5 Research suggests that Latino children are at an elevated risk for a variety of mental health problems (Flores, Fuentes-Affl ick, Barbot, et al., 2002). Latinos are often vulnerable to the deleterious effects of poverty, institutional racism, community violence and other types of psychoso- cial stressors, which have been linked to negative mental health outcomes (Flisher, Kramer, Grosser, et al., 1997; Saunders, Resnick, Hoberman, et al., 1994). Furthermore, Latino children are likely to face signifi cant barriers to accessing mental healthcare services, such as limited availability of Span- ish-speaking providers, diffi culty obtaining and navigating health insurance, and cultural obstacles, such as the belief that mental illness is a spiritual or religious matter. The current paper will: (1) explore specifi c risk factors for mental health disorders among Latino children; (2) examine barriers to appropriate mental health treatment among Latino children; (3) provide an overview of the types of intervention strategies currently used to address men- tal health problems among Latino children; and (4) offer recommendations for the development of additional and/or improved methods for the prevention and treatment of mental health disorders among Latino children. here are more than 11.6 million Latino children living in the U.S., compromising the largest minority group of children in this country (Flores, et al., 2002). Despite the growing number of Latino children, there is a dearth of empirical research on specifi c mental health problems experienced by this burgeoning population. Lack of education regarding childhood mental illness and limited access to services are suspected to contribute to underreporting and, in turn, lack of treatment among Latino children. For example, studies have demonstrated that White children are more than twice as likely to receive diagnosis and treatment of Attention Defi cit Hyperactivity Disorder (ADHD) than African American and Latino children (Olfson, Gameroff, Marcus, et al., 2003; Eiraldi, Mazzuca, Clarke, et al., 2006). In addition, despite problems with surveillance of Latino childhood mental health problems, a study by Canino, Could, Prupis, and Shaffer (1986) indicated that Latino children are at greater risk for depression, anxiety, school refusal, and diffi cult interpersonal relationships with other children than their Black or White counterparts. Ian Holloway T LATINO CHILDREN’S MENTAL HEALTH: AN ANALYSIS OF RISK FACTORS, HEALTHCARE ACCESS, AND INTERVENTION STRATEGIES LATINO CHILDREN’S MENTAL HEALTH 6 JOURNAL OF STUDENT SOCIAL WORK, VOL. V IA N H O L L O W A Y The disproportionate mental health disease burden among Latino children is especially troubling given the negative health outcomes that result from childhood mental health disorders (Flores, et al., 2002). Childhood is a crucial period in the lifecycle, marked by rapid changes in cognitive and emotional development; mental health disorders can cause academic and social impairment, which have serious ramifi cations on the developmental trajectories of children later in life. For example, research has demonstrated that early-onset emotional and behavioral problems in children are related to negative consequences in adolescence, such as educational diffi culties (Tuakli-Williams & Carillo, 1995), substance use (Sterling, Kohn, Lu, & Weisner, 2004), juvenile delinquency and school dropout (Loeber, 1991; Ramey, & Ramey, 1998), and attempted suicide (CDC, 1999). Risk Factors for Latino Children’s Mental Health Problems While it is clear that additional research must be conducted in order to determine base rates of mental illness among Latino children, a signifi - cant body of literature exists documenting risk factors that may lead to or exacerbate mental health disorders among Latino youth. Twenty-eight of Latino families reside in poor families (NCCP, 2005), and Latino children are more likely to live in resource poor, urban neighborhoods than their White counterparts (Kasarda, 1993; Fass & Cauthen, 2006). These children are often exposed to negative environmental stressors, such as overcrowding, neighbor- hood disorder, community violence, and trauma exposure, factors which have been linked to childhood psychopathology (Wandersman & Nation, 1998; Vostanis, Tschler, Cumella, et al., 2001; McKay, Lynn, & Bannon, 2005). A study by Xue, Leventhal, Brooks-Gunn, et al.(2005) demonstrated that children in neighborhoods of low socioeconomic status have the highest levels of mental health problems when compared to children in medium and high socio- economic status neighborhoods. Low social control, lack of community cohesion, and compromised social capital networks have all been linked to negative mental health outcomes in children (O’Brien, O’Campo, & Muntaner, 2003; Xue, et al., 2005). Two other crucial factors that may contribute to the development of childhood mental health disorders among Latinos are acculturation and adjustment stress. Recent data from the Mexican American Prevalence and Services Survey indicated a positive association between acculturation and risk for lifetime prevalence of diagnosable mental disorders, such as affective, 261809_Columbia 01-72 Sec1:6261809_Columbia 01-72 Sec1:6 4/5/07 2:12:12 PM4/5/07 2:12:12 PM 7 IA N H O L L O W A Y anxiety, and substance use disorders (Organista, Manoleas, & Herrera, 2001). Latinos who emigrate to the U.S. often experience diffi culties maintaining their traditional cultural norms while attempting to integrate North American cultural practices and beliefs (Sue & Sue, 2003). While some Latino children are able to navigate the acculturation process smoothly and establish a bicultural identity, which has been shown to be the most benefi cial resolu- tion to acculturation confl icts for the individual (Miranda & Umhoefer, 1998), other Latino children often fi nd themselves caught between expectations of their family and their school or peer groups (Flores-Gonzalez, 2002). These types of acculturation confl icts can cause signifi cant psychosocial adjustment stress, which may lead to the development of mental health problems. Latino Children’s Access to Mental Health Care Despite the greater need for mental health services among Latino populations, there is evidence that the majority of these children are not receiving necessary care. Recent studies by Kataoka, Zhang, and Wells (2002) and Zimmerman (2005) revealed that Latino children have especially high rates of unmet need in terms of mental health service delivery relative to other children. This diffi culty accessing mental health services can be attributed to three primary factors: (1) insuffi cient services, (2) health insurance barriers, and (3) cultural barriers. Insuffi cient Services The U.S. currently faces a dramatic shortage of mental health providers who are specifi cally trained in the provision of mental health services to children and adolescents (Kim, 2003). A recent study by Thomas and Holzer (2006) indicated that youth living in poverty were least likely to have access to specialty child psychiatry services. These fi ndings are especially salient for Latino families, 28% of which are living below the federal poverty line (NCCP, 2005). A study conducted by Lopez (2002) cited availability of services as one of the many barriers to accessing mental health care among Latino families. In addition, many Latino families lack information regarding mental health services and recognition of child mental health problems (Teagle, 2002). Thus, Latino parents may not have the knowledge necessary to obtain appropriate mental health services for their children even when such services do exist. Furthermore, some Latino families may have diffi culty seeking mental health treatment due to immigration status. A study by Granados and LATINO CHILDREN’S MENTAL HEALTH 261809_Columbia 01-72 Sec1:7261809_Columbia 01-72 Sec1:7 4/5/07 2:12:12 PM4/5/07 2:12:12 PM 8 JOURNAL OF STUDENT SOCIAL WORK, VOL. V IA N H O L L O W A Y colleagues (2001) demonstrated that Latino children of immigrant parents were less likely to access routine healthcare than Latino children of U.S. born parents. While more research must be conducted to determine specifi c reasons why children of immigrant parents seem to have more diffi culty accessing healthcare services, one possible explanation is that these parents may fear that they will be questioned about their immigration status when seeking care for their children. Research conducted by Canlas (1999), which examined mistrust of the health care system among Latinos in East Harlem, New York, found that fear of deportation was a major reason given for underutilization of medical services by Latino participants. As such, undocumented Latino parents may be afraid to inquire about mental health services for their children, for fear they may be questioned about their immigration status, harassed or deported. Health Insurance Barriers Other factors impacting Latino children’s ability to access mental health services revolve around health insurance. Approximately 26% of Latino children are uninsured, compared with 10% of White children and 14% of African American children (Flores & Vega, 1998). While signifi cant improve- ments have been made in health insurance for minority children over the past 30 years, such as the expansion of Medicaid eligibility and the introduction of the State Children’s Health Insurance Program (SCHIP), insurance status continues to present a signifi cant barrier to Latino families’ ability to access mental health services (Alegría, Canino, Ríos, et al., 2002; Busch & McCue Horwitz, 2004). Medicaid and private insurance benefi ts are often administered through managed care organizations.While this arrangement has conserved a considerable amount of government money, signifi cant questions arise regarding pre-certifi cation for mental health services, disenrollment, and quality of care provided to minority children with mental illness. In addition to ineffective diagnostic and referral systems, managed care’s confusing guidelines also complicate coordination efforts between mental health providers, families, and schools. Children with mental health problems are often treated by many different systems and agencies, including schools, so- cial services, and the juvenile justice system. Lack of coordination and failed communication (many times resulting from language barriers) among teachers, social workers, and the courts often lead to inconsistent care for Latino children. In some cases there may be an overlap in services, where children and families receive confusing messages from multiple sources. However, more commonly, due to large caseloads and reduced funding, children 261809_Columbia 01-72 Sec1:8261809_Columbia 01-72 Sec1:8 4/5/07 2:12:13 PM4/5/07 2:12:13 PM 9 IA N H O L L O W A Y fall between the cracks as the various agencies try to pass off costs to other sectors. This is evidenced by the fact that 92% of children with serious emotional disturbances receive mental health services from two or more systems, and 19% from four or more (Glied & Cuellar, 2003). Cultural Barriers Latino communities face signifi cant cultural obstacles to obtaining mental health care. Research suggests that Latino families often do not view mental illness as a medical problem; instead some Latino families conceptualize mental illness as a spiritual or religious issue (Maduro, 1983; Sue & Sue, 2003). As a result, Latinos tend to underutilize mental health services while relying heavily on religious services for the resolution of emotional and interpersonal disturbances (Organista, Manoleas, & Herrera, 2001). While churches and other religious organizations may be a useful source of psychosocial support for Latino families, staff is seldom trained in the recognition of mental health disorders, which may lead to underreporting of mental health disorders and in many cases insuffi cient treatment of Latino children with mental health disorders. Insuffi cient research has been conducted on the impact of culture and language on the etiology of mental health disorders and the underutilization of mental health services among Latino children (Flores, et al., 2002). For example, few studies have examined the ways in which cultural constructs specifi c to Latino populations may impact the way in which mental health is viewed and treated in Latino communities. A shortage of bilingual and bicultural mental health providers further impedes access to effective mental health services for Latino children (Vega & Lopez, 2001). As a result, if Latino children are receiving mental health services, these services may be culturally irrelevant and ineffective, leading to premature discontinuation of treatment. Some critics of the U.S. mental health system assert that the dearth of bicultural mental health professionals is representative of a form of aversive institutional racism that may make it diffi cult for Latino families to participate in treatment altogether (Whaley, 1998). Latino Children’s Mental Health Service Delivery Micro-level Interventions: Individual & Family The majority of intervention programs that address Latino children’s mental health on the micro level have been carried out within family systems. LATINO CHILDREN’S MENTAL HEALTH 261809_Columbia 01-72 Sec1:9261809_Columbia 01-72 Sec1:9 4/5/07 2:12:13 PM4/5/07 2:12:13 PM 10 JOURNAL OF STUDENT SOCIAL WORK, VOL. V IA N H O L L O W A Y Children’s ability to access health care services almost always relies on their parents’ willingness to seek out and/or accept these services (Newacheck, Hughes, Hung, et al., 2000). Unfortunately, Latino parents may not realize that their children may be experiencing a serious mental health problem. For example, a recent study that sought to measure parental problem recognition and its impact on child mental health service use, determined that parental perceptions of their children’s mental illness played a key role in determining whether or not their children were able to receive services (Teagle, 2002). Education at the parental level is crucial to the identifi cation of serious mental health problems. A handful of empirically tested intervention programs specifi cally tailored for Latino populations have helped to educate Latino parents on normal childhood development and train parents to identify abnormal child behavior. For example, culturally adapted parent management training was de- signed by the Oregon Social Learning Center to educate parents on mental illness and help parents acquire general parenting skills in order to decrease external- izing behaviors in their adolescent children (Martinez & Eddy, 2005).This inter- vention proved successful in reducing a range of adolescent problem behaviors, including aggression and drug use. The strength of this program was its specifi c- ity; all parent-adolescent dyads studied were Spanish-speaking and parents were encouraged to express their own views of normal vs. abnormal child behavior based on previous experiences. Mezzo-level Interventions: School & Community School-based interventions are perhaps the most widespread programs to address mental health problems among Latino children. Schools are a logical place for the identifi cation of child mental health problems because the vast majority of children attend school and can be closely monitored by teachers and ancillary mental health staff (Hoagwood, Burns, Kiser, et al., 2001). One of the primary strengths of school-based programs is their ability to provide consistent support to children struggling with mental health problems. In 1999, Ambruster and Lichtman conducted a study to evaluate the effectiveness of 36 school-based mental health services in inner city New Haven, Connecticut. This study demonstrated that children enrolled in school-based mental health services showed comparable improvement in functioning on the Children’s Global Assessment Scale and the Global Assessment of Functioning Scale to children enrolled in clinic-based mental health care. This study also highlighted the crucial role that schools can play in mental health problem 261809_Columbia 01-72 Sec1:10261809_Columbia 01-72 Sec1:10 4/5/07 2:12:13 PM4/5/07 2:12:13 PM 11 IA N H O L L O W A Y identifi cation and treatment because they are able to reach disadvantaged children who otherwise would not have access to mental health services. School- based mental health services can be highly affective at improving academic achievement in high-poverty urban areas (Atkins, Frazier, Birman, et al., 2006) and are able to coordinate treatment planning with teachers and administrators, which allows for the development of educational plans that are informed by mental health treatment and vice-versa. Community-based interventions that address mental health treatment are also widespread (Hoagwood, et al., 2001). These interventions most often take place in community outpatient mental health centers or through integrated treatment coordinated through case management services at community-based organizations.While these settings are particularly effective in addressing mental health problems among children due to the presence of more skilled providers and psychiatrists who are able to prescribe medication, the weaknesses of community-based interventions lies in their inability to reach many Latino children. As previously mentioned, structural barriers, such as availability of services and insurance restrictions inhibit Latino children’s access to mental health services (Flores, et al., 2002). Furthermore, cultural barriers to treatment, such as lack of Spanish-speaking and/or bicultural providers, even in communities where the majority of children come from Latino backgrounds, often prevent Latino families from utilizing community outpatient services (Vega & Lopez, 2001). Macro-Level Interventions: Structural Transformation and Policy Development Policies to improve insurance coverage for low-income children, such as Medicaid expansion and the formulation of SCHIP, are examples of structural level interventions that have helped to alleviate the mental health disease burden in Latino children (Shone, Dick, Crach, et al., 2003). Another example of structural level change resulting in improved access to mental health services for Latino children is the Mental Health Parity Act, which took effect in 1996. This act, which was an important step in acknowledging the importance of mental health and placing it on an equal plane with physical health, ensured that mental health care benefi t limits were comparable to all other benefi ts (Sturm & McCulloch, 1998). This change was accompanied by the development of many new pharmaceuticals to treat mental health problems, and increased prescription benefi ts. As a result, insurance companies now cover mood stabilizers and psychotropic medications in the same way other medications LATINO CHILDREN’S MENTAL HEALTH 261809_Columbia 01-72 Sec1:11261809_Columbia 01-72 Sec1:11 4/5/07 2:12:14 PM4/5/07 2:12:14 PM 12 JOURNAL OF STUDENT SOCIAL WORK, VOL. V IA N H O L L O W A Y are covered, which has further equalized the mental and physical health sectors while reducing costs to patients. Two other examples of macro-level interventions that have helped improve mental health among Latino children are Head Start and Early Head Start, two Federal programs within the Administration on Children, Youth and Families in the Department of Health and Human Services.These programs offer comprehensive services aimed at improving the physical and emotional well-being of pre-school children in low-income families (ACYF, 2007). Head Start programs have been effective in promoting mental health among participants by working closely with parents to identify mental health problems in the family system and work with children and parents to address these concerns (Mann, 1997). While Head Start and the other structural level interventions mentioned above were not specifi cally aimed at improving the mental health of Latino children, such far-reaching policy implementation has been crucial to the improvement of Latino children’s mental health due to its ability to affect systemic change. Recommendations Micro-level Interventions: Individual & Family Mental health disorder identifi cation in children can be most effective if it occurs early (DHHS, 2000). Future intervention programs aimed at Latino families must target parents of younger children in order to help them recognize abnormal behaviors and seek appropriate care. In addition, all individual and family level interventions targeting Latinos must be culturally tailored to the specifi c Latino subgroup being targeted. There is a tendency in social work and public health research to group all Latino populations under the umbrella terms “Latino” or “Hispanic,” without paying attention to specifi c differences between subgroups based on country of origin (Flores, et al., 2002). This is problematic in that it fails to recognize the unique social and historical differences between Latino subgroups, including acculturation and other factors which may speak directly to child development and mental illness. While emerging research in the fi eld of mental health has begun to examine Latino subgroup differences, this is another area for the improvement of intervention strategies on the individual level. Mental health problem intervention programs must be tested with specifi c Latino subgroup populations in order to determine effi cacy and inform further specifi city. 261809_Columbia 01-72 Sec1:12261809_Columbia 01-72 Sec1:12 4/5/07 2:12:14 PM4/5/07 2:12:14 PM 13 IA N H O L L O W A Y Clinicians who work with Latino youth must also make themselves aware of the unique social and cultural issues affecting this population and the ways in which these factors may impact clinical work on the individual level. As previously mentioned, Latino youth are disproportionately affected by a number of psychosocial stressors, including the deleterious effects of poverty, institutional racism, and community violence. In preparing to work with Latino children, social workers must make a thorough assessment of the context in which the client lives, as well as individual functioning. Parental involvement is crucial to any intervention aimed at children (McKay, Pennington, Lynne, et al., 2001). Recent research has demonstrated that family support and family cultural confl ict were strongly associated with self- rated mental health among Latinos (Mulvaney-Day, Alegria, & Sribney, 2007). Therefore, it is essential that social workers treating Latino children engage parents and other family members in their efforts to help the child achieve greater psychosocial functioning. Mezzo-level Interventions: School & Community In order to improve school and community-based services, a number of steps could be taken. First, schools and community-based clinics could begin funding and implementing social marketing campaigns to educate children, parents, and community members about mental health problems. Social marketing campaigns can have small-to-moderate effects on health knowledge, beliefs, attitudes, and behaviors, which can be translated into signifi cant, positive public health outcomes (Noar, 2006). Community mental health intervention programs with a strong social marketing component have been used in Australia with favorable results (Wright, McGorry, Harris, et al., 2006); similar programs that specifi cally target Latino children’s mental health in the U.S. may also be effective. Through culturally tailored materials and targeted outreach efforts in English and Spanish, schools and community-based clinics may educate Latino families on the early detection of childhood mental health problems, inform parents of where to take their children for mental health screenings, and help to reduce the often confl icting information regarding etiology and treatment of mental illness in Latino communities. Service providers, especially teachers and pediatricians that work with Latino families, may also be targeted on a community level. These professionals are often encumbered by limitations in implementing preventative services. For example, teachers are often assigned large class sizes and primary care LATINO CHILDREN’S MENTAL HEALTH 261809_Columbia 01-72 Sec1:13261809_Columbia 01-72 Sec1:13 4/5/07 2:12:14 PM4/5/07 2:12:14 PM 14 JOURNAL OF STUDENT SOCIAL WORK, VOL. V IA N H O L L O W A Y physicians are required to see more patients in less time. As a result, these professionals have less time to develop strong, ongoing relationships with families and are less likely to identify mental health problems (AAP, 2000). While the American Academy of Pediatrics recommended increased funding for specialized training programs and job incentives for qualifi ed child mental health clinicians in 2000, the U.S. continues to lack suffi cient numbers of trained mental health workers to handle the specifi c mental health care needs of Latino children. In order to address this problem, school- and community-based interventions may offer teachers and pediatricians extensive training on the recognition of mental health problems in children. By educating these providers about the importance of mental health screening, school- and community-based programs can expand the network of competent providers evaluating Latino children for mental health problems. Macro-Level Interventions: Structural Transformation and Policy Development Despite the success of existing policy-level interventions, much more can be done to improve Latino children’s mental health on a structural level. For example, one of the key problems with mental health service delivery to Latino children is the severe shortage in culturally competent, bilingual service providers. Without Spanish-speaking mental health professionals who are able to understand and address the unique cultural considerations surrounding mental illness in Latino communities in clients’ preferred language, Latino children will continue to be underserved by the mental healthcare system. Local, state, and federal governments must be involved in efforts to expand minority provider networks. This may be done through the implementation of scholarship programs for Latinos interested in mental healthcare and/or tuition payback programs for providers who learn Spanish, participate in cultural competency trainings and work in minority neighborhoods after graduation. These types of programs currently exist but they are often fi nanced by private foundations. City, state, and federal policymakers may expand such programs by drafting legislation that institutionalizes and funds tuition payback programs in order to improve Latino children’s mental health in a more widespread manner. Policymakers can also improve mental health services for Latino children by implementing monitoring systems for mental health service provision and economic penalization for substandard service. “Families need mechanisms to communicate their comments and experiences [regarding mental health services] to those who purchase health care plans” (AAP, 2000, p. 862). In turn, healthcare purchasers must be responsible for providing adequate 261809_Columbia 01-72 Sec1:14261809_Columbia 01-72 Sec1:14 4/5/07 2:12:15 PM4/5/07 2:12:15 PM 15 IA N H O L L O W A Y LATINO CHILDREN’S MENTAL HEALTH information to clients about the quality and availability of culturally relevant mental health services. Many Latino children receive mental health services through federal programs, such as Medicaid and SCHIP. By setting up feedback systems that allow parents to express dissatisfaction with the quality of care their children are receiving, policymakers will help clients have a voice in the type of care they are offered. Opening channels for criticism, and backing up criticism with economic ramifi cations, will encourage mental health care providers to increase levels of service to meet clients’ needs. State and federal level policies can also help improve the detection and prevention of mental health problems among Latino children by implementing mandatory mental health screening programs in public schools. One of the main reasons for disparity in the need for mental health services and service provision is missed opportunities for early intervention. While time, energy, and fi nancial resources have been devoted to programs promoting children’s physical health, little emphasis has been placed on mental health among children. U.S. children are required to have physical examinations in order to attend public school; however, psychological evaluations are usually reserved until social, behavioral, or cognitive problems are far advanced. Government policies to implement mandatory screening for mental health problems in public schools will ensure the early detection of Latino children’s mental health problems. However, in order for screening programs to be effective, they must be reinforced by comprehensive services to treat Latino children’s mental health problems. Conclusion Latino children are at heightened risk for developing mental health problems due to a range of psychosocial factors, including poverty, community violence, acculturation, and adjustment stress (Wandersman & Nation, 1998; Vostanis, Tschler, Cumella, et al., 2001; McKay, Lynn, & Bannon, 2006). At the same time, these children often face signifi cant barriers to receiving mental health services resulting from limited education regarding mental illness, scarcity of bilingual and bicultural service providers, and aversion to the mental health system due to cultural, spiritual, and religious factors. While some intervention programs have been implemented at the individual, community, and structural levels to address Latino children’s mental health, much remains to be done in order to address this signifi cant public health concern. 261809_Columbia 01-72 Sec1:15261809_Columbia 01-72 Sec1:15 4/5/07 2:12:15 PM4/5/07 2:12:15 PM 16 JOURNAL OF STUDENT SOCIAL WORK, VOL. 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Zimmerman, F.J. (2005). Social and economic determinants of disparities in pro- fessional help-seeking for child mental health problems: Evidence from a national sample. Health Research and Educational Trust, 40(5), 1514-1533. IAN HOLLOWAY is a second year student in the dual-degree master’s program with the Mailman School of Public Health, within the Reproduc- tive, Adolescent and Child Health track in the Heilbrunn Department of Population and Family Health and CUSSW, within the Advanced Clinical Practice method, in the Health, Mental Health and Disabilities fi eld of practice. He is a graduate of the University of California, San Diego with a bachelor’s degree in Literatures of the World and a minor in Law and Society. Ian is currently placed at the Payne Whitney Clinic of New York Presbyterian Hospital. His e-mail address is iwh2101@columbia.edu. 261809_Columbia 01-72 Sec1:20261809_Columbia 01-72 Sec1:20 4/5/07 2:12:17 PM4/5/07 2:12:17 PM