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According to Federal classifications, African Americans (blacks), American Indians and Alaskan Natives, Asian Americans and Pacific Islanders, and white Americans (whites) are races. Hispanic American (Latino) is an ethnicity and may apply to a person of any race (U.S. Office of Management and Budget, 1978). For example, many people from the Dominican Republic identify their ethnicity as Hispanic or Latino and their race as black, white or otherwise.
Hispanics/Latinos are the largest minority group nationwide, comprising 14% of the total population in 2005 (compared to 13% for Blacks and 5% for Asians). By 2050, it is predicted that Hispanics will comprise nearly 29% of the population, more than doubling their 2005 representation (El Nasser, 2008).
New York State is home to over 3.1 million Hispanics/Latinos, or 16% of the New York State population (U.S. Census Bureau, 2006). Hispanics/Latinos of Caribbean origin make up the largest majority of the NY Hispanic/Latino population (58%), followed by those of South American origin (15%), Mexican origin (12%), and Central American origin (9%) (Pew Hispanic Center, 2006).
Hispanics/Latinos make up 25% of New York City’s total population (38% are White, 23% are black, and 14% are Asian/Pacific Islander or Other) (Van Wye et al., 2002/2004). Many Hispanics/Latinos reside in New York City’s East Harlem (El Barrio, as it is referred to by Hispanic residents). According to the 2000 census, Latinos comprise 52.1% of East Harlem’s population, followed by African Americans at 35.7% (with Whites at 7.3%). Among Latinos, Puerto Ricans are the largest subgroup in East Harlem, making up 57.7% of the Latino population, followed by Mexicans (16.9%) and Dominicans (7.7%) (Dávila, 2004).
There is significant variability in the socio-demographic characteristics of different ethnic Latino subgroups. Puerto Ricans are more likely than other subgroups to be born in the U.S., spend more than 70% of their lifetime on the U.S. mainland, and live in the Northeast. Mexicans are more likely to be in the lowest income group (<$14,999) and live in the West. Cubans report higher household incomes and more education and are likely to spend 30% or less of their lifetime in the U.S. (Alegria et al., 2008).
Despite growth in the population, Hispanics/Latinos, as a group, face economic and social barriers in this country. They are overrepresented in low-income jobs and underrepresented in professional employment. According to a 2006 U.S. Census Bureau report, 24.4% of Hispanics, in comparison to 13.7% non-Hispanic Whites, worked within service occupations. 16.6% of Hispanics in comparison to 39.9% of Whites worked in managerial or professional occupations. Among full-time year-round workers in 2007, 55% of Hispanic households, in comparison to 68.2% of non-Hispanic White households earned $35,000 or more. 21.5% of Hispanics in comparison to 8.2% of non-Hispanic Whites were living at the poverty level (U.S. Census Bureau). In New York State specifically, 34% of Hispanics under age 17, and 20% of Hispanics ages 18 to 64 live in poverty (compared to 11% and 4%, respectively, of non-Hispanic whites in the same age groups) (Pew Hispanic Center, 2006).
Prevalence rates of mental illness
Mixed evidence exists with regards to the prevalence of psychiatric morbidity among Latinos when compared to other ethnic groups. The majority of reports on the mental health of Latinos in the U.S. indicate that they experience less psychological impairment than their non-Latino White counterparts. For instance, The National Survey on Drug Use and Health reported that 10.2% of Hispanic or Latino adults in the U.S. experienced serious psychological distress in 2007 compared to 11.3% of non-Latino Whites (The NSDUH Report, 2008).
A recent study by Alegria et al. (2008), based on data from two major national surveys, also reported lower prevalence rates for all disorders (except agoraphobia without panic disorder) among Latino subjects (29.7%) compared to non-Latino White subjects (43.2%). Similarly, 15.7% of Latino subjects reported any anxiety disorder compared to 25.7% of non-Latino white subjects. 11.2% of Latinos reported lifetime prevalence of substance disorder, compared to 17.7% for non-Latino white subjects (Alegria et al., 2008). A meta-analysis of eight recent studies did not find a clinically significant preponderance of depressive disorders or depressive symptoms among Latinos compared with non-LatinoWhites (Menselson et al., 2008).
Substance abuse is also a growing problem for Hispanics/Latinos. According to the US Department of Health and Human Services, between 1991 and 1998, emergency room use for drug related complications increased by 80% (Acosta 2004). Latinos have higher rates of alcohol use disorders when compared to Whites and are more likely than Whites to remain dependent once abuse begins (Galvan & Caetano 2003). A primary risk factor for alcohol use disorders among Latinos is unemployment, and some protective factors for women include older age, retirement and religiosity (Galvan & Caetano 2003). Chronic alcohol abuse has significant health repercussions; compared to Whites, Latinos have a significantly higher prevalence of hepatitis C, chronic liver disease, and cirrhosis, all of which are caused by or complicated by heavy drinking (Galvan & Caetano 2003). Heroin poses a particular problem to this community. In 1997, Latinos accounted for 32% of treatment admissions for heroin, and 32% of all deaths among Latinos related to drug use were attributed to heroin (Caetano & Galvan 2001).
One point that may obfuscate the ability to detect differences in rates of psychiatric illness between Latinos and other ethnic groups is a failure to consider the broad variability within the “Latino” ethnic category. Evidence suggests that significant differences may exist between individuals from different national origins, as well as between those with different levels of acculturation. Major epidemiological studies have examined the associations between either substance use or psychiatric disorders and Latino ethnicity, with different ethnic subgroups reporting different prevalence rates. Recent analysis by Alegria et al. (2008) reported prevalence of any lifetime disorder highest among Puerto Ricans at 37.4%, followed by Mexicans (29.5%), Cubans (28.2%), and other Latinos (27%). Prevalence rates for anxiety disorder ranged from 21.7% for Puerto Ricans to 14.1% for other subgroups. The Hispanic Health and Nutrition Survey (HHANES) found that the largest subgroups, Puerto Rican and Mexican-Americans, are more likely to have past or present drug use (43% and 42% respectively) than Cuban Americans (20%). Increased substance use was attributed, specifically, to acculturation (Amaro et al., 1990). Alegria et al. (2008) estimated prevalence of substance disorder at 13.8% for Puerto Ricans, almost double the rate of disorder in Cubans (6.6%). Interestingly, rates of depressive disorder were not found to be significantly different between any ethnic subgroups (Alegria et al., 2008).
Nativity also serves as a discriminating factor in differential prevalence rates among Latino subgroups. Alegria et al. (2008) reported significantly higher risk among U.S.-born Latinos than immigrant Latinos for any disorder (37.1% versus 24.9%), major depressive episode (18.6% versus 13.4%), social phobia (8.5% versus 6.0%), posttraumatic stress disorder (5.9% versus 4%), anxiety disorder (18.9% versus 15.2%), and substance disorder (20.4% versus 7%). These findings are consistent with the “immigrant paradox,” a phenomenon which contributes protection against psychiatric disorders to foreign nativity, despite the stressful experiences and poverty associated with immigration. Hypotheses abound (although evidence lacks) for such a phenomenon, among them the easy availability of drugs in the U.S., the U.S. convention for self-medicating, and societal pressure for productivity (Alegria et al., 2008).
Cultural views of mental illness
Both the presentation of psychiatric illness and explanatory models differ between Hispanics/Latinos and other ethnic groups. Latinos with depression are significantly more likely to present with somatic complaints when compared to White Americans (Lewis-Fernandez et al., 2005). This may be one reason why Hispanic/Latino patients with depression are more likely seek medical treatment for these ailments, rather than seek mental health care. Importantly, the somatic presentation of depression among Latinos may mislead primary care physicians, resulting in misdiagnosis, administration of unnecessary tests, and inadequate treatment (Lewis-Fernandez et al., 2005).
Latinos may have different beliefs about the cause of their illness; for instance, some Latinos believe in spirits or sins as the reason for their illness; an interpretation not readily understood by mental health professionals (Ruiz, 1985). They may also use different language to describe their symptoms; culture-bound terms may further preclude recognition of mental illness. Failure to properly distinguish between common psychiatric illnesses and culture bound syndromes may contribute delays in seeking care, inadequate treatment, and poor outcomes.
A well known culture bound syndrome among Latinos is "ataque de nervios," an idiom of distress particularly prominent among Latinos from the Caribbean, but recognized among many Latino groups. It is described in the DSM-IV Glossary of Culture-Bound Syndromes; symptoms include: screaming uncontrollably, attacks of crying, trembling, heat in the chest rising into the head, and becoming verbally or physically aggressive. Ataque de nervios typically occurs as a direct result of a stressful life event, specifically relating to the family. After the ataque de nervios, the person often experiences amnesia of the event, but otherwise rapidly returns to a normal level of functioning. Ataque de nervios is often compared to a panic episode because symptoms closely match. Factors that distinguish ataque de nervios from panic episode are the close association between an ataque with a precipitating event and the absence of the symptoms of fear and apprehension (Carrillo & Guarnaccia, 2008). Because ataque de nervios describes an emotional reaction to difficult, but temporary, life circumstances, individuals may not recognize debilitating mental illness or the need for mental health care (Ruiz, 1985).
Another culture-bound syndrome described by the DSM-IV is “susto”, a folk illness prevalent among Latinos in the U.S., as well as in Mexico, Central and South America. Susto results from a frightening event whose cause is attributed to the soul leaving the body, resulting in an unhappy mood and sickness. The DSM-IV provides the following symptoms: lack of appetite or gain in appetite, sleeping too much or too little, depressed mood, lack of motivation, feelings of low self-worth and dirtiness. Those suffering from susto also experience feelings of inadequacy associated with fulfilling their social roles. Symptoms may appear anywhere from days to years after the precipitating event. (Carrillo & Guarnaccia, 2008)
Whereas symptoms of susto closely resemble DSM-IV criteria for major depressive disorder, treatment implications may differ. Traditional treatment for susto consists of a ritual healing practice meant to call the soul back to the body and to “cleanse” the person to restore body balance. Such a ritual is conducted by Latino traditional healers. Whereas patients with susto may experience some improvement with conventional treatment for major depressive disorder, a failure to take into account the patient’s cultural beliefs may limit the treatment’s efficacy, affect adherence, and shape confidence (or lack thereof) in the formal mental health sector. The event that precipitates the susto seems to correlate with differential Western diagnoses. For instance, susto resulting from an interpersonal conflict is highly correlated with the Western diagnosis of major depression (Carrillo & Guarnaccia, 2008).
Impact of cultural values on the use of mental health services
Hispanics/Latinos have a collectivist orientation; being family oriented (familismo), helpful toward one another, and united are central attributes of Latino culture (Interian et al., 2007). Familismo, a word unique to the Spanish language that emphasizes strong family relationships, may serve as a protective factor, fostering positive social support and protecting individuals against depression even in the face of substantial environmental risk (Menselson et al., 2008). Familismo is thought to contribute to Latinos’ resilience to a range of negative health outcomes, such as infant mortality and low birth weight, and is often cited as an explanation for the immigrant paradox.
As of the 2000 census, Latina women comprised 51.5% of the U.S. Latino population (U.S. Bureau of the Census, 2000). Most Latinas are concentrated in low-paying occupations, for example, factories, restaurants, or clerical work. They experience twice the rate of unemployment compared to that of White women, and suffer from multiple social and economic disadvantages, such as low levels of education, low income, single parenting and high levels of poverty. All of these factors impact their health and limit their access to and utilization of health services. (Giachello, 2001)
Shame and stigma
A recent study found significant levels of stigma associated with depressive symptoms and antidepressants. Latino participants who participated in a study receiving treatment for depression believed that an experience with depressive symptoms is labeled negatively, viewed particularly within their social contexts. When asked about complications adhering to prescribed antidepressant medication regimen, 73% of participants made comments related to stigma, second only to side effects (87%) (Interian et al., 2007). Taking antidepressants seemed to subject participants to disapproval from their family and social support systems.
Hispanics are transforming the religious landscape of the US, not only because of their growing numbers in the general population but also because of the distinct way in which they practice Christianity. The majority of them are Roman Catholics (68%), 20% self-identify as Protestant, 8% as secular, and 3% as Other. About a third of all Catholics in the US are now Latinos (Pew Forum, 2009).
A recent study suggests that Latinos practice a distinctly ethnic-oriented Roman Catholicism. It strongly suggests that Latino Roman Catholicism is not simply a product of immigration or language but involves a broader and more lasting form of ethnic identification. Two-thirds of Latino worshipers attend churches with Latino clergy, services in Spanish and heavily Latino congregations. While this was most predominant among the foreign-born and Spanish speakers, Hispanic-oriented worship is also prevalent among native-born and English-speaking Latinos (Pew Forum, 2009).
More than half of Hispanic Catholics identify themselves as “charismatics” - saying they have witnessed or experienced occurrences typical of spirit-filled or renewalist movements, including divine healing and direct revelations from God - compared with only an eighth of non-Hispanic Catholics. The renewalist movement has similar presence among Latino Protestants, with more than half identifying with spirit-filled religion, compared with about a fifth of non-Hispanic Protestants. Those who do not identify as “charismatics” appear deeply influenced by spirit-filled forms of Christianity as well.
Attending Church has practical implications; immigrants often attend Church as a means of integrating into community life (Center for the Study of Latino Religion, 2007). Across all major religious traditions, most Latinos view the pulpit as an appropriate place to address social and political issues. Latinos see religion as a moral compass to guide their own political thinking, and they expect the same of their political leaders. Accordingly, religion for Latinos sheds light on political beliefs and public affairs. Political affiliations are often based on religious affiliations.
Mental health care seeking patterns
Sources and types of formal help
Hispanics/Latinos are much more likely to rely on primary care doctors than on mental health professionals as their sole or preferred providers (Vega et al., 2007). Preferential use of primary care services for psychiatric problems may be explained by multiple factors, including low health literacy, somatic presentation of psychiatric distress, and stigma associated with seeking mental health care (Vega et al., 2007; Lewis-Fernandez et al., 2005; Vega & Lopez, 2001). Once in mental health care, Hispanics have high rates of dropout and missed appointments, and poor medication adherence (Opolka et al., 2001). The general lack of commitment to mental health care has been attributed to linguistic and financial barriers as well as cultural inadequacy and minority status.
Sources and types of informal help
One reason that Hispanics/Latinos may be less apt than their White counterparts to seek formal mental health care because of a cultural reliance on the family. The social resources sought out include the family and the network of friends and godparents, religious denominations, spiritualists, and other folk-healing practitioners and self-help groups (Vega & Alegria, 2001). These resources are often used instead of professional mental health services, but the literature suggests that they do not effectively replace professional services (Vega et al., 1999)
A study by Feldmann et al. (2008) reported high use of folk and traditional medicine (FTM) among Mexican American adolescents. 26.9% of subjects at community-based organizations reported FTM use, prompted by illness. 23.6% used herbal remedies and 4.4% used traditional healers. Importantly, the researchers found that lack of access to professional care did not appear to motivate use of FTM, since it is considered a complementary rather than a comprehensive treatment.
Botanicas (ethnic healing stores) are particularly present in New York City. Botanicas are local stores that offer healing, religious, and spiritual products and services to a diverse clientele mostly comprised of immigrants from Latin America and the Carribbean. The presence of Botanicas in NYC has been traced to the drug dispensaries (droguerias) that appeared in the early 1900s. Today, they are mostly located in areas where Latinos are increasingly the majority. They are small stores where magic, religious syncretism and herbal remedies with roots in Asian and Latin American spiritual traditions may be found. Specifically, they are retail businesses, which sell medicinal herbs often imported from Puerto Rico and the Dominican Republic. Additionally, botanicas provide unique counseling services to those seeking spiritual and emotional guidance on a variety of issues, ranging from financial concerns to mental health issues (consultas). The perceived effectiveness of folk practices, combined with the fact that services and herbal remedies offered at botanicas are cheap and highly accessible, attracts Latinos who are seeking informal mental health services. (Bacca et al., 2006)
In a study by Bacca et al. (2006), healers claimed to be able to cure a vast array of physiological, spiritual and emotional ailments. They had a unique explanatory model for diagnosis and cure compared to Western models: with psychosomatic causes (psychosoma) explained as an outcome of strained social relationships (sociosoma).
Mental health service utilization challenges
Hispanics/Latinos with existing health and mental health conditions are less likely than Whites to use health services. In 2007, only 29.6 percent of Hispanics/Latinos with serious psychological distress received mental health services, compared to 50.9% of non-Hispanic Whites with serious psychological distress (The NSDUH Report, 2008). Racism and discrimination, lack of access to economic and social resources, and other sources of stress due to social disadvantage are cited as explanations for underutilization of services (Menselson et al., 2008).
In New York State, 83% of Hispanics/Latinos do not speak English at home (U.S. Census Bureau, 2006). Lack of English proficiency serves as a major barrier to accessing mental health care. Gilmer et al. (2007) found that 36% of Latinos living in San Diego County between 2000 and 2005 reported a preference for Spanish-language services. More importantly, those who preferred to receive mental health care from Spanish-speaking providers were less likely than English-proficient counterparts to access the public mental health system (28% compared with 39%). Those who were not English-proficient also received fewer outpatient services over time than their English-proficient counterparts. As compared with Latinos who were proficient in English, those with limited English proficiency were older, more likely to have major depression, more likely to live independently and less likely to have insurance, all contributing risk factors for psychological distress (Gilmer et al., 2007).
Hispanics/Latinos have the highest rates of being uninsured of any racial or ethnic group within the United States. Lack of health insurance precludes access to care. In 2007, 32.1% of the Hispanic population was not covered by health insurance, as compared to 10.4% of the non-Hispanic White population (Hispanic/Latino Profile, 2009). Rates are higher for Mexican Americans (37.6%) than for Puerto Ricans (20.4%) and Cubans (22.8%) (Centers for Disease Control and Prevention, 2004). In total, nearly 40% of Latinos under age sixty-five do not have health insurance. Latino children make up 29% of the uninsured under eighteen (compared to 11% of Whites in this age bracket) (Carrillo et al., 2001). A major reason for the lack of health insurance is that employers do not offer coverage; only 44% of Latinos have health insurance through their employers (compared to 69% of Whites). The low rate of employer-sponsored coverage is attributed to a number of factors, among them citizenship, educational status, and workforce characteristics.
Shame and stigma
Lower utilization rates among Hispanics/Latinos may be partially attributable to the social consequences of seeking services. Research has suggested that Hispanics/Latinos are reluctant to seek services because of fears of deportation, distrust of service providers, and fear of law enforcement (Lewis et al., 2005). Other studies have suggested that individuals fear bringing shame to the family for seeking professional mental health services. Because the family and extended family act as a tight-knit unit, Hispanics/Latinos view mental health problems as matters that are private and ought not to be shared with others outside the family (Leaf et al., 1987).
Specific Health Risks
Rates of obesity and high blood pressure are higher among Hispanics/Latinos than among Whites, and they are less likely to engage in leisure time physical activity (U.S. Department of Health and Human Services, 2000). Consequently, there is higher risk for obesity, metabolic syndrome, and diabetes among this group.
In 2002, the third National Health and Nutrition Examination Survey (NHANES) found that Hispanics had the highest age-adjusted prevalence of metabolic syndrome (31.9%) of any ethnic group. The rate among the general US population was 23.7%, comparatively (Cruz et al., 2004). Metabolic syndrome is defined as having at least three of the following: abdominal obesity, low high-density lipoprotein (HDL) cholesterol, hypertriglyceridemia, hypertension, and/or impaired glucose tolerance (NCEP-ATP III, 2002). Having the syndrome is a risk factor for the development of type II diabetes. Literature suggests a link between the high prevalence of metabolic syndrome in Hispanics and the higher prevalence of obesity in this group (Ford et al., 2002).
Researchers at Hunter College and Fordham University found specific health crises in New York City’s Latino population. They found that the obesity rate for Hispanics is just over 25% across all five boroughs. By gender, 28.5% of Hispanic females are obese, and 24.5% of Hispanic males are obese – the highest prevalence rates among all ethnic groups. Diabetes rates correlate, with NYC Hispanic males at 13.8% and NYC Hispanic females at 11.8%, double the rates among their White counterparts (6.5% and 6.1%, respectively). (Rivera, 2008)
Specific attention has been paid to the higher rates of obesity among NYC Hispanics/Latinos, compared to Hispanics/Latinos nationwide. The Centers for Disease Control (2008) found that 13.1% of New York Hispanics have been diagnosed with diabetes, compared to 9.8% of Hispanics across the US. They contribute the higher rate of diabetes to the higher rate of poverty among NYC minority groups, suggesting that poverty is a risk factor for diabetes.
Because mood and anxiety disorders are found to be slightly higher among persons with diabetes (Lin & Von Korff, 2008), it is important to consider the mental health implications of the high rates of diabetes and its associated risk factors for this group.
Specific age/gender group problems
Hispanic/Latino children are the largest minority group and have the fastest growing poverty rates of all children in the U.S. Hispanic/Latino children are three times more likely to be poor (36%) than White children (11%) (U.S. Bureau of the Census, 1999b). Puerto Rican children are the most affected by poverty, with more than half (53%) living below the poverty level in the U.S. Importantly, while 87% of Latino children are U.S. citizens, either born or naturalized, they suffer from limited accessibility to primary and preventative health services due to factors such as low family income, lack of or inadequate insurance, and poor education (Flores & Zambrana, 2001).
Multiple studies document high rates of illicit drug use, alcohol consumption, and tobacco use among Latino adolescents. According to the Youth Risk Behavior Survey of 1997, Latino youth were more likely than African American youth to have consumed alcohol during their lifetime, to report current drinking, or to report episodic heavy drinking (Caetano & Galvan, 2001). Factors associated with present and future alcohol consumption include most friends drinking, mother drinking, smoking cigarettes, marijuana use, finding it easy to obtain alcohol, and getting in trouble in the last month (Flores & Zambrana, 2001).
Latino adolescents (and Latina women in particular) have the highest prevalence of depressive symptoms of any ethnic group, with prevalence rates for clinical depression reported as high as one-quarter of high school students (Flores & Zambrana, 2001; Emslie et al., 1990). Suicidal ideation is also reportedly higher in Latinos (10.7%) than in African American (7.3%) or White youth (6.3%) (Centers for Disease Control and Prevention, 1997). Importantly, care disparities exist between Hispanic and other non-Hispanic youth. Even when "in care," Hispanic youth receive fewer therapeutic services and remain in care for longer periods of time than other non-Hispanic youth groups (Acosta, 2008). Moreover, while less likely to receive mental health services, Hispanic youth are significantly more likely to be involved with the juvenile justice and/or child welfare system (Vega & Alegria, 2001).
The U.S. Hispanic/Latino elderly population is expected to increase by 555% over the next three decades, compared to an increase of 93% in the White population (American Association of Retired Persons, 1994). Elderly Latinos are more likely to be in poor health and economically disadvantaged. 22.5% of Latino elders are poor (compared to 12% of White elders). Poor health has been attributed to low socioeconomic status and time spent in physically taxing occupations (Becerra, 1984). Taken together, the population’s access to health services is extremely limited (Villa & Torres-Gil, 2001).
Familismo is thought to act as a protective factor among Hispanic/Latino elderly. Strong reliance on the family seems to translate to better mortality than expected (Villa & Torres-Gil, 2001).
However, recent data from the Collaborative Psychiatric Epidemiology Surveys (CPES), a project supported by the National Institute of Mental Health (NIMH) is conflicting. Elderly Hispanics reported more use of psychotropic medication than any other racial/ethnic adult group. 33% of Hispanics aged 65 and older self-reported use of psychotropic medications in the past twelve months compared to 23% of Asians, 14% of whites, and 8.5% ofAfrican Americans/Afro Caribbeans. According to the researchers, the reason for the racial/ethnic difference is unclear at this point (Tucker, 2009).
Impact of acculturation on treatment
Degree of acculturation among foreign-born Hispanics/Latinos residing in the US may be a factor in predicting mental disorder, and evidence for the role of acculturation has been somewhat inconsistent. For example, Ortega et al. (2000) reported increased likelihood for both psychiatric and substance disorders in highly-acculturated Latinos than in their less acculturated counterparts. Likewise, a study of Mexican-Americans in California valley reported that recent immigrants had the lowest rates of psychiatric illness, while immigrants who had been in the U.S. for over 13 years had higher rates, which approximated general U.S. population rates of psychiatric illness (Vega et al., 1998). On the other hand, Fabrega and Wallace (1970) found that less acculturated Mexican-Americans had more psychiatric impairment than those who were more highly-acculturated. The reasons for such inconsistencies are unclear, but literature suggests differences in premorbid risk factors; differences in acculturative strain; and culture-based experiences, values, or beliefs as potential explanations (Levine, 1973; Vega et al., 1993).
The American way of life imposes cultural changes and structural strains on the traditional Latino way of life. Stresses of adaptation to American culture may undermine family cohesiveness (familismo). While parents continue to speak Spanish after immigration to the U.S., thereby reinforcing their Latino culture and values, children become fluent in English more rapidly, which accelerates their own social and cultural learning. This dichotomy may undermine familismo. Without a strong cultural and familial support system, the mental health of children or their parents may deteriorate (Vega & Alegria, 2001).
[Rachel Levenson, Antonio Abad, MD, and Annika Sweetland, LCSW contributed to this report.]
© 2009, OMH
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