Child and adolescent mental health

In Asian countries, all forms and degrees of mental illness and intellectual disability are grouped together and described as ‘crazy ’ by the general public. Due to this, there is strong stigma attached to mental illness in Asian countries.

• Asian parents may feel ashamed and may hide their children with mental illness from friends or their community.
• Some families may seek alternative or traditional assessment and treatment including spiritual guidance and intervention, or delay Western treatment until the illness becomes acute or severe and is too difficult for them to manage eg the child is self-harming or harming others.
• Stigma may also result in the refusal to use professional interpreters by Asian families who are not familiar with interpreting services and who have concerns about the confidentiality of interpreters.
• There is strong resistance to continuous medication or treatment especially when families feel the side effects of drugs are affecting the child. Close supervision and support to ensure medication compliance is necessary.
• Asian families tend to have high expectations when they access the public health system eg hospital or mental health services. They may feel that the family has no further responsibility once the child is in the care of the health services. Their lack of participation in the recovery plan for the child may be due to their limited knowledge of the mental illness of their child, or their unfamiliarity with the notion of the need for family involvement to support the child or young person to recover. Psycho-education and close liaison is necessary.
• Asian clients tend to somatise their mental illness. For example, they will say they have a headache or stomach pain rather than saying they suffer from depression or other mental illness.
• Language barriers and cultural complexity prevent adequate diagnosis and treatment for Asian migrants and refugees. Presentation of mental health symptoms and acceptance of treatment is challenging in cross cultural psychiatric practice.
• Migrants and refugees may not seek psychological services or attend psychological sessions when referred. They may agree but may not turn up for the appointments.

(Waitemata DHB, eCALD® Services, 2010)

In traditional Asian families, children are highly valued and protected. They are taught to be quiet, humble, shy, polite and deferential. Emotional outbursts are discouraged and conformity to expectations is emphasized. Failure to meet expectations brings shame and loss of face to the child and the family, so parents are often reluctant to accept that there is a mental health problem. Generally parents do not express affection or praise for fear of encouraging laziness (Kramer, et al., 2002).

Adolescence has little meaning in most Asian cultures as individuation has no value and seeking an identity outside the family is discouraged (Kramer, et al., 2002). However, after migration the adolescent faces the significant challenge of bridging opposing expectations in a new culture, and this often becomes a cause of intergenerational conflict. While individualism is attainable for migrant Asian adolescents, individuation is not a likely option (Ehthnolt & Yule, 2006).

Assessing children and adolescents is best done in a semi-structured way in order to establish rapport, engage the child and collect information. This relationship building approach is particularly important at the first interview when parents are usually included.

Further interviews may need to be more structured, especially when assessing for diagnostic criteria, medico-legal reports etc.

Rho and Rho (2009) suggest that: 

• Having a parent or caregiver present may be useful in the initial interview.
• A qualified interpreter is important and the child should not be expected to act as an interpreter.
• A holistic approach is mandatory when working with children.
• Time should be taken to explain what a mental health worker is and what services are available.
• Care needs to be taken when analysing the results of questionnaires as many scores have a western bias. Allowances must be made for language and cultural differences.

Rho and Rho (2009) remind us that children either internalise (manifesting as depression or anxiety) or externalise (manifesting as disruptive behaviour) their emotions. Aggression and disruptive behaviour are more common in boys, whilst anxiety and adjustment issues tend to be more prevalent in girls. Depression, anxiety and sleep disturbances are common complaints in children, and depression and anxiety is common in Asian adolescents.

In New Zealand, schools tend to make the most referrals to mental health services, where social, interpersonal and family problems are of concern. Referrals made by caregivers are often influenced by culture and the caregiver's perceptions of emotional and behavioural problems.

Parent’s expectation of the child’s development and behaviour

Conducting culturally sensitive interviews with a young child can be challenging, particularly if the parents do not understand why they have been referred. They may be hesitant to disclose details about the child's behaviour at home if they do not know why they are being asked for the information (Rho & Rho, 2009). It is important to understand the parent's expectation of the child's development and behaviour, and whether they see the issue as problematic in their own culture.

Child’s insight into what behavior is acceptable at home

Using culturally sensitive assessment toys and gaining insight into what behaviour is regarded as acceptable at home, can help the clinician to understand the reason for referral. Children may be encouraged to be assertive and outspoken at school, but in the collectivist culture they come from, this may not be acceptable.

Parenting style

According to Rho and Rho (2009) corporal punishment is commonly used in Asian countries, especially Korea. When children get referred to clinicians by child protection services, it is important to treat the parents in a culturally sensitive, non-shaming way and to explain that in New Zealand alternative forms of punishment are preferred and that corporal punishment is illegal. Normalising the behaviour in an understanding way and providing guidance on alternative forms of punishment like time-out, is very useful to parents. Educating the referring agencies about the need for cultural sensitivity is essential, as well as correcting misattributions like bruising that are caused by cupping and coining, and not by physical violence (see Coining section under Traditional health beliefs and practices: Humoral/Body Balance in this resource). Educating parents through language appropriate parenting programmes such as the Incredible Years Programme (IYP) will assist with developing parenting skills in the New Zealand context.

Acculturation and migration experiences

Assessing Asian children who are in the process of acculturating can be challenging (Rho & Rho, 2009). These children are navigating their way through developmental milestones in a foreign country, in a foreign language, in a culture that is unfamiliar. Because developmental processes can be disrupted during migration due to acculturation (as well as pre-migration experiences for some refugees), it can be difficult to assess developmental stages in the context of cultural norms.

Age at the time of migration is an important factor when assessing cultural differences in expression of psychological symptoms (including somatization). The influence of acculturation is more obvious in those adolescents who immigrated at a young age (Chan & Parker, 2004).

Suggested assessment approaches

Rho and Rho (2009) suggest taking the following cultural factors into account when conducting assessments:

Children:

• When assessing children's development, it is important to bear in mind that childhood milestones can be culturally based (eg expectations for toileting skills can vary from 4 months to 4 years, ages at which children walk or talk can depend on child-rearing practices etc.).
• In many cultures, children are expected to be 'seen and not heard' and may not communicate assertively with adults, whilst in other cultures children are the centre of attention and are accorded many privileges until a certain age. Expressiveness, both vocal and physical may differ significantly across cultures.

Adolescents

• It is important to assess whether identity has been established. Emerging independence in adolescence, recognised in Western cultures may not be relevant to other cultures. In holistic cultures where modesty, respect, courtesy and loyalty are valued, independence is usually not valued. Conflict may occur within families, but also within the adolescent who is caught between two cultures and is trying to define themselves, their values and their beliefs.
• Sexuality issues, interracial relationships and taboo subjects like homosexuality will need to be explored in a very sensitive way.
• If delinquency issues are involved, referral to school liaison teams may be needed. However, parents may need to be educated about the process and this will require careful cultural consideration.
• Due to peer pressure to join a new culture, and adjustment difficulties, drug and alcohol abuse may be a problem. Information may not be accessible to parents due to language barriers.
• In general, and in Korea in particular (because of conscription factors) age difference between boys is significant with a difference of only one year providing a child status over another. This can often result in bullying between boys that seem of a similar age.

Engaging with family

Many Asian children are likely to come from families that are family-centered, with extended members, rather than from nuclear families. It is important to ask who the main caregiver and /or decision maker is and to involve them in the process. Our individually oriented care is often not appropriate for clients where families make decisions, and independence and empowerment are not valued in the same way, or are at odds with families' wishes.

Problems arise in our approaches because:

• Families are consulted.
• There is insufficient understanding about how family structures differ across cultures, and who is included in family boundaries.
  • Key family members are not included in consultations and treatment plans and therefore family members so do not support, or may even prohibit proposed interventions. Family members attending the consultations may not fully understand the plans or reasons for them and are unable to convey these to the head of the family. Sometimes the misunderstanding is because of language or lack of familiarity with the medical terminology, at others it may be due to confusion around multiple services and clinicians.
  • The key caregiver in the family needs to be included in the consultations. This person is not always a parent, and may also not be the key decision maker. If they are not involved they may not understand or be invested in procedures or care plans.

Implications for practice

• Involving parents or family in the assessment of a CALD child is helpful in establishing acculturation rates of the child and parents. Acculturation, and differences in levels between parent and child, are often at the root of a problem, but may not be obvious in the presenting issue.

Explanatory models of illness

• Children also have their own explanations for illness, so it is important to explore the child (as well as the family's) understanding of the problem, and their expectations and beliefs about outcomes.

(Waitemata DHB, eCALD® Services, 2010)

In spite of the resilience of children from refugee backgrounds, many experience mental health difficulties that only manifest sometime after settling. In particular, PTSD may present 2-3 years after migration when the child/adolescent has developed trust in their surroundings.

Young refugees are frequently subjected to multiple traumatic events before and during their migration journey. These may include the loss of parents and siblings, extended family, friends, security and homes, as well as witnessing or experiencing extreme trauma. Ongoing stressors within the host country may exacerbate previous stress. Children are also vulnerable to the intergenerational transmission of trauma. The Cambodian and Vietnamese refugees (and some Laotians) who resettled in New Zealand in the 1970s and 1980s were a highly traumatised group and they have tended not to seek mental health intervention for a variety of reasons. A migration history for Southeast Asian children and adolescents who present to mental health services will be important. Some of these children may be carrying burdens of the unresolved issues of their parents and grandparents.

An awareness of relevant risk and protective factors is important. Commonly reported issues include PTSD, grief, depression, anxiety, sleep disorders, somatic complaints, conduct disorders, social withdrawal, attention problems, generalised fear, over-dependency, restlessness and irritability. In New Zealand substance abuse is a problem amongst refugee adolescents, and PTSD, depression and anxiety disorder are recognised as co-morbid features. Despite treatment, reoccurrence is common.

Refugee children are often reticent to discuss past traumas and choose to focus on the future. This should not be discouraged because a future-orientated view has been associated with lower rates of depression in refugees (Beiser & Hyman, 1997).

Some brief pointers for working with Asian children and adolescents are added here to include those children from refugee backgrounds who are from Asian backgrounds (including: Indo-Chinese groups from Cambodia, Vietnam and Laos; Sri Lankan Tamils; Nepali-speaking Bhutanese or "Lhotsampas", and Burmese groups). This serves to remind the practitioner to investigate the client's migration/refugee experience and ethno cultural background and to orient care accordingly.

Suggested approaches:

• Stigma, 'saving face', absence of Cartesian mind-body dichotomy, somatization, health-seeking pattern, language barrier and reframing are essential concepts to be aware of when doing assessments. Demonstrating an awareness and understanding of these will go a long way towards good rapport and trust with your client, as well as accessing the more subtle factors in a presentation.
• A distinction needs to be made between somatizing distress and how distress is reported to others. Explore how clients experience their psychological and emotional distress.
• Whether assessing adults or children, understanding their ethnocultural identity, migration experiences and acculturation levels, are essential. Ask about migration experiences and settlement challenges; these are often inextricably linked with the problem.
• Milestones can differ, depending on cultural norms and values. When assessing Asian children and adolescents, explore family expectations and perspectives on development and behaviour. Goals for treatment need to be congruent with family's and child's norms.
• Problems related to pre-migration trauma may present years after refugees have settled. Knowing your client's migration history can alert you to possible underlying issues at problem presentation. Be alert for cues and explore these sensitively, but do not push clients to speak about issues that may have been dormant for years.

Intergenerational conflict, that is, between parents and children, between parents and grandparents, and between children and grandparents, is very common in Asian migrant and refugee families (Potocky-Tripodi, 2002). Intergenerational conflict between parents and grandparents is explored in the section on ‘Intergenerational and interethnic family relationship issues’. This section will explore the conflict between parents and children and children and grandparents.

Intergenerational conflict is due largely to different acculturation rates between the generations, meaning that the different generations adopt the norms of New Zealand society at different rates, resulting in different expectations of behaviour from parents and grandparents (Matsuoka, 1990).

Many Asian families maintain close ties with family members in countries of origin and therefore the concept of family is transnational. Physically distant family members have a significant influence on parenting and child rearing practices, and on decisions about health care and family dynamics.

The following framework is useful for providing a general understanding of the range of intergenerational conflicts faced by most Asian migrant families.

Conflicts across three generations of migrant and refugee families

(Adapted from Pettys & Balgopal, 1998 cited in Potocky-Tripodi, 2002 pp 316-318)

Intergenerational conflict related to children and adolescents

The major source of intergenerational conflict is differential acculturation. This is particularly true in relation to migrant children and adolescents. Immigrant and refugee background children learn English and New Zealand culture before their parents and grandparents. Children are often given adult responsibilities and placed in the role of interpreter/translator in relation to dealing with schools; health care and social support services etc. Role reversal may lead to a lack of respect by children of their parents and grandparents. Children will follow the norms of behaviours of their peers which may be upsetting to parents and grandparents.

Parents may be so overwhelmed by the stressors of the migration process that they are unable to provide emotional support to their children and may turn to their children for emotional support themselves (Athey & Ahern, 1991).

• Intergenerational conflict and gender role expectations

Another source of conflict between children and parents/grandparents may be gender roles. Parents may have gender role expectations for their children that are incompatible with behaviours the children need to function effectively in New Zealand society. For example, parents may expect girls to be quiet, obedient and subservient, whereas assertiveness, initiative, independence and competitiveness are needed in order to achieve in school (Potocky-Tripodi, 2002). When faced with these contradictions, girls may rebel at home. Parents may place more restrictions on the behaviours of daughters than sons, leading to resentment by girls, particularly in comparing themselves to their peers.

• Maintaining parental discipline

Parental discipline of children is often problematic. The long hours that parents spend at work in order to support their family may lead to children being without parental supervision for long periods (Matsuoka, 1990). Intergenerational role reversals may result in a loss of parental authority over children. Children soon learn that some kinds of discipline eg corporal punishment are considered child abuse in New Zealand and some use this knowledge to threaten to report their parents to the police. Parents should be encouraged to attend parenting programmes, for example Incredible Years Training to learn new parenting practices.

• Intergenerational conflict with grandparents

Conflicts are likely to arise between grandparents and grandchildren, and also between grandparents and parents, because grandparents may disapprove of the parent’s new child rearing practices (Carlin, 1990). For example, conflicts about what language should be used in the home are common. Grandparent’s lack of English language ability makes them highly dependent on younger family members, adding to the increased likelihood of conflict.

Asian cultures place a high value on filial piety, which refers to children treating parents with a high degree and respect and taking care of them in their old age (Chang & Moon, 1997). In Asian cultures, older family members are wise advisors. However, this status is lost, since their life experience is seen as irrelevant to living in New Zealand, leading to a lack of respect by younger people.

Life Cycle Issues

A major developmental task of adolescence is identity formation. Migrant adolescents frequently experience substantial conflict regarding their ethnic identity. For Asian migrant children, the task of forging an ethnic identity is compounded by competing demands from two cultures (Potocky-Tripodi, 2002). Whereas at school and with their peers, children are rewarded for westernising as quickly as possible, at home new habits and behaviours are discouraged.

Adolescent’s reactions to ethnic identity conflict may vary. Some may reject one culture or the other, effectively removing themselves from interaction with members of that culture. Some may develop a heightened sense of ethnic/religious pride, often in reaction to experiencing racism and discrimination. Others will experience alternating periods of identifying with one or the other culture and some will selectively choose elements from both cultures to fit their circumstances (Gopaul-McNicol, 1993). This is considered to be the ideal outcome (Potocky-Tripodi, 2002).

• Expectation of academic achievement

Asian parents have expectations for high academic achievement for their children (Carlin, 1990).

• Some children faced with migration stressors, refugee resettlement, the developmental tasks of adolescence, ethnic identity conflicts and pressure to succeed are at risk of developing mental health problems arising from multiple stressors.

Ann An, 19, moved to New Zealand as a child with her parents from China. "If I said I felt fully Chinese I would be lying, because I see myself more as a New Zealander". •Parents want children to carry on their ethnic values and identity. Strict parenting styles may be perceived as being authoritarian. Youth identify more with their peers in a new country than their family. This may lead to complicated relationships and negotiations with their parents. Children balance parents'/grandparent’s expectations; and want to be like Kiwi friends. Migrant parents fear losing children to the new culture but want children to have a better life.

NZ Herald (May 18^th 2016).

(Waitemata DHB, eCALD® Services, 2010)

This tool has been adapted for use with children and adolescents. The following questions are useful for exploring the cultural and ethnic identify and explanatory models of illness with children and their families.