"That Was a State of Depression by Itself Dealing with Society": Atmospheric racism, mental health, and the Black and African American faith community.

Despite increased societal focus on structural racism, and its negative impact on health, empirical research within mental health remains limited relative to the magnitude of the problem. The current study-situated within a community-engaged project with members of a predominantly Black and African American church in the northeastern US-collaboratively examined depressive experience, recovery, and the role of racism and racialized structures. This co-designed study featured individual interviews (N = 11), a focus group (N = 14), and stakeholder engagement. A form of qualitative, phenomenological analysis that situates psychological phenomena within their social structural contexts was utilized. Though a main focal point of the study was depressive and significantly distressing experience, participant narratives directed us more towards a world that was structured to deplete and deprive-from basic neighborhood conditions, to police brutality, to workplace discrimination, to pervasive racist stereotypes, to differential treatment by health and social services. Racism was thus considered as atmospheric, in the sense of permeating life itself-with social, affective, embodied, and temporal dimensions, alongside practical (e.g., livelihood, vocation, and care) and spatial (e.g., neighborhood, community, and work) ones. The major thematic subsections-world, body, time, community, and space-reflect this fundamental saturation of racism within lived reality. There are two, interrelated senses of structural racism implicated here: the structures of the world and their impact on the structural dimensions of life. This study on the atmospheric nature of racism provides a community-centered complement to existing literature on structural racism and health that often proceed from higher, more population level scales. This combined literature suggests placing ever-renewed emphasis on addressing the causes and conditions that make this kind of distorted world possible in the first place.

"If You Want to Know About the Book, Ask the Author": Enhancing Community Engagement Through Participatory Research in Clinical Mental Health Settings.

Participatory research, in which people with lived experience of the study phenomenon are involved as collaborators, has been conducted for decades; however, these innovations have struggled to take hold in mental health settings-until recently. The slow uptake of community partnered research in mental health has been unfortunate, especially because this field already suffers from poor community relations, pervasive community mistrust, and racial and ethnic disparities. But now, people with lived experience of severe mental illness-long considered to be "incapable" of functioning as co-researchers-are beginning to be included on research teams. However, training and opportunities for conducting such work are still lacking. This report describes a two-year initiative to improve the quality and quantity of participatory research being conducted in a department of psychiatry at a large medical school, which culminated in an innovative training program for both researchers and patients, developed in direct collaboration with stakeholders. In addition to detailing this program, we also discuss the deep legacy of mental health mistrust and our own efforts to address issues of social justice and health equity.

"I Want to Come Home": Vietnam-Era Veterans' Presenting for Mental Health Care, Roughly 40 Years After Vietnam.

There continues to be an increase in the number of Vietnam-era veterans receiving a diagnosis of PTSD in the Veterans Health Administration, nearly four decades after Vietnam. In the present study, our aim was to better understand what prompts Vietnam-era veterans to present to a VHA mental health clinic, and to determine the meaning of this experience for them. Participants were interviewed regarding the experiences that prompted their visit to the mental health clinic at a VA medical center. Ensuing narratives were analyzed via phenomenological qualitative methods. Findings revealed that veterans did not hold a clear and determinate understanding of "PTSD" prior to attending the mental health clinic. Their engagement was instead the culmination of a long process wherein trusted others (e.g., family, other veterans, primary care doctors) suggested that their difficulties may be indicative of a problematic pattern that required attention beyond the everyday ways of dealing with them. In general, veterans suffered from a longstanding experience of social rejection, abandonment, and even betrayal following the war, including pervasive stigmatizations and perceived "weaknesses," and their own preferences for self-reliance over inattentive social and governmental institutions. Many veterans were newly focused on renewing meaning and purpose in their lives. The findings suggest the need to build stronger bridges between the VA and veterans' community supports, who greatly influenced veterans' care seeking. Further efforts to welcome Vietnam-era veterans home, validate their experiences of rejection and abandonment, and respectfully process their ensuing pain and anger are warranted.

Development and Initial Validation of the Multicultural Personality Inventory (MPI).

Two studies summarize the development and initial validation of the Multicultural Personality Inventory (MPI). In Study 1, the 115-item prototype MPI was administered to 415 university students where exploratory factor analysis resulted in a 70-item, 7-factor model. In Study 2, the 70-item MPI and theoretically related companion instruments were administered to a multisite sample of 576 university students. Confirmatory factory analysis found the 7-factor structure to be a relatively good fit to the data (Comparative Fit Index =.954; root mean square error of approximation =.057), and MPI factors predicted variance in criterion variables above and beyond the variance accounted for by broad personality traits (i.e., Big Five). Study limitations and directions for further validation research are specified.

The effects of race and other socioeconomic factors on health service use among American military veterans.

This study examined the extent to which racial disparities in service utilization exist in veterans (VA) and non-VA health care systems. An observational study design was used with a nationally representative sample of veterans. Logistic regression models were constructed using sociodemographic characteristics, health insurance and benefits, and health status as predictors of health service use in both VA and non-VA health care systems. A population weighted sample of 19,270 veterans from the 2001 National Survey of Veterans was used, which included 17,004 (88.24%) White, 1,864 (9.15%) African American, 414 (2.15%) Native American/Alaskan Native, and 87 (0.45%) Asian American/Pacific Islander veterans. Results showed that use of the VA health care system was not associated with race, but was associated with VA disability compensation, lack of private health insurance, and greater health care need. Contrarily, in non-VA healthcare systems, veterans who were racial minorities, less educated, and without private health insurance were less likely to use services. Together, these findings demonstrate the socioeconomic context in which health disparities exist and suggest the influence of health insurance on racial disparities in service utilization.

Closed Reduction and Percutaneous Fixation of Lisfranc Injury Using Suspensory Fixation.

Background: This closed reduction and percutaneous fixation (CRPF) technique utilizing suspensory fixation is indicated for the treatment of Lisfranc injuries with displacement or instability of the tarsometatarsal joint complex-and typically only for low-energy, purely ligamentous Lisfranc injuries. The goal of this procedure is to restore joint stability and prevent common complications of Lisfranc injuries (e.g., midfoot arch collapse and posttraumatic arthritis) while avoiding the complications and risks associated with open reduction and internal fixation (ORIF) and primary arthrodesis. We recommend performing the procedure within 10 to 14 days of the injury; otherwise, an open debridement may be necessary to address scar tissue formation. Description: We start with the patient in the supine position and perform a fluoroscopic stress examination of the joint. Next, the Lisfranc joint undergoes closed reduction, which is held in place with a clamp. Following reduction, a guidewire is drilled from the lateral border of the base of the 2nd metatarsal medially through the medial cuneiform, followed by a medial-to-lateral cannulated drill. The suspensory fixation is then passed lateral-to-medial, placing the suture button on the lateral cortex of the 2nd metatarsal base. The tape is then tensioned while a bioabsorbable interference screw is inserted to maintain tension. Alternatives: Prior studies have assessed both operative and nonoperative alternatives to CRPF with suspensory fixation for the treatment of Lisfranc injuries. Nonoperative treatment with closed reduction and cast immobilization of Lisfranc injuries is typically reserved for nondisplaced injuries; however, a number of studies have shown poor outcomes with use of this technique1-3. The 2 most common operative alternatives are ORIF and primary arthrodesis4. Rationale: CRPF with suspensory fixation offers several benefits over both traditional surgical techniques such as ORIF and primary arthrodesis, as well as over percutaneous reduction and internal fixation (PRIF) with a screw. Compared with ORIF and primary arthrodesis, a number of studies have shown that percutaneous treatment of Lisfranc injuries minimizes soft-tissue trauma and reduces the risk of postoperative complications such as wound breakdown, infection, and complex regional pain syndrome, while allowing for earlier participation in rehabilitation5-10. A systematic review of outcomes following PRIF with screw fixation also showed that percutaneous treatment of Lisfranc injuries is a safe and effective technique with good functional outcomes11. When comparing PRIF with a screw to our technique of CRPF with suspensory fixation, CRPF has the added benefit of creating a nonrigid fixation in the Lisfranc joint, which allows for increased range of motion of the medial column and improved return to activity12,13. The rigid fixation in PRIF with a screw can also lead to metal irritation, intra-articular screw fracture, and impaired mobility, which often necessitate the need for screw removal13-15. This fixation-related drawback is not present with our technique, and also avoids the need for use of a biologic substitute such as tendon grafts13. Expected Outcomes: Following CRPF with suspensory fixation, patients can expect to return to full activity at 12 to 16 weeks postoperatively. Postoperatively, patients are typically kept non-weight-bearing for 6 weeks. The operative foot is kept immobilized in a splint for the first 2 weeks, then transitioned to a boot. Between postoperative weeks 6 and 12, partial progressive weight-bearing is introduced with use of an arch support, progressing toward full weight-bearing13,16,17.For comparison, patients who underwent PRIF with screw fixation had a similar postoperative course, but almost all required screw removal at 4 to 6 months postoperatively13,16. Cho et al. retrospectively reviewed the results of 63 patients who underwent either PRIF with screw fixation (n = 32) or CRPF with a suture button (n = 31) and found that CRPF patients had significantly better American Orthopaedic Foot & Ankle Society midfoot scale scores (81 versus 74 points) and visual analog scale scores (3.1 versus 4.6 points) at 6 months postoperatively and prior to screw removal in the PRIF group (p < 0.001). There were no significant differences in these scores, radiographic outcomes, weight-bearing analysis, or complications at 1 year postoperatively. The authors concluded that both techniques provided comparable fixation stability and clinical outcomes. Of note, however, the PRIF group had 4 patients whose postoperative course was complicated by screw breakage13. Important Tips: Start with a fluoroscopic stress examination to identify all components of instability.Ensure that the reduction clamp does not interfere with or affect your guidewire path.If the joint cannot be reduced, convert to an open procedure and debride the obstruction. Acronyms and Abbreviations: ORIF = open reduction and internal fixationPRIF = percutaneous reduction and internal fixationCRPF = closed reduction and percutaneous fixationNSAID = nonsteroidal anti-inflammatory drugOR = operating roomAP = anteroposteriorCT = computed tomographyMRI = magnetic resonance imagingAOFAS = American Orthopaedic Foot & Ankle SocietyVAS = visual analog scaleROM = range of motionPT = physical therapyASA = acetyl-salicylic acid (aspirin)BID = twice dailyPRN = as needed.

System-Centered Care: How Bureaucracy and Racialization Decenter Attempts at Person-Centered Mental Health Care.

This article presents a study exploring structural biases within mental health organizations, in the context of person-centered care-an emerging framework for health systems globally. Findings revealed how surrounding institutional structures conditioned a powerful influence on clinical operations, in which there is a risk for clients to be systemically seen as a non-person, that is, as a racialized or bureaucratic object. Specifically, the article elucidates how racial profiles could become determinants of care within institutions; and how another, covert form of institutional objectification could emerge, in which clients became reduced to unseen bureaucratic objects. Findings illuminated a basic psychosocial process through which staff could become unwitting carriers of systemic agenda and intentionality-a type of "bureaucra-think"-and also how some providers pushed against this climate. These findings, and emergent novel concepts, add to the severely limited research on institutional bias and racism within psychological science.

Experiences with Racism Among Asian American Medical Students.

Importance: Asian American physicians have experienced a dual pandemic of racism and COVID-19 since 2020; understanding how racism has affected the learning environment of Asian American medical students is necessary to inform strategies to promoting a more inclusive medical school environment and a diverse and inclusive workforce. While prior research has explored the influence of anti-Asian racism on the experiences of Asian American health care workers, to our knowledge there are no studies investigating how racism has impacted the training experiences of Asian American medical students. Objective: To characterize how Asian American medical students have experienced anti-Asian racism in a medical school learning environment. Design, Setting, and Participants: This qualitative study included online video interviews of Asian American medical students performed between July 29, 2021, and August 22, 2022. Eligible participants were recruited through the Asian Pacific American Medical Students Association and snowball sampling, and the sample represented a disaggregated population of Asian Americans and all 4 medical school years. Main Outcomes and Measures: The medical school experiences of Asian American medical students. Results: Among 25 participants, Asian ethnicities included 8 Chinese American (32%), 5 Korean American (20%), 5 Indian American (20%), 3 Vietnamese American (12%), 2 Filipino American (8%), and 1 (4%) each Nepalese, Pakistani, and Desi American; 16 (64%) were female. Participants described 5 major themes concerning their experience with discrimination: (1) invisibility as racial aggression (eg, "It took them the whole first year to be able to tell me apart from the other Asian guy"); (2) visibility and racial aggression ("It transitioned from these series of microaggressions that every Asian person felt to actual aggression"); (3) absence of the Asian American experience in medical school ("They're not going to mention Asian Americans at all"); (4) ignored while seeking support ("I don't know what it means to have this part of my identity supported"); and (5) envisioning the future. Conclusions and Relevance: In this qualitative study, Asian American medical students reported feeling invisible within medical school while a target of anti-Asian racism. Addressing these unique challenges related to anti-Asian racism is necessary to promote a more inclusive medical school learning environment.

A return to lived experiencers themselves: Participatory action research of and by psychosocial clubhouse members.

Introduction: Within the history of psychology and phenomenology, people with lived experience of mental illness have often served as participants in research, but far less as co-researchers themselves. There is now a growing movement focused on "participatory" research, where people with lived experience directly contribute to various stages of the research process. This article presents such a qualitative, participatory research study, led by members of a large psychosocial rehabilitation clubhouse-Fountain House in New York City-and informed by phenomenological research principles. The study focused on collaboratively assessing and improving the clubhouse program for its members. Methods: A key feature of the project was the extent of lived experiencer involvement, for instance, in designing and conducting the study, and co-writing this research report. Members of Fountain House were trained in phenomenologically-informed research methods and developed a research study that focused on the quality improvement of their clubhouse program. Member researchers conducted a series of focus groups with fellow clubhouse members, generating qualitative data that were analyzed and written up by member researchers in collaboration with staff and university partners. Results: Overall, study findings place emphasis on the theme of action in members' experiences-both with respect to how action, agency, and valued activity were key drivers of meaning and recovery for people facing severe mental illness, and with respect to the key component of the research process itself [i.e., participatory action research (PAR)]. Four major subthemes emerged from the study. First, findings revealed how members with mental illness experienced the clubhouse as a "new hope" and "the place for me," to counteract their experience of inactivity, stigma, depression, and hopelessness prior to that point. Second, findings showed how, as members' life goals changed, so did the precise meaning and role of Fountain House in their lives. Third, findings portrayed members' need for, and pursuit of, transformation within the clubhouse space itself to provide more opportunities for meaningful work rather than what they viewed as merely busy-work. Finally, member researchers viewed their direct participation in this project as an opportunity to actively combat stigma, to be a driver of research, and to engage in what they viewed as a generative activity. Discussion: These action-oriented themes serve as a counter to the historical view of people with mental illness as merely passive experiencers of symptoms and passive recipients of mental health care. We discuss how the process and content of participatory research can help enhance the relevance of research for stakeholders' lives and contexts.

Impact of Opioid Restriction Legislation on Prescribing Practices for Outpatient Plastic and Reconstructive Surgery.

BACKGROUND: Overprescription of opioids for acute postoperative pain, plastic surgery procedures included, is contributing to the pervasive opioid epidemic in the United States. This study examines the effect of a statewide legislation limiting postoperative opioids on opioid prescription behavior among providers following outpatient plastic surgery procedures at a high-volume academic center. METHODS: Retrospective review of all outpatient surgical encounters between June 1, 2016, and November 30, 2018, was performed. Encounters were grouped into two cohorts: prepolicy and postpolicy. Primary outcomes included total oral morphine equivalents prescribed on the day of surgery and proportion of patients prescribed greater than 210 oral morphine equivalents. Secondary outcomes included proportion of patients requiring an opioid refill within 30 days following surgery, and number of refills required. RESULTS: The mean oral morphine equivalents prescribed on the day of surgery was reduced from 271.8 to 150.37 oral morphine equivalents ( p < 0.001) following implementation of the legislation, with an associated decrease in the standard deviation of oral morphine equivalents prescribed from 225.35 to 196.71 ( p < 0.001), suggesting a decrease in the variability of prescriber practices. Time series analysis demonstrated the decrease in oral morphine equivalents remained significant when accounting for baseline level of change in opioid prescription patterns. CONCLUSION: This study provides evidence that legislation at the state level restricting postoperative opioid prescriptions is associated with a decrease in opioid prescriptions without an increase in the need for refills in the acute postoperative setting following outpatient plastic surgery procedures.

Impact of Changed Use of Greenspace during COVID-19 Pandemic on Depression and Anxiety.

The COVID-19 pandemic has had devastating consequences for health, social, and economic domains, but what has received far less focus is the effect on people's relationship to vital ecological supports, including access to greenspace. We assessed patterns of greenspace use in relation to individual and environmental factors and their relationship with experiencing psychological symptoms under the pandemic. We conducted an online survey recruiting participants from social media for adults in Korea for September-December 2020. The survey collected data on demographics, patterns of using greenspace during the pandemic, and major depression (MD) and generalized anxiety disorder (GAD) symptoms. The Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder 2-item (GAD-2) were applied to identify probable cases of MD and GAD. A logistic regression model assessed the association decreased visits to greenspace after the outbreak compared to 2019 and probable MD and GAD. Among the 322 survey participants, prevalence of probable MD and GAD were 19.3% and 14.9%, respectively. High rates of probable MD (23.3%) and GAD (19.4%) were found among persons currently having job-related and financial issues. Of the total participants, 64.9% reported decreased visits to greenspace after the COVID-19 outbreak. Persons with decreased visits to greenspace had 2.06 higher odds (95% CI: 0.91, 4.67, significant at p < 0.10) of probable MD at the time of the survey than persons whose visits to greenspace increased or did not change. Decreased visits to greenspace were not significantly associated with GAD (OR = 1.45, 95% CI: 0.63, 3.34). Findings suggest that barriers to greenspace use could deprive people of mental health benefits and affect mental health during pandemic; an alternative explanation is that those experiencing poor mental health may be less likely to visit greenspaces during pandemic. This implies the need of adequate interventions on greenspace uses under an outbreak especially focusing on how low-income populations may be more adversely affected by a pandemic and its policy responses.

Implicit organizational bias: Mental health treatment culture and norms as barriers to engaging with diversity.

There are increased efforts to improve patient-provider relations and engagement within North American mental health systems. However, it is unclear how these innovations impact care for ethnic minorities, a group that continues to face social and health disparities. This study examined one such engagement innovation-person-centered care planning-to gain a better understanding of this overall process. We specifically explored how mental health providers trained in person-centered care planning work with their patients of Latinx and Asian backgrounds. In-depth interviews were conducted with mental health providers in community clinics, and narratives were analyzed via phenomenological methods. Findings revealed that regardless of specific practice innovations, it was providers' own embeddedness in their mental health organizational culture that became conspicuous as a determinant of care. This culture contained implicit preferences for clients considered to be ideal (e.g., are verbal, admit a problem or illness, accept services, and are individually oriented). These clients were experienced as ideal largely because they helped the system operate efficiently. Findings suggest that these organizational norms, preferences, and expectations-and bureaucratic demands for efficiency-may engender an implicit organizational bias that creates barriers for culturally different groups. These biases may also hinder practice innovations, whether patient-centered, disparities-focused, or otherwise. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The complex relationship between estrogen and migraines: a scoping review.

BACKGROUND: Migraines are a chronic disease for millions worldwide and have been hypothesized to be hormonally mediated due to their higher prevalence in females and menstrual associations. Estrogen has been commonly implicated in migraine pathogenesis, yet its exact role in the pathophysiology of migraines has yet to be fully understood. METHOD: We conducted a scoping review of the literature regarding estrogen's role in migraine pathogenesis and included 19 studies out of an initial 202 in the final review. Two independent reviewers screened and extracted data from included studies based on predetermined inclusions and exclusion criteria. RESULTS: The estrogen withdrawal hypothesis, discussed by 12 of the reviewed studies, is the most discussed theory about estrogen's role in migraine physiology and describes the association of migraine onset with natural declines in estrogen levels, particularly when estrogen levels fall below 45-50 pg/mL after an extended period of priming. Additional findings suggest that women with a history of migraine have an increased sensitivity to physiologic fluctuations in estradiol levels. Several studies suggest that migraines are associated with menstruation. CONCLUSION: It appears that estrogen is very likely to play a key role in migraine pathogenesis, but seems to affect patients in different ways depending on their past medical history, age, and use of hormonal therapy. Further research is warranted to isolate the effects of estrogen in each unique patient population, and we believe that studies comparing menstruating women to postmenopausal women could help shed light in this area.

An "oasis within a desert," but the desert remains: Clubhouse members' experiences of social belonging and societal oppression.

Persons living with mental health challenges are at increased risk of stigma, social isolation, and social exclusion. Due to its emphasis on member participation and community, the clubhouse model of mental health may help address these issues. In this study, we examined experiences of social belonging and of various social determinants of mental health among members attending a psychosocial clubhouse. Twelve members of a large psychosocial clubhouse were interviewed regarding their experiences of community life and belonging. Phenomenological qualitative methods were utilized to examine the meaning and structure of these experiences. Members overwhelmingly experienced the clubhouse as a central site of belonging ("an oasis"), but members also recounted devastating portraits of life in the outside world ("a desert"). This world presented fundamental restrictions on their movement and speech and held deeply sedimented norms pertaining to who is considered valuable, productive, and even human, which they were reminded of through an endless tyranny of questions ("what do you do," "where do you live," etc.). Life in the clubhouse presented an alternative world for members to experience nourishment, dignity, reaffirmed personhood, and a sense of beauty. And yet, the desert outside remained. Implications of these findings for clubhouses, mental health practice, and sociopolitical and community engagement are discussed, including the need to address profound deprivations and power imbalances within the wider world, beyond the walls of humane spaces such as these. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Comprehensive strategies to minimize radiation exposure during Interventional electrophysiology procedures: state-of-the-art review.

INTRODUCTION: Cardiac electrophysiology (EP) procedures are frequently performed in patients with cardiac arrhythmias, chronic heart failure, and sudden cardiac death. Most EP procedures involve fluoroscopy, which results in radiation exposure to physicians, patients, and EP lab staff. Accumulated radiation exposure is a known health detriment to patients and physicians. AREA COVERED: This review will summarize radiation exposure, dose metrics, complications of radiation exposure, factors affecting radiation exposure, minimizing radiation exposure, zero or near-zero fluoroscopy strategies, and up-to-date research in the area of reducing radiation exposure and best practices. EXPERT COMMENTARY: Comprehensive strategies should be implemented in EP laboratories to minimize radiation exposure with standard fluoroscopy. There are routine techniques that can mitigate significant amounts of radiation exposure using standard equipment within the EP lab. The operators need to emphasize that EP practices routinely incorporate non-ionizing radiation sources for cardiac imaging (e.g. magnetic resonance imaging, advanced electroanatomical mapping systems, intracardiac ultrasonography) in addition to other novel technologies to mitigate radiation exposure to patients and physicians.

A Pilot Study of Motive Control to Reduce Vengeance Cravings.

Violence is a serious public health problem in the United States, and a common risk factor for many forms of violence is the perpetrator's motivation to achieve personal justice for past wrongs and injustices. Using a fictional transgression scenario to stimulate revenge feelings, we studied the preliminary efficacy of an intervention designed to mitigate revenge desires among victims of perceived injustice. The intervention consisted of a guided role-play of key figures in the justice system (e.g., victim, prosecutor, defendant, judge, etc.) in an imaginary mock trial of the offender. Study participants' revenge desires toward the perpetrator decreased significantly immediately after the intervention and at a 2-week follow-up interview. Benevolence toward the offender increased immediately postintervention and at a 2-week follow-up interview. These results suggest that the intervention has promise to decrease revenge desires in people who have been victimized, and it potentially opens the door to behavioral health motive control approaches to violence prevention. Findings on the roles of vengeance and the desire for retaliation in relation to violent acts, as well as neuroscience research that suggests a connection between retaliatory aggression and the neural circuitry of anticipated reward and cravings, are discussed. Limitations of this pilot study are also discussed, and recommendations for future research are provided.

The discovery of autism: Indian parents' experiences of caring for their child with an autism spectrum disorder.

The current study investigated the lived experience of 12 parents of children with an Autism Spectrum Disorder in everyday cultural contexts in Goa, India. Narratives from parents collected between 2009 and 2010 were analyzed using the procedures of phenomenological psychology. Four temporal phases of parents' experience emerged from these data. Findings showed that the earliest phase of the child's life was a period of relative normalcy and social cohesion. In the second phase, the child's behaviors began to disrupt the everyday social order, but parents viewed these unexpected behaviors as temporary. In the third phase, parents' observations in public situations, along with assessments of others, led to a qualitative shift in which parents began to perceive that there was a persisting problem interfering with their child's social and practical activities. In the fourth phase, parents grappled with developing their child's capacities to meet existing practical opportunities in the local society, while attempting to reshape the social world to accommodate the abilities and limits of children like their own. Parents' fundamental concerns throughout their journey were: learning to meet new and unfamiliar challenges as parents, caring for their child's basic needs, and finding an engaging niche with a sense of belonging for their child in the everyday milieu. Both culture-specific and potentially universal levels of experience are delineated in the overall findings. Implications for culturally sensitive research and practice in India and other low- and middle-income countries are discussed.

Challenges, coping strategies, and unmet needs of families with a child with autism spectrum disorder in Goa, India.

Autism Spectrum Disorders (ASD) are increasingly recognized in developing countries like India. However, little is known about the experiences of parents raising a child with ASD. This study aimed to describe the experiences of families in Goa, India with a view to understanding the unmet needs of families raising a child with ASD. Twenty in-depth interviews and nine focus group discussions were carried out with families of children with ASD and key community stakeholders such as special educators, teachers, and parents of typically developing children. This qualitative data was triangulated to explore the experiences, life impact, and unmet needs of raising a child with ASD. Key findings suggest that raising a child with ASD puts a tremendous strain on families due to competing commitments, often leading to initial social withdrawal with later reintegration into social networks. Second, the impact is multidimensional, involving the personal sphere but also extending into the wider community with negative experiences of discrimination. Third, parents actively respond to these challenges through a range of approaches with help from existing and new social support networks and health care providers. Fourth, professionals from the health, education, and religious sectors have a low awareness of the unique needs of families living with ASD which leads to a considerable economic and emotional burden on families. Finally, as a consequence of these experiences, several unmet needs can be identified, notably for supporting increasingly isolated families and the limited access to multidisciplinary evidence-based services for ASD. Autism Res 2012, 5: 190-200. © 2012 International Society for Autism Research, Wiley Periodicals, Inc.