Adolescent Psychiatry - Volume 3, Issue 1, 2013

Objectives: The recent essay by Ethan Watters (2010) in the New York Times on the Americanization of mental illness with greater globalization raises many important assertions and concerns about the dissemination of Western models of mental illness throughout the world. At the same time, a there has been parallel trend towards the adoption of Western models of family structure and child rearing. Methods: The authors review these parallel trends and reference some studies that support their inter-connection and their potential adverse consequences on the psychosocial risk factors faced by youth. They also briefly review cases that illustrate these risks. At the same time, it also presents the counterpoint that globalization may have positive aspects in crossnational collaboration and learning in addressing the mental health of youth and families. They briefly review the content of this Special Issue as examples of the benefits from such learning and cross-pollination, tempered with the necessary adaptation of such lessons to differing cultural contexts and needs. Conclusion: Increased understanding of these trends as well as inter-national and cross-cultural collaboration will allow us to more effectively serve American youth and families as well as youth and families in diverse cultures and nations.

Background and objectives: Economic conditions, policies, family environment and cultural models of parenting all impact a child’s well- being and development. Differing theoretical orientations in mental health between countries govern the respective under standing, assessment, and treatment of children and their families. Method: This paper provides an overview and critical examination of child mental health care systems in North America and Europe using the United States (US) and France as comparisons. Results: France has a national policy of universal access to health care; in the US access is determined largely by insurance companies and varies from state to state. Conclusions: By examining the similarities and differences between health care systems, mental health providers, training, diagnosis and treatment approaches in this cross-national comparison, much can be learned about developing effective practices to improve health care delivery worldwide.

Background and Objectives: There has been very little research on child/adolescent mental health in the Philippines compared to other developing countries. The few reports that exist have been case studies, literature reviews, intervention research (particularly disaster mental health studies), and surveys and studies on Filipino immigrants in other countries. As part of the World Health Organization (WHO) Seven Nation Collaborative Study (2007), the Philippine study showed that 16% of children had mental disorders. Method: Drawing on population-based studies, this article explores the challenging issues of mental health care for youth in the Philippines and will also provide suggestions that can help in improving these challenges. Results: Unlike many other developing countries, the Philippines has a national health policy. Filipinos, both in their native and adoptive countries, greatly underutilize public outpatient mental health services compared to other Asian populations. Conclusions: Along with stigma, the adherence of traditional practices and healing methods remains a formidable barrier to the appropriate provision of care Furthermore, the onset of mental illness in childhood and adolescents can be missed without appropriate screening and services.

Objective: Child mental health promotion and implementation of research initiatives have been particularly challenging in Low and Middle Income (LAMI) countries. Pakistan is one such country facing challenges in recognition, awareness and promotion of its pediatric mental health needs. Methods: A review of the literature was done to identify the epidemiology, challenges to recognition and delivery and resources available regarding pediatric mental health disorders. From a few studies that have been done, the mean prevalence of pediatric mental health disorders was found to be15.8%. Behavioral symptoms were found to be the most common cause of referral and ADHD the most common diagnosis. The numerous challenges that developing countries like Pakistan face in the promotion and implementation of child mental health care are discussed and include stigma, illiteracy, lack of adequate statistical data and severe shortage of pediatric psychiatrists. Results: From a few studies that have been done, the mean prevalence of pediatric mental health disorders was found to be15.8%. Behavioral symptoms were found to be the most common cause of referral and ADHD the most common diagnosis. Conclusion: Creative ways of implementing and incorporating child mental health services within the existing systems of care are needed in LAMI countries like Pakistan.

Objective: To trace the history of psychiatry in the Dominican Republic. Method: Historical accounts are reviewed from the archival history of the DR. Results: The part of the island of Hispaniola which would one day become the Dominican Republic was the site of the first European settlement in the American continent, yet for more than three and a half centuries it was forgotten and neglected by its European colonial masters. Organized mental health care began in this newly independent republic at the end of the nineteenth century, but it later underwent a period of paralysis that began to change after the arrival of the first trained psychiatrists in the 1940s. The decade of the 1970s fostered great progress with development of a community mental health infrastructure and the creation of the first psychiatry residency training programs. Conclusions: Although much progress has been made, to this date, there is no formal training in child and adolescent psychiatry or other any of the other psychiatric subspecialties. New economic prosperity and globalization offer great hopes for the improvement of mental health care for the Dominican population.

Objectives: The total number of suicides in Flanders, Belgium, and Lithuania is higher than the European Union (EU) average. This paper compares suicide rates among adolescents in Flanders and Lithuania and discusses trends and public policy initiatives for prevention. Methods: Using Pub Med and other databases we compared suicide rates among adolescents in Flanders, Belgium and Lithuania and identified interventional initiatives and evidence for their effectiveness in each country. Results: The statistics for adolescents aged between 15 and 19 years revealed that the suicide number for this particular group remained especially high in both countries in the period of 1994-2009. The figures are significantly higher among boys and boys tended to choose more violent means such as hanging or shooting. Conclusions: Prevention initiatives in Lithuania are more fragmented, while Flanders has a more advanced preventive policy, which already has produced some positive results. The Flemish experience creates an opportunity for a transfer of knowledge to Lithuania and other countries.

Goals: The geo-political and socio-economic landscape of Europe has undergone significant changes since the World Wars creating challenges for both health policy makers and health service providers. This paper aims to review immigration trends in Europe and identify problems and needs of immigrant and ethnic minority children and youth with respect to mental health services. Methods: Published reports and studies on mental health of immigrant and ethnic minority youth are reviewed and discussed. Results: Data show immigrant and ethnic minority youth in the European Union consistently experience discrimination, marginalization and stigmatization, which increases their risk for mental health problems. The stigmatization of mental health problems within their groups decreases their propensity to seek mental health services or to respond to interventions when they are offered. Conclusions: The most vulnerable population with respect to having poor health profiles and outcomes are immigrants and ethnic minorities ; within these groups are many children and young people with mental health problems. In societies with higher rate of immigration such as Europe it is important that mental health services are both accessible and culturally sensitive. Using various evidence based interventions in appropriate setting would improve mental health of these children and prevent developing serious mental health disorders. Are mental health services and interventions geared to meet the needs of these population groups in a culturally sensitive and appropriate way?

Objective: As have many nations in the West and North America, Ireland has become a multicultural nation after being a fairly homogeneous one. The balance of migration has been inward, only stemmed by the recent financial crisis, and this has changed its complexion culturally and in terms of mental health needs. Method: We report on trends and data on the mental health needs of the growing population of children of immigrants in Ireland and the implications for Irish child mental health services. Results: Despite immigrant children making up 10% of the primary school-going population in Ireland, very little research has been published on their mental health wellbeing. Challenges, both positive and negative, continue to confront many families. As a group they are generally faring less well than native born Irish children in terms of overall quality of life, school inclusion, and sense of acceptance. Access and uptake of mental health services is poor and may reflect lack of culturally competent assessments. Conclusions: The management of immigration and integration will continue to be a challenge for the Irish State. Establishment of cross cultural competency in mental health services and inclusion of migrant families in policy formation would go a long way to understanding what services will best meet their needs.

Background and objectives: We aim to provide clinicians with clinically relevant information about Turkish culture and provided some clinical case experience from the United States. We discuss common values, traditions, and nuances within Turkish culture, and highlight basic Turkish family structures and roles in the U.S. Our objective is to help clinicians be aware of clinically important characteristics of their patients' cultures and make appropriate adjustments. Results: According to the US Census population report, by 2030 European-origin children will no longer be a majority in the US and this is already the case among 7 years old children and younger. Culture and ethnicity may have significant impact on diagnosis, treatment, and outcome in psychiatry. Culturally uninformed evaluation and care can lead to acculturative stress, a weak therapeutic alliance, non-adherence, neglect, and misdiagnosis. Methods: We review of demographic information and literature regarding Turkish immigrants to the US. Since, there has been so far no research about Turkish children, adolescents, and families in the US, we rely on our clinical experience and research conducted in countries other than the U.S. Results: Overall there are about 7 million American Muslims, whose lives are significantly influenced by Islamic values. The Turkish and Muslim population in Europe and North America will likely continue to increase due to globalization, strong economic growth in Turkey, and the effects of the “Arab Spring” on the Islamic World. Conclusions: We hope this article will provide an initial guide for clinicians treating minority Turkish patients and families and also advance awareness about the need of cultural competence in psychiatry.

Background: Forcibly displaced children and adolescents may be exposed to continued risks to their healthy development in their new low- and middle-income countries. However, previous studies have focused mainly on those resettled in high-income countries. Objectives: We sought to present a family case report and to review the literature on the mental health of child and adolescent refugees in Brazil. “child and adolescent,” “mental health,” “refugee,” “asylum,” “low and middle income country,” “developing countries,” “migration” “Latin America,” “Brazil.” Sources such as official reports of United Nations High Commissioner on Refugees and Brazilian Ministry of Justice and Health were also used. A family case is presented to illustrate mental health issues of young refugees in Brazil. Results: While the majority of the world's refugees move within the developing World, few studies were found to assess pediatric mental health in low- and middle-income countries. There were no studies conducted in Brazil, whose asylumseeker and refugee population is increasing. Conclusions: Migrant children and adolescent mental health have not been yet addressed in a systematic way in Brazil, where the mental health of children and adolescents is an evolving discipline. Assessment of mental health needs of the small but increasing number of asylum-seeking and refugee youths in Brazil is necessary if appropriate mental health care to this population is to be provided.

Objectives: Acculturative stress is a significant problem for International exchange students in the US, and has been associated with a variety of psychiatric symptoms and psychosocial impairment. In this article we focus on the mental health issues of exchange students from East Asia, who typically are dealing with differences in culture as well as high expectations for academic success. Methods: We review the literature on the acculturation of foreign exchange students and suicide in East Asian populations. We then present a case study of an East Asian high school student who attempted suicide during his exchange program in the United States and give a cultural formulation. We discuss the systems of care that were involved in treating the student in an inpatient psychiatry setting and returning him home. Results: Suicide, suicidal ideation and suicidal behaviors are common problems among adolescents and adults in East Asia, with academic stress and family conflict being the most common precipitants. Those who come to the US have the added stress of adapting to a different culture. It can be difficult for treatment providers to distinguish between personality features unique to the patient and those that are culturally determined. Conclusions: Treatment in this case involved a significant interaction between health care, legal, cultural, and educational concerns. Enhancement of the patient's sense of efficacy and control was an important goal of treatment. It is important that child and adolescent mental health care providers become familiar with this population.

Objective: This paper aims to explore the pathogenesis of often serious recurring psychopathological presentations in adolescent girls coming from immigrant families who were separated from their mothers in childhood and subsequently reunited with them at a later date. Method: We present two cases treated with psychotherapy: a Chinese girl in puberty, with selective mutism, and a South American teenager with an eating disorder and a history of family abuse, both of whom had immigrated to Italy to be reunited with their mothers. Results: The traumatophilic tendency, which has been observed in young immigrants, exposes them to the repetition of traumatic situations which are largely relatable to their parents' failure to work through the trauma of migration. The reunification, for which the children are often unprepared, presents itself as a second trauma: the abrupt separation from the emotionally invested caretaker is often experienced as the action of an envious mother who deprives the child of a good relationship. Feelings of exclusion, jealousy and anger are acted out in the refusal and devaluation of maternal care, or through direct attacks on maternal femininity. The mothers themselves appear powerless to provide any sort of emotional containment, persecuted by guilt and paralysed by their own ambivalence and disappointment. Conclusions: Working in parallel with the mothers and teenagers can provide a second chance to achieve a coming together based on mutual understanding. At the same time, the acknowledgement and acceptance of the traumatic experience which can be achieved through therapy, contributes to the processing of the migration shock and can provide an opportunity for new modes of development.

Objectives: The purpose of this mixed method study was to characterize the patterns of psychosocial adjustment among adolescent African refugees in U.S. resettlement. Methods: A purposive sample of 73 recently resettled refugee adolescents from Burundi and Liberia were followed for two years and qualitative and quantitative data was analyzed using a mixed methods exploratory design. Results: Protective resources identified were the family and community capacities that can promote youth psychosocial adjustment through: 1) Finances for necessities; 2) English proficiency; 3) Social support networks; 4) Engaged parenting; 5) Family cohesion; 6) Cultural adherence and guidance; 7) Educational support; and, 8) Faith and religious involvement. The researchers first inductively identified 19 thriving, 29 managing, and 25 struggling youths based on review of cases. Univariate analyses then indicated significant associations with country of origin, parental education, and parental employment. Multiple regressions indicated that better psychosocial adjustment was associated with Liberians and living with both parents. Logistic regressions showed that thriving was associated with Liberians and higher parental education, managing with more parental education, and struggling with Burundians and living parents. Qualitative analysis identified how these factors were proxy indicators for protective resources in families and communities. Conclusion: These three trajectories of psychosocial adjustment and six domains of protective resources could assist in developing targeted prevention programs and policies for refugee youth. Further rigorous longitudinal mixed-methods study of adolescent refugees in U.S. resettlement are needed.

Objective: To review and discuss the mental health needs of children and adolescents in India. Methods: Recent community-based and clinic-based epidemiological data in child and adolescent psychiatry (CAP) from a tertiary referral center for CAP in India [National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India] are reviewed. Results: The ICD-10 DCR criteria for CAP disorders and Rutter's penta-axial diagnosis are used in these data. The community prevalence rate for CAP disorders is found to be 12.5% (n = 2064). The most common diagnoses in community are non-organic enuresis (6.2%), specific phobia (2.9%), ADHD (1.6%), stuttering (1.5%) and ODD (0.9%). Only 37.5 per cent of the families perceived that their children had any problem. The profile of CAP disorders among patients presenting to the CAP clinic [n=374 over six months period; age-group 0-16 years; 240 (64%) boys and 134 (36%) girls] differs from that in community: ADHD—16.6% (highest prevalence), autism spectrum disorders—15.5%, depression—12%, dissociative disorders—8.8%, bipolar disorder—4.2% and psychoses—4%. 284 (75%) of children evaluated in the clinic have at least one abnormal psychosocial situation. Physical abuse and the presence of parental psychopathology are significantly associated with psychiatric morbidity. Conclusions: Prevalence rates of CAP morbidity in India are lower than Western figures. With our total population figures, the absolute numbers with psychiatric morbidity would be very large. We discuss the implications for manpower training, practice, awareness building and policy initiatives.

Background and objectives: India has the world's highest population density and growth, with children constituting almost 37% of the population. There are very few studies on epidemiology of childhood psychiatric disorders in India and these are mostly limited to prevalence, varying widely in their methodology. The main objective of this paper is to review what is known of the extent and nature of psychiatric disorders in school children in a defined geographical area and their psychosocial correlates. Methods: We report on two epidemiological research projects using standardized instruments and detailed psychiatric assessments. These studies were carried out between 1995-2006 in a representative sample pool of school children in North India who were aged 4-11 at the time of the initial assessment. The 186 children out of the sample who had no disorder at initial assessment were followed up 6 years later using standardized instruments and detailed psychiatric assessments. Results: In the first study, a prevalence rate of 6.33% was found. In the second study, 20 children out of 186 with no disorder at the time of the initial study had a psychiatric disorder at the time of follow-up. The annual incidence rate of disorder for this representative sample of school children was calculated as 18/1000/yr. Children who had disorder at follow-up did not differ from those who did not on age, gender and psychological (temperament, parental handling, life stress and IQ) parameters at baseline. Sixty percent of the new onset disorders were conditions generally considered adult psychiatric disorders (anxiety, depression, personality disorders). Conclusions: The prevalence and incidence rates found in these studies are lower than those reported in developed countries, and further clarification of the reasons for this finding is needed. Studies like these represent important steps in the development of training, service and research programs in developing countries like India.

Goals: In 2012 a harrowing report into the deaths of children in State care in Ireland was published. This confirmed the already well-established view of these children as physically and emotionally vulnerable. This study aimed to look at the training levels and need of social workers working within the child protection and social services system. Methods: This paper reports on a study examining the level of training in mental health in a cohort of 92 social workers in a Dublin area, most of whom were employed in child protection and social services posts. All participants had completed third level or university/college education in areas closely related to the care sector. A subgroup attended and evaluated a training workshop on mental health issues. Results: Nearly half (49.1%) of those responding to the survey reported no prior mental health training. The most requested topics for training included specific MH disorders and issues related to various kinds of child abuse and neglect. They also wanted training in multidisciplinary team working, play therapy and managing separation and access. Conclusions: We make recommendations to address the perceived deficits. The recognition of higher rates of mental health problems in these children emphasise the importance of adequate training in mental health for personnel working with children in care, and easy access to mental health services.

Background: Pediatric health care providers are in an ideal position to recognize and respond to early symptoms of child mental health disorders. However, pediatric services in Nigeria have little or no mental health component. In order to promote Child and Adolescent Mental Health (CAMH) programs attempts must first be made to determine the views of providers regarding the need for CAMH training. Methods: A cross-sectional descriptive study was carried out in Lagos, Nigeria. Health care providers involved in the care of children in government and private institutions were surveyed using a 21 item questionnaire. Standard descriptive statistics were employed in analysis of the data. Results: One hundred and thirty three surveys were completed, for a response rate of 88.6%. Respondents included nurses (26.5%) and doctors (73.4%), in the following specialties: pediatrics (62.4%), family medicine (18.0%), psychiatry (9.8%) pediatric surgery (9.0%), and dentistry (0.8%). 98.4% treat children and adolescents and 58.9% of the entire sample reported feeling incompetent in CAMH issues. 90.9% felt CAMH training was necessary for health care providers involved in the care of children and 94.7% of participants expressed interest in CAMH workshops/training programs. Conclusions: To the authors' knowledge, this is the first study of this nature within a region in Nigeria to explore CAMH needs of health care providers who work with children and it reveals a significant need for increased CAMH training and willingness of providers to participate in CAMH training initiatives.

Objectives: Youth suicide is a major social and health problem world-wide. Over the last decade Turkey has become a regional power with growing regional aspirations with a young population and rapidly growing economy. The limited literature on Turkish youth suggests that suicidality is a growing challenge for Turkish youth. This study aims to examine the prevalence and risk factors of suicidal ideation amongst Turkish youth in Istanbul, its main metropolitan center. Methods: This study analyzed responses from 31,272 students, consisting of 20 percent of the total high school (HS) student population of Istanbul. The main survey instrument was a combination of the ESPAD 2007 survey and the Youth in Europe 2012 survey, examining risk factors commonly reported in the literature. Results: Our findings indicate a prevalence of one week suicidal ideation of 25.77 %, with depression, anxiety, selfesteem, anomie, irritability, "antisocial" behavior, peer influence, and illicit substances identified as associate risk factors. Other contextual factors were significant in different student sub-groups. Conclusions: To our knowledge this is the first study with results generalizable to all HS students of Istanbul and confirms findings of similar studies with other populations of Turkish youth as well as other nations.