www.crossingdialogues.com/journal.htm 15 ORIGINAL ARTICLE Psychopathological risks in children with migrant parents FRANCESCA ROMANA MONTECCHI & CATIA BUFACCHI Clinical Centre "La Cura del Girasole" Onlus, Rome, Italy In Western societies many immigrants live in difficult social and working conditions. Together with other factors, this state of affairs represents a risk for the well being of their children. This article will consider the principle risk factors for child psychopathology and/or distress, with a distinction between temporary and permanent factors and with a peculiar attention to the interplay between risk and protective factors. Risk factors can be ordered in cultural, social, familiar/parental and individual factors. Some of these are general risk factors, applying to child and adolescent psychopathology and distress independently from the status of immigrants' offspring (among them there are some risk factors related to poor social conditions, independently from being an immigrant or a low-social-class Western citizen). Other factors are specific of migration, some of them being related to: a) different ways of immigrated families to situate themselves within the host society (assimilation, separation, integration, marginality); b) cultural/familiar attitudes in child's nurture and education; c) the family role of women as well as factors specific of the pregnancy period in immigrants; d) the ability of the school system to enhance and support children's abilities to integrate within the new society; e) the political/bureaucratic facilitation/impediment to the regularization of VISA, with the consequent effect on the sense of identity/rejection within/from the host society. In conclusion, the programs for monitoring immigrants' living and health conditions should also include: the assessment of parental skills, the dynamic indicators of risk and protection indexes, the assessment of living conditions and social school environment, with a careful attention to those early signs of discomfort that might precede possible later onset of psychopathology and/or social distress. Key words: migration, psychopathological risk factors, child psychopathology, prevention, trans-cultural psychiatry, social psychology DIAL PHIL MENT NEURO SCI 2009; 2(1): 15-23 INTRODUCTION Recent data relating to legal proceedings show that the detainees in juvenile prisons are predominantly immigrants often suffering from psychological discomfort (De Blasio and Acquistapace, 2004). In fact, the social problems of immigration and labour have an impact on living conditions and development of migrants' sons (Giovannetti, 2000). These children are in Italy for different reasons: some are immigrants arrived with their parents, others have been separated from their parents for a prolonged period of time; some are refugees or nomads, others unaccompanied Montecchi & Bufacchi DIAL PHIL MENT NEURO SCI 2009;2(1):15-23 16 children or arriving for international adoptions (Arnosti and Milano, 2006). During the last fifteen years, the intense migratory phenomenon in Italy has been characterized by family reunion, increasing in steady families of different nationalities and exponential raise in the percentage of children. Up to now this slice of people in Italy is equivalent to a quarter of the foreign resident population (Favaro and Napoli, 2004). Most of these children (native from Romania, Morocco, Nigeria, Albania, India, China, Ukraine, Philippines, South America and many other countries) face deep differences and contradictions between the native culture and the one of the host country. Migration studies only recently focused on medical and social aspects of adult education and inclusion of children and adolescents (Favaro and Napoli, 2004). Some studies focused on the psychological and psychopathological characteristics of migrants (Mazzetti, 1996; Pertíñez Mena et al., 2002; Aragona et al., 2005), while analyzing the state of the art studies addressing the assessment of parenting skills, styles of treatment, care and education result to be rare. Few early studies showed that immigrants' children well integrated between the two cultures do not exhibit developmental and psychopathological risks more than the Italian children on equal terms, but if we compare the risk factors normally used to identify children at risk or unprotected psychopathology (De Blasio and Acquistapace, 2004; Montecchi, 2005) it emerges that most children of immigrants are seriously exposed to changing situations of risk. Accordingly Italian citizens have the same risk factors and the same pathogenic conditions if we take into account the same socioeconomic class and age groups. However, the psychological impact of migration and adaptation may expose immigrants to additional risks that deserve to be studied. This article will analyze those risk factors arising from the living conditions that are forced by migrants' children and are a potential psychiatric risk. They will be considered from the developmental psychopathology perspective. A distinction between temporary and stable factors, as well as the interplay of risk and protective factors in these children will be studied. THEORETICAL BACKGROUND The study of conditions of risk in children requires the adoption of interpretative complex models taking into account lots of variables involved like the environment, the native culture, the family features, the traits of the child, the quality of interpersonal relationships. Developmental psychopathology (Ammaniti, 2001; Fonagy and Target, 2005) is a main explanatory model because it provides a conceptual scheme based on a logical format and able to integrate data from different theoretical fields (neuroscience, psychiatry, developmental psychology). This approach proposes to consider from an evolutionary point of view cognitive, emotional, relational, social and biological aspects of the human race, focusing particularly on context and steps of development. In other words, this is an ecological perspective using the main contexts of development in order to better understand the models used to adapt the human being to different steps of his evolutionary path. This approach is particularly convincing because it recognizes the importance of socio-cultural factors in the gradual organization of personality. The process of migration and subsequent cultural and social adjustments plays also a key role in the individual's mental health (Bhugra and Jones, 2001). The concepts of risk and protective factors are theoretical nodal points of the psychopathology of development and lead to develop a new interpretative model inside which are crossing both the elements that endanger the child and the resources should be exploited to counteract or reduce risks factors. To avoid misunderstanding we need to clarify what we mean discussing risk and protective factors. The risk factors are the conditions constituting the substrate on which one can make an event www.crossingdialogues.com/journal.htm 17 or a pathological development, alarm signals for early detection and treatment of cases at risk. The risk indicators are the social, family and individual features which can guide and steer towards a diagnosis and indicate where primary prevention should be oriented to. The protective factors are the environmental or individual characteristics with which the players interact and which provide the care. Protective processes show dynamic movements through which protective factors alter and change risk factors (Mosten and Reed, 2002). Using rigidly the protective processes without applying a flexible and dynamic perspective of risk factors and without considering, at the same time, the plot created by the protective factors could generate negative consequences. It should be considered that in spite of a negative influence, a protective factor comes into play and so the previously risky trajectory changes into a positive direction (De Blasio and Acquistapace, 2004). Moreover, the risk factors should be evaluated in their entirety as a whole as they are the elements of vulnerability due to the cumulative effects of reinforcement and which should always be compared with the protective factors and family resources. So it should be avoided equating the presence of risk factors as an objective risk (Montecchi and Marinucci, 1998). In the case of migrant families, assessing the potential pathological risk factors is essential to further distinguish which of them are identified in two additional categories: 1. factors related to a temporary situation; 2. factors related to a more stable condition. In terms of intervention: 1. Aspects of pre-migration conditions (preexisting psychopathology, parent's trauma, adverse life events, developmental disability, etc.); 2. Factors associated with post-migration difficulties (trans-cultural stress, poverty, social support, nostalgia for their country, etc.). The risk factors that undermine parenting skills and expose children to poor protection, such as abuse, violence and psychopathology evolution, can be divided into four groups (see Table): cultural, social and familiar, parental, individual of the child (Montecchi, 2005, largely modified). However, this distinction cannot be considered sharply, because they are four groups continuously interacting each other. In the following discussion only some examples of those risk factors specific of the migratory condition will be considered. MIGRATION RISK FACTORS IN CHILDREN Cultural attitudes The way in which the migrant creates relationship with the guest society will be decisive in establishing a healthy parent-child relationship (Ambrosini and Molina, 2004). The identity and social relations of migrants can be classified as follows: Assimilation: migrant moves towards accession to behavioural patterns and values of the guest company in whole or in part by rejecting the elements of their native culture. Separation: migrant remains linked to his own native culture and, at the same time, avoids contact with people belonging to the host culture. Marginality: migrant does not maintain ties neither with his native culture nor with that of the guest society. This is more dangerous for the psychological well-being as it potentially prevents the chance of developing an identity able to deal with the cracks caused by migration. Integration: migrant maintain his cultural heritage and, at the same time, he is open to people and assets of the guest society. The birth and socialization of migrants' children determines the development of interactions, exchanges but also conflicts between immigrants and host society; the children are therefore unaware of their role of mediators between different cultures. Montecchi & Bufacchi DIAL PHIL MENT NEURO SCI 2009;2(1):15-23 18 Table: main risk factors for child distress/psychopathology Cultural factors Social and familiar factors Parenting factors and parent/child difficulties Individual factors of the child cultural attitudes respect to the host society poverty the past ill-treatment suffered by the parents or childhood experiences of neglect or lack of emotional security Genetic factors (Rutter et al., 1998; Thapar et al., 1998; Campbell et al., 1996) attitudes toward violence and punishment as "educational" strategies difficulty or dissatisfaction with housing, job reasons of migration (forced vs. voluntary) biological problems during pregnancy family culturally considered nonaffectively poor social support trans-cultural stress perinatal complications suspicion and distrust towards the social and health services loss of relationships or the support of families of origin difficulty recognizing their own needs early separation from mother at birth instability and insecurity young age of the parents (especially the mother) or strong age difference chronic diseases (physical, psychological) difficulties in communication reversal of parental roles, especially paternal liability and assumption of a strong male role by the mother conducted physiological disorders: disorders sleepwake rhythm racial discrimination, membership of a racial or ethnic group perceived as different from the dominant domestic violence and conflicts in partnerships sphincter control disorders poor educational level and low school attendance conditions of stress eating disorders mono-parental families emotional and mental distress: personality disorders, alcohol addiction and drugs, impulse control disorders, etc. motor disorders (hyperactivity, tics, etc..) multiple critical events in the family the life pauperisation in pregnancy care "difficult temperament" poor family functioning: confusion of family roles, low neutrality and flexibility biological or psychological problems during pregnancy low-performance at school difficulties to seek help and benefit from the social and health services (for example, do not see your paediatrician or family doctor) stability of the mother-child dyad maternal separation and breaking of family and social ties (Bowlby, J. 1969) cares quality: attachment, emotional regulation, physiological regulation, the game, parental scaffolding (De Rosa et al. 2002) www.crossingdialogues.com/journal.htm 19 Beside these possible ways to approach the host culture, some other cultural factors might be at stake. For example, although this applies only to a minority of immigrants, it should be considered the following possible cultural risks: • cultural attitudes toward violence as a means to solve problems or to achieve some goal; • attitudes towards punishment, using harsh and punitive educational strategies; • design of the household not considered as the space where sharing affective values, ensuring the continuity of generations, not even as a place of protection and solidarity; • design of the institutions to support the family considered as a source of support primarily economic; • attitude of suspicion and distrust towards the social and health services, and consequently persecutory and threatening attitude of social interventions. School Schools and schoolmates are the first step in socialization for children. School is the place where children and families are introduced to other cultures. In case of major language disadvantages for the migrants' children compared to their peers, this is likely to result in problems at school and failure in classes leading to discrepancies between the behaviour learned in the family and the one acquired at school. In their early years, immigrant children speak their native language while the school teaches them the language and culture of the host nation (Portera, 1997). Language is full of emotional charge that cannot be transmitted in any other way; thus, traditions and rules of communication are learned in the native language. During the school age young immigrants live in two main areas of socialization: schools and families; they are torn between two identities: the former of the parents (of the ethnic group they belong) and the latter of the school (local society). Then the process of integration of the child follows the first one; the condition becomes more and more complex when the child is deprived of a residence permit. The child is affected by his living in secrecy even though he is able to attend school and function in society. The condition of children shows alarming data in relation to school attendance: 14% of children from 7 to 12 years old does not attend primary school, so that this slice of population is at risk both physical and mental. Indeed, the typical profile of these children is deeply characterized by extensive problems in introducing at school (delay, lack of attendance), often broken families and lack of protection by adults. Family The cultural factors, attitudes towards violence, punishment, education and the conception of the family are not the same for all populations; in fact conditions considered aberrant in some cultural contexts are "normalized" in others. The trans-generational and cultural conditions create virtual containers reducing the potential pathogenic effect, which is released when travelling to another culture with different concepts of childhood. In these cases the same educational attitudes become potentially dystonic and potentially pathogenic (Ancora, 1997). In particular, here we are referring to: • the use of corporal punishment; • intra-family sexual abuse culturally shared in some poor zone of the territory or in some countries (where there are no rights for children and they are considered property of the family head), under conditions of severe neglect and physical abuse; • the exploitation of children as workers or machines with poor care to their needs (especially in the event of illness and of emotional discomfort); • the assistance delegated to the community which tends to cover conditions of poor supervision or neglect. Moreover, there is the risk coming from instability of work and house of parents with a Montecchi & Bufacchi DIAL PHIL MENT NEURO SCI 2009;2(1):15-23 20 high impact on children. The limit of dangerous overcrowding in housing is marked by an area of 8-10 square meters per person; less then 10 square meters per person is a critical area of almost permanent dissatisfaction: the child in a confined space has a very limited exploration, his parents are already hypersensitive to emotional tension and he is more often subject to prohibitions and corporal punishment. The insufficient control on foreign children is cause of traumatic disorders with a frequency exceeding that of native children (they spend a long time alone, without any parental figure, therefore they are less protected and more exposed to injuries and trauma of various kinds up to thinking to the phenomenon of the "abandonment" of the child). To the reduction of parental abilities contribute also components due both to parents and children self-fostering and amplifying each other. This state can become even worst in case the parents had in their childhood experiences of mistreatment (Montecchi, 1998), serious emotional weak-nesses, psychiatric disorders (psychotic, borderline, depressive, obsessive, drug addiction, alcoholism, etc.), in cases of young age of parents and in conditions of family breakdown (Campbell et al., 1996). A research about immigrants in Rome showed that for a sample of 100 women with at least one child aged between 1 and 12 years, the immigrant children living with both parents are very few. Therefore the figure of the father, which is considered very important in models of child development, is very often lacking. Another condition of exposure to risk is the pregnancy carried out in solitude and with real problems preventing the mother from creating a mental space for her child and, at the same time, the early maternal separation: data document that 16% of children do not live with the mother longer than three years and if this limit is lowered to the age of two the percentage rises to 37%, 57% for children aged 2-5 years living away from their mother and 78% of children living away from at least one parent; the percentage of complete families, i.e. those in which parents and children live in the same house, is 26% (Benvenuti et al., 1996). Another problematic area concerns roles in family. In case migrant children own innate good resources and these can be invested even in an environment made of adverse conditions, they become "young adults". A small reversal of roles takes place and they become caregiver of their parents, facilitating them to overcome problems of integration. On one side, this is a positive, protective factor. In fact, their greater plasticity, the ease with which they learn the host language allows them to act as guides and mediators for their parents. The recognition of these children leads us to highlight, in the evaluation process, the potential for resilience, i.e. the ability to cope with the traumatic events in a positive way, to organize their lives positively in spite of difficulties, the ability sometimes innate allowing them to face the adversities and giving new impetus to their existence and then achieving important goals (Mosten and Reed., 2002). On the other side, the reversal of family roles and the praecox "adultization" of these children is a possible source of distress and risk because of their new and great responsibilities and the different role compared to their peers. It is necessary to recognize and understand these situations, to enable migrant parents in the transformation process necessary to accept the new way to treat the child with rights and needs of physical and emotional care. In addition to taking care of the development of their children, migrant parents should encourage dialogue to discuss the different value systems. This may facilitate the comparison and integration of different cultural values by children who could consequently be able to build their identity throughout the crucial developmental steps in their adolescence. Unclear civil status Worsening the situation is the "aggravating factors reinforcement" Many of the children taken into exam are in Italy, but they are not recognized as "Italians" from the society around them or in terms of civil rights. The www.crossingdialogues.com/journal.htm 21 cultural level is, at same time, in a difficult position of "pivot" between two cultures threatening to crush them. The breakpoint emerges during the adolescence through the expression of acute discomfort and is expressed on the intrapsychic side with anxious, depressive, psychotic, and social syndromes with varying degrees of antisocial behaviour and delinquency. A peculiar and temporary condition: pregnancy Apparently life begins in the moment of birth, in fact when a child is born biologically he brings with him a large amount of information and emotional experience received and gained from the moment of conception. These experiences are transmitted from the mother through vascular and humoral signals; any variation of the physical and maternal emotional status is taken from foetus as a pleasant or distressing, as a good or distorted communication with the mother. However, the mother does not notify the child only her own personal experiences, but she plays also a role of mediator between the foetus and the "outside world", the communication between mother and child is the result of the personal stories of parents including the evolution lived by the couple and the relationship it interweaves with the social context it lives in. Pregnancy is a time of particular importance in women's lives, it is characterized by regression and the pregnant experience guides and channels the regressive movement. From this regression, the future mother draws the ability to communicate firstly with foetus and then with the child. This regressive movement is functional in the child development, because it allows the woman to feel the child, turning on that function that Winnicott (1956) called "primary maternal preoccupation" and Bion (1962) highlighting particular aspects of thought called "maternal reverie". The mother is the link between the foetus and the outside world. The regression in pregnant women leads to a kind of personal prehistory, but she needs to withdraw gradually from the external duties of family and social context and she demands the presence of a third figure: the future father and partner who must fulfil a function of protection, container of the dyad, the link between the mother and the outside world, welcoming the element and transforming the anxieties that accompany pregnancy occupying the mental world of women. Even a bright event in the life of a woman as the arrival of a child may have some dark side. Comparing the above perspective with the real life of a pregnant migrant woman (the discomfort for the expulsion from her native country, the instability of her inclusion in the society of arrival, the housing difficulties of work, family disruption), it emerges that pregnancy carried out in a migration time is a peculiar moment involving development risks for child who will be born and for the development of parenting skills. The necessary concern for what happens in the world outside of pregnant migrant women determines the block of the process of regression and the absence of fantasies in which women are prevented from opening in themselves the mental space necessary to build the relationship with their son, creating an absence of thought and concern, becoming a carrier of disease and inability to create a mental space of care, love and protection for the unborn child. Pregnancy and post-partum are the conditions under which the vulnerability of women increases and a serious risk of evolution to the unborn child is generated: lower foetal growth, reduced cognitive and behavioural development in childhood and adolescence, poor nutritional status and health are the most frequent adverse outcomes for the child, which have been associated with maternal inadequate care for child health and low affective and emotional prenatal and postnatal care (Bowlby, 1969). CONCLUSIONS This study evaluated some child risk factors related to migration. Their importance was already stressed in previous studies showing that when children were grouped according to Montecchi & Bufacchi DIAL PHIL MENT NEURO SCI 2009;2(1):15-23 22 the number of risk factors that impacted upon them (no risk, moderate risk, child-risk only, family-risk only and multiple-risk), boys in the multiple-risk factor showed the poorest functioning and most problems over a nine year period of study (Campbell et al., 2000). Other studies indicate that it is the number of serious risks, rather than the nature of any risk, that is critical (Sameroff, 2000). Those risks that cut across child, parenting, family and socio-demographic domains are considered the most problematic ones (Fuligni, 1997). Our study explored some examples of risk factors that in their interplay with other conditions (even protective), may lead to the emergence of distress and in some cases of psycho-pathology. The evolutionary phases are characterized by complex aspects and facets in which each developmental stage has its own specific character. Migratory variables are often related to the age of parents and their ability to integrate, store and filter the new world and offer it to their children. Radical changes related to the migratory dynamic may lead to parents' anxieties and depression that open to the possibility of "psychotic" defence mechanisms such as denial, splitting, idealization. In turn this may affect child's identity. The individual has an identity if his parts are sufficiently integrated into a "whole" that he feels as characterizing him while distinguishing himself from the others. What is not detected during the growth of the child is that after a childhood in which the society did not recognized the child in his age, the same process will present itself once again during adolescence. The adolescent immigrant who is not sufficiently integrated expresses the aspects of the sick society hosting him with anti-sociality and psychopathology. If the social group does not include and take care of the child but exploits him as a container of unwished things (the sick and perverse parts that the host society does not recognize as its own), then the adolescent (immigrant) is transformed into a whipping boy loaded by a pseudo-identity of delinquent or psychopath. The discussed risk conditions indicate that it would be very important to introduce into programs for monitoring living conditions and health of migrants: • the assessment of parenting skills; • the dynamic between indexes of risk and protection; • the assessment of good social and educational conditions; • the attention on any signs of discomfort which might be precursor of the psychopathological development. This assumes further importance to prevention of psychiatric pathologies in the younger people who will be integral part of the adult society of the future. In fact, the attention to the factors of psychopathological risk in the children of migrants represents a valid investment for the health and the psychological comfort of the future adult population. Corresponding Author: Catia Bufacchi Centro Clinico: "La Cura del Girasole" Onlus via Gregorio VII, 186, 00165 Rome, Italy Tel/Fax: +39-06-6381992 e-mail: onlus@lacuradelgirasole.it www: www.lacuradelgirasole.it Copyright © 2009 by Ass. Crossing Dialogues, Italy REFERENCES Ambrosini M, Molina S. Seconde generazioni. Un'introduzione al futuro dell'immigrazione in Italia. Fondazione Agnelli, Torino, 2004. Ancora A. La dimensione transculturale della psicopatologia. Edizioni Universitarie Romane, Roma, 1997. www.crossingdialogues.com/journal.htm 23 Ammaniti M. Manuale di psicopatologia dell'infanzia. 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