Focusing on Racial, Historical and Intergenerational Trauma, and Resilience: A Paradigm to Better Serving Children and Families.

Research across populations demonstrates that intergenerational trauma can have lasting biological, psychological, and social consequences and affects groups of individuals in different ways. An appreciation of intergenerational trauma as experienced in diverse populations is important not only for understanding vulnerabilities and risk but also for cultivating opportunities for posttraumatic growth and healing. Understanding the contexts of trauma for children and families and the unveiling of structural inequities, both past and present, offers the opportunity to address these in using clinical and systems of care approaches in the public health spheres.

Immigration and Race: A Challenge of Many Shades.

This article describes the history of race relations and the rapidly changing racial topography of the United States. The authors address the history of racism and discrimination experienced by minority populations and immigrants of color and the psychological effects on these populations and describe the risk factors and protective factors that come into play when individuals are faced with experiences of discrimination and racism. They describe the process of ethnic-racial identity development and the different styles of ethnic-racial socialization and cultural orientation. Ultimately, it explains the importance of ethnicity and race in the psychotherapeutic encounter.

Structural Inequities and the Impact of COVID-19 on Latinx Children: Implications for Child and Adolescent Mental Health Practice.

In the United States, the Latinx community (Latinx is a gender-neutral term to describe any person of Latin American descent or heritage) is a heterogeneous population with diverse cultural origins, different migratory experiences, and different socioeconomic and educational realities. The disruptions to daily life and the associated stresses of the 2019 novel coronavirus disease (COVID-19) pandemic have been perhaps most acutely felt by Black and Latinx children from low-income families, including first-generation and undocumented immigrants.1 Structural inequities, such as the lack of employer-sponsored insurance in the service and retail industries; barriers to applying for public benefits, even for those who qualify; chronic poverty; and the lack of linguistically and culturally effective services have contributed to the disproportionate impact. In this article, the authors consider how structural inequities have rendered Latinx children particularly vulnerable to the devastating physical and psychological effects of the pandemic, identify risk and protective factors that are related to mental health outcomes, and recommend ways in which child and adolescent psychiatrists can respond to the escalating needs.

Utilizing Psychodynamic Principles to Teach Professionalism to Medical Students Through an Innovative Curriculum.

Professionalism is a fundamental expectation of practicing medicine and a core competency in medical education, yet the methods of how to teach and evaluate it are still experimental. Professionalism involves self-reflection, a psychodynamic understanding of the patient's and the doctor's predicament, and conflict resolution, so psychiatrists are uniquely qualified to teach it. This article describes an innovative course that utilizes psychodynamic principles to teach professionalism to medical students. The authors present a novel 2-year curriculum for teaching professionalism to first- and second-year medical students utilizing psychodynamic principles to help develop awareness of others' feelings and motivations, self-reflection, compassion, empathy, and skills in ethical conflict resolution by means of written and oral narrative exercises. Outcomes are evaluated by the student ratings about the course and the faculty, and by using the test for emotional intelligence (EI), administered as a baseline and then at the end of each year. Each subsequent year the students demonstrated a statistically significant increase in EI scores, student evaluations of the course ranked among the highest in the medical school, clerkship supervisors and residency training directors noted the high degree of professionalism of the students, and the number of student applicants to psychiatry residency were consistently higher than the national average. In addition, this course was awarded the 2018 Alpha Omega Alpha Honor Medical Society's Edward B. Harris Medical Professionalism Award for the best professionalism course of U.S. medical schools. Psychodynamic principles are fundamental for teaching medical professionalism at a medical-student level. Professionalism also serves as a way to introduce students to psychiatry early in the curriculum, and psychiatrists and other mental health professionals are uniquely qualified to teach medical professionalism.

The HIV/AIDS Epidemic in the Dominican Republic: Key Contributing Factors.

This article reviews HIV/AIDS epidemiological data and recent research conducted in the Dominican Republic, with a focus on explaining the variability in estimated seroincidence and prevalence within the country. HIV seroprevalence estimates range from 1.0% (in the general population) to 11.0% among men who have sex with men (MSM). Some have indicated that the highest HIV seroprevalence occurs in Haitian enclaves called bateyes (US Agency for International Development [USAID], 2008), which are migrant worker shantytowns primarily serving the sugar industry in the Dominican Republic. Others report higher or comparable rates to the bateyes in areas related to the tourism and sex industries. As in other Caribbean and Latin American countries, reported HIV transmission in the Dominican Republic is predominantly due to unprotected heterosexual sex and the infection rate has been increasing disproportionally among women. The Dominican Republic represents two thirds of the Hispaniola island; the western one third is occupied by Haiti, the nation with the highest HIV prevalence in the western hemisphere. Although data is limited, it shows important differences in seroprevalence and incidence between these two countries, but commonalities such as poverty, gender inequalities, and stigma appear to be pivotal factors driving the epidemic. This article will discuss these and other factors that may contribute to the HIV epidemic in the Dominican Republic, as well as highlight the gaps in the literature and provide recommendations to guide further work in this area, particularly in the role of governance in sustainable HIV prevention.

Acculturation, development, and adaptation.

The rapidly changing demographic landscape of the United States, brought about by immigration, has resulted in an increasingly multiracial and multicultural population. These changes have become accentuated by the phenomenon of globalization, which occurs when there is an acceleration of movement of people, ideas, and products between nations, which also brings about an increase in the complexity of everyday problems. This article discusses the concept of identity formation and how the stresses of immigration and acculturation and the factors of resiliency and risk affect immigrant children, adolescents, and their families, so that clinicians treating these populations can be prepared to understand divergent, and often well-hidden, world views, which may cause intrafamilial conflicts and interfere with the child's developmental process.

Culturally informed child psychiatric practice.

Child and adolescent psychiatrists are already serving an increasing population of culturally and ethnically diverse patients and families in their practices and in different agency settings. This article discusses adaptations to practice that enable child and adolescent psychiatrists to address the diverse clinical and cultural needs of this emerging population. Special attention is given to work in psychotherapy and in agency settings where diverse children and youth are found in large numbers.

Psychotherapy with a narcissistic playboy facing the end of his life: a self-psychology and object relations perspective.

Narcissistic Personality Disorder is considered to be one of the most tenacious and stable types of personality organization. It usually presents a challenge to clinicians and is often resistant to treatment. The continuous search for the affirmation by others of the grandiose self and the devaluation of others in an attempt to stabilize their self-esteem is typically seen in individuals with narcissistic personality organization. On the other hand, corrective life events such as personal achievements, long-term nurturing relationships, and the management of loss and disillusionment can contribute to a more realistic realignment of the person's Ego Ideals and self-esteem. One such example is the case of Don Joaquin, a 69-year-old playboy who was facing death from leukemia. This article will describe the supportive and psychodynamic psychotherapy treatment approach that was utilized, and how Self-Psychology and Object Relations Theory provided a useful framework to bring help and relief to this patient, as he prepared to face the end of his life.

Effects of open-label atomoxetine on African-American and Caucasian pediatric outpatients with attention-deficit/hyperactivity disorder.

BACKGROUND: Data on the management of attention-deficit/hyperactivity disorder (ADHD) in African-American children and adolescents are limited. METHODS: This study sought to evaluate the tolerability, safety, and efficacy of atomoxetine hydrochloride in the management of ADHD in African-American children and adolescents by conducting a post hoc subgroup analysis of 2 multicenter, open-label studies. RESULTS: Atomoxetine was safe and well tolerated, with >or=3.0% of African-Americans and Caucasians discontinuing treatment because of adverse events. A significantly higher proportion of Caucasians reported >or=1 treatment-emergent adverse event, including vomiting (7.2% vs 1.2%; P=.037) and fatigue (6.1% vs 0%; P=.012). No serious safety concerns were observed. Changes from baseline in height, weight, and hemodynamic variables were modest and similar in both racial subgroups. African-Americans and Caucasians showed significant improvement from baseline to end point in the mean ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored (ADHDRS-IV-P:I). Scores decreased by 20.1 in African-Americans and by 19.55 in Caucasians, without significant between-group differences. Patients in both racial groups experienced similar, significant improvements in ADHDRS-IV-P:I inattention and hyperactivity-impulsivity symptoms, Clinical Global Impression-ADHD-Severity, and Conners' Parent Rating Scale-Revised: Short Form. CONCLUSIONS: Atomoxetine exhibited similar tolerability, safety, and efficacy profiles in African-Americans and Caucasians with ADHD.

A psychotherapy model for treating refugee children caught in the midst of catastrophic situations.

A psychotherapy model for treating child and adolescent refugees caught in the midst of catastrophic situations is proposed. Empirical studies of the peri-traumatic period, comprised between the moment of departure and up to the moment of arrival of the refugees to the sheltering country, are scarce and difficult to complete. A review of the literature reveals that negative, long term mental health outcomes in these populations are related to autonomic dysregulation and impaired narratives of the events, which result from exposure to overwhelming stress. The author combines case material from his own clinical experience treating Cuban children and adolescents inside refugee camps, with the available literature, in order to design the model. The role of the therapist is threefold and involves: (1) intervening to decrease hyperarousal and protect the refugee's neuroendocrine integrity, (2) helping the patient construct a cohesive narrative of the events during the peri-traumatic period and, (3) becoming an advocate for the refugee children and their families, helping to empower them so they can attain mastery and control over the forces that threaten to overwhelm their coping capacities. This model addresses a neglected area of refugee studies: treatment interventions during the peri-traumatic period. It attempts to bridge the empirical research gap that exists, due to the inherent difficulties of studying refugee populations "in the field." This model could potentially be extrapolated to treat other similar populations.

Correlates of early alcohol and drug use in Hispanic adolescents: examining the role of ADHD with comorbid conduct disorder, family, school, and peers.

This study examined correlates of early adolescent alcohol and drug use in a community sample of 217 eighth-grade adolescents with behavior problems and from Hispanic/Latino immigrant families. Structural equation modeling was used to examine relationships of multiple contexts (e.g., family, school, and peers) to alcohol and drug use. Results suggest that conduct disorder in youth with high levels of hyperactivity symptoms, poor school functioning, and peer alcohol and drug use was directly related to early adolescent alcohol and drug use. Attention deficit/hyperactivity disorder with comorbid conduct disorder and family functioning was indirectly related to early alcohol and drug use through poor school functioning and through peer alcohol and drug use. Results are discussed in terms of possible targets for interventions to prevent alcohol and drug use in Hispanic adolescents.

Latino versus Caucasian response to atomoxetine in attention-deficit/hyperactivity disorder.

ABSTRACT We examined the effects of atomoxetine in Latino (n = 108) versus Caucasian (n = 1090) pediatric outpatients (aged 6 to <18 years) during the first 10-11 weeks of treatment in two multicenter, open-label trials. Mean modal doses were not significantly different in Latinos (1.22 mg/kg per day) versus Caucasians (1.27 mg/kg per day; p = 0.22). Both groups showed significant and similar improvements: Mean ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored (ADHDRS-IV-P:I) scores decreased by 54% in Latinos (40.9-18.9; p < 0.001) and by 52% in Caucasians (37.7-18.2; p < 0.001). Other efficacy measures, such as Conners' Parent Rating Scale-Revised: Short Form (CPRS-R:S) and Clinical Global Impressions-ADHD-Severity (CGI-ADHD-S), demonstrated similar and significant decreases. The only significant between-group difference was a greater decrease in the ADHDRS-IV-P:I Hyperactive/Impulsive subscale at weeks 8-11 for Latinos; however, Latinos had higher baseline scores compared with Caucasians. This was not demonstrated in the CPRS-R:S Hyperactivity subscale. There was a significantly higher frequency of CYP2D6 slow metabolizers in Caucasians compared with Latinos. Caucasians reported significantly more abdominal and throat pain, whereas Latinos reported more decreased appetite and dizziness, but no differences in other common adverse events were reported. No suicidal behavior was reported in either group. We found that Latino and Caucasian children with attention-deficit/hyperactivity disorder (ADHD) exhibit a similar pattern of efficacy and tolerability with atomoxetine. The lack of placebo controls was a limitation of this study.

Considering cultural diversity in the management of ADHD in Hispanic patients.

Attention-deficit/hyperactivity disorder (ADHD) is diagnosed less often in Hispanics than in Caucasian patients. Furthermore, Hispanic patients with ADHD are undertreated. The reasons for these disparities are unknown, although difficulties with access to care among this population may offer a partial explanation. In order to improve treatment outcomes in Hispanic patients with ADHD, healthcare providers must reflect on the diversity of the Hispanic population, which consists largely of persons of Mexican, Puerto Rican and Cuban descent. In spite of the fact that Hispanics share a similar language, religion and belief system, there are other significant cultural differences among these subgroups. In addition, English-language proficiency and socioeconomic variables, factors that are known to influence healthcare outcomes, may also differ markedly among Hispanic subgroups. Therefore, strategies to improve the treatment of ADHD in the Hispanic population must include overcoming language barriers by increasing the availability of Spanish-speaking professionals and medical translators and using culturally sensitive diagnostic instrumentation. Furthermore, improving knowledge of cultural practices of particular Hispanic subgroups may improve the therapeutic relationship between patients and clinicians, facilitate the diagnosis of ADHD and allow healthcare providers to make appropriate treatment recommendations.

Luis Llorens Torres and the impossible return: identity, conflict and hope in the national poem of Puerto Rico.

The psychodynamic exploration of the content of literary words and of the personal lives of their authors oftentimes reveals how they can be mutually reflective of the other. Such is the case of the poem, "Valle de Collores" (The Valley of Collores), considered by many to be the national poem of Puerto Rico and of the author Luis Llorens Torres (1876-1944), regarded as the "Poet Laureate of Puerto Rico." The timelessness and wide appeal of certain literary works has been attributed, among other reasons, to the fact that they address universal inner conflicts that affect all human beings. The poem "Valle de Collores" is the narrative of a country boy who leaves home to face the larger world and, as he reaches adulthood, he looks back and expresses his impossible longing to return to the rural home of his childhood. It is a description of the universal struggles of human development and of separation-individuation, loss and mourning and a longing to return, and a wish to merge with the early parental objects of childhood. The poem also parallels the history of the Puerto Rican people, in their transition from a rural society under Spanish rule to an industrialized society as an American Commonwealth. This difficult transition resulted in a massive immigration of Puerto Ricans to the United States that continues to this day. The poem also represents the longing of many Puerto Rican immigrants to return to their island home, and to a simpler time of more fundamental values. The land that is left behind and longed for becomes a metaphor for the early maternal imago.

Luis Llorens Torres and the impossible return: identity, conflict and hope in the national poem of Puerto Rico.

The psychodynamic exploration of the content of literary works and of the personal lives of their authors oftentimes reveals how they can be mutually reflective of the other. Such is the case of the poem, "Valle de Collores" (The Valley of Collares), considered by many to be the national poem of Puerto Rico and of the author Luis Llorens Torres (1876-1944), regarded as the "Poet Laureate of Puerto Rico." The timelessness and wide appeal of certain literary works has been attributed, among other reasons, to the fact that they address universal inner conflicts that affect all human beings. The poem "Valle de Collores" is the narrative of a country boy who leaves home to face the larger world and, as he reaches adulthood, he looks back and expresses his impossible longing to return to the rural home of his childhood. It is a description of the universal struggles of human development and of separation-indi-viduation, loss and mourning and a longing to return, and a wish to merge with the early parental objects of childhood. The poem also parallels the history of the Puerto Rican people, in their transition from a rural society under Spanish rule to an industrialized society as an American Commonwealth. This difficult transition resulted in a massive immigration of Puerto Ricans to the United States that continues to this day. The poem also represents the longing of many Puerto Rican immigrants to return to their island home, and to a simpler time of more fundamental values. The land that is left behind and longed for becomes a metaphor for the early maternal imago.

Aggressive adolescents benefit from massage therapy.

Seventeen aggressive adolescents were randomly assigned to a massage therapy group or a relaxation therapy group to receive 20-minute therapy sessions, twice a week for five weeks. The massaged adolescents had lower anxiety after the first and last sessions. By the end of the study, they also reported feeling less hostile and they were perceived by their parents as being less aggressive. Significant differences were not found for the adolescents who were assigned to the relaxation group.

Posttraumatic stress disorder among Cuban children and adolescents after release from a refugee camp.

OBJECTIVE: The authors compared self-reported symptoms of posttraumatic stress disorder (PTSD) in a cohort of Cuban children and adolescents with assessments of internalizing and externalizing behaviors by the children's teachers. METHODS: Eighty-seven children and adolescents who had left Cuba by sea in the summer of 1994 and who had been confined to refugee camps for up to eight months before arriving in the United States were evaluated four to six months later. Self-reported symptoms of PTSD were assessed with the Post-Traumatic Stress Disorder Reactive Index, and internalizing and externalizing behaviors were assessed with the Child Behavioral Check List-Teacher Report Form. RESULTS: A majority of the children reported moderate to severe PTSD symptoms. The most common symptom clusters were avoidance (67 percent), regressive behaviors (64 percent), reexperiencing the traumatic events (60 percent), somatic symptoms (52 percent), and hyperarousal (51 percent). Eighty-six percent of the children reported that the refugee experience had severely affected most of their peers. A statistically significant dose-effect relationship was found between the number of stressors and the severity of self-reported PTSD symptoms. There was a modest relationship between withdrawn behavior and children's feelings that they would die at sea and witnessing violence at the camps. Age and witnessing violence in the camps were moderately associated with PTSD. Teachers' overall ratings of externalizing and internalizing behaviors did not produce any clinically significant findings. CONCLUSIONS: PTSD symptoms among refugee children and adolescents who have been exposed to multiple and prolonged stressors may continue unabated after the stressors are removed. The symptoms are experienced subjectively and may go unnoticed by adults.