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   Table of Contents - Current issue
Coverpage
May-August 2022
Volume 4 | Issue 2
Page Nos. 51-173

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EDITORIAL  

Child Mental Health and Social Psychiatry – Global and Local Perspectives p. 51
Andres Julio Pumariega, Eugenio Rothe, Rama Rao Gogineni
DOI:10.4103/wsp.wsp_27_22  
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REVIEW ARTICLES Top

Poverty, Homelessness, Hunger in Children, and Adolescents: Psychosocial Perspectives Highly accessed article p. 54
Andres Julio Pumariega, Rama Rao Gogineni, Tami Benton
DOI:10.4103/wsp.wsp_17_22  
Poverty, hunger, and homelessness have been shown to be perhaps the greatest adverse biological and social risk factors for mental health problems and disorders worldwide. They also have significant adverse impact on cognitive, psychological, psychosocial, and physical development in children and youth. This article reviews the psychosocial effects of poverty, hunger, and homelessness on children and youth, including their impact on psychopathology and mental health. It also includes recommendations for governmental entities, advocates, and care providers on mitigating their adverse effects.
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Mental Health Disparities of Ukrainian Children Exposed to War: A Narrative Review p. 63
Aida Mihajlovic, Lara Segalite, Allison Lawler
DOI:10.4103/wsp.wsp_20_22  
Although there has been a lot of research focused on the effect of war on child refugees, along with those impacted directly, there are no recent studies comparing these two groups side-by-side. In this paper, we review psychiatric comorbidities associated with children (defined as 17-year-olds and younger) exposed to war, with an additional emphasis on approaches to treatment. In addition, we aim to understand these children's thoughts and insights into their situation(s). We will do so by presenting narratives given by close relatives of (1) two children currently in Ukraine in the midst of the war, (2) another young Ukrainian child war refugee who was able to recently leave the country, and (3) an adult and his experiences of being a war refugee and then resettling in the United States as a child. We never know when or where a war will begin. It is important that we have mental health professionals that can help children through the current and unexpected adversities that arise with war and displacement. These children need assistance with their uncertainties about the future and the risk of disruption of peace or comfort. Moreover, mental health disparities are substantial amongst children exposed to the traumas associated with war, and treatment is limited. We share this research to encourage mental health professionals to seek understanding of the impact the current war is having on Ukrainian youth. It is our hope that, with presenting these narrative accounts, mental health providers will gain a deeper understanding of what these children are encountering and will become prepared to support them and their mental health.
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A Review of Intersection of Social Determinants and Child and Adolescent Mental Health Services: A Case for Social Psychiatry in Pakistan p. 69
Aisha Sanober Chachar, Ayesha I Mian
DOI:10.4103/wsp.wsp_23_22  
Pakistan faces the accelerated growth of a young population each year. The country's many structural challenges include an unstable economy, poverty, gender inequality, health disparities, and vulnerable systems (especially sectors serving education and justice). The advent of the 21st century has witnessed rapid societal change globally. This societal evolution has inevitably shaped the sociocultural landscape for Pakistan's children, families, and childrearing practices as well, yet the social determinants remain stacked against them. Although children make up one-third of the Pakistan population, they remain the most physically, economically, and socially vulnerable group. For children growing up in low-income families, which are the majority, these challenges are magnified to a greater degree. These children are more likely to experience multiple family transitions, frequent moves, and change of schools. The schools they attend are poorly funded, and their neighborhoods more disadvantaged. The parents of these children have fewer resources to invest in them. Thus, the home environment becomes less cognitively stimulating, and parents invest less in education. Living in poverty and struggling to meet daily needs can also impair parenting. Socioeconomic deprivation during childhood and adolescence can have a lasting effect, making it difficult for children to escape the cycle of poverty as adults because the adverse effects of deprivation on human development accumulate. Health services for children are also underresourced. This state is evident by the extreme shortage of child and adolescent mental health (CAMH) services in a country with a significantly high disease burden among children and adolescents experiencing mental health disorders. The article examines the social determinants of CAMH in Pakistan and their implications for the orientation and effectiveness of child mental health services.
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PERSPECTIVE/VIEWPOINTS Top

Beyond Shared Care in Child and Adolescent Psychiatry: Collaborative Care and Community Consultations Highly accessed article p. 78
Vincenzo Di Nicola
DOI:10.4103/wsp.wsp_19_22  
Based in the multicultural context of Montreal, Quebec, Canada, this article reviews shared care and collaborative care models which privilege consultations between primary and specialty care in children's mental health. An overview of Canada's two largest child psychiatric epidemiological studies outlines the nonclinical community prevalence in Ontario (18.5%) and Quebec (15%) of children's mental health problems along with salient family and community risk factors. Given the high prevalence of children's mental health problems and the burden of care undertaken by primary care practitioners, the interface between the first line of care and mental health services is crucial yet often characterized by poor communication, a lack of mutual comprehension, and limited collaboration. Collaborative mental health care has been defined as “a family physician or other primary care provider working together with a psychiatrist or other mental health worker in a mutually supportive partnership.” This definition is extended to describe a spectrum of partnerships in child and adolescent psychiatry (CAP): shared care, collaborative care, and related collaborative community practices. The author's experience with these models is presented with an overview of a pilot study on CAP shared care in Montreal. Two other recent trends in Quebec are explored: an innovation called “Medical Specialists Responding in Child and Adolescent Psychiatry” for community mental health-care teams and the pair aidant or “peer helper” model reaching out to patients and families with a member who suffers from mental health problem to serve as a helper, a model, and part of the support network.
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Inside the Mind of the Adolescent School Shooter: Contributing Factors and Prevention p. 85
Eugenio M Rothe
DOI:10.4103/wsp.wsp_18_22  
Situations involving active firearm shooters in schools have increased exponentially in recent years, especially in the United States. These events result in death and psychological traumatization, not just to the involved school but also to the surrounding communities and to the rest of the population of the United States and other countries who observe these massacres in the media. This article will review the recent statistics of school shooting incidents in the United States, the psychological profiles of the perpetrators, the pattern of circumstances that contribute to the buildup until the point the act if committed, the effectiveness of the responses by authorities, the possible risk factors and precipitating factors for these attacks, the psychological sequelae to individuals, families, and the communities, and the evidence-based preventive interventions.
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The Physician's Role in Confronting Humanitarian Challenges: A Guide for Action p. 94
Jaime Guzman, Pamela Mcpherson, Scott Allen, Dimitri Alphosus, Dana Gold
DOI:10.4103/wsp.wsp_24_22  
An increase in humanitarian challenges has resulted in an increased demand for mental health resources. Social psychiatrists face a clinical and moral imperative to study and treat mental disorders precipitated or impacted by sociocultural events. Immigration detention is but one example of a setting that can take a toll on the mental health of those detained. Psychiatrists working in detention settings do not have immunity from feeling overwhelmed and may suffer the effects of moral distress. Many question how to take action beyond direct clinical care. Here we present a case study on physician action to address the humanitarian crisis of family separation and family detention of immigrants at the US. Southern border. Subject matter and advisory committee experts for the US Department of Homeland Security were recruited to identify concerns and provide recommendations in this guide for action.
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Children Orphaned Due to COVID-19 Pandemic: Learning from the Past and Preparing for Their Future p. 101
Consuelo Cagande, Raman Marwaha, Mariam Rahmani, Rama Rao Gogineni
DOI:10.4103/wsp.wsp_22_22  
A worldwide spread of children orphaned due to COVID-19 was another tragedy many families and communities faced. Between March 2020 and October 2021, 5·0 million COVID-19 deaths had occurred worldwide, and roughly 5·2 million children had lost a parent or caregiver due to COVID-19-associated death. However, the great orphaning was not affecting all demographic groups equally, with different racial and ethnic groups experiencing different levels of mortality. This study further discusses the impact of the pandemic on transnational orphans in the U.S., society, development, and emotions. In addition, there were lessons learned from prior global pandemics such as the Spanish Influenza of 1918 and the HIV pandemic that left children orphaned. Therefore, there were strategies to help mitigate the impact on children orphaned due to a pandemic. They include engaging the community, developing and improving evidence-based programs, and providing a safe environment as well as protective and mental health services and trauma-informed care for children worldwide. Lessons from the past should drive the advocacy for such programs and hope for the future.
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A Psychodynamic Perspective on Psychological Traumas in Children and their Psychosocial Consequences p. 106
M Botbol, T Lebailly, S Laplace, S Saint André
DOI:10.4103/wsp.wsp_21_22  
Psychological trauma may occur in children as it does in adults. However, due to children's specific dependency on their caregivers, some cardinal characteristics differentiate common acute psychological trauma from long-lasting ones for which the traumatic stress field has adopted the term “complex trauma,” including abuse and neglect and intrafamilial from extrafamilial psychological traumas. These characteristics are influential on the weight of psychological trauma psychosocial consequences, considerably higher in children than in adults. It is especially the case in infants in whom intrafamilial long-lasting psychological traumas are, by far, the most frequent and the most destructive. The purpose of the present article is not to provide an updated review of the current literature on psychological trauma in children and adolescents but to show how psychoanalytical theoretical approaches contribute to the treatment of childhood trauma. One must remember that considerations of children's psychological traumas were crucial in developing psychoanalytic theories. More than 100 years ago, psychoanalysis comprehensively explained the behavioral and affective symptoms currently considered central in children's and adolescents' psychological trauma. Moreover, these explanations are generally consistent with the theories supporting the current mainstream approach to the question.
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Continuous Traumatic Stress in Palestine: The Psychological Effects of the Occupation and Chronic Warfare on Palestinian Children p. 112
Iman Farajallah
DOI:10.4103/wsp.wsp_26_22  
For more than 70 years, the children of Palestine have experienced increasing levels of war trauma due to the ongoing conflicts with Israel. These children have been subjected to danger and violence to such an extent that it has created a societal underclass that has become the focus of research to determine the psychological impact of near-constant war. This article examines the growing body of literature devoted to analyzing how war and postwar trauma in children, specifically the children of Palestine, reveals a modern-day tragedy of epic proportions. The article presents the continuous traumatic stress in Palestine and the psychological effects of the occupation and chronic warfare on Palestinian children through the victims' war trauma experiences.
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ORIGINAL ARTICLES Top

Anomie, Loneliness, and Psychopathology: Results from the Study of Youth in Istanbul p. 121
Mariam Rahmani, Andres Julio Pumariega, Parna Prajapati, Alican Dalkilic, Hatice Burakgazi-Yilmaz, Ali Unlu
DOI:10.4103/wsp.wsp_13_22  
Objective: “Anomie” describes social dysregulation or a social condition in which individuals feel isolated instead of united with other members of the society. The literature on the association of anomie and loneliness with suicidality and youth psychopathology has been demonstrated in some studies based in Western nations. This study aims to compare the association of anomie and loneliness, substance use, and psychosocial risk factors with suicidal ideations in a sample of high school (HS) students in Istanbul. The context of modern-day Turkey provides a setting where stress from socio-economic and cultural transitions resulting from globalization could contribute to higher degrees of anomie and isolation/loneliness. Methods: The study data were collected from a 66-question survey of 31,604 HS students administered by the Istanbul Department of Education. The primary questions and subquestions were used to generate variables of interest to explore the relationship between anomie, loneliness, and psychopathology. In addition to the descriptive analyses, logistic regressions were used with anomie and loneliness as dependent variables, and psychosocial variables and psychiatric symptoms were used as two main independent variable clusters. Results: Our findings show that 45% of Turkish youth experienced anomie and 17% experienced loneliness. Both anomie and loneliness are strongly associated with particular psychosocial variables. More time spent with family and higher parental education are protective factors, whereas peer influences and substance misuse increase the risk of anomie and loneliness. Both anomie and loneliness are also associated with psychiatric symptomatology, particularly suicidality. Conclusions: Identification of youth struggling with anomie and loneliness can be an important approach to reaching out to at-risk youth, particularly in a context of socioeconomic and cultural transition.
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Impact of Rural-Urban Immigration on Substance Use in a Sample of Turkish Youth p. 132
Hatice Burakgazi Yilmaz, Parna Prajapati, Alicanz Dalkilic, Ali Unlu, Mariam Rahmani, Andres Pumariega
DOI:10.4103/wsp.wsp_16_22  
Objectives: This study examines the data from a large survey of youth in metropolitan Istanbul to examine the generation status in rural-urban immigration and its relationship of substance use/alcohol use in a high school (HS) setting. Methods: The study data were collected by the Istanbul Department of Education on 31,604 HS students which were a survey of 66 questions administered in the school setting. Immigration statuses of the students and their parents were categorized, and it was compared with the type of substance use. Odds ratios were calculated by using the participants from rural area as the reference category. Results: A total of 31,272 participants, 14,477 (46.6%) male and 16,581 (53.4%) females between the ages of 13 and 21 years constituted the final sample size for this study. Out of the total number of participants included in analyses (24,974), 18% had all family members from Istanbul, 16% had at least one family member from outside of Istanbul, 44% had majority of family members from outside of Istanbul, and 21% were from outside of Istanbul. About 15% of participants from Istanbul reported using tobacco, whereas those from outside of the city reported about 12%. Twenty-seven percent of participants from Istanbul reported using alcohol as compared to 18% in participants from outside of Istanbul. The combined category usage (alcohol and any substance use) was found in 33.7% in participants from Istanbul and 24% in participants from outside of the city. Conclusion: Rural background may play a protective role in substance and alcohol use in Turkish adolescents and young adults. In Istanbul, nonimmigrant individuals are more likely to use any type of illicit substance, or combination of illicit substances and alcohol as compared to immigrant individuals.
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Level of Care Determination: The Child and Adolescent Service Intensity Instrument (Dutch Version) p. 139
Astrid Janssens, Thirsa Van Dongen, Inge Glazemakers, Kathy Uvin, Andres Julio Pumariega, Dirk Deboutte
DOI:10.4103/wsp.wsp_14_22  
Background: The Child and Adolescent Service Intensity Instrument (CASII) is a tool to determine the appropriate level of care placement for a child or adolescent. The CASII links a clinical assessment of the child and its environment with standardized levels of care using a detailed algorithm. It can be used for children aged 6–18 years with psychiatric disorders, substance use disorders, or developmental disorders. This study reports on the translation of the instrument into Dutch and tests of its validity and reliability using both case vignettes and real-life cases seen within the Belgian mental health and child welfare systems. Methods: Reliability testing of the CASII was conducted based on both standard vignettes and live cases. To test the validity, the CASII was compared to the Children's Global Assessment Scale (CGAS) and the Strengths and Difficulties Questionnaire (SDQ). Trained professionals with various education and active in different sectors completed the CASII. Results: Using case vignettes, the intraclass correlation coefficients for the different dimensions ranged from 0.29 to 0.79. The intraclass correlation coefficient (ICC) for placement recommendations was excellent (0.74). The ICCs for the subscale ratings for the live cases ranged from 0.40 to 0.90. The CASII showed good validity when compared to the CGAS (correlations ranging between 0.47 and 0.82). When compared to the SDQ, the CASII correlated low to moderate with the total difficulties score (0.05–0.37) but correlated slightly higher with the impact score (0.25–0.35). Conclusions: The data confirm the usefulness of the CASII among different service providers of different sectors with a broad range of clinical experience and professional training. The findings extend and partially replicate other findings and suggest reasonable but not unequivocal validity and reliability across linguistically and culturally different contexts.
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Child and Adolescent Service Intensity Instrument Development in Japan: Initial Psychometrics and Use p. 152
Yoshiro Ono, Andres Julio Pumariega, Akira Yamamoto, Kazuhiro Yoshida, Hiroshi Nakayama, Daisuke Nakanishi, Kanae Aihara, Kayoko Ichikawa, Masami Hanafusa, Udema Millsaps
DOI:10.4103/wsp.wsp_28_22  
Objectives: Level of Care (LOC) determination is an important process of care planning for emotionally disturbed children and adolescents. As a tool of LOC determination, the Child and Adolescent Service Intensity Instrument (CASII) has been developed and tried to extend the usage out of the United States. As part of that effort, the CASII is currently being evaluated for its psychometric property in Japan. Methods: The CASII has been translated into Japanese, and then, 23 child psychiatrists and 70 nonpsychiatrist professionals who completed CASII training rated 7 vignettes to test inter-rater reliability. External validity was being evaluated by comparing the CASII ratings of 163 participants aged 6–17 against the Child Behavior Checklist (CBCL)/Youth Self-Report (YSR) and Child Global Assessment Scale (CGAS). Results: Inter-rater reliability among psychiatrists showed intra-class correlation coefficients ranging from 0.63 to 0.91 and those by nonpsychiatrists from 0.42 to 0.80. Cronbach's alpha was higher than 0.97 for both psychiatrists and nonpsychiatrists. The CASII ratings and LOC determination for 145 participants were significantly correlated with the Actual LOC and ratings of CBCL/YSR and CGAS except for the Internalizing Problem scores. There was no significant difference between LOC Recommended and Actual LOC. Conclusions: The Japanese version of the CASII showed fairly good inter-rater reliability and validity to use in the practice of mental health as well as child welfare in Japan.
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Strabismus and Quality of Life: The Impact of Surgical Intervention in Children and Adolescents in Colombia p. 159
Paola Pacheco, Sarah Andrews, Roberto Chaskel
DOI:10.4103/wsp.wsp_25_22  
Introduction: Strabismus is a condition that impacts a variety of functional and psychosocial domains. One of the major areas of interest in the management of strabismus is improvement in the patient's quality of life (QOL), yet, the effect of surgical intervention on QOL is unclear, especially in pediatric populations. The aim of this study is to evaluate changes in the perception of QOL using the KIDSCREEN-52 questionnaire in a pediatric population both before and after surgical correction of strabismus. Methods: A prospective descriptive study was conducted in a sample of 8–17-year-old children and adolescents whose perception of QOL was evaluated using the KIDSCREEN-52 questionnaire. The questionnaire was administered prior to and 3 months after surgical correction and administered in two specialized institutions in Bogota, Colombia. Results: Twenty seven subjects were included, 59.3% (n = 16) were male with a mean age of 11.5 years. The etiology of strabismus was identified as congenital in 66.7% (n = 18) and bilateral in 59.3% (n = 16), while esotropia was the most common type (55.6%). The QOL measure, KIDSCREEN-52, resulted a statistically significant positive effect in all dimensions, except for the Financial Resources dimension. Conclusion: Subjects who underwent surgical intervention perceived improvement in almost all areas of QOL. These results highlight the importance of early surgical intervention, with an added opportunity to improve the patient's mental and social wellbeing, secondary to surgical correction of strabismus.
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Systematic Youth Suicide Screening in a General Hospital Setting: Process and Initial Results p. 164
Andres Julio Pumariega, Udema Millsaps, Gerald Richardson
DOI:10.4103/wsp.wsp_15_22  
Objectives: Adolescent suicide rates have been rising since 1999, and efforts to identify youth at risk with systematic approaches are important in secondary prevention. The Columbia Suicide Severity Rating Scale (C-SSRS) screener is a tool that has demonstrated predictive validity in identifying youth at risk of attempting suicide. Health care settings are key venues where at-risk youth can be identified effectively. Methods: A tertiary hospital in the Northeast U.S. developed a suicide risk protocol, consisting of systematic screening of patients for suicidal ideation/behavior with a screening version of the C-SSRS and a response algorithm based on risk levels derived from the screen. A total of 840 nurses were trained on the C-SSRS Screener, with a response protocol addressing environmental safety and psychiatric consultation. Results: This report focuses on the screening results for adolescents (ages 12–17) within this cohort, occurring over a 11-year period. Posttraining inter-rater reliability on the C-SSRS Screener definitions of ideation and behavior were high and independent of level of education or mental health experience. Of 6126 patients screened in this age group, 9.6% were in the highest risk category, as compared to 0.93% of adults during a 12-month period. Middle adolescents, females, African American and Latino patients, patients with psychiatric diagnoses, and patients with some medical diagnoses were at significant risk. Conclusions: These findings suggest that a systematic screening and clinical response protocol using the C-SSRS screener can potentially enhance the ability to identify suicide risk in the adolescent population in medical surgical hospitals and can focus services on patients with the most need.
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