Interdisciplinary case discussions as a training modality to teach cultural formulation in child mental health.

The DSM-5 Cultural Formulation Interview (CFI) may become an important tool to help operationalize culture in the clinical realm. However, challenges exist in teaching its use to avoid the risk of stereotyping and oversimplification, which could result in misunderstanding and stigma. The aim of this article is to document whether the CFI can be taught using regular Interdisciplinary Case Discussion Seminars (ICDSs), proposed as continuing education in child mental health and as part of clinical rotations for new trainees. During a two-year evaluative research project, ICDSs were held monthly in three different primary care settings servicing recent immigrants in Montreal, Canada. ICDSs were recorded and analyzed to examine their effect on the cultural formulation process and focus groups were conducted to explore the subjective experience of the participant trainees and professionals. Results suggest that ICDSs are a helpful way to teach the use of the CFI. The group discussions helped participants to better capture the complexity of the cultural and social experience of the child and family by moving away from simple identity assignations, supporting an inquiry into structural dimensions, and considering stigma and inequality in their formulation. The multiple levels of diversity (individual, disciplinary, and interinstitutional) represented in the discussion groups helped clinicians to understand the cultural formulation as situated in a specific relational context and a particular moment and, in so doing, helped trainees to avoid cultural formulations that essentialize culture.

[Youth mental health at the cross roads of service organization]. / La santé mentale jeunesse: un domaine à la croisée des chemins.

The importance of children and youth mental health is increasingly recognized. This rapidly developing field cannot be conceptualized as an extension of adult services to a younger age group and its developmental and organizational specificities are the object of debate. Reviewing recent literature in this domain and some preliminary information about the Quebec Mental Health Plan implementation, this paper addresses some of the questions which structure this debate in Quebec.Quebec mental health plan has put at the forefront collaboration among disciplines and partnership among institutions. In spite of having produced significant improvement in the field, discontinuities in services, which interfere with an ecosystemic model of care, persist. Recent studies suggest that the organisational climate which surrounds youth mental health services has a direct impact on the quality of services and on youth health outcomes. A flexible management structure, which engages clinicians and health workers, favors empowerment, minimizes work stress and facilitates partnership, is needed to foster successful interdisciplinary and intersectorial collaboration. This collaboration is the cornerstone of youth mental health services.

Refugee children and their families: supporting psychological well-being and positive adaptation following migration.

The support of refugee children and their families is a worldwide concern. This article will highlight models of mental health care for refugee children and their families, focusing on collaborative care with primary care providers. Case vignettes are provided to illustrate how collaborative care can support refugee children׳s psychological well-being and positive adaptation following migration.

Refugee children: mental health and effective interventions.

The mental health consequences of war and other forms of organized violence for children represent a serious global public health issue. Much of the research on the mental health of war-affected civilians has focused on refugees who have sought asylum in high-income countries and face the dual stress of a traumatic past and resettlement. This review will focus on the mental health of refugee children who have fled war as well as interventions to both prevent and treat adverse mental health outcomes. While war can have devastating mental health consequences, children raised in the midst of armed conflict also display resilience. Effective interventions for refugee children will be discussed both in terms of prevention and treatment of psychopathology, with a focus on recent developments in the field.

Addressing trauma in collaborative mental health care for refugee children.

Primary care institutions, including clinics, schools and community organizations, because of their closeness to the family living environment, are often in a privileged position to detect problems in traumatized refugee children and to provide help. In a collaborative care model, the child psychiatrist consultant can assist the primary care consultee and family in holding the trauma narrative and organizing a safe network around the child and family. The consultant can support the establishment of a therapeutic alliance, provide a cultural understanding of presenting problems and negotiate with the consultee and the family a treatment plan. In many settings, trauma focused psychotherapy may not be widely available, but committed community workers and primary care professionals may provide excellent psychosocial support and a forum for empathic listening that may provide relief to the family and the child.

Partnership at the forefront of change: documenting the transformation of child and youth mental health services in quebec.

OBJECTIVE: The Quebec Plan d'action en santé mentale (PASM) (Mental Health Action Plan) reform, a major transformation of the province's mental health care system, has put primary care rather than hospital-based care at the forefront of mental health service delivery. This study documents perceptions of changes in child and youth mental health (CYMH) services following the reform, as well as facilitators and obstacles to collaboration and partnership in CYMH services, and the specific challenges related to collaboration and partnership when servicing multi-ethnic populations. METHODS: This qualitative participatory research study collected data using semi-structured individual interviews, focus groups and participant observation in community-based health and social service institutions. Thematic analysis was performed. RESULTS: The reform process encountered challenges in building a common culture of care within and between institutions, while collaboration and partnership evolved in a positive direction throughout the study. Study results highlighted the importance of fostering communication at all levels. Collaboration and partnership was facilitated by opportunities for clinical discussions, dialogue on models of care, harmonizing administrative and clinical priorities, and involving key actors and structures. The results revealed difficulties in implementing multidisciplinary work and in negotiating partners' responsibilities. Quality of partnership and collaboration appeared particularly crucial in providing optimal care to vulnerable families, including migrants. CONCLUSION: The PASM reform involved a major and challenging transformation in CYMH services. Continuous dialogue through time and leadership sharing appeared promising to foster this transformation.

Measuring the quality of interprofessional collaboration in child mental health collaborative care.

OBJECTIVE: This pilot study examines the potential utility of the Perception of Interprofessional Collaboration Model and the shared decision-making scales in evaluating the quality of partnership in child mental health collaborative care. METHODS: Ninety-six primary care professionals working with children and youth responded to an internet survey which included the Perception of Interprofessional Collaboration Model scale (PINCOM-Q) and an adapted version of a shared decision-making scale (Échelle de confort décisionnel, partenaire-ECD-P). The perceptions of child mental health professionals were compared with those of other professionals working with children. RESULTS: The PINCOM-Q and the ECD-P scales had an excellent internal consistency and they were moderately correlated. Child mental health professionals' Individual Interprofessional Collaboration scores from the PINCOM-Q individual aspects subscale were better than that of other child professionals. CONCLUSION: These scales may be interesting instruments to measure the quality of partnership in child mental health collaborative care settings. Research needs to replicate these findings and to determine whether the quality of collaboration is a predictor of mental health outcome.

Working with Interpreters in Child Mental Health.

BACKGROUND: A consensus exists about the importance of interpreters for refugee and immigrant patients presenting with mental health problems. However, beyond this consensus, the specificities of working with interpreters in child mental health are barely mentioned in the literature. METHOD: This paper describes some of the challenges associated with working with interpreters for the diagnosis of child psychiatric disorders and for intervention in situations of family crisis. RESULTS AND CONCLUSION: There is a need to develop appropriate training programs for interpreters and clinicians involved in child mental health. These programs should be evaluated and incorporated into existing practice guidelines in order to equip clinicians working with children and young people in multicultural communities.

From the family universe to the outside world: family relations, school attitude, and perception of racism in Caribbean and Filipino adolescents.

Caribbean and Filipino immigrant families in Canada have much in common: the women have often immigrated as domestic workers, first-generation children may be separated from their parents for long periods, and they must deal with negative stereotypes of their ethnic group. This transcultural study looks at the associations between family relations and adolescents' perceptions of both their own group and the host society, and analyzes how these affect their mental health. The results suggest that family cohesion plays a key role in shaping adolescents' perceptions of racism in the host country and in promoting a positive appraisal of their own community, thus highlighting the need for a systemic understanding of family and intergroup relations.

DSM IV, culture and child psychiatry.

OBJECTIVE: The expanding cultural diversity of children and families with mental health needs raises questions about the cultural appropriateness of diagnostic classifications like the DSM IV. This paper briefly surveys the literature on culture and DSM-IV in child psychiatry, presenting ADHD as an example of the relationship between diagnostic categories and cultural issues, and illustrating some of the clinical dilemmas of differential diagnosis in a migration context. METHOD: A literature review was performed and analysed, and a case vignette was constructed to illustrate key points. RESULTS: The literature does not provide a definite answer about the DSM IV cultural validity in child psychiatry. On the one hand it suggests that all diagnostic categories may be found universally. On the other, variations in prevalence rates support the hypothesis of a role for social and cultural factors in the diagnostic process. The clinical formulation may be a useful tool to address the validity issue by modulating the process of diagnosis with a cultural understanding of the symptoms, the patient-therapist alliance and the appropriateness of treatment recommendations. CONCLUSION: Although the DSM IV diagnostic categories may be found cross culturally, clinicians need to be aware of how culture may influence the diagnostic process in child psychiatry.

Prevalence and correlates of conduct disorder and problem behavior in Caribbean and Filipino immigrant adolescents.

This study investigates the prevalence and subtypes of conduct disorder (CD) and behavioral problems among youth in two communities characterized by prolonged parent-child separation upon immigration. CD and problem behaviors were assessed in 252 Caribbean-Canadian and Filipino-Canadian adolescents (12-19-year-old) using the DISC-C, the YSR and the CBCL cross-informant construct. Adolescents reported less problem behaviors than their host country peers, despite immigrant background or parent-child separation. The high adolescent-onset CD rate supports the hypothesis that psychosocial stressors play a role in the emergence of the disorder. Specifically, high levels of perceived racism and low collective self-esteem predicted problem behaviors in these youngsters.

Caribbean and Filipino adolescents' and parents' perceptions of parental authority, physical punishment, and cultural values and their relation to migratory characteristics.

This article describes the perceptions of parents and adolescents of physical punishment in relation to family and migratory characteristics. Adolescents and their parents of Caribbean (n=118) and of Filipino (n=136) heritage responded to questions on their attitude toward physical discipline, their family relations, and their socio-demographic and migratory characteristics. Data analyses show that many Caribbean (78%) and Filipino (41.9%) parents perceive that they should have the right to physically punish their children, while youth disagree with this. The dissonance between parents' and their children's attitudes is related to acculturation factors due to the earlier and more intense exposure of youth to their host society. Further studies should be conducted on the impact of the divergence between parents and their youth's opinions on the actual shifts in power in the parent-child relationship, as well as on immigrant parents' discipline strategies and on the family's adaptation to the challenges of migration.

Caring for migrant and refugee children: challenges associated with mental health care in pediatrics.

This article reviews aspects of the mental health care of migrant and refugee children. It highlights the challenges of access to care for these children and of considering the role of pediatricians in their mental health care. It also looks at the sources of differences in presentation of mental health issues of migrant youth when compared with dominant culture youth, examining the contributions of culture, context, and the families' own views. Models of care will be described that have tried to elicit a better understanding of the difficulties migrant and refugee children may encounter. Some avenues through which we may expand our current psychiatric models of care will also be addressed. These avenues include the use of interpreters and cultural brokers, addressing the debate around ethnic matching between therapists and patients, promoting a sensitivity to otherness and mediation, and looking at the importance of time issues.

The development and therapeutic modalities of a transcultural child psychiatry service.

INTRODUCTION: To look at the specificities of the work of a Transcultural Child Psychiatry Team developed to meet the need for specialized services for Montreal and Quebec's culturally diverse immigrant and refugee pediatric population. METHOD: A Transcultural Child Psychiatry Team was started at McGill University in 1995. The clinic's development and method of service provision for its patient population will be described. RESULTS: Modalities of assessment and treatment are modified to meet the needs of the team's clientele and also reflect the philosophical underpinnings of the team's practitioners. CONCLUSION: In this model of service delivery, current mental health care practice is modified in order to address the social specificities and cultural diversity of transcultural child psychiatric populations.

Immigrants and mental health services: increasing collaboration with other service providers.

INTRODUCTION: This article examines the potential modifications of care indicated to engage migrant and refugee families in making use of needed mental health services for their children in Canada and the role psychiatrists can play in this process. METHOD: The clinical and consultative role of the members of the Transcultural Child Psychiatry Service at the Montreal Children's Hospital is used as a model. This model has been useful in engaging both migrant families and local front line service providers to work with each other in a collaborative manner. RESULTS: Important aspects to be considered in these cases are: Modifications in obtaining access to care; Issues of communication (i.e., the use of interpreters); Addressing cultural differences in understanding and responding to a child's difficulties; recognizing the plasticity of culture; Collaboration with colleagues in hospitals and with professionals in the community. CONCLUSIONS: New models of care, involving increased collaboration between professionals, need to be devised to facilitate the mental health care of immigrant and refugee children and their families.

Remaking family life: strategies for re-establishing continuity among Congolese refugees during the family reunification process.

The restrictive immigration and refugee policies of many Western countries force most refugee families to remain separated for long periods. Although there is much discussion among professionals in the community and the clinical milieu about the problems families encounter after reunification, the strategies employed by refugees to restore family life have not been paid much attention. This longitudinal study documents the pre- and post-reunification experiences of 12 refugee families from the Democratic Republic of Congo in Montreal. Our results suggest that family separation can be understood as an ambiguous loss, in that the temporary absence of other family members cannot be fully acknowledged because of the perpetual uncertainty and permanent risk to them. Memory work, in the form of shared family memories, attenuates the pain of the absence. Once reunited, family members must re-establish continuity in spite of the many denied rifts between them. The capacity to recall a personal, familial or collective history of previous separation and loss appears to be protective, as if the memory of life's discontinuities provides an opportunity to recreate a partial sense of continuity out of repeating experiences of chaos.