Andrés Martin, MD, MPH

SPECIAL REPORT: MINORITY MENTAL HEALTH PART 1

According to the 2019 US Census Bureau population estimate, Hispanics comprise 18% of the total US population (61 million), with 31% aged less than 18 years, making them the nation’s largest and youngest racial and ethnic group.

 Since more than half of mental health disorders begin by age 14 years, and 75% by age 24 years,

 the role of culturally humble, curious, and attuned child and adolescent mental health professionals is critical.

Although we will use the terms Latino/Latina/Latinx and Hispanic interchangeably, there are distinctions between them: “Hispanic” refers to a common language and describes those whose ancestry derives from Spain or Spanish-speaking countries; “Latino/Latina,” most recently replaced by the gender-neutral alternative “Latinx,” refers to geography and indicates a Latin American origin.

 The federal government recognizes just 1 ethnic group in its classification system: according to the 2010 and 2020 Census, “Hispanic or Latino” is defined as “a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.”

 This one-size-fits-all definition of “Hispanic or Latino” and collective labeling of several self-sustained ethnicities can lead to overgeneralizations, misconceptions, and stereotyping of the diverse 

. The prevalence and clinical presentation of mental illness, the willingness to seek and accept care, and lived experiences can vary significantly among Latinx subgroups. Given this heterogeneity, clinicians should embrace such diversity, recognizing the clinical importance of providing respectful subgroup-specific care (

 Keys to Clinical Humility and Cultural Awareness

Latinx individuals often face inequities in education, socioeconomic status, insurance coverage, and even risk of death related to police intervention. Unfortunately, disparities are further exacerbated among Hispanics due to language barriers and undocumented immigration status. Patients with limited English proficiency or English as a second language struggle during mental health visits; communication of abstract concepts such as emotions and psychiatric symptoms in a language other than one’s mother tongue is extremely challenging, especially during times of internal distress.

According to the US Census Bureau, Hispanics on average hold a lower educational level in the United States compared with other racial and ethnic groups.

 Hispanics also have the highest uninsured rates of any 

 within the United States (19% of the Hispanic population was not covered by health insurance vs 6% of the non-Hispanic White population).

 Similarly, the unemployment rate and the percentage of individuals living at or below the poverty level are higher for Hispanics as compared with non-Hispanic Whites.

Further compounding such disparities, food insecurity is associated with a heightened risk of past-year mood, anxiety, and substance use disorders in children.

 Poverty and mental illness interact in a negative cycle: Individuals who live in poverty are at increased risk of mental illness and, in turn, there is an increased likelihood that those living with mental illness will drift into or remain in poverty.

Hispanics have the highest prevalence 17% of type 2 diabetes in the countryat 17%; for non-Hispanic Whites, the prevalence is 8%.

 Diabetes is also increasingly recognized as a risk factor for serious mental illness, depression being twice as high in individuals with type 1 or type 2 diabetes compared with the general population.

 However, given the diversity within Latinx/Hispanics, it is not surprising that the rates of illness can also vary significantly within subgroups. For example, Puerto Ricans are twice as likely as someone whose background is South American to develop type 2 diabetes

; Puerto Ricans also suffer disproportionately from asthma, HIV-AIDS, and infant mortality.

Asian American Mental Health: Treating a Diverse Population at a Crossroads

Geoffrey Z. Liu, MD; Margaret Cheng Tuttle, MD

According to a 2019 US Census Bureau report, 24% of Hispanics, in comparison with 15% of non-Hispanic Whites, worked within service occupations; 24% and 45%, respectively, worked in managerial or professional occupations.

 These differences in occupations explain in part why Latinx parents have difficulties accessing medical care for themselves and their children: Hispanics are more likely to work in jobs that do not provide paid time off; at other times, they do not request sick leave due to fear of, or threats of, deportation by employers. Communication and language barriers, cultural differences between patients and providers, and 

 in health care systems are other factors affecting access to health care, especially psychiatric care.

, 111 children have died by police use of force in the United States over the past 6 years; 22 of those children were aged less than 16 years, and three-quarters of these 22 were children of color.

 One of those children was Adam Toledo, a Latinx 13-year-old boy who, although unarmed, was shot and killed by police in Chicago after an officer believed the boy was holding a weapon. A recent study published in Pediatrics found that Black and Hispanic adolescents are significantly more likely to die from shootings related to police intervention compared with non-Hispanic White adolescents.

 Compared with non-Hispanic White children, Hispanic children had a risk of death due to legal intervention almost 3 times higher. These disparities are clear and unacceptable, and they should alarm clinicians, especially those caring for children and adolescents of color.

These data are not only heartbreaking but point to inescapable effects on the mental health, physical health, well-being, and overall future of the family members left behind. The death of a young Latinx male, often the primary breadwinner for immigrant or first-generation families, leaves a void within the family system and the overall community. The offspring of the young victim grow up without a male role model, directly affecting the overall sense of safety offered by a tight-knit family. It also leads to the need for single mothers to take multiple jobs to make ends meet, causing a rupture in the family system, with older siblings often taking the role of primary caretakers for younger siblings, in turn increasing the likelihood of dropping out of high school and decreasing the likelihood of college attendance; lower levels of educational attainment limit future job options and lead to lower-paying or less stable jobs.

The alarming frequency of young Black and Hispanic individuals’ deaths by gunshot wounds during police encounters have a wide-ranging impact on the entire community, exacerbating feelings of 

hopelessness, oppression, discrimination, and distrust in the legal system

. In our clinical experience this, in turn, can have the unwanted effect of further alienating communities of color from medical and political systems that are often viewed as complicit, leading to fewer medical check-ups, less openness to seek medical or psychiatric attention when needed, and even less likelihood to vote, further perpetuating the cycle of discrimination and isolation for generations to come. Research has shown that police violence can take a toll on the mental health of communities; police brutality and killings can be associated with greater risks of distress and 

The year 2020 saw 2 major cultural phenomena: the COVID-19 pandemic, and a resurgence of the conversation around racial equity and structural racism in the United States.

 The synergistic nature of the health and social problems facing people of color, as well as the toxic stress resulting from racial and social inequities, have been magnified during the pandemic, bringing to the forefront disparities in access to care among Latinx communities.

According to data gathered through March 2021, Latinx Americans had experienced 18% of COVID-19–related deaths in people of known race.

 Latinx individuals were held in precarious and at times inhumane conditions in US Immigration and Customs Enforcement (ICE) detention facilities, and individuals in ICE facilities had rates of SARS-CoV-2 infection that were 6 to 22 times higher per month than those of the general population between April and August 2020.15 Children and families in immigration detention settings and those 

 and living in shelters endured similarly disproportionate risk of exposure.

Latinx youth and their families have been impacted severely by COVID-19, with Centers for Disease Control and Prevention (CDC) data showing disproportionate hospitalization rates (more than 3 times higher compared with non-Latinx Whites), and death rates that are more than twice as high.

 Latinx children had higher pediatric case rates, hospitalizations, and virus-related complications.

 among Latinx children worsened health care access and exacerbated gaps in educational attainment, especially throughout the multiple lockdowns and in-person school cancellations during the COVID-19 pandemic.

Health care barriers, including lack of insurance and immigration fears, have also contributed to the worsening of preexisting health conditions (eg, asthma, diabetes) and delays in COVID-19 treatment during acute illness and for aftercare.

 In addition, Latinx individuals, especially undocumented immigrants, have limited job options, do not have paid sick days, and often endure unhealthy work environments in which employers use threats or fear of deportation to their advantage. When they do get sick or are symptomatic, they continue working, increasing their own risk of worse outcomes from COVID-19 and potentially spreading the virus among coworkers.

Adding insult to injury, there is a large gap in COVID-19 vaccination rates for Hispanics. Black and Hispanic individuals have received a smaller share of vaccinations in proportion to the cases and deaths in their populations, and, in most states, in proportion to total population. Across 42 states, the percentage of the White population that has received at least 1 

 dose (39%) was roughly 1.5 times higher than the rate for Black (25%) and Hispanic individuals (27%) as of May 3, 2021.

The American Academy of Pediatrics published “The Impact of Racism on Child and Adolescent Health” in August 2019. This policy statement, endorsed by both the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association, states that “racism, which is mediated through implicit and explicit biases, institutional structures, and interpersonal relationships, is a social determinant of health that undermines health equity for all children, adolescents, emerging adults, and their families.”

 The race-based traumatic stress theory suggests that some racial and ethnic minority individuals may experience racial or ethnic discrimination as a psychological trauma, as it may elicit a response comparable with posttraumatic stress.

 These experiences of racial or ethnic discrimination include threats of harm and injury, humiliating and shaming events, and witnessing harm to other people of color due to real or perceived racism.

Experiences of marginalization and discrimination have led to chronic and toxic stress, and they have shaped social and economic factors affecting the health and well-being of Latinx communities. Maladaptive reactions to racial and ethnic discrimination through use of avoidant or passive coping strategies may render minority groups, particularly youth, more vulnerable to negative mental health outcomes, including posttraumatic stress and dissociative symptoms. Flores et al found that Mexican American adolescents who reported racial discrimination also reported more 

, and in turn, greater drug and alcohol use—a common avoidant coping strategy evident in trauma-exposed individuals.

 Factors including a strong racial/ethnic identity, ethnic/racial socialization within family, and religiosity/spirituality have shown to be protective against the damaging effects of racial and ethnic adversity.

Historical bias, lack of culturally humble and aware providers, inadequate or misinformed care, fear of deportation, language barriers, and underrepresentation of Latinx child psychiatrists are just a few of the factors that exacerbate disparities in access to care among Latinx communities. Clinicians should use a cultural component in their formulation when conceptualizing clinical presentations, thinking ethnographically while remaining patient-centered so that patients and families can teach providers about their own culture. Clinicians should not shy away from asking patients about experiences they have had in facing racism, discrimination, or hierarchical mistreatment. An understanding of patients’ sociocultural background, including experiences of discrimination and racial/ethnic trauma, will have important effects on treatment adherence and the likelihood of seeking future care.

 Recommendations to Alleviate Health Care Disparities Among Latinx Communities

We should continue working to address existing socioeconomic, health care, and structural inequities, which place so many children and families at risk of poor outcomes (

). Health interventions that consider the nuances of race, ethnicity, culture, and community differences, provided by self-aware and culturally humble clinicians, have a vital role in reducing health disparities, promoting health equity, increasing trust in systems of care, and improving both the physical and mental health of Latinx children, adolescents, and families.

 is a board-certified adult and child/adolescent psychiatrist. She is an instructor in psychiatry at Harvard Medical School and an attending at the Massachusetts General Hospital Chelsea Health Center. She also has a small private practice in Boston. 

 is the Riva Ariella Ritvo Professor in the Child Study Center and director of the Standardized Patient Program, Teaching and Learning Center, both at the Yale School of Medicine. He is also medical director of the Children’s Psychiatric Inpatient Service at Yale-New Haven Hospital. Dr Martin served as editor-in-chief of the 

Journal of the American Academy of Child and Adolescent Psychiatry

1. Profile: Hispanic/Latino Americans. US Department of Health and Human Services, Office of Minority Health. April 5, 2021. Accessed June 2, 2021. 

https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64

2. Al-Mateen CS, Parekh R, Lisotto MJ, Carter RD. Introduction to cultural psychiatry. In: Parekh R, Al-Mateen CS, Lisotto MJ, Carter RD, eds. 

Cultural Psychiatry with Children, Adolescents, and Families, 1st ed.

 American Psychiatric Association Publishing; 2021:1-20.

3. Lisotto MJ, Fortuna LR, Martin A. Bridging the gap in psychiatric care of Latinx youth and families. In: Parekh R, Al-Mateen CS, Lisotto MJ, Carter RD, eds. 

Cultural Psychiatry with Children, Adolescents, and Families, 1st ed. 

American Psychiatric Association Publishing; 2021:71-92.

4. About Hispanic origin. United States Census Bureau. Updated October 16, 2020. Accessed April 20, 2021. 

https://www.census.gov/topics/population/hispanic-origin/about.html

Impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review.

6. U.S. Census Bureau releases new educational attainment data. News release. United States Census Bureau; March 30, 2020. Accessed April 29, 2021. 

https://www.census.gov/newsroom/press-releases/2020/educational-attainment.html

7. McLaughlin KA, Greif Green J, Alegría M, et al. 

Food insecurity and mental disorders in a national sample of US adolescents.

8. Lund C, De Silva M, Plagerson S, et al. 

Poverty and mental disorders: breaking the cycle in low-income and middle-income countries.

9. Hispanic/Latino Americans and type 2 diabetes. CDC. Updated April 7, 2021. Accessed uly 1, 2021. 

https://www.cdc.gov/diabetes/library/features/hispanic-diabetes.html

The mental health comorbidities of diabetes.

11. Tate J, Jenkins J, Rich S. Fatal force: police shootings database 2015-2021. 

. Updated May 29, 2021. Accessed June 2, 2021. 

https://www.washingtonpost.com/graphics/investigations/police-shootings-database/

12. Badolato GM, Boyle MD, McCarter R, et al. 

Racial and ethnic disparities in firearm-related pediatric deaths related to legal intervention.

Impact of police violence on mental health: a theoretical framework.

14. APM Research Lab Staff. Color of coronavirus: COVID-19 deaths analyzed by race and ethnicity in the U.S. APM Research Lab. March 5, 2021. Accessed June 2, 2021. 

https://www.apmresearchlab.org/covid/deaths-by-race

COVID-19 testing and cases in immigration detention centers, April-August 2020. 

16. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. CDC. Updated May 26, 2021. Accessed June 2, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html

17. Aguilera E. The virus and the vulnerable: Latino children suffer higher rates of COVID-19. CalMatters. July 7, 2020. Accessed June 2, 2021. 

https://calmatters.org/children-and-youth/2020/07/the-virus-and-the-vulnerable-latino-children-suffer-higher-rates-of-covid-19

18. García E, Weiss E. COVID-19 and student performance, equity, and U.S. education policy: lessons from pre-pandemic research to inform relief, recovery, and rebuilding. Economic Policy Institute. September 10, 2020. Accessed June 21, 2021. 

https://www.epi.org/publication/the-consequences-of-the-covid-19-pandemic-for-education-performance-and-equity-in-the-united-states-what-can-we-learn-from-pre-pandemic-research-to-inform-relief-recovery-and-rebuilding/

19. Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations race/ethnicity. Kaiser Family Foundation. Updated June 30, 2021. AccessedJuly 1, 2021. 

https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity/

20. Trent M, Dooley DG, Dougé J; Section on Adolescent Health; Council on Community Pediatrics; Committee on Adolescence. 

The impact of racism on child and adolescent health. 

Racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress.

22. Flores E, Tschann JM, Dimas JM, et al. 

Perceived racial/ethnic discrimination, posttraumatic stress symptoms, and health risk behaviors among Mexican American adolescents.

23. Neblett EW Jr, Rivas-Drake D, Umaña-Taylor AJ. 

The promise of racial and ethnic protective factors in promoting ethnic minority youth development.

Articles

Understanding a patient's sociocultural background will have an important effect on treatment, especially for Hispanic patients. 

Reconceptualizing Hispanics in America: From Reading Stark Statistics to Confronting Racial and Ethnic Trauma

Anxiety disorders are the most common mental conditions in the general population, including in children and adolescents. Young people can present with a pattern of anxiety symptoms somewhat different from that typically seen in adults. One of the most common aspects of this difference is that children (especially younger ones) may not report overt worries or fears, but instead manifest pronounced physical symptoms.

Separation anxiety consists of excessive difficulties or protests about leaving home and loved ones, particularly parents. It usually will present in a pediatric office with school refusal or a wide variety of somatic complaints. It is helpful to obtain an early separation history, including whether the child could be left with relatives or other caretakers, and what early preschool or kindergarten separations were like. Sunday night and Monday morning "illnesses" are common telltale signs in these children, who often feel fine on Fridays and weekends. These children have a very difficult time going back to school after holiday breaks and especially after summer vacations.

Treatment usually consists of a behavior program set up in conjunction with parents, whereby the child is positively reinforced for tolerating progressively longer separations from their parents. Family and individual therapy are often utilized, but the evidence for their superiority over routine supportive therapy is not conclusive. There is robust evidence for the use of fluoxetine (Prozac) in the short-term treatment of anxiety disorders (separation anxiety disorder, generalized anxiety disorder and/or social phobia) (Birmaher et al., 2003; Varley and Smith, 2003). A listing of various anxiety disorders and their pharmacological treatments is given in the 

Specific phobias are marked by persistent fears that are excessive or unreasonable in reaction to specific objects or situations. They constitute the most common forms of anxiety disorders. An element common to all successful treatments for a specific phobia is persuading the patient to confront the phobic object or situation: the patient who fears flying must fly; the patient who fears closed spaces must spend time in them. The key is developing an appropriate set of graded exposure exercises and ensuring the patient's compliance with them.

Treatment is straightforward with easily manipulated phobic objects (e.g., dogs, snakes, spiders, heights, driving) and somewhat more challenging, but still quite feasible, with less easily controlled phobic cues (e.g., airplanes, storms). Traditionally, systematic desensitization has been employed, and there is now evidence that computer-generated virtual-reality exposure may also be effective. Recently, cognitive therapy has been successfully employed for specific phobias, which may be comparable in effectiveness to desensitization. Graduated in vivo exposure in combination with contingency management and self-control strategies appear to be the most promising treatment approaches to date. Drug treatment of specific phobia has not been extensively studied. In general, behavioral techniques are the first-line therapeutic intervention for most simple phobias.

 Selective mutism is the failure of the child to speak in social situations when the child has the capacity to speak and in the absence of an underlying language problem. Onset is typically in childhood. In a familiar setting, and in the company of familiar adults or family, the child may speak normally. In contrast, the child may be silent at school or other public settings. These youths are often painfully shy. The disorder cannot otherwise be explained by a developmental abnormality. There is a high rate of multiple anxiety disorders in the families of these youths. Behavior therapy appears effective, and treatment with fluoxetine seems modestly effective (Varley and Smith, 2003).

 Although panic disorder (PD) was thought to be rare in children and adolescents, the prevalence in community samples ranges between 0.5% and 5.0%, and in pediatric psychiatric clinics from 0.2% to as much as 10%. Psychoeducation and psychosocial treatments are recommended, and it appears that selective serotonin reuptake inhibitors are a safe and promising treatment for children and adolescents with PD.

One study tested the hypotheses that offspring of parents with panic disorder and offspring with anxiety disorders display relatively greater sensitivity and attention allocation to fear provocation (Pine et al., 2005). Results supported an association between parental panic disorder and offspring responses to fear provocation using computer-generated face viewing.

Agoraphobia, the fear of open or public places, is related to panic disorder and often is experienced as a fear of leaving the home. Agoraphobia is understood as developing in response to the fear of having a panic attack in a public place, or as having anxiety about being in places and situations from which escape might be difficult or embarrassing. Although agoraphobia can occur alone, it most often occurs in the presence of panic disorder (Varley and Smith, 2003).

 Social phobia is manifested by a marked and persistent fear in one or more interpersonal or performance situations. This may be manifest as fear of rejection by peers, fear of public speaking or inability to use a public restroom. It is understood to be situationally bound to a social context. Medication (particularly the SSRIs) appears effective in treating social phobia over the short and long term, although this has yet to be established definitively in a pediatric population.

 The Pediatric OCD Treatment Study (POTS) Team (2004) epidemiological data suggest that approximately one in 200 young people have obsessive-compulsive disorder (OCD). It may occur at any point throughout the life span. It can severely disrupt academic, social and vocational functioning. Among adults with OCD, one-third to one-half developed the disorder during childhood or adolescence, which suggests that early intervention may prevent long-term morbidity. The efficacy of pharmacotherapy with a serotonin reuptake inhibitor for pediatric OCD has been established for clomipramine (Anafranil), fluvoxamine (Luvox), sertraline (Zoloft) and fluoxetine. The pediatric literature is consistent with the adult literature in revealing a 30% to 40% reduction in OCD symptoms with pharmacotherapy, which still leaves the majority of patients who respond to medication management with clinically significant residual symptoms (POTS, 2004).

Prospective open-label studies also suggest the potential usefulness of cognitive-behavioral therapy (CBT) for pediatric OCD. One direct comparison of CBT versus clomipramine for pediatric OCD found an advantage for CBT. The results of the POTS (2004) study indicated that children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor or with CBT alone. In a study examining the efficacy of group cognitive-behavioral therapy (GCBT) versus the use of sertraline in treatment-naive children and adolescents with OCD, it was found that GCBT may be effective in decreasing symptoms and should be considered as an alternative to either individual CBT or to medication such as sertraline (POTS, 2004).

Posttraumatic stress disorder/acute distress disorder.

 Posttraumatic stress disorder (PTSD) and acute stress disorder are a constellation of signs and symptoms that derive from extreme experiences that were actual or perceived threats of death or serious injury, either to oneself or to others. There is little empirical support for the use of pharmacotherapy in pediatric PTSD, consisting mostly of small case series or open trials.

For example, an open-label trial reported the use of transdermal clonidine (Catapres) as being effective for alleviating seven patients' symptoms, with the main adverse events being skin irritation and rebound hypertension. Similarly, relatively low doses of oral clonidine also have been shown to diminish hyperarousal and impulsivity symptoms in children and adolescents (De Bellis and Van Dillen, 2005). Guanfacine was reported as being helpful in a case report when used to treat nightmares of a 7-year-old patient (De Bellis and Van Dillen, 2005). The SSRIs frequently are used in children with PTSD, based on extrapolation from adult evidence. For example, citalopram (Celexa) was useful over eight weeks of open treatment (De Bellis and Van Dillen, 2005). The SSRIs also may be useful in youths with PTSD symptoms and comorbid depressive or panic symptoms. There is limited evidence to support the use of atypical antipsychotic agents in cases of pediatric PTSD (De Bellis and Van Dillen, 2005).

 Hallmark symptoms of GAD are broad-based and center on excessive worry and feelings that are difficult to control. The focus of the anxiety and worry is not as specific as in other anxiety disorders. Although studies have documented the safety and efficacy of benzodiazepines in adults, few studies have been conducted in the pediatric age group children with ADHD and comorbid anxiety (separation anxiety disorder, generalized anxiety disorder and/or social phobia) have a response rate to stimulants for ADHD that is comparable with that of children with general ADHD. The benefit of adding fluvoxamine to stimulants for anxiety remains unproven (Abikoff et al., 2005; RUPP Study Group, 2001; Walkup et al., 2002)

In a study done to assess the efficacy of and tolerability of fluoxetine for the acute treatment of children and adolescents with generalized anxiety disorder, separation anxiety disorder and/or social phobia, the authors found fluoxetine to be useful and well tolerated for the acute treatment of anxious youths (Birmaher et al., 2003). Often considered to have a mild side effect profile, an open trial of buspirone (BuSpar) in prepubertal children hospitalized with anxiety and aggression (n=25) documented agitation and manic symptoms in a significant number of treated subjects. The efficacy of the SSRIs and scant data supporting the use of buspirone argue against its use in pediatric anxiety (Reinblatt and Walkup, 2005).

Considerable advances have been made in the assessment and treatment of pediatric anxiety disorders. Strong relationships exist between pediatric anxiety disorders and various manifestations of adult psychopathology. Many of these disorders share a common thread and represent a developmental condition characterized by high levels of fear and apprehension. Despite the similarities of these varied disorders, advances in neuroscience will likely continue to assist in differentiating their unique symptom profiles and associated features. One area of research focuses on the amygdala and its role in aberrant processing of emotional information (Easter et al., 2005). There is a pressing need for better treatments for these often impairing conditions, and for comparison and combination studies of those currently available modalities that have proven effective.

Abikoff H, McGough J, Vitello B et al. (2005), Sequential pharmacotherapy for children with comorbid attention-deficit/hyperactivity and anxiety disorders. J Am Acad Child Adolesc Psychiatry 44(5):418-427.
 

Birmaher B, Axelson DA, Monk K et al. (2003), Fluoxetine for the treatment of childhood anxiety disorders: J Am Acad Child Adolesc Psychiatry 42(4):415-423.
 

De Bellis MD, Van Dillen T (2005), Childhood post-traumatic stress disorder: an overview. Child Adolesc Psychiatr Clin N Am 14(4):745-772.
 

Easter J, McClure EB, Monk CS et al. (2005), Emotion recognition deficits in pediatric anxiety disorders: implications for amygdala research. J Child Adolesc Psychopharmacol 15(4):563-570.
 

Pine DS, Klein RG, Mannuzza S et al. (2005), Face-emotion processing in offspring at risk for panic disorder. J Am Acad Child Adolesc Psychiatry 44(7):664-672.
 

Pediatric OCD Treatment Study (POTS) Team (2004), Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 292(16):1969-1976.
 

Reinblatt SP, Walkup JT (2005), Psychopharmacologic treatment of pediatric anxiety disorders. Child Adolesc Psychiatr Clin N Am 14(4):877-908.
 

Research Unit on Pediatric Psychopharmacology (RUPP) Anxiety Study Group (2001), Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 344(17):1279-1285 [see comments].
 

Varley CK, Smith CJ (2003), Anxiety disorders in the child and teen. Pediatr Clin North Am 50(5)1107-1138.
 

Walkup J, Labellarte M, Riddle MA et al. (2002), Treatment of pediatric anxiety disorders: an open-label extension of the research units on pediatric psychopharmacology anxiety study. J Child Adolesc Psychopharmacol 12(3):175-188.

Andrés Martin, MD, MPH

Articles

Reconceptualizing Hispanics in America: From Reading Stark Statistics to Confronting Racial and Ethnic Trauma

Understanding Anxiety Disorders in Children and Adolescents: Brief Overview and Update