factorconceptualization, however, is not without itscriticisms (Rudmin 2003). Under this two-factor framework, variations in acculturativeoutcomes include a bicultural/bilingual iden-tity (Berry 1994, Cuellar et al. 1995, Marin &Gamboa 1996) as well as complete assimilationinto the mainstream culture.

A deep structure understanding of culturalchange and adjustment can inform intervention

adaptations so that they address issues of ac-culturation change, as these may increase riskbehaviors among some members of a subcul-tural group. Acculturation stressors in familialand social contexts have been associated withhigher rates of substance use (Vega et al. 1998),implicating the erosion of native culture familyvalues, attitudes, and behaviors (Gil et al. 2000,Samaniego & Gonzales 1999). Other studies ofacculturative stress among African Americans(Anderson 1991) have also alluded to the ero-sion of Afrocentric values that may reduce fa-milial protections against substance use.

Cultural Relevance andCultural Adaptation

To the extent that an EBI lacks relevance to thecultural needs and preferences of a subculturalgroup (i.e., beliefs, values, customs, traditions,and lifestyles), that intervention may receiveunfavorable responses from these participants.When compromised by low participation rates,that EBI will likely exhibit a loss in effectiveness.This intervention phenomenon has promptedthe emergence of a principle of cultural rele-vance (Castro et al. 2004, 2007; Frankish et al.2007). This principle indicates that an EBI thatlacks relevance to the needs and preferencesof a subcultural group, even if the interven-tion could be administered with complete fi-delity, would exhibit low levels of effectiveness.This principle also suggests that an interven-tion developer must develop a deep structureunderstanding of a subcultural group’s culture(Resnicow et al. 2000) in order to develop a cul-turally relevant and effective EBI.

By contrast, high consumer responsivenessand participation would be expected for an in-tervention that is high in cultural relevanceas characterized by (a) comprehension: under-standable content that is matched to the linguis-tic, educational, and/or developmental needs ofthe consumer group; (b) motivation: contentthat is interesting and important to this group;and (c) relevance: content and materials thatare applicable to participants’ everyday lives(Castro et al. 2004).


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Terminology for ApproachingCultural Adaptation

Another challenge is the choice of strategy inthe design of a cultural adaptation of an EBI.The concepts and terminology used in plan-ning an adaptation will influence this strategy.Three terms have been used to describe ef-forts to incorporate culturally relevant contentinto an intervention: culturally adapted, cultur-ally informed, and culturally attuned. In a lu-cid commentary, Falicov (2009) described cul-tural adaptations to EBIs as procedures thatmaintain fidelity to the core elements of EBIswhile also adding certain cultural content tothe intervention and/or its methods of engage-ment. She saw cultural adaptations as a mid-dle ground between two extreme positions:(a) a universal approach that views an origi-nal EBI’s content as applicable to all subcul-tural groups and, therefore, not in need of alter-ations, and (b) a culture-specific approach thatemphasizes unique culturally grounded con-tent consisting of the unique values, beliefs,traditions, and practices of a particular sub-cultural group. From this middle ground, cul-tural adaptation may draw criticism from bothextremes by proposing alterations regarded asdeviations from fidelity. Thus, from one per-spective, it goes too far; conversely, from theother perspective, it lacks sufficient integra-tions of cultural perspectives and thus does notgo far enough. Falicov (2009) observed thatcultural adaptations are based on the premisethat

. . .the core components of a mainstream formof treatment should be replicated faithfullywhile adding-on certain ethnic features. Thisassumption must be based on the idea thatthe core components are culture-free andeven more problematically, that the theoryof change involved is universally powerful(p. 295).

Bernal and colleagues have defined culturaladaptation as the systematic modification of anEBT (or intervention protocol) to consider lan-guage, culture, and context in such a way that it

is compatible with the client’s cultural patterns,meanings, and values (Bernal et al. 2009).

The term “culturally informed interven-tion” might convey a sense that culture is amore primary consideration than it is in cul-tural adaptations (Falicov 2009), although thatdistinction is not widely acknowledged. Inter-vention development studies sometimes favorthe term “culturally informed” over “culturaladaptation” (e.g., Santisteban & Mena 2009,Weisman et al. 2006). For example, CulturallyInformed Therapy for Schizophrenia, a family-based therapy, was piloted with Latinos livingin Miami and added specific modules on keycultural components such as collectivism andspirituality (Weisman et al. 2006). More com-mon topics that might be found in other family-training interventions such as communicationand problem solving also were included.

“Cultural attunement” is a term that wascoined by Falicov (2009) to refer to additionsto evidence-based therapies that are intended toboost engagement and retention of subculturalgroups in treatment. This terminology and ap-proach focuses on the process of interventiondelivery rather than on intervention content.Providing services in clients’ native language,including familiar cultural traditions, and uti-lizing bicultural staff are examples of featuresthat might attract subcultural groups into treat-ment and increase their comfort in sustainedparticipation. The additional implication hereis that attunement is a surface structure adap-tation that does not modify core interventioncomponents that were designed to affect ther-apeutic change mechanisms or outcomes.

In reality, there exists a continuum amongcultural adaptations that varies between the ex-tremes of making no alterations to an originalEBI in its application to a subcultural groupand the complete rejection of the EBI in favorof a novel, culturally grounded approach thatis developed in collaboration with the intendedconsumers. In between those two extremes arealterations that change few or many of the fea-tures of an intervention to affect engagementand/or the intervention’s core components thatinfluence mediating mechanisms of change.


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PROFESSIONAL CONTEXTSAFFECTING THE DESIGN OFCULTURAL ADAPTATIONS

Distinctions Regarding Types ofEvidence-Based Interventions

Evidence-based treatment and evidence-based practice. In addition to the noted vari-ation in terminology and approach to inter-vention adaptation, there are two approachesto the application of research evidence, i.e.,evidence-based treatment (EBT) and evidence-based practice (EBP) (Kazdin 2008). EBT refersto the specific interventions or techniques, suchas cognitive therapy for depression, that haveproduced therapeutic change as tested withinclinical trials. By contrast, EBP is seen as abroader term that refers to “clinical practicethat is informed by evidence about interven-tions, clinical expertise, and patient needs, val-ues, and preferences and their integration intodecision-making about individual care” (Kazdin2008, p. 147). As in the realm of culturaladaptations, in reality a continuum exists be-tween the extremes of EBT and EBP, and of-ten these boundaries blur. From a somewhatbroader perspective, the APA 2005 Presiden-tial Task Force on Evidence-Based Practice,defined evidence-based practice in psychology(EBPP) as “the integration of the best avail-able research with clinical expertise in the con-text of patient characteristics, culture, and pref-erences” (Am. Psychol. Assoc. 2006, p. 273).From this perspective, in addition to empiricalresearch evidence, clinical expertise is also re-garded as a viable source of evidence that canguide the development of clinical interventions.

Clinical practice is characterized by theapplication of clinical experience and judgmentto alleviate a specific presenting problem aseffectively as possible (Am. Psychol. Assoc.2006). On a practical level, one ongoingconcern involves the extent to which clinicianscan and actually do utilize the results of clinicalresearch to guide their clinical interventions.Some clinicians have been skeptical about theclinical applicability of certain EBIs, especially

when intervention procedures have beenincorporated into a treatment manual (Duncan& Miller 2006).

Evidence-based intervention treatmentmanuals. Treatment manuals describe anintervention in sufficient detail so that thepractitioner can appropriately implement corecomponents in treatment delivery (Addis &Cardemil 2006) and produce targeted treat-ment outcomes, provided that the treatment isconducted with adherence to the manualizedtechniques and activities. Despite some criti-cisms about the reputed rigidity of treatmentmanuals, well-constructed treatment manualshave been described as not rigid and, to thecontrary, afford therapists flexibility and allowdiscretionary decision making under a seriesof dialectics that encourage (a) balancingadherence to the treatment manual versusclinical flexibility and (b) balancing attentionto the therapeutic relationship versus attentionto therapeutic techniques (Addis & Cardemil2006).

Also, the greater the therapist’s experience,the greater the range of flexibility that thetherapist can exercise in applying clinicaljudgment in response to a client’s uniqueneeds. The experienced therapist may be seenas conducting a single-case cultural adaptationwhen tailoring an EBI to the unique needsof a particular racial/ethnic minority client.This flexibility is likely pervasive within dailyclinical practice, although it raises questionsabout the limits of flexibility that a therapistmay exercise. How can a therapist tailor theoriginal EBI in response to the unique culturaland treatment needs of any individual minorityclient while also adhering to an EBI’s manual-ized tested-and-effective therapeutic principlesand methods (Addis & Cardemil 2006)?Within this context, examples exist of adap-tations of EBIs that were not effective whendeviating from core procedures contained inthe original EBI (Kumpfer et al. 2002), thusraising concerns about a loss of efficacy whendeviating significantly from the established


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tested-and-effective EBI. Also, when does flex-ibility in adaptation merge into misadaptation,a haphazard or inappropriate change in theproscribed procedures of a manualized EBI(Castro et al. 2004, Ringwalt et al. 2004)?

FOUR MAJOR ISSUES INCULTURAL ADAPTATION

The Fidelity-Adaptation Dilemma

Core issues affecting cultural adaptations.A fundamental controversy in this field ofadaptations is the fidelity-adaptation dilemma,which consists of a dialectic involving argu-ments favoring fidelity in the delivery of anEBI as designed versus arguments favoring theneed for adaptations to reconcile intervention-consumer mismatches in accord with the needsand preferences of a subcultural group (Bernal& Scharron-del-Rıo 2001, Castro et al. 2004,Elliott & Mihalic 2004). There are reasoned ar-guments on both sides of the fidelity-adaptationissue. On the one hand, intervention re-searchers spend years developing, refining, andtesting the efficacy of a theory-based and struc-tured intervention, thus recommending that itbe administered with high fidelity to the inter-vention procedures as designed. This view isthat efficacy is best attained under strict adher-ence to the intervention’s procedures as testedand validated; there should be no compromises(Elliott & Mihalic 2004). By contrast, if anintervention lacks relevance and fit with theneeds and preferences of a specific subculturalgroup (an intervention-consumer mismatch) orwithin diverse ecological conditions, then cer-tain adaptations are usually necessary.

Castro et al. (2004) developed a tablethat shows the possible sources of mismatchthat can occur between a program validationgroup and the current consumer group (seeTable 1). These specific sources are presentedunder three domains: (a) group characteristics,(b) program delivery staff, and (c) administra-tive/community factors. The general adapta-tion strategy is to identify specific sources ofintervention-consumer mismatch and then to

introduce specific adaptive elements or activi-ties that resolve each of these sources of mis-matches to enhance relevance and fit.

CONCERNS OVER EROSIONOF INTERVENTIONEFFECTIVENESS

The distinction between efficacy and effective-ness is central to the aims of cultural adapta-tion. Whereas efficacy measures how well anintervention works when tested within the con-trolled conditions under which it was designed,effectiveness measures how well the interven-tion works in an applied, real-world setting(Flay et al. 2005, Kellam & Langevin 2003).Due to the greater challenges in the applicationof a tested-and-effective intervention in com-plex real-world settings, level of effectiveness, asmeasured by effect size, is almost always smallerrelative to efficacy. The challenge involves sus-taining the full intervention effects of the vali-dated intervention when transitioning from labto community. Similarly, this aim of maintain-ing the full intervention effects is central in thetransition from the original EBI to an adaptedEBI.

One other consideration regarding inter-vention efficacy and effectiveness involves thecriterion of effectiveness, as defined in refer-ence to a specific population or group. This cri-terion is that “A statement of efficacy should beof the form that, ‘Program or policy X is effi-cacious for producing Y outcomes for Z pop-ulation.’” (Flay et al. 2005, p. 154). In otherwords, for many interventions, a general state-ment regarding the “universal effectiveness” ofan intervention for all people and outcomes isessentially meaningless. This criterion for ef-fectiveness refers to the external validity of theoriginal EBI and the role of a cultural adap-tation, given that the effectiveness of an EBIshould be defined in relation to the population(or populations) with which it was tested; effec-tiveness remains undefined or is indeterminatein relation to a population that is significantly orculturally different from the original validationpopulation.


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Table 1 Sources of intervention-population mismatch

Source of mismatch Original validation group(s) Current consumer groupActual or potential mismatch

effectGroup characteristicsLanguage English Spanish Consumer inability to

understand program content; amajor adaptation issue

Ethnicity White, nonminority Ethnic minority Conflicts in beliefs, valuesand/or norms; reactance

Socioeconomic status Middle class Lower class Insufficient social resources andculturally different lifeexperiences

Urban-rural context Urban inner city Rural, reservation Logistical and environmentalbarriers affecting participationin program activities

Risk factors: number andseverity

Few and moderate in severity Several and high in severity Insufficient effect on multiple ormost severe risk factors

Family stability Stable family systems Unstable family systems Limited compliance in programattendance and participation

Program delivery staffType of staff Paid program staff Lay health workers Lesser or different program

delivery skills and perspectivesStaff cultural competence Culturally competent staff Culturally insensitive staff Limited awareness of, or

insensitivity to, cultural issuesStaff cultural competence Culturally insensitive staff Culturally competent staff Staff will refer to missing

cultural elements and criticizethe program for beingculturally insensitive orunresponsive; misadaptation

Administrative/community factorsCommunity consultation Consulted with community in

program design and/oradministration

Not consulted withcommunity

Absence of community“buy-in,” communityresistance or disinterest, andlow participation

Community readiness Moderate readiness Low readiness Absence of infrastructure andorganization to address drugabuse problems and toimplement the program

Source: Castro FG, Barrera M Jr, Martinez CR. 2004. The cultural adaptation of prevention interventions: resolving tensions between fidelity and fit. Prev.Sci. 5:41–45.

Issue #1: Are Cultural Adaptations ofEvidence-Based TreatmentsJustifiable?

A history of objections to the 1995 TaskForce on Promotion and Dissemination of Psy-chological Procedures notes that some haveviewed this report as reflecting a double stan-dard (Bernal & Scharron-del-Rıo 2001). The

report appeared to endorse the use and dis-semination of EBIs under the premise that ad-equate support exists regarding their efficacy.Nonetheless, it was apparent that the founda-tion research had limited external validity ow-ing to the limited inclusion of diverse samples toestablish intervention efficacy with these vari-ous constituencies. In the absence of sufficient


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Awareness of

treatment availability

Entry into treatment

Participation in treatment

activities

Completion of

treatment

Treatment participants

Evidence-based

treatment

Common mediator (supportive parenting)

Unique mediator

(immigration stress)

Common outcome (depression)

Unique outcome

(immigration distress)

OutcomesEngagement

Action theory Conceptual theory

A

B

C

D

W

X

Y

Z

V

Unique adaptive element

Figure 1A heuristic framework for the cultural adaptation of interventions.

evidence that an EBI is effective for a partic-ular subcultural group, some scholars have ar-gued that cultural adaptations or even novel cul-turally grounded treatments are justifiable andeven necessary.

Lau (2006) has provided a thoughtful anal-ysis of the issue of when to develop a culturaladaptation for an EBI. She advocated a theory-and data-driven selective and directed approachfor determining whether an EBI should be cul-turally adapted and, if so, which treatment ele-ments might be altered. In a related approach,Barrera & Castro (2006) developed Figure 1in their commentary on the Lau (2006) arti-cle to illustrate the features of an interven-tion that might be considered for adaptation.The cultural adaptation of an original EBI isjustified under one of four conditions: (a) in-effective clinical engagement, (b) unique riskor resilience factors, (c) unique symptoms of

a common disorder, and (d ) nonsignificant in-tervention efficacy for a particular subculturalgroup.

Ineffective engagement. As shown inFigure 1, during the engagement stage, afirst justification for an adaptation is thatan intervention exhibits deficiencies in itsability to engage clients from a particularsubcultural group relative to rates of engage-ment found for other groups. The variousforms of engagement include (a) awareness oftreatment availability, (b) entry or enrollmentinto treatment, (c) participation in treatmentactivities, (d ) retention and completion oftreatment (see Figure 1, paths A, B, C, D). In(e) prevention interventions, this includesactive outreach to a targeted group to mobilizetheir participation. In prevention interven-tions, attracting and retaining the participation


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of community residents and/or members ofhigh-risk subcultural groups remains oneof the greatest challenges in the design andimplementation of efficacious and successfulprevention-related EBIs.

Unique risk or resilience factors. A secondjustification arises when the original EBI showsdiminished efficacy because a subcultural groupdemonstrates unique risk or resilience factorsthat are related to a clinical outcome. This istantamount to suggesting that certain subcul-tural groups exhibit different etiological pro-cesses that influence the occurrence and courseof a common disorder. Such culturally specificmechanisms would suggest the need to add newand efficacious intervention components thatare different from the original core componentsin order to prevent or change the occurrenceand/or severity of a targeted disorder. One hy-pothetical example is an EBI for childhood de-pression developed initially for children withno experience with immigration stressors. If ev-idence for a new subcultural group (e.g., thechildren of immigrants) suggests that immigra-tion stressors are related to childhood depres-sion, an adaptation of the original EBI that addsa unique adaptive component to buffer the ef-fects of immigration stressors would be justified(see path X in Figure 1).

Research evidence on risk factors can alsosuggest the modification or deletion of certaincore intervention elements or components thatdo not contribute to improving targeted out-comes. A multistudy project by Yu & Seligman(2002) provided an example of the culturaladaptation of a prevention program for youthsin Beijing, China, that modified original corecomponent material on assertiveness in orderto accommodate local cultural norms and ex-pectations. These investigators cited researchsupporting their view that low assertiveness wasless of a risk factor for the Chinese children ascompared with Western children. Within thisChinese cultural context, culturally assertiveinteractions of Chinese children with theirparents were qualitatively different from theassertive interactions of their Westernized

peers with their parents. This cultural contextprompted the design of a modified adaptationcomponent that was culturally responsive tothese cultural differences involving the form,meaning, and risk potential of low assertiveness.

Unique symptoms of a common disorder.A third situation that justifies cultural adapta-tions is when a subcultural group shows uniquesymptoms that are associated with a commondisorder (see path Z in Figure 1). Lau (2006)illustrated this condition by describing researchthat showed that southeast Asian refugees hadunique manifestations of panic attacks that wereameliorated when specialized treatment proce-dures were added (Hinton et al. 2005). Theidentification of unique risk/resilience factorsand unique symptom features can be accom-plished by a careful review of basic epidemio-logical research or by new studies (e.g., Yu &Seligman 2002).

Nonsignificant intervention efficacy. Afourth justification for the cultural adap-tation of an intervention is provided whenan EBI is implemented with fidelity with asubcultural group, yet the quantitative resultsreveal less-effective outcomes, as indicated byattenuated effect sizes. As one example, anadapted version of a preventive interventionfor depression (the Penn Resiliency Program)was tested with Latino and African Americanyouths in Philadelphia (Cardemil et al. 2002).Results showed that the intervention wassuccessful in reducing depression symptomsfor Latinos, but the intervention did not affectthe hypothesized mediating mechanisms ordepression for African American youths. Thedata indicated that this intervention requiredadditional adaptive elements to be effectivewith African American children.

An entirely new intervention. A fifth con-dition that extends well beyond adaptationis a case where an entirely new interventionis proposed. Such an extreme option wouldbe justifiable and necessary when no relevanttreatment exists to meet the unique needs of a


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particular subcultural group. Given the prolif-eration of scores of treatment and preventioninterventions now available, it is difficult tojustify the development of an entirely newintervention. A preferable approach would beto identify a closest-fitting EPI for a particularsubcultural group and then consider thevarious aforementioned approaches to culturaladaptation.

The growing need for cultural adaptations.In their conclusions regarding the state of sci-ence on psychosocial interventions for ethnicminorities, Miranda and colleagues (2005) in-dicate that a question that remains unansweredinvolves the extent to which interventions needto be culturally adapted to be effective withminority populations. This question shouldbe reframed, in part, to accommodate theconsiderable within-group variation that existswithin each of the four major racial/ethnicminority populations of the United States:Latinos/Hispanics, African Americans, AsianAmericans, and Native Americans. When theunit of analysis is the total population of agiven ethnic/racial group, e.g., Latinos, theanswer to this question depends on the culturalcharacteristics of the particular targeted sub-cultural group. For example, among Latinos,the most basic form of cultural adaptation,linguistic adaptation (translation from Englishto Spanish; Castro et al. 2004), is unnecessaryand is not relevant for high-acculturatedLatinos, whereas it is absolutely necessary forlow-acculturated Latinos. By contrast, beyondthis instance of a need for a linguistic adapta-tion, conducting a more substantive culturaladaptation requires that the interventionistcommand a deep-structure understanding ofthe needs and preferences of members of aspecific subcultural group to successfully adaptthe original EBI in response to these needs andpreferences.

Miranda and colleagues (2005) also identi-fied three core issues regarding future effortsto improve the quality and availability of inter-ventions for racial/ethnic minority populations.These issues involve (a) the need to consider

cultural context in the delivery of interven-tions; (b) the need for methodologies that tailorEBIs for specific subcultural groups, includingthe identification of cultural factors that areamenable to adaptation; and (c) the need formethods that will actively engage ethnic mi-norities in interventions, including outreach tothese populations and ways to deliver interven-tions on a larger scale (Miranda et al. 2005).

Finally, a recent Institute of Medicine reporton prioritizing comparative-effectiveness re-search (Iglehart 2009) identified two prominentneed areas: (a) understanding the operationof health care delivery systems, and (b) un-derstanding the effects of racial and ethnicdisparities on health. Within these areas,improving the delivery of EBIs within healthsystems and enhancing EBI effectivenessfor reducing health disparities via culturaladaptations serve as relevant and importantresearch and practice goals.

In summary, the applicability of an EBI to aparticular subcultural group can be ascertainedfrom a reasoned analysis of engagement factors,the theoretical models of unique and commonrisk factors, and the targeted outcome variables.An analysis of these factors can serve as the ini-tial stage of a planned, structured, and collabo-rative process for culturally adapting an originalEBI.

Issue #2: What Procedures ShouldIntervention Developers Follow WhenConducting a Cultural Adaptation?

Stage models are prominent in the developmentand testing of new drugs, medical procedures,and psychosocial interventions (Rounsavilleet al. 2001). Several stage models also have beenproposed for the cultural adaptation of EBIs,and these introduce considerations that differfrom those that guide the development of newinterventions. Table 2 summarizes three mod-els and suggests how they converge and divergein content, comprehensiveness, and scope. Acritical aspect of these models is that they con-tain deliberate steps that guide intervention de-velopers in using qualitative and quantitative


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Table 2 Comparison of adaptation process models

Kumpfer et al. (2008) McKleroy et al. (2006) Wingood & DiClemente (2008)1. Gather needs assessment data onetiological precursors

2. Careful selection of the best EBT toculturally adapt and transport: reviewliterature for evidence of effectiveness;conduct focus groups of parents andstaff to review intervention materials

3. Pilot original EBT with just minorchanges to the surface structure

4. Staff selection and training5. Program implementation with fidelityand quality

6. Cultural adaptations madecontinuously with pilot groups

7. Revisions of program materials toimprove engagement

8. Empowerment evaluation to improveoutcomes and implementation

9. Disseminate results of the effectivenessof the culturally adapted version

1. Assessment: target population’s risk factors,behavioral determinants, risk behaviors;potential evidence-based treatments andtheir internal logic; stakeholders, potentialcollaborators; agency’s capacity toimplement the intervention

2. Selection: use assessment data to selecttreatment and determine if adaptation isneeded

3. Preparation: make necessary changes toEBI (but maintain fidelity to core elements);prepare the organization; pretest with focusgroups, test materials for reading level,attractiveness

4. Pilot test the adapted intervention5. Implementation: with conscientiousmonitoring of fidelity and outcomes

1. Assessment: assess focus groups withtarget population and key communitystakeholders to understand risk factors

2. Decision: which EBI fits needs best,and is it going to be adopted oradapted?

3. Administration: specific decisionsabout which treatment components areadopted or adapted

4. Production: create initial draft versionof the adaptation

5. Topical experts: identify experts toassist in adaptation

6. Integration: create second draft of theadaptation from input of topical experts

7. Training: train staff to implementrefined version of the adaptation

8. Testing: conduct pilot research andshort-term outcome study to evaluateefficacy of the adaptation

data to determine the need for a cultural adap-tation, the elements of the intervention thatmight be changed, and estimates of the effectsof intervention alterations.

These comprehensive stage models ofcultural adaptations are illustrated with specificinterventions: the Strengthening FamiliesProgram (Kumpfer et al. 2008) and HIV/AIDSprevention (McKleroy et al. 2006, Wingood& DiClemente 2008). The comprehensivenessof those models is understandable becausethese stages were intended for the national andinternational dissemination of the core inter-ventions. Activities such as assessing agencycapacity and staff selection are indicative ofthe models’ grounding in the practicalities ofbroad-scale dissemination. A recent article de-scribing the ADAPT-ITT model is particularlyvaluable because it contains specific descrip-tions of methods, including marketing researchstrategies that can be used at each stage (Win-good & DiClemente 2008). The ADAPT-ITTmodel was illustrated with applications toAfrican American women in Atlanta and Zulu-speaking adolescent women in Africa. This

model, which grew out of a public health tradi-tion, has considerable relevance for applicationsto more mainstream clinical psychology topics.

A simplified framework by Barrera & Castro(2006) contains the essential elements of com-prehensive adaptation models. It presents fourstages, consisting of (a) information gather-ing (review the literature to understand com-mon and unique risk factors and conduct focusgroups to assess perceived positives and nega-tives of the original EBI), (b) preliminary adap-tation design (develop recruitment strategiesand modify the intervention based on informa-tion gathered in step a), (c) preliminary adapta-tion tests (pilot test the modified recruitment,intervention, and assessment procedures), and(d ) adaptation refinement (modify the interven-tion based on pilot results and subject the in-tervention to a full evaluation with quantitativeand qualitative data) to evaluate the efficacy ofthe adapted intervention.

This model was used in the adaptation ofa lifestyle intervention for adult Latinas whohad diabetes (Barrera et al. 2010). The pilottesting stage served as the most valuable step


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in the adaptation process, particularly becauseit contained mechanisms for ongoing feedbackfrom participants and intervention staff mem-bers. Similar stages were developed indepen-dently of the Barrera & Castro (2006) frame-work and illustrated in the adaptation of adepression preventive intervention for Latinofamilies (D’Angelo et al. 2009).

Other models contain steps that are sub-sumed by models shown in Table 2. DomenechRodrıguez & Wieling (2004) drew fromRogers’s (2000) framework on the diffusion ofinnovations to propose a three-phase CulturalAdaptation Process Model. That model in-cludes the steps of (a) studying the relevant liter-ature, establishing a collaborative relationshipwith community leaders, gathering informationfrom community members on needs and inter-ests; (b) drafting a revision of the intervention,soliciting input from community members, andpilot testing; and (c) integrating the lessonslearned from the preceding phase into a re-vised intervention that could be used and stud-ied more broadly. These strategies include bothbottom-up and top-down approaches; thus, likethose in the other process models, they strike“a balance between community needs and sci-entific integrity” (p. 320).

These conceptual frameworks describe theprocesses that intervention developers can fol-low in designing, implementing, and evaluatinga culturally adapted EBI. Others have pro-vided guidance in identifying the interventioncontent that might be adapted. Hwang (2006)offered a psychotherapy adaptation and modifi-cation framework and illustrated it with consid-erations that were made in adapting a cognitivebehavior therapy (CBT) for Asian Americanclients. The psychotherapy adaptation andmodification framework contains six generaldomains and 25 therapeutic principles that wereorganized within those domains. The domainsconsist of aspects of the entire psychotherapyenterprise that therapists should be aware ofwhen treating clients from subcultural groups:(a) dynamic issues and cultural complexities,(b) orientation of clients to therapy, (c) cultural

beliefs, (d ) client-therapist relationship,(e) cultural differences in expression and com-munication, and ( f ) cultural issues of salience(e.g., shame and stigma, acculturative stress).

Bernal et al. (1995) presented a frameworkthat contains eight dimensions that can bethe subject of culturally sensitive interventions:(a) language of the intervention, (b) similar-ity and differences between the client andtherapist, (c) cultural expressions and sayingsthat might be used in treatment, (d ) culturalknowledge, (e) treatment concepts, ( f ) goals,(g) treatment methods, and (h) context of thetreatment (e.g., developmental stage, phase ofmigration, acculturative stress). In summary,these somewhat overlapping frameworks re-garding the content of treatment interventionsimplemented within clinical settings comple-ment other models that describe the steps inconducting a cultural adaptation.

Thus, criticisms that there exist no frame-works for guiding the cultural adaptation of in-terventions are no longer valid. It is clear thatsignificant advancements have been made in es-tablishing systematic, data-driven, consumer-sensitive processes for determining if EBIsshould be adapted, how they should be adapted,and what the results of those adaptations are onengagement and intervention outcomes. Someof the published exemplars of those approachesreport only on results from pilot data with verysmall samples that offer encouraging results(e.g., Barrera et al. 2010, D’Angelo et al. 2009,Matos et al. 2006), although larger-scale out-come studies will appear soon. It will be in-teresting to determine if cultural adaptationsthat were developed through such comprehen-sive, multistep processes will exhibit higherlevels of effectiveness, as compared with ear-lier adaptations that were conducted beforesuch process frameworks appeared in the litera-ture. A related question is whether the adaptedEBI, when compared with the original EBI,can offer value-added effects by exhibiting sig-nificantly better outcomes, including signifi-cantly larger effect sizes on targeted outcomevariables.


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Issue #3: Is There Evidence thatCultural Adaptations are Effective?

At the present time, the best answer to thequestion regarding the effectiveness of cul-tural adaptations has been provided in a meta-analytic review by Griner & Smith (2006). Theyreviewed 76 published and unpublished studiesthat contained explicit statements that interven-tion content, format, or delivery was adapted,“based on culture, ethnicity, or race.” The re-view produced several important findings:

1. Half of the studies used two to four typesof adaptation activities; 43% used five ormore. The most common adaptation ac-tivities (84% of studies) involved the in-clusion of cultural values and concepts.This was followed by native languagematching of clients to therapists (74%),ethnic group matching of clients to ther-apists (61%), and treatment in clinics thatexplicitly served clients from diverse cul-tural backgrounds (41%).

2. The weighted average effect size wasd = 0.45, which indicated that cultur-ally adapted interventions were moder-ately effective.

3. Interventions provided to groups ofsame-race participants (d = 0.49), werefour times more effective than interven-tions provided to groups consisting ofmixed-race participants (d = 0.12).

4. Studies that explicitly described interven-tions in which therapists spoke the samenon-English language as clients had ahigher effect size (d = 0.49), as com-pared with studies that did not describelanguage matching (d = 0.21).

5. For studies that included Latino partic-ipants, average effect sizes from stud-ies of low-acculturated Latinos (mostlySpanish-speaking clients) were twice aslarge as the average effect sizes fromstudies in which the Latino participantsexhibited moderate levels of accultur-ation (bilingual/bicultural clients). Al-though the authors’ confidence in this

observation was attenuated by the smallnumber of studies, they interpreted thispattern as suggestive evidence that low-acculturation participants are in greaterneed of a cultural adaptation and stand tobenefit more.

6. Adapted interventions with younger par-ticipants produced somewhat smaller ef-fect sizes than did adapted interventionswith older participants.

This review provided suggestive evidencethat culturally adapted interventions are effec-tive. Some findings pointed to the possibil-ity that clients who had the greatest need foraccommodations (i.e., low-acculturated, non-English-speaking adults) received the greatestbenefit from such adaptations. Future researchstudies that are explicitly designed to evalu-ate particular intervention components and fea-tures may clarify if these components operateas new core components that enhance targetedintervention outcomes. The studies included inthis review were completed before 2005. Sincethat time, several journal special issues (Bernal2006, Bernal & Domenech Rodrıguez 2009)and other noteworthy studies have been pub-lished that have added further support to theconclusion that culturally adapted interventionsare effective.

By contrast, Huey & Polo (2008) conducteda detailed review that, unlike Griner & Smith(2006), was restricted to just EBIs and researchthat involved ethnic minority children and ado-lescents. However, these investigators reacheda much less positive conclusion than did Griner& Smith (2006) about the evidence support-ing cultural adaptations. For example, one ar-gument in favor of cultural adaptations is thatEBIs are relatively ineffective for ethnic minor-ity clients. Huey & Polo (2008) reported that 5of the 13 studies that tested for treatment-by-ethnicity interactions found evidence of differ-ential treatment efficacy. Three studies foundthat the EBIs were more effective for ethnicminority children when compared with whitechildren, whereas two studies found the oppo-site pattern.


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Huey & Polo (2008) also looked for evi-dence that culturally responsive EBIs enhancedtreatment outcomes. They contrasted the ef-fect sizes from studies that were identified asculturally responsive with those that were not.A conservative definition resulted in 10 stud-ies that used culturally responsive treatmentsand 10 that used standard treatments. A moreliberal definition resulted in the classificationof 14 treatments as culturally responsive and 6as standard. Neither the conservative nor lib-eral classification methods resulted in signifi-cant differences in effect sizes when culturallyresponsive treatments were compared to stan-dard treatments with ethnic minority children.However, the authors acknowledged the lackof statistical power for making such compar-isons. Also, as Griner & Smith (2006) noted, theneed for culturally adapted treatments might belower for children than for adults. Overall, onthe basis of the studies they reviewed, Huey &Polo (2008) concluded that the “utility of cul-tural adaptation remains ambiguous” (p. 293)and warrants more research.

In summary, evidence from these two meta-analytic studies is mixed regarding the efficacyof culturally adapted EBIs relative to the orig-inal EBI and regarding their effectiveness ingeneral. Is the glass half empty or half full?One way to interpret these results is to in-dicate that current evidence shows the perva-siveness of cultural adaptations that have beendeveloped from original EBIs. These adapta-tions are typically effective in general. Theyare often, but not always, as effective as theoriginal EBI and usually exhibit greater rel-evance to the needs of a targeted subculturalgroup.

Issue #4: How Can WideWithin-Group Cultural VariationBe Accommodated in a CulturalAdaptation?

It is ironic that cultural adaptations intended tocorrect the one-size-fits-all application of EBIsby creating an ethnic adaptation that applies tomost members of a given ethnic group can be

subjected to the criticism that they too do notadequately respond to the heterogeneity thatexists within that cultural group. Within a largepopulation, such as within the United States,a given ethnic minority group, e.g., Latinos,consists of many individuals who differ broadlyfrom each other on dimensions of acculturationand other cultural factors. How might a culturaladaptation be effective for such a diverse pop-ulation? One noted approach involves popula-tion segmentation (Balcazar et al. 1995), a vari-ation of market segmentation (Lefevre & Flora1988), that consists of identifying a smallerand more homogeneous subpopulation (or sub-cultural group) whose members have commonneeds and preferences that are more effectivelyaddressed with a focused cultural adaptationthat is tailored to this subcultural group’s col-lective needs and preferences.

Another solution to this problem restswith intervention procedures that containstandardized decision rules for varying thecontent and “dosage” of treatment, dependingon the characteristics of particular sectors ofparticipants or groups, e.g., families. This isthe essence of adaptive intervention designs(Collins et al. 2004). The word “adaptive” isunavoidably awkward in the context of thisdiscussion about culturally adapted EBIs. Inmost outcome research studies, investigatorsseek to provide the same treatment contentsin the same number of sessions to all of theparticipants who are assigned to an interven-tion condition. This approach emulates therigors of experimental research designs, albeitat the expense of sensitivity to within-groupindividual variations in clinical and culturalneeds and preferences. In contrast, adaptive in-terventions are closer in form to individualizedclinical practice because they provide explicitguidelines for the delivery of different dosagesof intervention components depending on theunique needs of individual clients and based onevidence-based decision rules for determiningvariations in these dosages. Such specificdecision rules would also allow replicabilityin clinical practice and research, such thatwell-crafted decision rules could be developed


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to respond appropriately to the common needsof a well-specified group of clients.

Collins et al. (2004) provide examples fromthe well-known Fast Track project to illus-trate how an adaptive intervention might beused with children who vary in their need foracademic, behavior management, and familysupport components of the intervention. Suchadaptive approaches hold considerable promisein general, and particularly for cultural adapta-tions that would be applied with specific andsomewhat heterogeneous subcultural groups.The broad dissemination and application ofsuch adaptive intervention designs would re-quire the availability of a sufficiently large actu-arial database that is drawn from a diverse set ofpopulations, from which evidence-based rulescan then be developed and ultimately appliedto a wide cross-section of clients. A related is-sue involves the cultural competence of the in-tervention developers and of the interventiondelivery staff. Cultural competence would beessential in developing culturally appropriatedecision rules from the accumulated actuarialevidence.

In the same spirit of adaptive interventions,Pina et al. (2009) has described a “culturally pre-scriptive intervention framework” that guidesthe tailoring of childhood anxiety interventionsdepending on the cultural features of the indi-vidual or family. Rather than applying a fixed setof adaptation activities, their treatment man-ual describes a uniform set of guidelines to assistinterventionists in determining how to attendto language and other cultural considerations(e.g., familism) in tailoring the intervention.The Pina et al. (2009) study also illustrateshow their childhood anxiety treatment adapta-tion incorporates the eight cultural parametersdescribed by Bernal et al. (1995) and the ini-tial treatment development stage described byRounsaville et al. (2001). This approach is real-istic and actively addresses the conflict betweenfidelity and fit.

In summary, one feasible goal in the designof culturally adapted EBIs is to utilize pop-ulation segmentation to identify a more nar-rowly defined subcultural group, thus reducing

the within-group variability that exists withina large ethnic population. A second strategy isto develop adaptive intervention protocols thatare tailored to the individual’s or subculturalgroup’s unique needs and preferences. Ideally,both segmentation and adaptive interventionapproaches can be used strategically to enhancethe intervention-consumer fit and the resultingintervention effectiveness.

APPLYING CULTURALADAPTATION APPROACHES

Exemplars of Culturally GroundedCognitive-Behavioral Treatments

CBT approaches in the treatment of adultdepression are among the most heavily re-searched EBIs (Butler et al. 2006). Munoz andcolleagues at the Depression Clinic of SanFrancisco General Hospital have conducted anumber of studies on the cultural adaptation ofCBT for adult depression treatment and pre-vention (e.g., Kohn et al. 2002, Miranda et al.2003, Munoz & Mendelson 2005). Munoz &Mendelson (2005) describe how these interven-tions were built on the core principles of so-cial learning theory (behavioral activation, so-cial skills, and cognitive restructuring) and thenwere modified to be culturally sensitive throughfive considerations: (a) ethnic minority involve-ment in intervention development, (b) culturalvalues, (c) religion and spirituality, (d ) accultur-ation, and (e) racism, prejudice, and discrim-ination. These manualized interventions havebeen used broadly with a variety of ethnic/racialgroups by a number of different investigativeteams in the United States and abroad, andthrough a variety of media.

Two studies conducted with CBT depres-sion treatment have special relevance for thisarticle. One was a small quasi-experimentalstudy that compared African American women(n = 10) who received the standard CBTgroup therapy through the Depression Clinicat San Francisco General Hospital with thosewho elected to participate in a group de-signed specifically for African American women


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(n = 8) (Kohn et al. 2002). The adaptationadded four modules concerned with healthy re-lationships, spirituality, African American fam-ily issues, and African American female identity.Although formal statistical analyses were notperformed, women in the standard treatmentshowed a 5.9 prepost drop in Beck DepressionInventory scores, whereas women in the cultur-ally adapted group showed a 12.6 point drop.In our estimation, this was one of only threestudies that have compared a cultural adapta-tion to a standard intervention (Botvin et al.1994, Kohn et al. 2002, Szapocznik et al. 1986)and the only one that has shown any suggestiveevidence of the extra benefits from the culturaladaptation. The possibility of additional bene-fits from adaptations to an intervention that wasalready modified to be culturally sensitive wasan encouraging outcome of this study. One lim-itation is the lack of statistical analyses, althoughthat dovetails with the small sample size. Otherlimitations can include design issues that alsocenter around these two aspects of a small study.

A second study (Miranda et al. 2003) con-sisted of a randomized trial that contrasted theCBT group therapy (n = 103) developed byMunoz and his colleagues with the same grouptherapy regimen supplemented with telephoneoutreach case management, i.e., CBT with sup-plemental case management (n = 96). Of the199 predominantly low-income participants,77 were Spanish speaking, 46 were AfricanAmerican, and 18 were Asian or American In-dian. Case managers worked with patients on“problems in housing, employment, recreation,and relationships with family and friends” (Mi-randa et al. 2003, p. 220). Results showed thatpatients who received supplemental case man-agement were less likely to drop out of treat-ment and attended more treatment sessions ascompared with patients who received just theCBT group therapy. For Spanish-speaking pa-tients, those who received supplemental casemanagement reported fewer depressive symp-toms at the end of treatment than did those whoreceived CBT groups only.

The addition of the supplemental case man-agement component was prompted by the

socioeconomic hardships and daily stressorsobserved among members of this subculturalgroup and not by any particular cultural aspectof race or ethnicity. Nevertheless, this studyillustrates how a supplemental adaptation de-signed to increase participant engagement toa culturally sensitive treatment could produceenhanced beneficial outcomes. It also illustratesthe importance of cultural competence amongthe intervention developers, as they aptly iden-tified and understood the most salient socio-cultural needs and preferences of members ofthis subcultural group and thus introduced asupplemental case management component toaddress these needs and enhance the originalEBI.

Exemplar of a Culturally GroundedSubstance Abuse PreventionIntervention

The Drug Resistance Strategies (DRS) Projectwas initiated in 1991 with the aim of de-veloping a culturally focused prevention pro-gram tailored for effectiveness with minorityyouths (Botvin et al. 1994, 1995). The result-ing “keepin’ it REAL” drug prevention cur-riculum was developed in Phoenix, Arizonafrom 1995 to 2002 (Marsiglia & Hecht 2005).It involved white nonminority, Latino/a, andAfrican American middle school and highschool youths from large city high schools increating and evaluating a culturally groundedsubstance abuse prevention curriculum. Youthsparticipated in the development of preventionintervention videos that featured African Amer-ican and Latino youths who modeled waysto refuse solicitations to use alcohol, tobacco,or drugs (Alberts et al. 1991; Hecht et al.1992, 1993; Polansky et al. 1999; Schinke et al.1991). These videos included white, Latino,and African American protagonists who pro-moted prosocial cultural values and norms.For example, for Latino youths, these videosendorsed familism, ethnic identification withLatino peers and family, traditional Latinocultural practices, and speaking the Spanishlanguage.


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The keepin’ it REAL curriculum targetedtheory-based social mediators (e.g., culturalnorms that oppose substance use and eco-nomic deprivation) as core intervention com-ponents and also targeted several protectivefactors (e.g., strong role models, educa-tional successes, school bonding, adaptation tostresses, and positive attitudes) (Clayton et al.1995, Hawkins et al. 1992, Moon et al. 2000).The keepin’ it REAL evaluation of youth in-volvement yielded positive results on their in-volvement in developing the substance abuseprevention videos (Holleran et al. 2002).

The evaluation of the effectiveness of thekeepin’ it REAL intervention also showed thatstudents from the experimental schools, rela-tive to the comparison schools, acquired higherlevels of drug resistance skills and adoptedmore conservative norms that eschew substanceuse; they also exhibited lower rates of alcoholuse and less positive attitudes toward drug use(Kulis et al. 2005). The keepin’ it REAL cur-riculum is now recognized as a model programby the Substance Abuse and Mental Health Ser-vices Administration and has been disseminatednationally and internationally.

In contrast to the positive results forMexican American and other Latino youths inArizona, when this intervention was exportedto Texas, the local Mexican American youthsresponded critically to the videos, expressingthat they “could not relate” to certain con-tent and activities that were depicted, such asbreak dancing, even though these videos incor-porated Mexican American youths as protag-onists (Holleran et al. 2005). This revelationprompted the need for a local adaptation of thekeepin’ it REAL intervention in accord withthe needs and preferences of youths who live inTexas communities (Holleran Steiker 2008).

As another example, based on of the needfor a developmental adaptation, the keepin’it REAL curriculum was adapted for a fifth-grade subcultural group. Using focus groups,the adaptation team consulted with teacherswho commented on the language, scenarios,and activities prior to the pilot studies. The cur-riculum development specialists then adapted

the existing curriculum over a six-month periodto make the lessons developmentally appropri-ate for fifth-graders and added two lessons toenhance intervention effects. The fifth-gradeversion utilized the same basic curriculum con-tent as the standard seventh-grade multiculturalversion. The adapted activities involved ad-justments in communication level/format andgreater concreteness in the presentation of con-cepts. Other adaptations addressed age-basedrelevance in the examples, including simplifica-tion in language and concepts and more age-relevant ways to model and practice resistanceskills using realistic situations.

ISSUES, ANSWERS, ANDABIDING CHALLENGES

Regarding our current state of knowledge aboutthe cultural adaptation of EBIs, we summarizeand comment on answers to four major issuesas framed according to the four key questions.

1. Are cultural adaptations developed fromoriginal EBIs justifiable? Generally, thecultural adaptation of EBIs appears jus-tifiable when the original EBI exhibitsone of four types of diminished interven-tion effects. Cultural adaptations are jus-tified under the conditions of (a) ineffec-tive client engagement, (b) unique risk orresilience factors in a subcultural group,(c) unique symptoms of a common disor-der that the original EBI was not designedto influence, and (d ) poor intervention ef-fectiveness with a particular subculturalgroup.

2. What procedures should intervention de-velopers follow when conducting a cul-tural adaptation? To guide the design andimplementation of a culturally adaptedEBI, we now have a variety of stagemodels, most of which exhibit similarstages for conducting a cultural adapta-tion of an EBI. Thus, the basic path-ways for planning and conducting cul-tural adaptations have now been chartedand involve variations of four stages:(a) information gathering, (b) developing


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preliminary adaptation designs, (c) con-ducting preliminary tests of adaptation,and (d ) adaptation refinement (Barrera &Castro 2006).

3. What is the evidence that cultural adap-tations are effective? The evidence forthe effectiveness of cultural adaptations ispromising but mixed. It appears that cul-turally adapted interventions are approx-imately as effective as the original EBI.Ideally, the adapted intervention wouldprovide a significant increment of im-provement on targeted outcome mea-sures, although few studies have con-ducted direct comparisons of this effect.Accordingly, we do not have sufficientevidence to address this issue with cer-tainty, and this calls for future studies thatare designed to test this effect. This is-sue raises another challenge involving thecosts and benefits of developing a cultur-ally adapted intervention. Is it worth thecost and effort of designing and evalu-ating such adaptations, if the effect sizes(and thus effectiveness) on targeted out-comes are approximately equal to thoseattained under the original EBI? Suchadaptations might provide demonstrablegains in consumer participation and sat-isfaction, but are these gains sufficient tomerit the effort and expense involved indesigning a cultural adaptation of an EBI?

4. How can within-group cultural vari-ation be accommodated in a culturaladaptation? Regarding responsiveness towithin-group variation, two classes ofanswers are evident. This problem ofwithin-group variation can be addressedby (a) population segmentation, which in-volves more narrowly defining a targetedsubcultural group (attenuating within-group variability), and (b) adaptive inter-ventions of various types.

Directions for Future Development

Direct comparisons between originalEBIs and adapted versions. In comparative

outcome trials, culturally adapted interventionshave usually been contrasted with a controlcondition and not with unaltered versionsof the original EBI (Griner & Smith 2006).In principle, the essential justification for acultural adaptation is its superiority to the orig-inal EBI in terms of participant engagement,targeted outcomes, or both. Comparativeresearch of this type is needed. Now thatinformative frameworks exist to guide thedesign of cultural adaptations of EBIs, it will beparticularly interesting to compare an originalEBI to a rigorously adapted EBI to evaluatepossible enhancements in the effectiveness ofthe adapted EBIs.

An ecodevelopmental approach to culturaladaptation. Given the emerging emphasis ofsystemic approaches in the conceptualizationand application of culture (Castro et al. 2009,Erez & Efrat 2004, Szapocznik & Coatsworth1999), the use of systemic models for adapta-tion planning and implementation is clearly in-dicated. A proposed cultural adaptation shouldconsider the influences of various cultural ele-ments such as religion, gender, and social class(Am. Psychol. Assoc. 2006, Cohen 2009). In ad-dition, this adaptation should also consider theinfluences of surrounding community and so-cioeconomic factors that can enhance or dimin-ish the effect of the EBI on targeted therapeu-tic outcomes. A systemic analysis of antecedentfactors, mediators, and outcomes and of waysto boost intervention effects would be useful inefforts to maximize the overall benefits of suchadapted EBIs.

Understanding underlying mechanisms ofcultural adaptations. To generate new andgeneralizable scientific knowledge, it is ben-eficial to understand an intervention’s mech-anisms of change, as this understanding canidentify critical intervention components thatinfluence behavioral and other mediators thatin turn influence the intended therapeutic out-comes (Kazdin 2008, MacKinnon et al. 2002).In addition, a study of cultural moderatorvariables, e.g., level of acculturation among


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subcultural groups of Latino clients (low accul-turated, bicultural, and high acculturated) couldreveal that the influence of a cultural element(e.g., the role of respeto—a respectful demeanorutilized by the therapist or interventionist) pro-duces strong and significant intervention effectsfor Latino subgroup A1 (e.g., low-acculturatedLatinos), yet produces no effect for Latino sub-group A2 (e.g., high-acculturated Latinos).

In this regard, intervention outcome re-search can be used not only to evaluate the ef-ficacy of an intervention, but also to test theory(Howe et al. 2002). When cultural adaptationsare explicitly designed to influence a culturalconstruct hypothesized as important for ther-apeutic change (to lower acculturative stress,increase trust in the therapist, or strengthencultural identity), such studies may test if the in-tervention was successful in changing that con-struct (action theory) and also if that changeaffected the outcome (conceptual theory) (seeMacKinnon et al. 2002).

Developing adaptive culturally adapted in-terventions. As noted above, adaptive inter-ventions offer different dosages of interventioncomponents to various types of clients, depend-ing on the needs of individual clients, underexplicit decision rules for determining varia-tions in dosages. The specification of an arrayof client-dosage decision rules would establishan intervention protocol that could be testedand replicated in clinical practice and in re-search settings. Such adaptive approaches holdconsiderable promise for prescriptive culturaladaptations that can be applied with multiplesubcultural groups. Moreover, a series of stud-ies on the effects of selected cultural moderatorvariables (e.g., acculturation, immigration ex-perience, religiosity) could further inform thedecision rules developed for these prescriptiveadaptive interventions.

Some Recommendations

Utilize available frameworks and stagemodels to guide the cultural adaptationprocess. Remarkable similarity exists in the

frameworks and stage models that have beendeveloped to systematically guide the culturaladaptation of EBIs, even though these appear tohave been developed independently (Barrera &Castro 2006, D’Angelo et al. 2009, DomenechRodrıguez & Wieling 2004, Kumpfer et al.2008, McKleroy et al. 2006, Wingood &DiClemente 2008). Collectively, these frame-works and models advocate the use of existingresearch that identifies the presence of uniquerisk and resilience factors that should be con-sidered in intervention revisions. These ap-proaches all contain early steps that employ fo-cus groups, marketing research strategies, andthe formation of community partnerships thatallow potential consumers to inform the pro-posed intervention. All employ the integrationof qualitative and quantitative research meth-ods. After a step that involves preliminary re-visions, all approaches include pilot researchand another opportunity to learn directly frompeople who resemble the intended consumersof the proposed cultural adaptation. Ultimately,these stages lead to a refined intervention thatcan be implemented with fidelity in broader-scale outcome research. Based on preliminaryfindings, these frameworks can be used to refineand implement effective cultural adaptations.

Specify core components and mechanismsof effect. The developers of an originalEBI, and those who propose an adaptationto that EBI, should present and describea theory-based model that specifies theirintervention’s putative core components andits related mechanisms of effect on targetedoutcome variables. This theory-based analysisof expected core component effects andmechanisms, as illustrated by Barrera & Castro(2006), would inform users of the interventionand would help research scientists to under-stand the role of the intended componentsand their intended therapeutic effects. Thiswould involve a formal core componentsanalysis that utilizes the mediational anal-ysis model presented by MacKinnon et al.(2002) and/or that utilizes a logic modelapproach, as has been conducted within


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health services and evaluation research studies(Goldman & Schmalz 2006, Gugiu &Rodriguez-Campos 2007).

Importance of cultural competence oftherapists and intervention agents. Finally,frameworks for guiding the process of cultur-ally adapting interventions often focus on in-tervention content rather than on the person-nel who deliver the interventions. Whether in

a treatment setting or in a community setting,the analyses by Bernal et al. (1995) and Hwang(2006) remind us that cultural competence andother clinical skills of the intervention agentsare essential for delivering effective culturallyadapted EBIs. Thus, one essential aspect of acultural adaptation should be the specificationof personnel skills and training for the culturalcompetence necessary to effectively implementthe culturally adapted EBI.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings thatmight be perceived as affecting the objectivity of this review.

ACKNOWLEDGMENT

This article was supported by grants from the National Center on Minority Health and HealthDisparities: Grant Number P20MD002316-010003, Felipe Gonzalez Castro, Principal Investi-gator, and Grant Number P20MD002316-01, Flavio F. Marsiglia, Principal Investigator. Thecontent is solely the responsibility of the authors and does not necessarily represent the officialview of the National Center on Minority Health and Disparities or the National Institutes ofHealth.

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Annual Review ofClinical Psychology

Volume 6, 2010 Contents

Personality Assessment from the Nineteenth to Early Twenty-FirstCentury: Past Achievements and Contemporary ChallengesJames N. Butcher � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

Prescriptive Authority for PsychologistsRobert E. McGrath � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �21

The Admissibility of Behavioral Science Evidence in the Courtroom:The Translation of Legal to Scientific Concepts and BackDavid Faust, Paul W. Grimm, David C. Ahern, and Mark Sokolik � � � � � � � � � � � � � � � � � � � � � �49

Advances in Analysis of Longitudinal DataRobert D. Gibbons, Donald Hedeker, and Stephen DuToit � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �79

Group-Based Trajectory Modeling in Clinical ResearchDaniel S. Nagin and Candice L. Odgers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 109

Measurement of Functional Capacity: A New Approach toUnderstanding Functional Differences and Real-World BehavioralAdaptation in Those with Mental IllnessThomas L. Patterson and Brent T. Mausbach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 139

The Diagnosis of Mental Disorders: The Problem of ReificationSteven E. Hyman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 155

Prevention of Major DepressionRicardo F. Munoz, Pim Cuijpers, Filip Smit, Alinne Z. Barrera, and Yan Leykin � � � � � � 181

Issues and Challenges in the Design of Culturally AdaptedEvidence-Based InterventionsFelipe Gonzalez Castro, Manuel Barrera Jr., and Lori K. Holleran Steiker � � � � � � � � � � � � 213

Treatment of PanicNorman B. Schmidt and Meghan E. Keough � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 241

Psychological Approaches to Origins and Treatments of SomatoformDisordersMichael Witthoft and Wolfgang Hiller � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 257

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Cognition and Depression: Current Status and Future DirectionsIan H. Gotlib and Jutta Joorman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 285

The Genetics of Mood DisordersJennifer Y.F. Lau and Thalia C. Eley � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 313

Self-InjuryMatthew K. Nock � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 339

Substance Use in Adolescence and Psychosis: Clarifying theRelationshipEmma Barkus and Robin M. Murray � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 365

Systematic Reviews of Categorical Versus Continuum Models inPsychosis: Evidence for Discontinuous Subpopulations Underlyinga Psychometric Continuum. Implications for DSM-V, DSM-VI,and DSM-VIIRichard J. Linscott and Jim van Os � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 391

Pathological Narcissism and Narcissistic Personality DisorderAaron L. Pincus and Mark R. Lukowitsky � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 421

Behavioral Treatments in Autism Spectrum Disorder:What Do We Know?Laurie A. Vismara and Sally J. Rogers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 447

Clinical Implications of Traumatic Stress from Birth to Age FiveAnn T. Chu and Alicia F. Lieberman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 469

Emotion-Related Self-Regulation and Its Relation to Children’sMaladjustmentNancy Eisenberg, Tracy L. Spinrad, and Natalie D. Eggum � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 495

Successful Aging: Focus on Cognitive and Emotional HealthColin Depp, Ipsit V. Vahia, and Dilip Jeste � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 527

Implicit Cognition and Addiction: A Tool for Explaining ParadoxicalBehaviorAlan W. Stacy and Reineout W. Wiers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 551

Substance Use Disorders: Realizing the Promise of Pharmacogenomicsand Personalized MedicineKent E. Hutchison � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 577

Update on Harm-Reduction Policy and Intervention ResearchG. Alan Marlatt and Katie Witkiewitz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 591

Violence and Women’s Mental Health: The Impact of Physical, Sexual,and Psychological AggressionCarol E. Jordan, Rebecca Campbell, and Diane Follingstad � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 607

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Documents

Issues and Challenges in the Design of Culturally Adapted Evidence-Based Interventions