The onset of psychiatric illness in a child is a life-changing event for families. Families from immigrant and ethnocultural communities often must come to an understanding of their child’s psychiatric difficulties while simultaneously interacting with an unfamiliar health care system and its practitioners.
In this article, we address clinical approaches to the assessment, management, and treatment of mental health difficulties of children and adolescents from immigrant and ethnocultural communities.
Cultural issues in assessment and treatment planning
Psychosocial stressors and exposure to trauma contribute significantly to the experiences of families from immigrant and ethnocultural communities. Some families may have experienced organized violence before immigration and are now exposed to violence, racism, and economic difficulties.1-5 The trust and collaboration that are fostered in the therapeutic milieu can help address and buffer the effects of discrimination and ethnic and racial profiling that are often experienced by immigrants.6,7
Address language barriers
Families who speak a language other than the dominant language of the health care system should be offered an interpreter. Interpreters facilitate the clinical encounter and, in some cases, act as cultural brokers and contribute to the diagnostic process assisting the clinical formulation by reframing or transmitting essential elements of cultural knowledge.8
Avoid asking children and family members to act as interpreters because this can contribute to biased assessments and introduce power imbalances among family members. For example, family members may not wish to disclose sensitive information to relatives who are acting as translators; as a result, this information may not be transmitted during the assessment. Asking children or spouses to act as interpreters can also give them a privileged avenue of communication during assessments, with power to decide what information is transmitted. This can reinforce problematic power relationships (ie, children having more power than their parents or one spouse having more power than the other).
Recognize shifting cultural identities
Family members may have multiple cultural identities that shift over time. The fluidity of culture and acculturation processes needs to be acknowledged. Bicultural and hybrid identities are dynamic elements that shift during child development and across generations, and they need to be explored.9,10 Identity issues are best explored through inquiry and addressing our preconceived ideas about the values and experiences of families and children of a particular culture.
Establish a therapeutic alliance
While it is possible that patients have had discriminatory or traumatic experiences, an alliance and the safety of the therapeutic space need to be established before these variables are explored. Pushing for immediate and detailed disclosure can result in retraumatization or a breakdown in alliance building. Similarly, openness to traditional healing strategies and explanatory models of illness should be encouraged; note, though, that these explorations are more likely to be successful after a trusting relationship with the clinician is established.
Recognize differences in cultural values and norms
Psychiatric assessment is influenced by multiple cultural references, in that children, family members, and practitioners may bring divergent values, developmental frameworks, and viewpoints to defining problems.
People from different societies may have differing ideas about what level of hyperactive-disruptive behaviors is considered unacceptable. Such differences affect decisions about what course of action should be taken.11 For example, in a research study carried out in Lebanon, parents were presented with vignettes of children with attention-deficit/hyperactivity disorder hyperactive/impulsive-type symptoms.12 Some parents described the children as “dammo hammy,” which translated to “hot-blooded” with a rather positive meaning of masculinity.
The Table cites factors that need to be considered in the assessment of cultural issues and suggests how these factors influence treatment. Each cultural reference can provide a framework or pathway to make sense of the difficulties faced by children and adolescents with mental health problems and their families. Such a framework includes families and social networks that contribute to the clinician’s understanding of the underlying concerns and cultural differences with the aim of optimizing treatment strategies.
For example, families may believe that a psychotic disorder in a child has both a medical cause and a spiritual cause. Treatment might include medication as well as traditional healing. In some instances, our clinic staff has met families who have consulted traditional healers who believe the psychosis is a curse. Such healers may invite family members to pray on a youngster’s behalf, thus mobilizing support within the family.
Keep an open mind
The exploration of cultural references in clinical encounters requires a clinical openness. The clinician must have the capacity to reflect on how others see him or her and to be open to seeing himself as a tool in the therapeutic work.13
1. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365:1309-1314.
2. Rousseau C, Drapeau A. Mental health, chapter 11. In: Health and Wellness, Recent Immigrants to Quebec: A Mutual Adaptation? Report of a Study With Cultural Communities 1998-1999. Montréal: Les Publications du Québec; 2002:211-245.
3. Jaycox LH, Stein BD, Kataoka SH, et al. Violence exposure, post traumatic stress disorder, and depressive symptoms among recent immigrant schoolchildren. J Am Acad Child Adolesc Psychiatry. 2002;41:1104-1110.
4. Gunew SM. Haunted Nations: The Colonial Dimensions of Multiculturalism. New York: Routledge; 2003.
5. Beiser M, Hou F, Hyman I, Tousignant M. Poverty, family process, and the mental health of immigrant children in Canada. Am J Public Health. 2002;92:220-227.
6. Hassan G, Rousseau C. Protecting children: issues of intervention in intercultural context. L’ARIC Bull. 2008;37:37-50.
7. Rousseau C, Hassan G, Measham T, et al. From the family universe to the outside world: family relations, school attitude, and perception of racism in Caribbean and Filipino adolescents. Health Place. 2009;15:721-730.
8. Hsieh E. Interpreters as co-diagnosticians: overlapping roles and services between providers and interpreters. Soc Sci Med. 2007;64:924-937.
9. Bibeau G. Cultural psychiatry in a creolizing world: questions for a new research agenda. Transcult Psychiatry. 1997;34:9-41.
10. Nadeau L, Measham T. Immigrants and mental health services: increasing collaboration with other service providers. Can Child Adolesc Psychiatr Rev. 2005;14:73-76.
11. Rousseau C, Measham T, Bathiche-Suidan M. DSM-IV, culture and child psychiatry. J Can Acad Child Adolesc Psychiatry. 2008;17:69-75.
12. Bathiche M. The Prevalence of ADHD Symptoms in a Culturally Diverse and Developing Country: Lebanon. Montreal: McGill University; 2008.
13. Kirmayer LJ, Rousseau C, Jarvis GE, et al. The cultural context of clinical assessment. In: Tasman A, Lieberman J, Kay J, eds. Psychiatry. New York: John Wiley & Sons; 2003:19-29.
14. Ecklund K, Johnson WB. Toward cultural competence in child intake assessments. Professional Psychol Res Pract. 2007;38:356-362.
15. Novins DK, Bechtold DW, Sack WH, et al. The DSM-IV outline for cultural formulation: a critical demonstration with American Indian children. J Am Acad Child Adolesc Psychiatry. 1997;36:1244-1251.
16. Shatter TG, Steiner H. An application of DSM-IV’s outline for cultural formulation: understanding conduct disorder in Latino adolescents. Aggress Violent Behav. 2006;11:655-663.
17. Egger HL. Psychiatric assessment of young children. Child Adolesc Psychiatr Clin N Am. 2009;18:559-580.
18. Green J, Howes F, Waters E, et al. Promoting the social and emotional health of primary school-aged children: reviewing the evidence for school-based interventions. Int J Ment Health Promo. 2005;7:30-36.
19. Rousseau C, Guzder J. School-based prevention programs for refugee children. Child Adolesc Psychiatr Clin N Am. 2008;17:533-549.
20. Pautler K, Gagné MA. Annotated bibliography of collaborative mental health care. September 2005. http://www.ccmhi.ca/en/products/documents/03_AnnotatedBibliography_EN.pdf. Accessed December 17, 2009.