Evidence-Based Practice in Special Education and Cultural Adaptations

Abstract

Many issues arise in the discussion of the evidence-based practice (EBP) movement and implementation science in special education and specific educational practices for students with severe disabilities. Yet cultural adaptations of EBPs, which have emerged as an area of research in other fields, are being left out as a focus of EBP discourse. The aim of this article is to examine key challenges and concerns in the movement of EBP and implementation science in special education, as well as the emergence of cultural adaptation of EBPs in other fields. Apart from an argument for the need of cultural adaptations of EBPs in special education, we discuss guiding principles and provide recommendations for developing culturally adapted EBPs in special education.

Keywords

evidence-based practice implementation science implementation fidelity cultural adaptation cultural competence

Evidence-based practice (EBP) has drawn considerable attention from both researchers and practitioners in the field of special education (Cook & Odom, 2013). As this movement continues to evolve, focus has gradually shifted from defining and identifying EBPs to implementation. A 2013 special issue of Exceptional Children was specifically dedicated to the topic of implementation science and EBPs in special education that cover such issues as the research-to-practice gap, dissemination and diffusion, fidelity and flexibility and fit, scaling up implementation, and professional development for implementation (Cook & Odom, 2013). Although all the above issues deserve close attention from researchers and further investigation, the dilemma between implementation fidelity and adaptation, a so-called “tug-of-war” as noted by Bopp, Saunders, and Lattimore (2013), is at the core of the challenges surrounding implementation of EBPs.

Leko (2015) pointed out that adaptations are most likely to take place in three stages of the implementation process: installation of an EBP in a local context, initial implementation, and innovation; the key to the entire implementation process is to find “the right balance of implementation fidelity and adaptation of specific EBPs in local contexts” (p. 81). Implementation fidelity refers to the extent to which a treatment or intervention is carried out procedurally as intended, and ensuring fidelity in school-based practices often involves “documenting quality of instruction, identifying professional development needs, and sustaining effective practices to improve student outcomes” (Harn, Parisi, & Stoolmiller, 2013, p. 184). Although different types of adaptations may as well be made for different reasons and under different circumstances, specific cultural adaptations are almost always required in the process of replicating EBPs across cultures (Morrison et al., 2009).

Cultural adaptation pits fidelity in delivering evidence-based interventions in their standardized form against the need to enable the fit of interventions to non-dominant cultural groups (Castro, Barrera, & Holleran Steiker, 2010). Standards for EBPs in social and health sciences, including special education as part of educational science, typically include implementation fidelity among their indicators for high-quality and trustworthy interventions as a means to ensure that components of any study can be measured reliably (e.g., Council of Exceptional Children, 2014). However, while such standards expect uniformity in treatment, the individuals and their families whom these treatments serve are not a uniform, homogeneous population. With this understanding, there have been calls for practitioners to deliver person-centered care that addresses the unique needs and preferences of individuals no matter their cultural, ethnic, gender, geographic, and social class identities (Institute of Medicine, 2001).

Some scholars have risen to the call to examine and generate new models of intervention, care, and support that adapt to the values and concerns of traditionally underserved populations. Much of the practices employed in the special education and mental health fields were developed for middle-class, majority culture groups (Southam-Gerow, Weisz, & Kendall, 2003) without regard for the notion that individuals and families from culturally and linguistically diverse (CLD) communities may respond differentially to treatment (Griner & Smith, 2006). Culturally adapted EBPs have emerged in the field of mental health care and clinical psychology as a response to the growing challenges that CLD people and families underutilize resources and services and are more susceptible to attrition (Kazdin & Mazurick, 1994). Applying treatment models developed for a majority population without modifications to CLD populations can attenuate the engagement of the clients as well as the outcomes of treatment (Lau, 2006).

This article aims to address one missing piece from the puzzle of implementation of EBPs in special education: cultural adaptations of EBPs. The purpose of our article is threefold. First, we examine key challenges and concerns in the movement of EBP and implementation science in special education as well as the intersection of cultural adaptation and EBPs in the fields related to special education. Second, we present an argument for the need to establish cultural adaptations of EBPs in special education as a necessary approach for propelling the EBP movement and implementation science forward. We also outline guiding principles and provide recommendations for implementing culturally adapted EBPs in special education. Third, cultural adaptation relative to the needs of students with severe disabilities is discussed.

Challenges of EBPs and Implementation Science in Special Education

There are several noteworthy limitations of EBP implementation identified in the field of mental health care, which are relevant to our discussion in special education. Aisenberg (2008) described these challenges as ambiguity of definition, underrepresentation or the exclusion of ethnic minority populations in research, and deep epistemological differences and shortfalls in cultural responsiveness of interventions. In particular, some of these limitations are derived from the assumption that “EBP privileges scientific knowledge over other epistemologies,” which suggests, “scientific knowledge is superior to cultural ways of knowing” (Aisenberg, 2008, p. 301). As a result, EBPs often reflect the dominant culture’s (as the norm) influence in defining what EBP is, and determining what constitutes effective interventions. Aisenberg’s comments shed light on our discussion of the challenges of EBP implementation in special education. Such questions as who should define what EBP is, for whom EBP intends to have a positive effect/impact, and who determines the effectiveness are in fact worth answering (see Castro et al., 2010, for an in-depth discussion of these issues).

Another salient issue concerns a fundamental assumption about universal applicability and effectiveness of EBP to all populations (Aisenberg, 2008). With this assumption, EBPs are supposed to be equally applicable and effective across all ethnic populations even when there is only documented evidence of effectiveness with certain populations (e.g., White students of suburban middle-class families). However, there is a lack of evidence in the literature supporting the efficacy of EBPs for communities of color. Racial and ethnic disparities in the United States have long been in existence throughout the entire system of mental health care with respect to both issues of access and utilization of services, and the quality and outcomes of care (Aisenberg, 2008). In particular, Aisenberg noted that the assumed “universal applicability” has not been substantially demonstrated in CLD populations. Also, Atkinson, Bui, and Mori (2001) contended that diversity of client characteristics has been largely overlooked in the existing EBP research evidence and have instead an exclusive dependence on White samples. Likewise, there seems to be similar issues about the legitimacy of implementation and dissemination of EBPs to populations of color in special education considering that most EBPs have been developed without even taking account of the cultural context and identity of cultural and ethnic minority communities.

Several researchers have suggested that adaptations of EBP programs are almost inevitable in real-world public health settings (Bopp et al., 2013). Harn et al. (2013) pointed out that implementing EBPs with fidelity in special education programs is very challenging and that professionals should prioritize EBPs that can be designed flexibly to match various contexts and student population. Despite growing attention to the issue of balancing implementation fidelity and adaptation in EBPs of special education (Leko, 2015), cultural adaptations of EBPs have not yet appeared on the radar screen for this important debate. There is an urgent need for the development of cultural adaptations of EBPs in special education to help address some of the important unanswered questions: Whether sociocultural differences necessitate different forms of interventions and how cultural factors moderate the impact of EBPs.

Defining and Implementing Culturally Adapted EBPs

The two identified challenges to EBPs—shortfalls in cultural responsiveness of interventions and the “tug-of-war” between fidelity and adaptation—both speak to the need of addressing a serious gap in EBPs and implementation science: cultural adaptation. In the fields of health care and mental health care, cultural adaptations of EBPs have emerged as an important area of research and will likely grow in prominence in the future as a result of two noteworthy trends: growing diversification of the U.S. population and growing demand for the use of EBPs (Cabassa & Baumann, 2013; Castro et al., 2010; Lau, 2006). Likewise, the EBP movement in special education calls for an embracement of cultural adaptation for the very reason of providing high-quality intervention to an increasingly heterogeneous special education population.

Due to multiple definitions given in different disciplinary and professional fields, culture, as a complex and universally studied construct, needs to be defined in the context of EBP implementation. Artiles, Kozleski, Trent, Osher, and Ortiz (2010) critiqued the issue of fragmentation and discontinuity in views of culture to examine many issues in special education, and they articulate three views of culture—one of which is the regulative view of culture. According to Artiles et al. (2010), the regulative view assumes culture is “located in the psyche of individuals” (e.g., their knowledge, beliefs, values), “in a group’s conventions and expectations for everyday life conduct” (p. 288), as well as in institutions’ function and survival. In other words, culture is not “a static set of values, norms, and practices” that embed within the individual, but a dynamic construct “as it is learned, transmitted and transformed by social interactions, conflicts, and power relations” (Cabassa & Baumann, 2013, p. 2). From a regulative view, cultural adaptation is defined as “a planned, organized, iterative, and collaborative process that often includes the participation of persons from the targeted population for whom the adaptation is being developed” (Castro et al., 2010, p. 215). Cultural adaptation also involves the process of modifying an evidence-based intervention protocol to take language, culture, and context into account to make it compatible with the cultural patterns, meanings, and values of those being served (Bernal, Jiménez-Chafey, & Domenech Rodríguez, 2009).

The emphasis of cultural adaptation in implementation science can bring the explicit attention of researchers, practitioners, and clients to culturally related issues, that is, making evidence-based interventions more responsive to the needs and preferences of diverse populations (Cabassa & Baumann, 2013). The integration of cultural adaptation and implementation science can help not only “clarify and specify what to adapt in order to achieve optimal balance between adaptation and fidelity, and address important implementation outcomes (e.g., acceptability, appropriateness)” (Cabassa & Baumann, 2013, p. 1) but also “clarify the knowledge, skills and roles of who should facilitate the process of implementation” (Cabassa & Baumann, 2013, p. 1) and when adaptations should be considered in the implementation process.

Cultural Adaptation Frameworks and Effectiveness of Culturally Adapted EBPs

While cultural adaptation has been scarcely studied in the field of special education, in the mental health care field, the process for systematic cultural adaptation has been examined under the direction of varying models (Griner & Smith, 2006). Some scholars and theorists have applied Bronfenbrenner’s (1977) construct of ecological validity (i.e., the degree to which the environment as experienced by participants matches the treatment environment as assumed by the researcher) as a guiding framework for designing culturally adapted mental health interventions with families and individuals of color. This framework has served as a resource for researchers to develop or adapt culturally responsive therapies to the Hispanic/Latino/a community and other non-dominant cultures. Among the dimensions recommended to researchers and practitioners to consider are the language of the intervention, the (racial/ethnic characteristics of the) persons administering the therapy, the metaphors/symbols/sayings embedded in the population, the content and cultural values of the community, and the unique context of the participants (Bernal, Bonilla, & Bellido, 1995). Aligning the treatment with the language and cultural knowledge and values of the population of interest may help the intervention be accepted in the community or help the intervention be received as intended (Bernal et al., 1995). Research conducted with Puerto Rican youths with depression, for example, took into consideration the cultural principles of familialism (that family interests supersedes individual interests) and respeto (“respect”); therapists focused on increasing positive family values, cultivated a sense of absolute respect for parents during interviews, involved parents in discussions throughout the phases of intervention, and sought parental observation on child progress (Rosselló & Bernal, 1999; Rosselló, Bernal, & Rivera, 2008). These two randomized clinical trial studies provided evidence for the success of cultural adaptation in therapeutic treatments (Rosselló & Bernal, 1999; Rosselló et al., 2008).

Ecological validity and other theories have also served as models for researchers investigating cultural adaptations for other underserved groups (Hwang, 2009; Nicolas, Arntz, Hirsch, & Schmiedigen, 2009). For example, Hwang (2009) developed the psychotherapy adaptation and modification framework (PAMF), a two-part framework based on cultural competency theories and research, expert therapists’ experiences, as well as his own experiences treating cultural minorities. According to the first framework, culture influences the understanding of mental health, including the ways mental illness is defined, the ways it is identified and assessed, the ways to seek treatment, as well as the ways to intervene. The second PAMF framework addresses the principles for working specifically with the Chinese American community and entails framing mental health and therapy concepts to Chinese beliefs and traditions (i.e., holistic, integrated mind-body conceptualization of health) to aid understanding of treatment goals and procedures; understanding client expectations of therapists as professional, authoritative experts (congruent with hierarchical norms in Chinese society); and being aware of additional life stressors that may exacerbate distress (e.g., racism, language differences, social mobility challenges, intergenerational conflict), among other considerations. Adapting treatments for culturally diverse populations, according to Hwang, would enhance the ecological validity of psychotherapy treatments developed primarily with the majority culture in mind. Such adaptation frameworks could also apply to designing interventions in the field of special education, for example, for students with intellectual disability.

Griner and Smith’s (2006) meta-analysis of culturally adapted practices in mental health services sheds light on understanding the overall effectiveness of culturally adapted EBPs and the useful types of strategies and approaches used in cultural adaptation of EBPs. In addition to a moderate effect size of culturally adapted EBPs (d = 0.45), Griner and Smith noted that a majority of the selected 76 studies for meta-analysis adopted at least one attempt of cultural attunement (Falicov, 2009), for example, matching the ethnicity of therapists and participants or providing services in the primary language of the clients. Moreover, some additional supports were provided as a means of cultural adaptation: consulting or working with individuals knowledgeable about the participants’ culture, offering extra services in efforts to retain clients of color (e.g., child care), providing sensitivity training to staff, and/or referring clients to external service agencies. The concrete practices and supports this meta-analysis suggests could be adapted by the education professionals and institutions serving students with disabilities, depending on the particular needs and contexts of the individual, family, or group.

Culturally Responsive Practices in Special Education

Despite the seemingly scarce literature on cultural adaptations of EBPs in special education, numerous studies have looked into issues regarding culturally responsive practices in special education, especially for students with severe disabilities. Examples include discussing issues of helping teachers understand various cultural interpretations of severe disability from families with CLD backgrounds, and the role of enculturation on family expectations and participation in special education programs (Rogers-Adkinson, Ochoa, & Delgado, 2003); applying the essential elements of cultural responsiveness and the critical skills for teachers to use in teaching diverse populations of students with severe disabilities (Harmon, Kasa-Hendrickson, & Neal, 2009); and establishing culturally responsive instruction which emphasizes teachers’ cultural self-awareness, uses diversity as a foundation for the curriculum, and recognizes the effect of language diversity on the educational needs of students with severe disabilities (Glimps & Ford, 2006).

In addition, there are also group studies centered on families of color in the developmental disabilities literature. Modification strategies for these studies employed cultural attunement and other approaches mentioned as common adaptations (Griner & Smith, 2006). For example, Davis and Rushton (1991) ran a coping skills training program in Britain that included a group of non-English speaking Bangladeshi parents of children with intellectual or multiple disabilities, and the parents received training from one full-time Bangladeshi-speaking mother as the primary adaptation approach. In another parent training study of Steps to Independence (Prieto-Bayard & Baker, 1986), the cultural adaptations to the standard program included holding meetings at the centrally located Regional Center, conducting trainings in Spanish, charging no program fees, providing a small transportation stipend, and offering child care services by Spanish-speaking individuals trained in behavioral principles. In addition, the training content was also streamlined and translated into Spanish, and incentives (e.g., toys for the children) were offered to parent participants who completed the program. Assessment measures were then also gathered and coded by Spanish-speaking assistants.

Although developing cultural adaptation frameworks is at a nascent stage for group experimental studies in special education, single case design studies in the area of developmental disabilities have long incorporated considerations of contextual fit. Contextual fit is a key feature of positive behavior supports (PBS), borrowing from the ecological validity model (Albin, Lucyshyn, Horner, & Flannery, 1996). Home-based PBS interventionists are most concerned with understanding and changing environmental variables within family routines and settings to facilitate positive behavioral development in the child and to improve family quality of life and functioning. Despite the natural alignment between contextual fit and cultural adaptation, few PBS studies detail the types of accommodations provided to individuals and families of diverse cultural backgrounds. Wang, McCart, and Turnbull’s (2007) illustrative example of PBS implementation with a Chinese American family explained the process for adapting the core intervention strategies within the cultural context of the family. In this case study, the intervention team practiced cultural competence through consulting with a cultural liaison to first establish rapport with the family (Wang et al., 2007). Conducting a functional assessment and developing a PBS plan proved to be challenging initially because the intervention team and the family held divergent perspectives about the causes of the student’s behavioral issues, about discipline practices, and about meaningful outcomes for the student. Through understanding the family’s beliefs and preferences, the team learned the need to incorporate the family’s values and practices into a PBS plan. For example, rather than dismissing the family’s reliance on spiritual or traditional treatments (e.g., herbal soup) of the student’s behavior, the interventionists encouraged family members to adjust their practices (e.g., give the soup earlier in the evening) to reduce problematic nighttime behaviors (e.g., bedwetting). Because of these efforts, the intervention team was able to help the family accomplish its goals.

Cheremshynski, Lucyshyn, and Olson (2013) combined qualitative and quantitative methodology to create a culturally appropriate PBS plan for a Japanese family in Canada. In this multiple-component single case design study, the researchers measured cultural and contextual fit prior to the start of intervention and collected interview data about the family’s and the interventionist’s culture before and during treatment as well as the interventionist’s reflections throughout the intervention period. In addition to the positive child outcomes noted in the quantitative component of the study, the qualitative portion proved to be beneficial in uncovering three themes of a culturally responsive behavior support process: (a) creating and sustaining a sense of mutual trust and understanding, much of which includes recognizing and addressing cultural barriers (e.g., learning important Japanese phrases and modes of nonverbal communication); (b) seeking guidance and support from a cultural interpreter; and (c) identifying and incorporating cross-cultural values that the family may have (in this case, these were both Japanese and Canadian beliefs and perceptions). The cultural adaptation process contributed to the success of the collaboration between the family and the interventionist, and it also encouraged the mother to adopt the interventionist’s strategies that ultimately helped to modify the child’s behaviors. This study contributes significant insights to a very small body of literature on culturally adapted EBP in the area of developmental disabilities.

Despite the increasing uptake of culturally responsive practices in special education and acknowledgment of its importance, issues of cultural adaptations of EBPs do not seem to have drawn much attention from special education researchers. The need to provide cultural adaptations for students with severe disabilities becomes particularly challenging, given that providing comprehensive services to students with severe disabilities is a complex and challenging endeavor, due to a wide array of conditions and variables that are related to students’ unique and compelling social, communication, and instructional needs (Harmon et al., 2009). Not every student with a severe disability will benefit from a cultural liaison, for example, but it would be helpful for the field of special education as a whole to borrow or to develop cultural adaptation frameworks, and to recognize the availability of cultural attunement strategies, as well as to understand when and how to apply these tools effectively.

Recommendations and Future Directions

As the field of special education begins to develop a framework for the cultural adaptations of EBPs, we should pay attention to some of the important lessons learned from other fields like medicine and mental health care. First, descriptions of culturally adapted EBPs should be made more explicit and detailed to increase reliability of future syntheses of this growing body of work. Studies are needed to undertake comparative analysis of utilization versus of non-utilization of specific culturally adapted EBPs (Bernal et al., 2009; Griner & Smith, 2006). Second, both issues of EBPs and culturally competent care should be discussed jointly and there should be more integration of the discussions for addressing culturally competent care within the discussions of EBPs (Whaley & Davis, 2007). Third, although what works for whom remains a difficult question to answer, research has shown that adaptations to specific cultural and ethnic groups have demonstrated some success in psychotherapy contexts (Bernal et al., 2009). The feasibility of conducting trials for all cultural groups with different types of disabilities or identities still needs inquiry.

Ogden and Fixsen (2014) raised three “wh” types of questions for research on the implementation of EBPs. At first, the what question asks for clear and specific descriptions of the intervention including information about the empirical nature, content, and procedures of the intervention. Second, the who question is about the individuals or groups of individuals (known as implementation teams or change agents) who carry out interventions. Third, the how question deals with identifying facilitators or barriers in the implementation procedures. Future research should answer all these questions in the context of special education EBP implementation.

Arzubiaga, Artiles, King, and Harris-Murri (2008) introduced the notion of “research as situated cultural practice” by integrating concepts primarily from the sociology of science, cultural psychology, and anthropology. They argued that special education ought to embrace a view of human nature laying its central concerns on culture because “culture becomes ubiquitous and requires that researchers tackle several challenges related to the study of the cultural nature of learning and development” (p. 312). This sociocultural/sociohistorical model not only enables researchers to keep their “traditional concern about cultural patterning of various communities” (Arzubiaga et al., 2008, p. 313) but also compels researchers “to be attentive to within-group diversity and to an individual’s construction of identities across contexts and time” (Arzubiaga et al., 2008, p. 313). Attention to ecological validity, which has been highlighted in the cultural adaptation models in other fields, can help us better understand the idea of research as situated cultural practice. Future research should explore what cultural considerations are needed to achieve ecological validity.

In addition, there are other specific issues about cultural adaptation of EBPs that need to be examined in future research, particularly as they apply to students with severe disabilities. Chief among these issues are (a) how research teams are created; (b) how access to local and cultural communities is achieved; (c) how samples are defined and selected; and (d) how the ongoing deliberation is conducted about researcher roles. For example, a research team should take into account the approach of participatory action research in their research plan and design to ensure that different stakeholders who represent local and cultural communities are included in the whole process of the research endeavor. As for the selection of study sample, there should be a specific sampling plan that puts emphasis on recruiting participants from CLD backgrounds as well as a plan with strategies to address possible high attrition rate of participants from CLD backgrounds.

Recommendations for Developing Culturally Adapted EBPs

It is evident in the literature that culturally adapted EBPs have been implemented successfully in other fields (Griner & Smith, 2006). Recommendations made by researchers in these fields (Bopp et al., 2013; Castro et al., 2010; Chen, Kakkad, & Balzano, 2008) for successful implementation of cultural adaptations of EBPs can shed light on how things need to be done in special education to promote culturally adapted EBPs. We provide some recommendations in the following areas along with Fixsen, Naoom, Blase, Friedman, and Wallace’s (2005) phases of implementation: (a) utilize available frameworks and stage models to guide the cultural adaptation process; (b) gain a good conceptual understanding of EBP programs by specifying core components and mechanisms of instructional or intervention programs; (c) develop a rigorous, adaptive, and flexible definition of implementation fidelity and completeness of the EBP programs; (d) gain a good understanding of contextual factors; (e) involve different stakeholders; (f) develop and enhance cultural competence of teachers and other professionals who provide services and support to students with severe disabilities; and (g) evaluate both process and impact/outcome of cultural adaptation related to the implementation of EBP programs.

Selecting appropriate frameworks or models regarding both process and components of cultural adaptations of EBPs is often the first step of action, followed by gaining a good conceptual understanding of the intervention/EBP program. Understanding how the EBP program is supposed to work conceptually is essential for subsequently developing a flexible approach and defining implementation fidelity and completeness. Researchers, educators, and other involved stakeholders (e.g., families) should collaborate on this effort in defining implementation fidelity. Next, considering the determinants of implementation and defining the core elements of the EBP program (i.e., the causal mechanisms) becomes a critical step. Despite their expertise in developing EBP programs, researchers should work with other stakeholders in specifying the determinants of implementation and core elements of the EBP program that are easily understandable (e.g., not jargonized) to practitioners and families. Subsequently, defining implementation fidelity and completeness needs to be accomplished in both rigorous and adaptive manners leaving proper room for cultural adaptations. Furthermore, understanding contextual factors of school, family, or community is critical because both internal and external factors related to school, family, and students with severe disabilities influence EBP program implementation, sustainability, and ultimately program outcome and impact. Interventions built with overt contextual flexibility (e.g., school settings and student variability) can better support practitioners to sustain the implementation of effective practices and positively impact student outcomes.

Working with stakeholders who are well informed about potential program contexts is another important step. “Early involvement of stakeholders, positive and trusting relationships, effective and ongoing communication, and providing implementation-skill development as well as ongoing support” (Bopp et al., 2013, p. 204) can all lead to greater implementation and sustainability. In particular, Chen and colleagues (2008) stressed that professionals (i.e., intervention agents), through education, training, consultation, and supervised experience, can obtain knowledge and skills in better serving culturally diverse populations in terms of different age, gender, race, ethnicity, national origin, immigration status, religion, language, socioeconomic, and support needs. Finally, process and impact/outcome evaluation of cultural adaptations should be undertaken throughout the phases of implementation to determine how cultural adaptations of EBPs worked and what key components facilitated their effectiveness.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Editor in Charge: George Singer

Author Biographies

Mian Wang, Ph.D., is a professor of special education at the Gevirtz Graduate School of Education, University of California, Santa Barbara. His research mainly focuses on family support and family outcomes (e.g., Family Quality of Life), cultural issues in special education research and practice, and cross-cultural comparison of inclusive education practices.

Yeana Lam, Ph.D., is a research analyst at the central office of the University of California, Education Abroad Programs (UCEAP). Her research adresses issues related to family support for families of children with disabilities and identity of college students with disabilities and their access to service.

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