Advocacy and Policy: A Focus on Migrant Youth.

Mental health challenges experienced by migrant children are shaped by multiple factors within the health care system and society at large. It is essential for health care providers to recognize the profound impact of these influences on child well-being. By actively engaging in advocacy and policy initiatives, health care providers can address structural barriers, social inequalities, and stigma that perpetuate mental health disparities. Through their advocacy efforts, providers can contribute to creating an inclusive society that upholds children's rights and ensures equitable access to mental health support and services.

Addressing Discrimination Against Asian American and Pacific Islander Youths: The Mental Health Provider's Role.

Asian American and Pacific Islanders (AAPI) are the fastest growing racial minority in the United States. With more than 40 subgroups in the diaspora, 1 in 10 American youths will be of Asian origin by 2060. Racism-defined as prejudice, discrimination or antagonism on the basis of membership in a particular racial or ethnic group-is increasingly recognized as a public health crisis.1 Anti-AAPI racism, such as unequal resource distribution in housing, education, employment, and health care, exclusionary naturalization policies and violence1,2 (eg, Pacific coast riots, Japanese Americans' internment during World War II, recent Atlanta shootings) is well documented. Anti-AAPI microaggressions-that is, the subtle, sometimes unintentional forms of racism such as characterizations as perpetual foreigners, ascriptions of intelligence, oversexualization of women, invalidated interethnic differences, and model minority myth-are common. The model minority stereotype dismisses real struggles1 and pits AAPIs against other racial minorities. Despite the proud tradition of AAPI activism , discrimination is often endured in silence, probably stemming from cultural values of stoicism and harmony, and tacit societal acceptance of racism.3.

Mental health of unaccompanied children: effects of U.S. immigration policies.

BACKGROUND: There is an unprecedented surge of forcibly displaced people globally, with a crisis of unaccompanied minors seeking haven across the US border. AIMS: This paper aims to provide an understanding of the intersection between mental health and immigration policies. METHOD: Examples of contemporary policies that focus on the deterrence, detention and deportation of unaccompanied minors in the USA, will be discussed, as well as the mental health effects of such 'iron triangle' immigration policies. RESULTS: In the ideal circumstances, systems and policies for migrant children would uphold international humanitarian law, hasten the shift from enforcement to protection, adhere to a 'do no (further) harm' model that uses a trauma-informed, culturally responsive approach to engaging with migrant children, engage the community as stakeholders to end detention and advocate to share the burden of responsibility. CONCLUSIONS: Building a humanitarian response that protects both country and migrant interest is possible through commitment and policy change that addresses mental, physical and legal protection needs.

Randomized, Placebo-Controlled Trial of the Angiotensin Receptor Antagonist Losartan for Posttraumatic Stress Disorder.

BACKGROUND: Evidence-based pharmacological treatments for posttraumatic stress disorder (PTSD) are few and of limited efficacy. Previous work suggests that angiotensin type 1 receptor inhibition facilitates fear inhibition and extinction, important for recovery from PTSD. This study tests the efficacy of the angiotensin type 1 receptor antagonist losartan, an antihypertensive drug, repurposed for the treatment of PTSD. METHODS: A randomized controlled trial was conducted for 10 weeks in 149 men and women meeting DSM-5 PTSD criteria. Losartan (vs. placebo) was flexibly titrated from 25 to 100 mg/day by week 6 and held at highest tolerated dose until week 10. Primary outcome was the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) change score at 10 weeks from baseline. A key secondary outcome was change in CAPS-5 associated with a single nucleotide polymorphism of the ACE gene. Additional secondary outcomes included changes in the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9, and proportion of responders with a Clinical Global Impressions-Improvement scale of "much improved" or "very much improved." RESULTS: Both groups had robust improvement in PTSD symptoms, but there was no significant difference on the primary end point, CAPS-5 measured as week 10 change from baseline, between losartan and placebo (mean change difference, 0.9, 95% confidence interval, -3.2 to 5.0). There was no significant difference in the proportion of Clinical Global Impressions-Improvement scale responders for losartan (58.6%) versus placebo (57.9%), no significant differences in changes in PTSD Checklist for DSM-5 or Patient Health Questionnaire-9, and no association between ACE genotype and CAPS-5 improvement on losartan. CONCLUSIONS: At these doses and durations, there was no significant benefit of losartan compared with placebo for the treatment of PTSD. We discuss implications for failure to determine the benefit of a repurposed drug with strong a priori expectations of success based on preclinical and epidemiological data.

Post-traumatic stress disorder, psychiatric comorbidities and associated factors among refugees in Nakivale camp in southwestern Uganda.

BACKGROUND: Armed conflict in Africa has led to displacement of over 24.2 million people, more than 1.4 million of whom are living in Uganda. Studies show that refugees living in Ugandan refugee settlements are at increased risk for post-traumatic stress disorder. However data on the prevalence of other mental health problems among refugees including depression, anxiety and substance use disorder among refugees in Uganda is lacking. Our aim was to determine the prevalence of post-traumatic stress disorder, its main psychiatric comorbidities and perceived psychosocial needs among refugees in Nakivale refugee camp. METHODS: We conducted a cross-sectional survey of refugee camp residents (n = 387) from nine different countries of origin. Psychiatric disorders were assessed using the MINI International Neuropsychiatric Interview (MINI) and perceived needs by the Humanitarian Emerging Settings Perceived Needs Scale (HESPER). RESULTS: The prevalence of psychiatric disorders was high among refugees as was the level of perceived needs. The most prevalent psychiatric disorders were generalized anxiety disorders (73%), post-traumatic stress disorder (PTSD) (67%), major depressive disorder (58%) and substance use disorders (30%). There was a higher level of comorbidity between PTSD and substance use disorder (OR = 5.13), major depressive disorder (OR = 4.04) and generalized anxiety disorder (OR = 3.27). In multivariate analysis, PTSD was positively associated with the perception of stress as a serious problem (OR = 6.52; P-value = 0.003), safety and protection for women in the community (OR = 2.35; P-value = 0.011), care for family (OR = 2.00; P-value = 0.035) and Place to live in (OR = 1.83; P-value = 0.04). After applying the Bonferroni correction, the perception of stress remained significantly associated with PTSD. CONCLUSION: Our findings suggest a strong association between PTSD, its main comorbidities and basic needs in Nakivale refugee camps. Mental health support should include psychological interventions as well as social assistance to improve the health of refugees.

Growing Up With an Undocumented Parent in America: Psychosocial Adversity in Domestically Residing Immigrant Children.

According to Pew Research Center, 6 to 7 million children are residing in the United States with at least one undocumented parent. The vast majority of these children were born in the United States themselves, and a small minority were born outside America. Even more noteworthy is the longitudinal data that 7% to 9% of all children born in the United States between 2003 and 2014 have at least one undocumented parent. Given the numbers, it is highly likely that all child health care providers will encounter this population clinically. In this Clinical Perspectives article, we start by reviewing general and specific vulnerabilities in this population, and then discuss how child and adolescent psychiatrists can effectively help these children and their families. The majority of data presented herein refers to the US-born children of undocumented immigrants, but some may include foreign-born children of undocumented immigrants residing in America.

Predicting the Mental Health and Functioning of Torture Survivors.

The psychological effects of war represent a growing public health concern as more refugees and asylum seekers migrate across borders. This study investigates whether sociodemographic, premigration and postmigration, and psychosocial factors predict adverse psychiatric symptoms in refugees and asylum seekers exposed to torture (N = 278). Hierarchical linear regressions revealed that female sex, older age, and unstable housing predicted greater severity of anxiety, posttraumatic stress disorder (PTSD), and depression. Cumulative exposure to multiple torture types predicted anxiety and PTSD, while mental health, basic resources (access to food, shelter, medical care), and external risks (risk of being victimized at home, community, work, school) were the strongest psychosocial predictors of anxiety, PTSD, and depression. Also, time spent in the United States before presenting for services significantly predicted anxiety, PTSD, and depression. Consequently, public-sector services should seek to engage this high-risk population immediately upon resettlement into the host country using a mental health stepped care approach.

A mental health needs assessment of children and adolescents in post-conflict Liberia: results from a quantitative key-informant survey.

Between 1989 and 2004, Liberia experienced a devastating civil war that resulted in widespread trauma with almost no mental health infrastructure to help citizens cope. In 2009, the Liberian Ministry of Health and Social Welfare collaborated with researchers from Massachusetts General Hospital to conduct a rapid needs assessment survey in Liberia with local key informants (n = 171) to examine the impact of war and post-war events on emotional and behavioral problems of, functional limitations of, and appropriate treatment settings for Liberian youth aged 5-22. War exposure and post-conflict sexual violence, poverty, infectious disease and parental death negatively impacted youth mental health. Key informants perceived that youth displayed internalizing and externalizing symptoms and mental health-related functional impairment at home, school, work and in relationships. Medical clinics were identified as the most appropriate setting for mental health services. Youth in Liberia continue to endure the harsh social, economic and material conditions of everyday life in a protracted post-conflict state, and have significant mental health needs. Their observed functional impairment due to mental health issues further limited their access to protective factors such as education, employment and positive social relationships. Results from this study informed Liberia's first post-conflict mental health policy.

Child Soldiers: Children Associated with Fighting Forces.

Around the world, there are an estimated 300,000 to 500,000 children involved in armed conflict. Children can be abducted into a fighting force to fight or serve as sex slaves. Child soldiers have depression, anxiety, and posttraumatic stress symptoms; however, evidence is mixed because of methodologic limitations. Various mental health interventions have been tried, with promising results. Child and adolescent psychiatrists are uniquely trained in understanding and assisting youth to heal from such extraordinary experiences. A public health paradigm could include interventions that are based on a comprehensive assessment of interweaving developmental, biological, psychological, and sociocultural factors.

A public health approach to address the mental health burden of youth in situations of political violence and humanitarian emergencies.

This paper describes how socio-ecological theory and a syndemic health systems and public health approach may help address the plight of youth in situations of political violence and humanitarian emergencies. We describe the treatment gap caused by discrepancies in epidemiological prevalence rates, individual and family needs, and available human and material resources. We propose four strategies to develop a participatory public health approach for these youth, based on principles of equity, feasibility, and a balance between prevention and treatment. The first strategy uses ecological and transgenerational resilience as a theoretical framework to facilitate a systems approach to the plight of youth and families. This theoretical base helps to engage health care professionals in a multisectoral analysis and a collaborative public health strategy. The second strategy is to translate pre-program assessment into mental health and psychosocial support (MHPSS) priorities. Defining priorities helps to develop programs and policies that align with preventive and curative interventions in multiple tiers of the public health system. The third is a realistic budgetary framework as a condition for the development of sustainable institutional capacity including a monitoring system. The fourth strategy is to direct research to address the knowledge gap about effective practices for youth mental health in humanitarian settings.

Psychological distress in torture survivors: pre- and post-migration risk factors in a US sample.

PURPOSE: To investigate the relationships between sociodemographic, pre- and post-migration variables with prevalence of psychological distress and global functioning in a heterogeneous sample of torture survivors. METHODS: Clients referred from resettlement agencies via the Office of Refugee Resettlement (ORR) to a community clinic in the United States (N = 278) were interviewed with structured, translated questionnaires. Univariate and multivariate logistic regression analyses determined the associations of sociodemographic, pre-, and post-migration risk factors with posttraumatic stress disorder (PTSD), depression, anxiety, and global functioning. RESULTS: Regression data indicate that length of time between arrival in US and clinical services was significantly associated with PTSD and depression; participants receiving services after 1 year of resettlement were more likely to experience PTSD (adjusted OR = 3.29) and depression (adjusted OR = 4.50) than participants receiving services within 1 year. Anxiety was predicted by female gender (adjusted OR = 3.43), age over 40 years (adjusted OR = 3.12), Muslim religion (adjusted OR = 2.64), and receiving medical services (AOR 3.1). Severely impaired global functioning was associated with female gender (adjusted OR = 2.75) and unstable housing status (adjusted OR = 2.21). CONCLUSION: Findings highlight the importance of examining post-migration variables such as length of time in country prior to receiving services in addition to pre-migration torture history upon relocated torture survivors. Clinicians and policy-makers should be aware of the importance of early mental health screening and intervention on reducing the psychiatric burden associated with torture and forced relocation.

Indero: intergenerational trauma and resilience between Burundian former child soldiers and their children.

Since many former child soldiers are aging and having children of their own, this study aimed to understand how the effects of trauma are passed to the next generation. In this qualitative study, semistructured interviews, focus groups, and observations were conducted with 25 former child soldiers and 15 matched civilian parents. Analysis used a grounded-theory approach. Trauma may be transmitted from former child soldiers to their offspring via (a) the effect on indero (how to raise a child); (b) severe parental emotional distress; and (c) community effects. Incorporating themes of indero values on how to raise children, the effects of parental posttraumatic stress and depressive symptoms on offspring, and the stigma associated with the families of former child soldiers may provide key areas of intervention in mental healing.

Annual Research Review: Resilience and mental health in children and adolescents living in areas of armed conflict--a systematic review of findings in low- and middle-income countries.

BACKGROUND: Researchers focused on mental health of conflict-affected children are increasingly interested in the concept of resilience. Knowledge on resilience may assist in developing interventions aimed at improving positive outcomes or reducing negative outcomes, termed promotive or protective interventions. METHODS: We performed a systematic review of peer-reviewed qualitative and quantitative studies focused on resilience and mental health in children and adolescents affected by armed conflict in low- and middle-income countries. RESULTS: Altogether 53 studies were identified: 15 qualitative and mixed methods studies and 38 quantitative, mostly cross-sectional studies focused on school-aged children and adolescents. Qualitative studies identified variation across socio-cultural settings of relevant resilience outcomes, and report contextually unique processes contributing to such outcomes. Quantitative studies focused on promotive and protective factors at different socio-ecological levels (individual, family-, peer-, school-, and community-levels). Generally, promotive and protective factors showed gender-, symptom-, and phase of conflict-specific effects on mental health outcomes. CONCLUSIONS: Although limited by its predominantly cross-sectional nature and focus on protective outcomes, this body of knowledge supports a perspective of resilience as a complex dynamic process driven by time- and context-dependent variables, rather than the balance between risk- and protective factors with known impacts on mental health. Given the complexity of findings in this population, we conclude that resilience-focused interventions will need to be highly tailored to specific contexts, rather than the application of a universal model that may be expected to have similar effects on mental health across contexts.

Who cares for former child soldiers? Mental health systems of care in sierra leone.

While numerous studies on former child soldiers (FCS) have shown mental health needs, adequate services are a challenge. This study aimed to identify priorities, barriers and facilitators of mental health care for Sierra Leonean FCS. Thematic analysis was done on 24 qualitative interviews with participants from diverse sectors. Priorities of mental distress, substance abuse, and gender-based violence were common among FCS clients. Barriers were governmental support and communication with other providers. Perceived facilitators of care were primary- and secondary-level interventions. A public mental health model would feasibly build upon local, culturally embraced interventions, targeting local priorities and reducing barriers to care.

Building an Effective Medico-Legal Intervention Model in post-Earthquake Haiti / Construcción de un modelo de intervención médico-legal efectivo tras el terremoto en Haití

The earthquake that struck Haiti on January 12, 2010 left the country and its people devastated, with overwhelming losses, death, homelessness and increased violence and safety concerns. This study proposes an effective intervention model for facilitating humanitarian parole for survivors of the earthquake. A medico-legal team of psychiatrists and human rights and immigration evaluated traumatized individuals and families in Port-au-Prince in March 2010. With support from local NGOs, the legal team screened and prioritized the most severe cases, and the medical team assessed individuals with acute medical and psychiatric concerns. 124 cases were screened for humanitarian parole. Psychological, psychiatric and medical assessments were completed in 48 families (68 individuals) to identify orphans and vulnerable children, survivors of past violence who faced a risk of re-traumatization, and those at high-risk of psychological trauma. All cases needed shelter, clean water and food. Mental health impairment beyond loss and grief were identified in 89.7% of cases. Our findings suggest that a multi-disciplinary, community-based model is effective in identifying individuals and families that meet the conceptual criteria for Humanitarian Parole. The model is also effective in identifying the psychosocial and medical needs of survivors and assisting them in receiving essential health services

El terremoto que azotó Haití el 12 de Enero de 2010 dejó devastados al país y a su gente, con abrumadoras preocupaciones en torno a la pérdida, la muerte, el aumento de la violencia y la seguridad. Este estudio propone un modelo de intervención efectivo para proporcionar refugio humanitario en EE.UU. a los supervivientes del terremoto. Un equipo médico-legal de psiquiatras, personal de inmigración, y de derechos humanos, evaluó a los individuos traumatizados y a sus familias en Puerto Príncipe en Marzo de 2010. con el apoyo de ONGs locales, el equipo legal valoró y priorizó los casos más graves, y el equipo médico evaluó a los individuos con problemas médicos y psiquiátricos. Se seleccionaron 124 casos para proporcionarles refugio humanitario en EE.UU. Se completaron las valoraciones psicológica, psiquiátrica y médica en 48 familias (68 individuos), con el fin de identificar niños huérfanos y vulnerables, supervivientes de violencia pasada con riesgo de nueva traumatización, y persona de alto riesgo de trauma psicológico. Todos los casos necesitaban albergue, agua limpia y comida. Se identificó desajuste mental más allá del propio de la pérdida y el duelo en un 89,7% de los casos. Nuestros hallazgos sugieren que un modelo multidisciplinar, basado en la comunidad, es efectivo para identificar las necesidades psicológicas y médicas de los supervivientes y asistirles para recibir servicios sanitarios esenciales

Asian student depression in American high schools: differences in risk factors.

There are inconsistent findings about depression in Asians. This study examined risk factors for depression in Asian and Caucasian adolescents. Stratified bivariate secondary analyses of risk indicators and depressed mood were performed in this cross-sectional study of high school survey data (9th to 12th grades) from 2,542 students (198 Asian). Asians had a higher prevalence of depressed symptoms, but similar risk factors as Caucasians. Smoking and injury at work were major risk factors for depressed mood among Asians. Asian-specific risk factors for depression were being foreign-born and having a work-related injury. Asian and Caucasian teens have similar risk factors for depressed mood, though being foreign born and having a work-related injury are risk factors specific to Asian youth, possibly related to social-economic status. Providers of care in school, such as school nurses, can be important primary screeners of depression for Asian students in particular.