Given the various stressors associated with the migration experience, it is necessary to understand the prevalence of mental health disorders among refuges and asylum-seeking migrants. Research has shown that in high income countries, such as the United States, the prevalence of mental health visits with asylum-seeking migrants continue to rise³. Psychiatric illnesses among refuges are common, as high as 40%, 44%, and 36% for anxiety, depression, and post-traumatic stress disorder, respectively⁴. Hence, increasing attention should be devoted to improving mental health practices for refuges and asylum-seeking migrants. In a review article⁵ published in the Canadian Journal of Psychiatry, Dr. Rousseau from McGill University provided the following recommendations:

• Medical education should include cultural competence training that increases awareness of refugee predicament and dismantle any associated negative perceptions.
• Besides directly psychiatric care, non-specific psychosocial interventions, which include establishing immigration status, education, employment, should also be prioritized, which can involve community organization.
• Increased advocacy efforts from psychiatrists to speak on immigrant mental health and to initiate protective social policies.

In San Diego, the following agencies provide services to the refugee communities:

• International Rescue Committee: https://www.rescue.org/united-states/san-diego-ca
• Jewish Family Services: https://jfssd.org/our-services/refugees-immigration/refugee/
• San Ysidro Health Center (Caldean/Iraqi): http://www.syhc.org/cmss-social-services/
• Catholic Charities: https://www.ccdsd.org/refugee-services
• Somali: http://www.somalifamilyservice.org/
• SD County Behavioral Health Services: https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/bhs/TRL/TRL%20Section%203/BHS-CYF%20Outpatient%20Clinics%204-4-19.pdf

Thanks to contributors:

Leo Meller, BS, is a first-year medical student at UCSD School of Medicine passionate about immigrant health.

Shawn Sidhu, MD, FAPA, is a child and adolescent psychiatrist at UCSD/Rady and program director of the Child & Adolescent Psychiatry Fellowship Program at UCSD.

A recent systematic review from a national cohort which included 779 refugee children found that psychiatric illness disproportionately impacts this group.  In particular, and not surprisingly, rates of PTSD, depression, and anxiety were higher than expected. Prevalence of PTSD was 22.71%, depression 13.81%, and anxiety disorders 15.77%.  Virtually all of these disorders are likely consequences of the dislocation trauma associated with the migration and refugee experience, but it is relevant to note that social isolation, social withdrawal and ongoing trauma from lack of fit with the new cultural expectation and as a consequence of rejection, bullying and the general demands of acculturation are factors that can lead to psychosocial stress and behavioral health difficulties, including higher rates of suicide and psychosis.   These difficulties and adaptation issues, of course, are magnified by the impact of detention and family separation that are sadly often an element of the relocation process.

These elevated prevalence rates highlight the importance of multimodal intervention strategies for this vulnerable population to include screening for both general behavioral health problems and for overt psychiatric disorder when refugee families come for care.

As with many at-risk populations, mental health services for migrants and refugee youth and families often encounter challenges in engaging the population. Amidst the multitude of challenges faced by these families, including adjustment to a new culture, language barriers, economic challenges, cultural barriers to family engagement, coupled with the perceived stigma and demands of pursuing treatment for mental health problems put timely intervention for these on the back burner for many.  In the face of these multiple issues, even sensitive healthcare providers may not adequately have the time or capacity to prioritize attention for timely and needed behavioral interventions for the youth and for their parents, many of whom have face similar emotional challenges.

Integrating behavioral health care within a nexus of community-based and family-focused services and supports in coordination with other care management activities for basic needs is generally seen as a best practice for refugee families (McNeeley et al, 2019).  Actualizing this ideal remains a challenge in most communities.

In San Diego, the following agencies provide services to the refugee communities:

• International Rescue Committee: https://www.rescue.org/united-states/san-diego-ca
• Jewish Family Services: https://jfssd.org/our-services/refugees-immigration/refugee/
• San Ysidro Health Center (Caldean/Iraqi): http://www.syhc.org/cmss-social-services/
• Catholic Charities: https://www.ccdsd.org/refugee-services
• Somali: http://www.somalifamilyservice.org/
• SD County Behavioral Health Services: https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/bhs/TRL/TRL%20Section%203/BHS-CYF%20Outpatient%20Clinics%204-4-19.pdf

Efforts to screen patients and raise awareness about the prevalence of behavioral and psychiatric challenges within primary care settings will increase our community’s opportunities to support refugee families.  We know that building a trusting relationship with our patients, increasing access to basic needs and targeting resiliency factors makes a difference.     Engagement of pediatric providers in screening, care coordination, treatment and appropriate referral activities can provide an important impetus and an access point to care when behavioral health intervention is indicated.

Blackmore R, Gray KM, Boyle JA, Fazel M, Ranasinha S, Fitzgerald G, Misso M, Gibson-Helm M (2019). Systematic Review and Meta-Analysis: The Prevalence of Mental Illness in Child and Adolescent Refugees and Asylum Seekers. J Am Acad Child Adolesc Psychiatry. 2019 Nov 25. pii: S0890-8567(19)32175-6. doi: 10.1016/j.jaac.2019.11.011.

California Department of Social Services (2017) Refugee Programs Bureau FFY 2017 Refugee Population Data Snapshot By County. https://www.cdss.ca.gov/Portals/9/Refugee/Arrivals/2017_Comprehensive_Chart.pdf?ver=2017-12-27-111308-203

McNeeley, C., Sprecher K., Bates-Fredl, D., Price, O., Allen, C., (2019). Identifying Essential Components of School-Linked Mental Health Services for Refugee and Immigrant Children : A Comparative Case Study. Journal of School Health 2019 1–12. https://doi.org/10.1111/josh.12845

While potentially more relevant as a screening and monitoring tool for family therapists, a brief discussion of the Family APGAR’s dimensions is offered herein to assist the primary care physician in their more informal psychosocial assessment and appraisal of their patient’s families.  Our goal is to assist PCPs in identifying ways in which a distressed family may be at risk and then facilitating their referral for educational intervention, supportive services, and/or formal therapies that will be most appropriate.

The five functional components of the Family APGAR are: Adaptability, Partnership, Growth, Affection, and Resolve.   Substantial deficits or distortions in any of these arenas may lead to challenges in child-rearing and child development that can lead to dysfunction that may manifest in physiological, psychological, and/or social domains.  For parent and other adult patients’ similar concerns about dysfunctional coping are of equivalent concern.  Families with greater functionality in the APGAR domains can deal better with adversity (medical, financial, sociocultural, etc.) in addressing both routine and exceptional challenges in their lives.

THE FAMILY APGAR DOMAINS

Component                                                                                         Definition

Adaptation              Adaptation is the utilization of familial resources for problems solving in the face  of life change(s) that disrupt the                                                        family’s equilibrium

Partnership             Partnership is the sharing of decision making and nurturing responsibilities within the family

Growth                     Growth is the physical and emotional maturation and self-fulfillment achieved by family members through mutual                                                     support  and guidance

Affection                 Affection is the caring or loving relationship that exists among family members

Resolve                   Resolve is the commitment to devote resources to other family members for physical and emotional nurturing

——————-

THE FAMILY APGAR QUESTIONAIRE:   Five questions rated using a 0, 1, or 2 score to represent

0   =    Hardly ever

1    =  Some of the Time

2   =   Almost Always

1. I am satisfied with the help I receive from my family when something is troubling me
2. I am satisfied with the way my family discusses items of common interest and shares problem solving with me
3. I find that my family accepts my wishes to take on new activities or make changes in my life
4. I am satisfied with the way my family expresses affection and responds to my feelings
5. I am satisfied with the amount of time my family and I spend together

In the ideal world, it would likely be desirable to utilize the Family APGAR, or a similar instrument, routinely to obtain both baseline and post-incident measures of a family’s resilience and adaptability, however, the realities of current day practice, with demands for screening of multiple health and behavioral health concerns, make implementation unlikely.  That said, it is hoped that this discussion of the Family APGAR screening tool will serve to highlight the various dimensions of family functionality and identify means of inquiry to assess these domains and result in enhanced clinical awareness and responsiveness for families in distress.

We encourage your making referrals of parents and families to the SmartCare Parent Line @ (858) 956-5900 when further evaluation attention may be desired to address psychosocial and behavioral health issues. Our staff can provide supportive guidance and assist in making referrals for those who present with service needs.

Reference:

The Family APGAR:  A Proposal for a Family Function Test and Its Use by Physicians,  G. Smilkstein, MD, The Journal of Family Practice, Vol 6, No 6, 1978

While there are resource challenges of both time and funding for families, and continued attention to the primary treatment needs of youth with mental health disorders should never be ignored, efforts to develop treatment plans that integrate diagnostic and treatment strategies across disciplinary boundaries is a sensible approach.  Though often not pursued with appropriate vigor, occupational therapy approaches can aid in identifying neurosensory, emotional regulatory, and cognitive ‘style’ considerations as part of the diagnostic process and can assist in identifying and promoting relevant social and emotional competency building experiences that can be incorporated in therapeutic intervention strategies to enhance self-esteem, social skills, and overall well-being in conjunction with psychological and psychopharmacologic interventions .

Two clinical examples:

• ADHD: Providing parents, teachers and the affected youth with a better understanding of their unique strengths and challenges in attending and in executing cognitive functions can often lead to the development of viable strategies in learning and can reduce feelings of helplessness.
• Anxiety: Recognition of an individual’s heightened sensitivities and reactivity to various environmental triggers can assist parents, teachers and the affected youth make choices about how to modulate exposure to stressors and to define social and recreational regimens that accommodate a youth’s individual needs.

Following are abstracts culled from the American Occupational Therapy Association’s Fact Sheet on this theme.¹

“Participation in meaningful roles (e.g., student, friend, family member) and activities (e.g., sports or hobbies) leads to enhancement of emotional well-being, mental health, and social competence. Social competence for children and adolescents includes doing what is necessary to get along with others, making and keeping friends, coping with frustration and anger, solving problems, understanding social etiquette, and following school rules. Recent studies indicate that behavior and social interaction skills (i.e., social competence), are stronger indicators of academic and lifelong success than academic skills.” ²

An occupational therapy evaluation can “assess all the components of social competence and determine whether a child’s motor, social-emotional, and cognitive skills; ability to interpret sensory information; and the influence from home, school, and community environments … impact” their “ability to meet the demands of everyday life.³ ”

“Occupational therapists use a client-centered evaluation process to develop an understanding of the child’s primary roles and occupations (activities), such as play, schoolwork, and age-appropriate self-care. A client-centered assessment for children also requires interaction with school staff, parents, care providers, and community members. Therapists then seek to determine what factors affect the child’s ability to meet the demands of these roles and activities and fully participate in them.”

“Interventions are used to promote social–emotional learning; regulate overactive or underactive sensory systems; collaborate with families and medical or educational personnel; and more. For example, occupational therapy practitioners can help the child incorporate sensory and movement breaks into the day to enhance attention and learning; and provide support to teachers and other school staff by breaking down study tasks, organizing supplies, and altering the environment to improve attention and decrease the effect of sensory overload in the classroom. Occupational therapy practitioners can also provide programming to establish social competence through planning and development of playground skill groups, bullying prevention, social stories, and after-school activities.”

“Occupational therapists … also collaborate with adults in the child’s life:

• Parents or care providers—to provide education about the social-emotional, sensory, and cognitive difficulties that interfere with a child’s participation in play, activities of daily living, and social activities; and to help develop emotional supports, structure, and effective disciplinary systems
• Educators and other school staff—to develop strategies for a child to successfully complete classroom, recess, and lunchroom activities, and to interact effectively with peers and adults
• Counselors, social workers, and psychologists—to provide insights into the interpersonal, communication, sensory processing, and cognitive remediation methods that aid emotional and social development
• Pediatricians, family physicians, and psychiatrists—to support medical intervention for persistent mental illness and to provide a psychosocial and sensory component to supplement medical intervention
• Communities—to support participation in community leisure and sports programs; encourage education, understanding, and early intervention for children with mental health problems; and develop advocacy and community programs for promoting understanding of the mental health diagnosis and decreasing stigma”

“Ultimately, the goal of” occupational therapy “intervention is to promote successful participation in” activities “that characterize a healthy childhood and set up the child for success throughout his or her life. Occupational therapy practitioners” can “help to promote safe and healthy environments for learning, growth, and development by addressing both physical and mental health.”

Bottom Line:  Judicious consideration of the potential benefits of referring an child and family for an occupational therapy evaluation and maintaining a focus on enhancing all elements in a child’s home, school and community environment can be important considerations in treatment planning and implementation in the face of underlying mental health and developmental difficulties.

References:

¹   Fact Sheet: Occupational Therapy’s Role with Mental Health in Children and Youth

Lisa M. Mahaffey, MS, OTR/L, for the American Occupational Therapy Association. copyright © 2016

²  Jones, D. E., Greenberg, M., & Crowley, M. (2015). Early social-emotional functioning and public health: The relationship between kindergarten social competence and future wellness. American Journal of Public Health, 105, 2283–2290. http://dx.doi.org/10.2105/ AJPH.2015.302630

³ Arbesman,M., Bazyk, S., & Nochajski, S. (2013). Systematic review of occupational therapy and mental health promotion, prevention, and intervention for children and youth. American Journal of Occupational Therapy, 67, e120–e130. http://dx.doi.org/10.5014/ajot.2013.008359

Multiple previous studies have shown a link between childhood bullying and the development of childhood mental health concerns, like low self-esteem, depression, poor academic performance and even an increased risk of suicidal thoughts and suicide. This is one of the first efforts to assess the longer-term effects of childhood bullying.

In the study, children were assessed for involvement with bullying (whether they were bullying others or being bullied by others or both) at age 8, then followed up with in their late teens and early adulthood. What was found was that the patients who were involved with bullying in childhood (whether they were being bullied by others or bullying others) were twice as likely to be receiving treatment for a psychiatric condition compared to the patients who were not involved with bullying in childhood. The group that was involved both in being bullied and being bullies themselves fared the worst – they were three times as likely to be receiving psychiatric treatment and were more likely to have more serious diagnoses like schizophrenia, substance abuse and mood disorders.

It is important to be aware of and address bullying with our pediatric patients. It is particularly important to be aware if a child is involved both as a bully and as a victim, because he is at a higher risk for serious problems both in childhood and adulthood.

Here are some additional resources that you may find helpful with regard to bullying.

https://www.sandiegounified.org/parents-and-guardians-bullying-and-intimidation-facts for information about San Diego Unified School District’s policy on bullying and their online bullying reporting system.

https://www.stopbullying.gov/index.html for information and support on bullying.

http://www.pacer.org/bullying/ for information and support on bullying.

References:

Association of Bullying Behavior at 8 Years of Age and Use of Specialized Services for Psychiatric Disorders by 29 Years of Age; JAMA Psychiatry, Online First, December 9, 2015.