Beyond Children’s Mental Health: Cultural Considerations to Foster Latino Child and Family Mental Health

Abstract

Clinicians trained to assess and treat child psychopathology are facing an increasing need to expand their clinical expertise outside of traditional frameworks, which have historically focused largely on the child or the child-mother dyad. Clinicians treating children also need to be prepared to assess and address the systems of care that affect a child’s mental health, starting with their family. There is a scarcity of Latino mental health providers and limited clinical opportunities or settings that serve this population by incorporating a developmental, cultural and sociopolitical framework into high quality care of the whole family.

Clinicians trained to assess and treat child psychopathology are facing an increasing need to expand their clinical expertise outside of traditional frameworks, which have historically focused largely on the child or the child-mother dyad. Clinicians treating children also need to be prepared to assess and address the systems of care that affect a child’s mental health, starting with their family. There is a scarcity of Latino mental health providers and limited clinical opportunities or settings that serve this population by incorporating a developmental, cultural and sociopolitical framework into high quality care of the whole family.

Promoting Latino children’s mental health requires that clinicians understand social systems and structures impacting the child’s wellbeing and engage in a therapeutic approach that considers and respects the child’s cultural identity and family cultural values. Hence this chapter will not only focus on Latino children’s mental health but will inform clinicians seeking to embrace and apply a developmental framework that incorporates cultural, environmental and sociopolitical dimensions into their clinical practice.

The Latino population is the largest and one of the fastest growing “minority” group in the U.S. combined, people of diverse Latin America heritage, including from the Caribbean, Central and South America. ¹ In the U.S., this population has historically been labeled Hispanic for census and research purposes. In the early 1980s, the U.S. began using the term Latino in the census, yet as of 2010, books were still using the term “Hispanic Americans.”²

Both terms, Hispanic and Latino, carry historical ties to colonial violence, sparking ongoing debate about their use. The term Latino has conferred some separation from and its violent overtaking of indigenous and native civilizations. Although the term Latino connects more than 20 Latin American countries, a 2019 survey from the Pew Research Center showed that most Latinos would rather be called by the name associated with their family’s country of origin (i.e. Mexican, Cuban, etc).³ For some, the terms Hispanic and Latino still inspire feelings of disconnection within this group, therefore, research findings should not be generalized when they do not offer clarity regarding the specific groups studied.

Regarding its highly gendered nature, the Spanish language has been experiencing a transformation. Women and activists have been pushing to decenter patriarchal domination in the Spanish language by trying to find more female-empowering ways of describing groups of people or items.⁴ This translates to the most current push to transition away from Latino and into the use of Latinx or Latine as a gender-neutral term that is more inclusive of all genders. In this article, the terms Latino and Hispanic are used interchangeably to maintain uniformity with their use in the cited research. The term Latinx is increasingly being used in the scientific literature when describing gender-heterogeneous or gender non-binary groups.

With these clarifications in mind, this chapter aims to expand the knowledge and expertise of clinicians working with Latino children by embracing empowering frameworks that destigmatize children’s behavior, are family-centered and incorporate inter-generational conceptualizations that include a consideration of immigration histories, loss of language and culture and other important socio-ecological factors. Conceptualization of care also includes considering the ongoing victimization due to systemic racism and violence frequently inflicted on Latino groups, especially indigenous and Afro-Latino people.

Sociocultural Concepts Pertinent to Latino Family Mental Health

Clinicians working with Latinos will find it useful to understand well-known concepts in Latino mental health literature described in the following sections. These terms should not be used as generalizations that perpetuate stereotypes, and instead as constructs that can guide inquiry about family values and cultural identities. In general, the scientific literature shows these concepts have both positive and negative effects on Latino mental health.

Acculturation, Enculturation, Ethnic identity

The terms Hispanic and Latino are considered an ethnicity as opposed to a racial group, though some scholars suggest the hybrid term “ethnoracial” may be a more inclusive and representative term that reflects these intersectional social constructs. While there are many factors that may contribute to the study of ethnic identity, acculturation, the process of cultural and psychological change that follows intercultural contact, is one of the most important processes studied in immigrants and their future generations.⁵

Many studies suggest that with increasing acculturation and time in the US, immigrants and their families have worse mental health outcomes and second generation youth have worse mental health than first generation immigrant youth.⁶ However, it is important to identify the ways that youth and their families adapt resiliently during the acculturation process.⁷ The concept of acculturation has evolved into a multidimensional construct where individuals who are bicultural, which is the ability to incorporate both their heritage and host cultures into their own, have the most adaptive, positive outcomes.^8,9 An expanding consideration of how enculturation and adaptive acculturation may contribute to positive mental health outcomes is emerging.^10,11

Ethnic identity refers to the sense of belonging, pride, and attachment to ethnic group membership.¹² Rather than emphasizing the designation that others attribute to the individual, this construct represents the individual’s subjective feelings towards their self-ascribed identity. A positive ethnic identity has been associated with prosocial behaviors, positive self-esteem, and fewer internalizing and externalizing symptoms. In young adult samples, strong ethnic identity has been found to be protective against hopelessness in the face of acculturative stress and discrimination, buffering vulnerability to depression and suicidal ideation.¹³ Other factors such as social position, experiences of social support versus social exclusion, and language competency and ability can all also influence mental health and the impact of acculturative stress. Exploring how these factors intersect allows clinicians to consider cultural nuances and adaptations from a resilience framework and not solely in terms of risk.¹⁴

Familismo

Familismo is a cultural concept that highlights the centrality of nuclear and extended family to the individual via importance of filial piety, family support (cohesion and loyalty), obedience, respect (particularly toward adults and elderly family members), and the role of obligation to family.¹⁵ This framework may be woven throughout decisions and behaviors seen throughout development. As child psychiatrists and mental health professionals practicing in a society that emphasizes the individual, we could instead consider the benefits of a developmental framework that emphasizes and understands the role of collectivism.

A systematic review found familismo protective for depression, suicide, and internalizing behaviors.¹⁶ There may be benefits to mental health across members, familismo may predict lower levels of depression for both youth and their parents.¹⁷ Family support can uniquely buffer negative effects of acculturation stress and depressive symptoms.^17,18 An association of stronger familism values with higher self-esteem, fewer internalizing and depressive symptoms has been previously described.^19,20 However, in samples with heavy parental alcohol use, these beneficial associations were no longer present.¹⁹ Overall, familism is central to Latinos and protective for mental health in the context of family cohesion, and it can be a source of vulnerability in the context of high intra-familial conflict and distress.

Developmental Considerations in Latino Family Mental Health

It is important to consider the sociocultural concepts discussed above in the context of developmental phases for Latino children and their families.

Pregnancy, infancy and early childhood

Although all phases of childhood development are sensitive to environmental changes, pregnancy and early childhood periods are particularly sensitive to environmental perturbations.²¹ Disruptions during this period can have lasting impacts through adulthood and intergenerationally. This is particularly important for Latino families in the United States who, as a whole, have been shown in epidemiological surveys to have intergenerational progressive decline in health.²² Biological embedding of stressors (e.g. acculturation stress, other psychological stress, food insecurity/diet, housing insecurity, discrimination) via fetal programming (changes in gene expression that affect fetal growth, and physiological parameters that are reset by environmental events and can endure over the lifespan) have been proposed as a mechanism for the observed intergenerational transmission of adverse health outcomes in US Latino families.^23,24

Acculturation is associated with morbidity and mortality during the perinatal period for Latino families. Multiple studies have shown that birth outcomes such as higher birth weight, lower infant mortality, and higher rates of breastfeeding are associated with lower acculturation in Latinos.^22,25,26 In addition, studies show higher risk of perinatal depression and anxiety disorders in Latina mothers who are more acculturated. Less is known about the role of acculturation and other values in Latino father’s risk for perinatal mental illness. Overall, focusing on parental mental health during the perinatal and early childhood period is of utmost importance, as it is highly linked to development and psychopathology risk in children.^27,28

The perinatal period may result in increased intensity of intergenerational conflict between new parents and their family of origin. Beyond the contextual stress of pregnancy and childbirth, additional acculturation and intergenerational conflict may serve as stressors for Latino families impacting attachment and child-rearing practices (e.g. feeding, sleeping, childcare arrangements, discipline practices, instillment of language and cultural values).^29,30 Conflicting viewpoints and parenting approaches may be offered by U.S. healthcare providers and family members, possibly resulting in excessive anxiety for new parents.

For example, a new mother who expresses feelings of depression may be encouraged to not complain and to fulfill her role with appreciation como una mujer buena (like a good woman). This example captures how the concept of Marianismo could impact the gender role expectation of Latina women to be dedicated primarily to the family by way of providing childcare, loyalty, and submissiveness to her husband, and withstanding sacrifices and suffering for the sake of the family.^31,32 Deviation from traditional cultural roles and expectations may result in psychological distress attributable to the conflict that it creates with family and peers; although it has been less frequently studied in fathers, clinical experience and conceptual frameworks highlight this experience is pertinent to both mothers and fathers.^31,33

Overall, it is important to note that gender role expectations vary by level of acculturation, specific national origin, nativity and other factors. The interaction of these variables has differential effects on parental and child mental health and wellbeing in the perinatal and early childhood years. A study including Mexican and Dominican immigrant families demonstrated relationship between maternal-reported level of familismo and acculturation on preschool children’s externalizing and internalizing psychopathology symptoms that varied by child gender, family income and cultural identity.³⁴ Therefore, when working with Latino families during this period, it is crucial that clinicians seek to understand specific nuances rather than generalize this knowledge.

Middle Childhood and Early adolescence

For many Latino families navigating acculturation stressors, children as young as eight years old are placed in a unique position of cultural brokerage.³⁵ Although sometimes reduced to mean a child helping their parents by assisting with interpretation of language, this role of interpreting and translating language may evolve into different forms of mediation as they assist in education, medical, commercial, employment, financial, and even legal settings. Mixed data shows both positive and negative effects of this childhood experience, so the pros and cons in these roles must be considered for each individual child.

These role-reversals have been postulated to put more strain on families, resulting in less effective parenting methods and resulting in deferring to children to make important decisions. Families in a study with higher language brokering burdens, had higher levels of family stress, lower levels of parenting effectiveness, poorer adolescent academic functioning and more substance use than those with lower burdens.³⁶ When youth who reported ethnoracial discrimination brokered more frequently, there was an increase in depression and social anxiety symptoms.³⁷ A longitudinal study of early adolescents found that perceiving language brokering as a burden was associated with increased acculturation stress, subsequently increasing the risk of marijuana and alcohol use. However, when the child perceived it as a positive experience, was confident in their skills and the activity was normalized amongst their peers, there was no significant association with substance use.³⁸

Some researchers argue that culture brokers may be in a unique position that allows them to empathize with the life experiences of their parents which may improve their relationships. This role may also help them build independence, maturity and self-esteem as they build new skills and competence while promoting both acculturation and enculturation. Mental health clinicians should work with families to understand their child’s social, emotional, and cognitive maturity to navigate the brokerage position, while connecting families to local resources that may help minimize the burden on the child.

Adolescence

As youth transition to adolescence, it is not uncommon for conflict to exist between youth and their parents as they begin to explore their identity, autonomy and independent appraisal of values and goals. Adolescents become more reliant on their community and peers. During this time, generational “gaps” may develop when the youth acculturates more quickly than their parents.³⁹ This can contribute to intergenerational conflict and poorer mental health outcomes if changing values, together with communication difficulties, arise and result in cycles of distress and conflict.⁴⁰ These conflicts can exacerbate the impacts of discrimination as was found in a study where parent-child conflicts mediated the relationship between acculturation conflicts and perceived discrimination on internalizing symptoms.²⁰

This is referred to as the “acculturation gap distress” model, which has been studied in broad measures of internalizing and externalizing symptoms, self-esteem, prosocial and antisocial behaviors, and use of substances. In a metanalysis of 61 research reports, acculturation mismatches mildly correlated with intergenerational cultural conflict, and this was negatively correlated with offspring mental health.⁴¹ The literature on the impact of acculturation and acculturation dissonance in parent-child dyads on mental health outcomes has overall been mixed, likely due to broad methodology.

Sibling relationships may also impact mental health outcomes. In adolescent sibling dyads of Mexican descent, sibling dyads who endorsed strong familism values and sibling intimacy had lower rates of depressive symptoms, and higher rates of positive values such as the importance of service to others or developing healthy habits. The younger sibling of these dyads were found to have less risky sexual behaviors as teenagers and into young adulthood.⁴² Latino siblings who were more enculturated described more sibling positivity during COVID related school closures.⁴³

Ethnic Identity in adolescence and Mental Health

While younger children may recognize the ethnic labels that society assigns to them, adolescents begin to contemplate what being Latino means as a self-determined identity. Enculturation in this stage of development may be protective. Stronger ethnic identity is associated with multiple positive outcomes such as higher self-esteem, lower depressive symptoms, and healthier diets.^44–46 Latino adults with stronger ethnic identity are less likely to perceive discrimination relative to those with lower levels of ethnic identity.⁴⁷

Everyday experiences of discrimination have been reported by up to 30% of US Latinos in adult samples, and these may impact mental health outcomes directly and indirectly.⁴⁷ Discrimination experienced by Latino adolescents and young adults is associated with higher depressive symptoms, lower levels of self-esteem, decreased life satisfaction, and in small pilot studies with greater physiologic reactivity.^20,46,48,49 Male Latino adolescents exhibiting a combination of stronger identification with their host culture and a weaker ethnic identity are at higher risk of discrimination-associated depressive symptoms and poor self-esteem. Females, however, were at risk of these negative impacts regardless of their identity strengths and compared to their male peers had higher levels of depression and lower self-esteem. Latinas with low family cohesion experience higher depression and anxiety symptoms. There are several cultural considerations for why Latina adolescents may be more at risk for experiencing internalizing symptoms as compared to their male counterparts. Further empirical investigation that includes an examination of the associations of intersecting identities, minoritized and family stress with mood disorders is needed.⁵⁰

Young Adulthood

A distinct developmental phase termed ‘emerging adulthood’ is defined as the time between ages 18–25 and is of particular interest to youth mental health in Western cultures, including the United States. During this time, young people can maximize their independence and exploration of their identities in the areas of love, work, and worldviews. This may not be applicable across all cultural and socioeconomic groups; some may not be able to defer adult responsibilities (e.g. financially contributing to family) to fully explore other life possibilities. Latinos in this age range are more likely than their White peers to continue to live at home. This has been attributed to both financial circumstances and attitudes about when it is appropriate for adult children to leave the home, factors that may be mutually reinforcing, particularly for communities with limited socioeconomic resources.⁵¹

Family obligations are central to decision-making regarding pursuits after high school. A family may depend on the young adult’s support financially and to care for the house, siblings, or elders.⁵² Due to a lack of generational wealth, Latino young adults are less likely to have sufficient funds to live independently as compared to their White non-Latino counterparts. How this relates to mental health outcomes can vary. Young adults of Central American origin experienced less negative self-image when they took personal responsibility for meeting familial expectations and needs. Meeting the family’s academic expectations was associated with both positive self-image and less negative self-image.⁵³ In a mixed gender sample, provision of emotionally supportive caretaking was associated with greater depressive symptoms when the youth endorsed average to high levels of familism, leading the authors to summarize “for children of immigrants, the burden of tasks that require them to be emotional supports for the family is magnified by the sense that it is their responsibility as a member of the family.”⁵⁴ As youth begin to approach mid to late teens, they may anticipate some of these unique challenges and decisions of emerging adulthood.

Improving Systems of Care for Latino Youth and Families

Foundational Clinical Skills

Experiencing discrimination in clinical encounters impact subsequent use of healthcare services.⁵⁵ Black, Latino and uninsured patients are likely to report discrimination in mental health and substance use treatment, with uninsured patients being seven times more likely to report these experiences.⁵⁶ Despite experiencing increased risks for mental illness, Latinos are less likely to receive formal mental health services or receive adequate care, and are more likely to terminate services prematurely.⁵⁷ Family engagement in mental health treatment has been identified as predictive of youth mental health treatment engagement, retention, and response.^58–60

Cultural and structural humility are foundational skills highly needed in the mental health system to decrease ongoing harms, disparities and structural inequities inflicted on patients by traditional care models.⁶¹ This is highly pertinent when discussing opportunities to improve access and quality of care for Latino children and their families. Lack of awareness about the social and structural drivers of health can result in treatment that disregards the patient’s current lived experience and results in further shame and stigma when accessing services.

Awareness of how policies and laws can impact Latino youth and family mental health is needed, as studies have shown that families experiencing fear of deportation or had a family member deported or detained have higher rates of heart disease, asthma, diabetes, depression, anxiety, suicidal ideation, externalizing symptoms and PTSD. These negative effects impact U.S. citizen children as well.⁶² Naturalistic research studies have also demonstrated that passage of laws increasing people’s ability to apply for documented status, such as the Deferred Action for Childhood Arrivals (DACA), is associated with improved sleep, high school graduation rates and employment outcomes, decreased rates of poverty, lower teen birth rates and an overall stronger sense of belonging. In contrast, the negative impacts were visible when political rhetoric threatened the discontinuation of this law around the 2016 election, with self-reported worsening of sleep.⁶³

Culturally Tailored Evidence-Based Interventions

Several evidence-based interventions have been adapted and tested with Latino children and families; however, it is important to note that the gold standard for the development of new interventions should integrate Latino youth and family voices to co-create tailored interventions. Lastly, as with any evidence-based intervention, there is a fine line to balance intervention fidelity with respect for the patient and family’s current needs and wishes.

The perinatal and early childhood periods present an opportune and critical time for family interventions with potentially lasting effects on child mental health. Not only is it a biologically salient time, but specific to Latinos, cultural values of familism and views on parenthood may be strong drivers for mental health treatment engagement. Interventions developed or adapted for Latinos and delivered during the perinatal period tend to focus primarily on maternal mental health as opposed to family mental health.⁶⁴ Some interventions, including Minding the Baby (MTB), an early home-visiting intervention developed and tested with Latina and Black mother-child dyads, incorporates community participatory strategies and a relational-based approach to improve the intergenerational health and mental health of mother-child dyads. Several studies show positive MTB intervention effects on child attachment, child health and parenting at the end of the intervention and even years after the intervention concluded.^65–67 This and other approaches need to be further refined and adapted to include the larger family context.

Familias Unidas uses culturally based parenting strategies to prevent adolescent risk behaviors. The intervention is manualized and includes communication techniques for parents to help protect adolescent risk behaviors. The intervention uses a telenovela series that depicts situations that take place within families and with peers and ways that adolescents can respond. The family sessions include each family’s particular needs by allowing them to prioritize family goals. The developers recently created a digital eHealth intervention format.⁶⁸

Measurement-based care (MBC), a client-centered practice of collecting and using client-reported progress data throughout treatment can inform shared decision-making with minoritized youth and their families, improve engagement, involvement in treatment, satisfaction, and retention in care.⁶⁸ MBC offers an opportunity to follow outcomes that are prioritized by families, including individualized measures of symptoms, and sociocultural measures (experiences of discrimination, acculturative stress) as well as monitor and address potential barriers to care that are collaboratively identified and addressed by the family and provider.

Other interventions that have incorporated family involvement to improve Latino child mental health include psychoeducation and accompaniment in advocacy activities. Empowering parents through coaching, co-attending check-in meetings with both the teacher and therapist, and role-playing exercises was found to promote positive skill building in Spanish-speaking Latino parents of children with ADHD.⁷⁰ Promising data shows that when Latino youth access mental health services in childhood, they are more likely to access services if needed again as young adults.⁷¹ Additionally, a randomized controlled trial in primary care that compared Brief Behavioral Therapy (BBT) to Assisted Referral to Treatment, found BBT to be an effective tool to engage Latino youth and families in mental health treatment.⁷² This has critical implications for the urgency to integrate behavioral health into schools and pediatric practices.

Conclusions and Clinical Takeaways

Prioritizing efforts that are centered on equity and justice and that aim to improve access to quality care are highly needed to better serve Latino families. As scholars, academicians, mentors, and educators, we encourage all readers to prioritize teaching material, opportunities for learning and clinical practice that promotes a stronger foundation for this and the next generation of mental health providers serving Latino families.

• Ensure that all mental health trainees have experience using the Cultural Formulation Interview (CFI), which was developed by the American Psychiatric Association to help engage individuals in mental health services. The CFI is a core interview of 16 open-ended questions, with prompts for clinicians to understand the cultural content behind each question and the perspective of the child, youth, caregiver, and family.⁷³

• It is important to teach trainees about cultural and structural humility and center these concepts in all clinical formulations and establish a curriculum that explicitly equips and empowers clinicians with the knowledge, vocabulary, and tools to address racism in mental health care along with family centered approaches.^61,74,75

• Structural humility invites clinicians to consider how the current polarized political climate and systemic inequities may impact the transmission of intergenerational trauma to younger generations and encourage incorporation of approaches that nourish ethnic pride and strong ethnic identity as a protective strength for youth and family mental health.

• As youth begin to approach mid to late teens, they may anticipate some of the unique challenges of emerging adulthood, including their role in supporting their families, and clinicians should explore these issues in clinical care, especially with depressed youth.

• Clinicians seeking to provide quality mental health services to Latino children and families must embrace skills and practices that allow families to develop trust in their care; discussing socio-political stressors and experiences of discrimination can assist patients to develop trust with clinicians and allow them to describe the extent of their stressors, how these impact their mental health.

• As clinicians working with diverse patient populations, who are navigating highly complex social structures, it is imperative that we engage in our own healing process, incorporating self-reflection about our own biases, lived experiences and intersectional identities in systems of power and disadvantage. Acknowledging our own healing and humanity will empower us to provide empowering care to the patients we serve.

Key Points:

• Promoting Latino children’s mental health requires clinicians to adopt frameworks that extend outside of traditional clinical practice or the medical model and include sociopolitical frameworks that incorporate the whole family’s well being

• Structural humility and competence, and anti-racism are foundational tools that all clinicians must embrace to reduce harms perpetuated by traditional mental health care models

• Clinicians can promote family engagement to improve Latino children’s engagement, retention, and response in mental health treatment

Clinics Care Points.

• Studies demonstrate the importance of several values in Latino culture that should be considered when caring for children including familism. However, the Latino experience is not monolithic and various levels of acculturation, racioehthnic identity, intersectionality, and migration patterns need to be taken into account in clinical formulations.

• Use the cultural formulation and other evidence-based practices and guides to guide non-judgmental discussion of the inter-relatedness of culture and mental health, particularly when these appear to be impacting or interfering with clinical care.

• When treating Latino children, identifying opportunities to strengthen their ethnic and racial identity and pride can be important ways to optimize clinical treatment.

• When serving Latino children in medical settings, educate medical providers about the possible negative impacts of language brokering and the importance of using interpreting services appropriately.

• Perinatal mental health providers, pediatricians, obstetricians, and family practitioners can foster mental health in new Latino parents and improve parent-child relational health by facilitating discussions about how acculturation and intergenerational belief systems may impact their parenting trajectory.