This month's expert: Andres J Pumariega, M.D., Chair of the American Psychiatric Association's Committee of Hispanic Psychiatrists.

Why should we be concerned about the mental health of Hispanic/Latino youth in the United States?

A number of smaller studies have indicated that Latino youth have a higher risk of significant mental health problems. These include depression, anxiety disorders, substance abuse, eating disorders, and even disruptive behavior disorders such as ADHD. However, for the first time, a large scale study, the 2005 Youth Risk Behavior Survey from the federal Centers for Disease Control, demonstrated that Latinos are at highest risk for a very serious problem: suicide. In this study of thousands of youth, Latinos had a significantly higher risk for suicidal ideation, suicide plans, suicide attempts, and suicide attempts requiring medical treatment than Caucasian, African-American, or Asian-American youth.

What are the factors that contribute to the increased risk of mental health problems in Latino youth?

There are multiple stressors that aggravate any biological vulnerability that Latino youth may have to mental health problems. For immigrants, traumas in their home nations prior to immigration (war, terrorism, disasters, poverty, famine, etc.) and traumas in the process of immigration (risky journeys, witnessing death, victimization by smugglers, undocumented status, separation from extended family an even parents) all contribute significant stresses. For example, Rothe and colleagues, examining children in the Guatanamo refugee camps in Cuba, found that up to 70 percent of children and youth suffered significant symptoms of post-traumatic stress disorder. For all Latino youth, immigrant or U.S.-born, added stressors include poverty, discrimination, domestic or community violence. Additionally, parents and extended family are often not available to supervise and monitor behaviors as a result of long work hours and to help them with the difficult task of acculturation, resulting in increased risk for disruptive behavioral problems.

How do the stresses of acculturation increase the risk of mental health problems in Latino youth?

The process of acculturation presents unique challenges and stressors for Latino children and youth and their families. Latino youth do learn the language, customs, and values of mainstream American culture faster than their parents, especially de to their exposure to popular peer culture and education. However, they often are torn between these new values and customs and the more traditional ones of their parents and elders. Parents and elders often feel left behind and threatened by their children's rapid acculturation and fear losing them to American culture. Such tensions often lead to inter-generational acculturation conflicts that, according to researchers such as Szapocznik and colleagues, lead to an increased risk for substance abuse and disruptive behavioral disorders. Increased acculturation to mainstream culture also contributes to the loss of natural protective values, which include taboos against suicide, familismo (strong orientation towards both the nuclear and extended family as opposed to orientation to individualism), spirituality, and a more traditional body image orientation. The loss of these traditional cultural values and beliefs have been associated with increased levels of mental health problems such as suicidality, substance abuse, disruptive behavioral problems, and eating disorders.

What are the best ways to address the mental health needs of Latino youth?

A major problem in addressing the mental health needs of Latino youth is their lack of access to and utilization of any mental health services. Studies show that Latino youth use about half as many visits or services than youth of other ethnic/ racial groups. The general shortage of child and adolescent mental health services disproportionately affects Latino youth due to the young age of the Latino population in the U.S. (36% under the age of 18). Lack of insurance coverage, economic disadvantage, and the stigma over the use of mental health services in Latino populations are other contributing barriers to access. Additionally, available mental health services often lack sufficient cultural competence to effectively serve the needs of Latinos, including the necessary knowledge, skills, and attitudes. Many programs also lack interpreter services to effectively communicate with Latino families with limited English proficiency.

In addition to addressing these barriers to accessing mental health services, Latino youth and their families are most effectively served by community-based programs that provide intensive treatment within the youth's own home, school, and community. These programs, delivered in the context of community-based systems of care, have been associated with improved access and outcomes for Latino youth. More research into the use of specific treatment modalities with Latino youth (both medications and psychological therapies) is showing promise and effectiveness. For example, the Multisite Treatment Study of ADHD has shown that Latino youth benefit most from combined behavioral therapy and medications, while Caucasian youth receive sufficient benefit from medications alone. Specific therapies developed to address special needs of Latino youth, such as intergenerational acculturation conflict and attitudes about suicide using "telenovelas" (Hispanic TV soap operas), are also demonstrating effectiveness.

Service programs also need to adopt new standards of care for culturally competent services in order to achieve effectiveness. Standards such as the Centers for Mental Health Services' Culturally Competent Standards for Four Underserved Racial/ Ethnic Populations and the Cultural and Linguistic Standards of the Office of Minority Health (both out of the U.S. Department of Health and Human Services) provide valuable guidance for clinical services, systems, and provider competencies in serving Latinos and other underserved populations.

References

Four Racial Ethnic Panels, Cultural Competence Standards for Managed Mental health Services for Four Underserved/ Underrepresented Racial/Ethnic Groups. Rockville, Md.: Center for Mental Health Services, Substance Abuse and Mental Health Administration, U.S. Department of Health and Human Services, 1999.

Pumariega, A.J., Rogers, K., & Rothe, E. Culturally Competent Systems of Care for Children's Mental Health: Advances and Challenges. Community Mental Health Journal. 41(5): 539-556, 2005.

Pumariega, A.J., Rothe, E., & Pumariega, J.B. Mental Health of Immigrants and Refugees. Community Mental Health Journal. 41(5): 581-597, 2005.