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What are the Mental Health Challenges Youth in Prince George's County Face?

While mental health is critical to all communities within the County, and all Puentes! member agencies provide services to native-born and immigrant communities alike, Puentes! is particularly interested in seeking support for the unmet mental health needs of Spanish-speaking immigrant youth. Generally speaking, youth with good mental health have a positive attitude and can manage life's challenges, feel good about and care for themselves and others, and act responsibly in school, on the job, and in all of their relationships. By contrast, youth with poor mental health are unhappy and indifferent, have low self-esteem, trouble coping with stress, struggle making friends and difficulty dealing with others. While not meant to be technical or exhaustive, the following describes some of the major types of mental health challenges these youth face:

• Relational Problems: poor child-parent relationships, poor skills in resolving conflict, problems expressing wants or desires, difficulty working with people to improve their circumstances, leads to coping behaviors based in anger/violence, youth not really understanding other people, assuming who people are, misinterpreting others words or actions.
• Anger: frequent frustration, leads to assuming something's wrong with me, reaction often is to implode or explode - imploding leads to depressive symptoms, explosion manifests as verbal or physical violence; often rooted in never dealing with emotional things in one's life: bereavement, loss of friends or family, particularly when loss is violent/gang related, family separation (parent being deported) or reunification (reuniting after family/parent had left to US and left youth behind), feel marginalized, put down, trouble dealing with a multi-level socio-political environment filled with anti-immigrant rhetoric.
• Identity Crisis: no purpose in life, lacking sense of who one is, where one comes from - leads to experimenting with drugs, clothing and music; adopts gang life style, clothing, street-code; if primary language is English, literally does not know how say or express certain things to parents in Spanish.
• Borderline Features: poor self esteem, poor coping skills, instability, can't problem solve so youth revert to self-harm or self-hate, have few boundaries, poor discipline, mixed with depressive symptoms.

These challenges, if untreated, can lead to many of the social problems that affect and concern us all:

• poor academic performance
• truancy
• fighting and violence in schools and in the community
• drug/substance abuse
• gang involvement and violence
• dropping out of high school
• delinquent behavior
• teen pregnancy
• self-injurious behavior like cutting
• depression
• suicide

Thankfully, All of These Mental Health Challenges Are Treatable

While each of these mental health challenges are serious, they are treatable. Proven, evidence-based strategies do exist, and are the very strategies Puentes! members, as direct service providers, use every day to great effect. Some examples of successful work with youth in the County include:

• A 17 year old Hispanic male was referred to a Puentes! member agency due to his difficulty in managing daily stress, which exhibited itself in poor job retention, interpersonal conflict, disrespecting authority, and his involvement in gangs. As is often the case, he was resistant at first to counseling, but after participating in other programs at the agency, he felt comfortable enough to begin counseling. After four months, the client showed increased ability to ask for help, understand and communicate more effectively with others, and control his anger. The client is no longer in a gang and is focused on maintaining gainful employment while attending community college.
• A 13-year-old girl from Mexico was referred by her school because of self-injurious behaviors. The girl's mother expressed great concern for her daughter and did not understand why her daughter was hurting herself or what she could do about it. After 8 weeks of both individual and family counseling the client has stopped all self-injurious activities and states that she no longer feels a desire to hurt herself. As well, the client and her mother are working on increasing their communication skills and deepening their relationship.
• A divorced mother of two from El Salvador came with her two children, ages 9 and 11, requesting counseling services. She had been separated from them for five years, when she had to come to the United States to work and entrusted her children to the care of her parents. Upon reunification with her children, the younger son in particular was experiencing a great deal of distress. He was anxious and would destroy the mother's family possessions when left alone. Impulsivity was also demonstrated at school. After 10 months of therapy, the children have successfully adapted, increasing their capacity to deal with school demands and establishing cooperative relations within the family.
• A 20 year old Hispanic female had a history of hospitalization due to suicide attempts. In four months with a Puentes! member agency, where therapy and case management was provided, the client has showed marked improvement. She has learned coping skills to decrease her depressive symptoms, notes fewer days of despair, and has made active attempts to improve her relationships with family members. While she has not been hospitalized in over a year, she continues to struggle against cutting and alcohol abuse.
• Children's Hospital referred a 7-year-old girl to a Puentes! member agency from Mexico, who had witnessed a great deal of physical and verbal abuse. It is also suspected she may have been sexually abused during the years she was separated from her mother, who came to the United States first. Upon reunification with her mother and new step-father, she presented behavioral problems both at school and at home. During therapy, the blended family has been able to improve their relationships. Also, the young girl's adjustment to school has increased and she has improved her academic performance.

The Need

From our perspective as on-the-ground service providers, Puentes! sees the unmet needs of immigrant youth as a consequence of at least four interrelated factors: poverty and lack of health insurance, lack of proper mental health coverage for those with insurance, linguistic and cultural challenges, and a lack of a properly-funded system of care.

Poverty & Lack of Insurance. Prince George's is challenged with a large number of relatively impoverished households, where far too many lack health insurance. According to the County's Enquirer-Gazette of October 30, 2008, Prince George's County has more than 150,000 people without insurance, the highest in the state.

Even Those With Insurance Are Not Adequately Covered. Particularly for the type of mental health challenges referred to above, even those with Medicaid are not adequately covered. Medicaid, as is well known, is the largest source of funding for health-insurance for those with limited income, but both the kind and quantity of services needed to best serve youth with the above-presenting challenges are not covered. This forces most mental-health providers in the community to do one of three things: 1) staunchly avoid serving this population, 2) pathologize youth by diagnosing them as having mental illnesses they may not actually have, so they can deliver them the services they need while getting paid for it, or 3) providing them services knowing that they will not be compensated.

Linguistic & Cultural Challenges. Genuine, trustful engagement with the existing community of care is more difficult for immigrants, who are often only beginning the process of linguistic and cultural adaptation. Many Latino families in need of care have mixed language and cultural realities - the parents may be native Spanish speakers and have a Central-American cultural identity, while their native-born youth (or those that came at a very young age) speak English best and have a distinctly North-American, urbanized cultural identity. Particularly when therapeutic strategies involve both youth and their parents, as they often do for best results, the ability of providers to manage multiple linguistic needs and connect with various cultural realities is key.
A Properly Funded System of Care Does Not Exist. Particularly for the mental health needs mentioned above, there does not appear to us to be a well-planned, County-wide, system of care. At all levels of government - federal, state and local - there is insufficient investment in the relatively few entities that do provide culturally and linguistically proficient services to this population. Particularly in the absence of a comprehensive system of care, individual sources of care need to be adequately and consistently funded, even in tough economic times, and every effort should be made to find and deliver increased funding when available.

Elements Towards a Solution

Our position as direct service providers affords us an up-close and critical perspective as to the positives and negatives of the current care structure. It is from that perspective that we believe a genuine solution to meeting the current unmet mental health needs of immigrant youth must include:

Mental Health Services Which Are "Embedded" In A Larger Set Of Services. Because of the stigma still largely associated with mental health, few youth who need services take a direct route to them. The availability of mental health service options along with or within other programs and services really helps to engage hard-to-reach youth. Mixing mental health services with other types of services helps to "normalize" the former and makes mental health practitioners more approachable. Programs that are a "natural fit" with mental health services include after school educational programs such as homework assistance and mentoring, out-of-school programs like GED classes, life skills/leadership programs, job readiness classes, and art programs.

Services Located In Existing Community Centers. Traditional, clinical office settings discourage youth and their families from connecting with the people and services that are available there. Community centers and community based organizations are a natural place where immigrant families feel welcome and are more likely to engage in mental health services. In addition, many immigrant families face transportation challenges with only one or no family vehicles and inconvenient public transportation options. Some Puentes! member agencies successfully service youth because of their proximity to local schools.

Personnel That Have The Multiple Cultural And Linguistic Competencies. As discussed above, multiple language and cultural competencies are necessary to truly connect with immigrant families, particularly when the most effective treatment strategies involve both parents and their youth.

As stake-holders in the future well-being of our County, Puentes! is resolute in our desire to work cooperatively towards a solution to address the unmet needs of young people and their families.

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