A guide for health professionals working with
immigrant and refugee children and youth

Immigrant adolescent health, Part 2: Guidance for clinicians

Key points

  • Health professionals can promote positive development in adolescent immigrants.  Culturally and developmentally appropriate care includes social integration and identity development, inquiring about strengths, discussing confidentiality, and supporting inclusive, immigrant adolescent-friendly approaches.
  • Health care providers should routinely meet with immigrant adolescents alone for some portion of the visit(s), and conduct a strengths-based, confidential, developmentally appropriate psychosocial interview (using HEEADSSS/SSHADESS) to assess sensitive psychosocial issues.
  • Health professionals can promote healthy coping and behaviours, help to establish protective factors such as positive peer and family connections and caring relationships with adults, and ensure that approaches to care are culturally appropriate and relevant.
  • Health professionals should be aware that cultural, linguistic and religious integration can affect:   
    • Psychosocial stressors and mental health
    • Suicidality
    • Family dynamics and conflicts  
    • Sexual and reproductive health
    • Substance use
    • Conflict, delinquency, youth violence 
  • Avoid using adolescents as interpreters for other family members. Engaging professional interpretation services is the best practice for all involved.
  • Immigrant adolescents are an exceptionally diverse group. Developmentally appropriate interventions and inclusive approaches to care are key to helping this population make important transitions.

Priority health concerns

Adolescent morbidity and mortality are often associated with accidents, suicide, violence and other preventable situations.1 Injuries and suicide are the two leading causes of death among Canadian youth 15 to 24 years old.2 Other important health concerns in adolescents involve mental health issues, sexually transmitted infections (STIs), substance use, aggression and violence, lack of physical activity and food insecurity .3

For more information, see Immigrant adolescent health, Part 1: Background and context, which describes issues such as identity development and acculturation, social determinants, and risk/protective factors for immigrant adolescent health.

Being mindful of common issues is especially important when caring for immigrant adolescents, whose priority health concerns overlap those of Canadian-born peers, both in daily life and in the literature. Themes include:

  • Psychosocial stressors and mental health
  • Suicidality
  • Family dynamics and conflicts  
  • Sexual and reproductive health
  • Substance use
  • Conflict, delinquency, youth violence 

Other adolescent-associated health issues are explored in detail elsewhere in this resource, such as depression, post-traumatic stress disorder, substance use, obesity, and mental health promotion.

Communicating about sexual health

Sara is a 16-year-old girl, born in Canada, whose parents emigrated from the Philippines. She recently began having vaginal intercourse with her boyfriend. The week before her health care visit, her boyfriend convinced her to have unprotected sexual intercourse, and Sara is now worried about possible pregnancy. She disclosed her fears to her best friend, who advised Sara to go to a clinic.

Sara is frightened about speaking to a stranger about sex and is especially afraid of her mother finding out. Her mother initially moved to Canada to work as a live-in caregiver and struggles to care for their family as a single mother. Her father worked in a restaurant, but died when Sara was very young. Sara has relatives nearby who arrived in Canada when she was in her early teens. While she does not generally feel close to them, she tells you about one younger aunt, only 27 years old, who like Sara, was born in Canada, saying “She seems to understand me better than my mom does.”

In her own words, Sara feels “pretty Canadian”, and spends most of her time with Canadian-born teens. She says: “My mom is really traditional. I can’t talk to her about dating or sex. She wouldn’t understand, and would get really angry”. Sara is afraid to speak with anyone in her family – who might tell her mother – and is also afraid of her other friends finding out. She also wonders if she can trust the doctor or clinic nurse, saying, “What if they tell my Mom?”

Questions to consider

1. What are this patient’s primary concerns?

  • Pressure to have unprotected sexual intercourse, with associated risks for unintended pregnancy, STIs.
  • Family financial stressors
  • Distrust of health care providers, at least partly due to concerns around confidentiality
  • Complex family relationships , likely related to the limited social integration of Sara’s mother and other acculturation gaps

2. What are the next steps?

  • Establish rapport and trust. Assure Sara that privacy and confidentiality are as important to you, the health care provider, as they are to her.
  • Complete a Adolescent Psychosocial Assessment to evaluate Sara’s sexual health (especially her risks for pregnancy and STIs), as well as risk and protective factors related to family, social functioning and mental health.
  • Assess attitudes, beliefs and knowledge around sexual health.
  • Offer counselling around pregnancy and STI risks, and safer sexual practices (especially condom use and hormonal contraceptives).
  • Screen for STIs.
  • Offer pregnancy testing and/or emergency contraception if indicated.
  • Assess potential immigration- and acculturation-related stressors: family conflict, economic stress, mental health and coping strategies, as well as this patient’s connectedness with other caring adults and pro-social peers.

3. What services should Sara be connected with?

  • If you are not able to provide confidential adolescent reproductive health services in your clinical setting, refer to an appropriate provider or service in your community.
  • If significant mental health issues are identified, refer to developmentally and culturally appropriate mental health services in your community.
  • Connect Sara with community youth organizations that promote healthy behaviours and positive development.

Learning points

The aim of care is to enhance Sara’s protective factors and reduce her risk factors, at each level: individual, family and community.

Individual interventions:

  • Assess and treat around sexual health and preventing STIs and unintended pregnancy.
  • Counsel around healthy sexual development, healthy relationships and sexual decision-making.
  • Assess the degree of acculturation and self-identity. 
  • Discuss confidentiality issues and laws pertaining to confidentiality.

Family interventions:

  • Recognize differences in social integration between parent and child, known as the “acculturation gap”, meaning that discrepant cultural beliefs and affiliations contribute to communication difficulties.
  • If Sara is willing, work with her and her mother to recognize and bridge the acculturation and generation gaps in their relationship. Consider referral to culturally appropriate family counselling resources.

Community interventions:

  • Help link Sara with a supportive, caring adult (such as a mentor or her aunt), to whom she can speak about relationships and sexual health issues.
  • Help link Sara with youth organizations that promote bicultural identity development and positive youth development.

Psychosocial stressors and mental health

“Immigration is not easy. It costs a lot and you don’t know if they accept you. It puts a lot of stress and uncertainty on families and affects emotional well-being and performance of youth in schools”.

Source:  "Fresh Voices" report

Immigrant adolescents face psychosocial stressors related to factors across and within multiple levels (individual, family, environment). These factors can have positive or negative impacts on physical health, family relationships and community support systems. More information on mental health promotion can be found in this resource.

Studies suggest that first-generation immigrant adolescents experience higher levels of psychological distress compared with second- and subsequent generations.4 And while adolescents born outside of Canada generally report the same levels of stress, despair and suicidality as Canadian-born adolescents,  foreign-born young women are less likely to report self-harm than their Canadian-born peers (22% vs. 18%).5 Length of time since immigration may affect mental health. For example, in particular subgroups, immigrant adolescents who have been in Canada for ≤5 years are more likely to report extreme despair compared to those who have been in Canada >10 years.6

Among newcomer girls, immigration has been described as a process of “uprooting”, involving multiple losses of friends, family members, and sense of belonging.7  Sources of mental stress include adapting to a new way of life, navigating a new place, concerns about personal safety, and finding work. Stressors related to the health care system include adaptation to a new culture of care and learning how to access services.8

Mental illness

Mental health disorders in adolescents are increasingly recognized as a public health challenge. In Canada, young people 15 to 24 years of age report higher rates of mood disorders (8.2%) and substance use disorders (11.9%) than any other age group.9 Common problems include depression (13% among females, 5% among males), anxiety disorders/panic attacks (13% among females, 4% among males), and attention-deficit/hyperactivity disorder (4% among females, 7% among males).10 Mental health problems often begin in childhood or adolescence, and poor mental health is closely linked with violence, substance misuse and suicide in later life.11

Mental health problems are initially lower among immigrants compared with the Canadian-population, although rates tend to converge over time.12 Some evidence suggests that rates of depression are lower in adolescent immigrants compared to Canadian-born adolescents,13 but rates of mental health problems vary considerably among immigrant groups.14,15 For instance, one study found higher prevalence of psychopathology among refugee adolescents living in Quebec.16

For information and clinical guidance on specific conditions, see:

Adolescent mental health promotion

Mental health promotion requires addressing risk and protective factors, implementing multiple interventions across multiple settings, and focusing on empowerment and resilience.17

Risk factors for adolescent mental health problems include:

  • A personal or family history of mental illness.
  • Pre-migration trauma (e.g., refugee camp internment, human-initiated harm or other disaster). Traumatic pre-migration experiences raise the likelihood of mental and emotional problems, such as PTSD and depression.18-20
  • Race-based bullying and discrimination.14,15,20,21
  • Having to help parents navigate the new culture, perhaps taking on a “cultural broker” or “system navigator” role that is far beyond their age and maturity.21-23
  • Linguistic barriers, challenges in adjusting to the Canadian education system, stigma associated with being an ESL student, race-based bullying and discrimination, and parental unemployment/underemployment.21
  • Identifying strongly with their community of origin, particularly when that community is marginalized and discriminated against.5,23,24
  • Gender identity issues. In the general population, lesbian, gay and bisexual adolescents are more likely to attempt suicide than heterosexual adolescents (28% versus 4%).5
  • Physical or sexual abuse.5
  • Stigma, shame and having different perceptions or cultural beliefs around mental health can prevent a family or adolescent from disclosing problems and seeking help. For more information on cultural barriers to care, see Mental Health Promotion in this resource.
  • Adverse childhood events, such as family disruption, mental illness or drug abuse at home, or maltreatment, especially if there are ≥3 events.15,25-27

Protective factors for mental health include:

  • A strong sense of belonging or connectedness with family. Parent-child cohesion is strongly associated with lower levels of depressive symptoms. Family connectedness is linked to a lower risk of emotional distress.6,28
  • A strong sense of belonging or connectedness at school. A positive school experience helps lower emotional distress.6
  • Having an adult inside or outside the family to talk to.5
  • Positive peer relationships, especially if peers discourage  risky behaviours.5,28
  • Participating in extracurricular activities.5
  • Engaging in meaningful activities.5 Emotional support can come from informal support systems (e.g., family, a local ethnic community or friends), and more formal ones (e.g., a religious institution, teachers at school, ESL classes or community youth programs).21
  • Being more socially integrated or having a more integrated acculturation style.  

Suicidality

The limited literature on suicidality among immigrant adolescents in Canada suggests that they have, on average, lower rates of suicidal behaviour compared with Canadian-born peers. However, isolated increases in suicide behaviours have been reported,14,15 and one British Columbia study found that immigrant youth reported suicidal ideation at rates comparable to youth born in Canada.5

A systematic review of 8 observational studies from high-income countries found that suicidal ideation was lower across most immigrant youth ethnicities.15 In The Netherlands, elevated suicide ideation rates appear to be associated with violence and instability within immigrant families.29 As with non-immigrants, factors associated with increased suicide rates include older age, drug use and psychological factors such as depression and loneliness.

Other exacerbating factors for psychological distress and suicidal ideation include:

  • A perceived discrepancy between child and parent in preferring the host country’s way of life in early adolescence. The acculturation gap is associated with depressive symptoms in late adolescence.30
  • Increased acculturation stress.31
  • Lack of parental support.32

Protective factors

  • Living in an intact family can be an especially important protective factor.32  

Family dynamics and conflicts  

An immigrant family’s unique dynamics can produce both protective and risk factors for adolescent health. The structure of the family can also play a role (see the text box).

Family structure models

Nuclear family: Both parents immigrate with their children
“Astronaut” families: One parent immigrates with their children
“Satellite” families: Children immigrate without their parents and are cared for by relatives
Homestay youth: A student attends high school in Canada and lives with a host family.

Protective effects

  • Family connectedness (feelings of being cared for, belonging), as well as connectedness at school, are strongly associated with positive mental health.5
  • Perceived child-parent cohesion (i.e., feeling that parents, particularly a mother, understands and is affectionate) is associated with a lower level of depressive symptoms.28
  • Adolescents who live with both parents have better academic outcomes and lower suicide rates.32
  • Immigrant adolescents who have one adult in the family to talk to about their problems are less likely to consider suicide than those without parental support.5
  • Emerging research among Asian immigrant families suggests that a parenting style with elements of authoritative or supportive parenting (which seeks to balance warmth, negotiation and guidance) and biculturalism (blending values from both the mainstream culture and the culture of origin) is associated with positive psychosocial and academic adjustment. Supportive parenting may also buffer the risks associated with child-parent acculturation gaps (see below).30,33-34

“I was separated from my father and for years I didn’t see him… My life became so much easier when the immigration issues of my family were solved”.

“My mom wants me to wear what she wants and not what other Canadian youth wear”.

“I became the head of the family to support with translation and navigating the system here [which] affected my performance at school”.

Source: "Fresh Voices" report

Risk factors

  • Lack of parental support is associated with distress and suicidal ideation, substance use and susceptibility to sexual abuse.32,35
  • Problematic conflict resolution between immigrant adolescents and their mothers is associated with higher levels of depressive symptoms.28
  • When parents live abroad, immigrant youth report inadequate adult supervision, feeling resentful of their parents, more family conflict, and symptoms of poor mental health.32,36
  • Preliminary research among Asian immigrant families suggests that highly authoritarian (not to be confused with authoritative) parenting (known as “tiger parenting”) is associated with family conflict and lower levels of academic and psychological adjustment.30,33,37

Family conflicts may involve:

  • Acculturation gaps or intergenerational cultural dissonance.  Cultural dissonance is the sense of tension, discord or conflict experienced by families adjusting to changing sociocultural environments
  • Language gaps
  • Role reversals (e.g., the role of a youth as the family interpreter)
  • Conflicting views and expectations around gender roles, dating and sexuality20

Acculturation gaps within families are a risk factor for parent–child conflict and alienation, mental health problems, lower academic functioning, substance misuse and delinquency.37-40

Sexual and reproductive health

Immigrant adolescents encounter conflicting messages from their families and Canadian media about sexual behaviour and health, and usually have less access to reproductive health education and care than their Canadian-born peers.19 However, health care providers should never generalize and/or stereotype clients or patients based on culture.

Factors that influence sexual health in immigrant adolescents include the following:

Knowledge and attitudes: Immigrant adolescents may come from countries with strong cultural or religious views on dating, relationships, adolescent sexuality, gender roles and identity, and sexual orientation. Cultural context will not only affect their own knowledge and attitudes on sexual health, but conflict with messages from popular culture. Confusion around sexual health is often aggravated by inadequate access to sexual education and care.19 One literature review of ethnic Chinese immigrant youth in Western countries showed lower sexual health knowledge than among Caucasion youth, higher levels of disapproval regarding uncommitted sex, and later onset of sexual intercourse.41
Acculturation: The literature on acculturation and immigrant adolescent sexual behaviours is complex. The links between degree of acculturation and sexual behaviour are further complicated by ethnicity, parenting and other social and cultural factors.42,43 Generally, the more acculturated immigrant adolescents are, the more likely they are to engage in uncommitted sexual intercourse, to have earlier first intercourse, and  to use contraception.41,42,44-46 One study of East Asian high school students in British Columbia found that immigrant youth who spoke English at home were more likely to engage in sexual intercourse.47 Along with the earlier initiation of sexual behaviour, acculturated teenagers have higher educational and occupational aspirations and view single parenthood as a more viable option than less acculturated teens.48,49
Family factors: One British Columbia study found that East Asian youth who arrived alone to study in Canada were significantly more likely to report substance use before sexual intercourse and to become victims of sexual abuse compared with East Asian youth who immigrated with their parents or who were born in Canada.35 A study of Chinese American adolescents found that living with both parents was associated with a lower likelihood of sexual intercourse,50 although Asian immigrant adolescents also report difficulties with talking to their parents about sex.41,42 Cultural issues in immigrant families may also affect whether they support or reject their lesbian, gay, bisexual and transgendered (LGBT) youth. Their family’s rejection places these youth at higher risk for mental health problems, substance abuse and risk behaviours.51

Substance use

Data on substance use disorders among immigrant adolescents in Canada are limited. The following associations are known:

Substance use disorders are less common in first-generation immigrant adolescents than in non-immigrant or in second- or subsequent generation immigrant peers.4,52  This tendency may be attributable to a stronger sense of self-identity, family support and resilience.2,53,54 Second- and later-generation immigrant adolescents are more likely than first-generation immigrant adolescents to participate in harmful drinking, illicit drug use and delinquency.4
Risk factors for substance use among immigrant adolescents include lack of family support and increased acculturation.55-57

More information on Substance use among immigrant and refugee youth can be found elsewhere in this resource. 

Conflict, delinquency and violence 

Similar to other youth, delinquency among immigrant adolescents relates to socioeconomic status, gender and cultural identity, while delinquency with violence is often shaped by experiences of discrimination and racism.58

A systematic review of studies across 8 countries, including Canada, showed that while first-generation immigrant youth experience a higher degree of bullying than locally-born youth, immigrant adolescents may face lower levels of neighborhood violence.15 Studies reporting on delinquency and substance abuse report lower levels of behavioural problems or conduct disorders among first-generation immigrant youth compared with those born in Canada.59 Other research has shown:

  • Many immigrant adolescents report being targeted for harassment, racism and discrimination.19,20,5,58
  • Young immigrant men are less likely to report feeling safe at school.5
  • Immigrant youth may experience conflicts in values between their family and peers,60 difficulties forming relationships with peers from different backgrounds, and social isolation.
  • Youth who immigrate at an older age sometimes find it difficult to join the already-established social networks of their Canadian-born peers.

All of these challenges can limit integration and contribute to social isolation, which could make these youth more vulnerable to both victimization and recruitment into criminal activities, such as gangs and prostitution.19

The literature on acculturation and youth violence and/or delinquency is inconsistent. While we know that less integrated or acculturated youth are less likely to engage in delinquency and violence, one Manitoba study of Chinese youth found that associating primarily with Chinese peers was also a risk factor for delinquency.4,57  Positive ethnic identity and bicultural self-efficacy (which is similar to an integrated acculturation style) appear to protect against delinquency and violence.61 Acculturation gaps between immigrant youth and their parents appear to be a risk factor for delinquency and violence, possibly because youth who experience conflict at home are more likely to associate with delinquent peers.39,62

Barriers and facilitators to health care

When seeking health care, immigrant adolescents generally value the same factors as other youth, such as cleanliness, honesty, competence, respect and confidentiality.63 Barriers to adolescents seeking and receiving appropriate care include: 63-67

  • Worries about confidentiality and respect
  • Difficulties navigating the health care system
  • Evolving adolescent capacity, autonomy and parent–child relationship
  • Difficulties discussing sensitive issues (sexual and mental health, substance use, risk behaviours)

Immigrant adolescents experience many of the same barriers and facilitators to care as newcomer children to Canada, as well as additional ones. For example, they are keenly aware of perceived prejudice or discrimination. They worry about health care providers making assumptions about their behaviours (e.g., expressing that clinicians should “not always assume that all Asian teens stay away from sex and drugs”). They want to feel sure they are being treated the same as other teens, to discuss sensitive issues, and to get help with navigating complex relationships with parents.63

Immigrant adolescents have expressed a wide range of views on the importance of confidentiality and the use of interpreter services. Divergence may, in part, be related to acculturation:63

  • Highly acculturated youth may value confidentiality more, wanting to protect their parents from distressing information. Less acculturated youth are more likely to feel that parents have a right to know all of their health information.
  • While some teens prefer to act as the family interpreter to protect confidentiality, they may also intentionally mistranslate to hide information from their parents.

Relying on an adolescent to interpret should be avoided because it makes a young person disproportionately responsible for the family’s health and well-being.

What health professionals can do

During the first transitional years in Canada, immigrant adolescents find the support of health care professionals to be among their most helpful resources, second only to their friends and on par with their teachers.5

Clinicians have a special role in providing adolescent-friendly care and can improve health encounters and outcomes by taking these steps:

Engage patients and possibly their families in a developmentally appropriate manner:

  • Assess and support the emerging capacity of adolescents to make informed medical decisions.68
  • Assess on a case-by-case basis the level of parent/caregiver involvement with medical decisions, consent and confidentiality. Consider the adolescent’s psychosocial development and capacity, as well as ethical and legal issues.68
  • Routinely meet with adolescents alone for some portion of each visit. Provide confidential care around sensitive topics (e.g., sexual health, mental health and substance use). Limitations to confidentiality may involve an adolescent’s emerging capacity, acute safety concerns (e.g., suicidal or homicidal ideation, neglect or abuse), and public health or ethical/legal issues.65,69
  • As for any adolescent, assess and manage sexual health issues (e.g., identity development, contraception, screening, STI prevention and counselling on risks and behaviours) in a confidential, developmentally appropriate manner.

Screen and assess immigrant adolescents:

  • Psychosocial interview: Perform a strengths-based, confidential, developmentally appropriate psychosocial interview with all immigrant adolescents. Discuss confidentiality with the adolescent and their parents/guardians, including limits.65,69 Interview tools that are commonly used (even though they are not validated) include:
    • HEEADSSS: Home, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety from injury or violence.70
    • SSHADESS: Strengths, School, Home, Activities, Drugs/substance use, Emotions/depression, Sexuality, Safety.71,72
  • Sensitive adolescent issues: Assess an adolescent’s stress and coping, personal and family mental health, substance use, and sexual health. Never assume that an individual from a particular culture is more or less likely to adopt a behaviour. This can lead to under- or over-screening and may be perceived as discriminatory.63 For more information, see Cultural Competence.
  • Promote resilience: Reinforce positive youth development by using the strengths-based approach described below.

Providing culturally competent care builds therapeutic, equitable relationships with immigrant adolescents. Clinicians should:73

  • Be mindful of, and manage, their own cultural biases
  • Recognize the role of culture on their patient’s beliefs and behaviours
  • Show respect, curiosity and humility with patients from diverse cultural backgrounds, and
  • Avoid perpetuating stereotypes and making assumptions. Avoid “checklists” designed for  use with particular ethno-cultural groups and recognize diversity.

Useful questions to explore identity and acculturation might include:

“Where were you born?”
“Where were your parents born?”
“What does being (insert ethnic group) mean to you?”
“What language do you speak at home?”
“What language do you prefer to speak?” and
“What ethnic group(s) do you prefer to hang out with?”
74

Clinicians can provide culturally competent care by inquiring about and addressing some of the following areas:74

  • Immigration experiences and impact on mental health: May include immigration history, immigration stress or trauma. Be alert to physical and mental health consequences of migration and acculturation stress and conflicts. Take into consideration factors such as pre-migration trauma, post-settlement stressors, intergenerational conflict and coping resources.
  • Identity development and acculturation: Assess immigrant adolescents’ racial/ethnic identity development, acculturation style, and experiences with perceived bias, racism or discrimination. As appropriate, ask what a young person’s particular health condition means to them, and how self- or their family’s care might be affected by cultural practices and beliefs. Support integrated acculturation (or bicultural identity) by encouraging affiliation and identity with their culture of origin, while also establishing ties with their new home.75
  • Explore family dynamics: Assess family connectedness and stress, potential acculturation gaps, family conflict patterns, parental stressors related to immigration, acculturation and socio-economic pressures, and possible attachment issues. Clinicians can help by building on an adolescent’s positive ethnic identity development (e.g., encouraging participation with family and community in cultural or religious events). They can also help parents to better understand their child’s stressors around personal development and acculturation, and facilitate parent-child communication.76 Adolescents may need extra help with acquiring the language skills to communicate how they feel and extra psychosocial support to build understanding, adaptability and coping skills.
  • Connectedness: Encourage involvement with family, school, pro-social peers and community. Be a knowledge hub by connecting immigrant adolescents with community services that support positive youth development and cultural identity.

See the Medical Assessment section for more information about Taking a History in young immigrants new to Canada.

Promote resilience and positive youth development

The “Five C’s” of PYD81
Competence: A positive view of one’s own actions in specific areas
Confidence: An internal sense of positive self-worth and self-efficacy
Connection: Positive bonds with people and institutions (e.g., peers, family, school and community)
Character: Respect for societal and cultural norms, and a sense of morality and integrity
Caring/compassion: Sympathy and empathy for others
Contribution (“Sixth C”): Contributing to community

Adolescent health care is traditionally problem-focused, emphasizing risk behaviours and factors. More recently, however, resilience and positive youth development (PYD) paradigms have emerged,77-79 which use a strengths-based approach. The PYD perspective views youth as “resources to be developed rather than problems to be managed”.80 This approach is especially important for immigrant adolescents because they face specific migration- and acculturation-related stressors that may promote unhealthy coping behaviours.  Also, acculturation and identity development can be strong influences on adolescent risk and protective factors.

Clinicians should counsel around sensitive health issues using a culturally and developmentally appropriate, strengths-based, evidence-informed approach.82,83 This process involves:

  • Building a trusting relationship, where confidentiality is respected
  • Recognizing and building on a patient’s strengths
  • Helping to develop and reinforce healthy behaviours and positive coping strategies82,83 

Useful counselling strategies to promote healthy coping and behaviours in youth include motivational interviewing, harm reduction, cognitive-behavioral therapy (CBT), and mindfulness.83

Clinicians can play a key role in identifying and helping to put in place protective factors, which in turn foster resilience and adaptation.84 Cultural, family and school connectedness are particularly important.5,79 A list of factors that promote resilience in young newcomers is available in this resource.

Encourage engagement in positive youth development activities

“Canada is not going to be a successful multicultural country until it builds bridges between different communities”.

“To feel belonging, you need to have connections. But here [there are] not enough spaces to make these connections and meet new people”.

“We need to hold … safe spaces for people to mix – immigrant, indigenous, and Canadian”.

Source:  "Fresh Voices" report

Clinicians should help put protective factors in place by becoming familiar with, and connecting youth to, culturally appropriate PYD programs in their community.  A list of community services for immigrant youth is available in this resource.

PYD programs promote protective factors, build connectedness with pro-social peers and adults, and address common risk factors. 

For example, being involved with art and music can build self-esteem, but any meaningful activity can be protective by helping immigrant adolescents to feel engaged and valued.5 Specific PYD program content varies depending on the needs of the specific families and communities, and may include the following: youth mentoring, peer support groups, training on healthy parenting, promoting school inclusion and attendance, teaching life management and social-emotional skills, teaching skills to create healthier relationships, and developing healthy ethnic, sexual, and gender identities. Such programs can significantly reduce risk behaviours,77,85 promote pro-social values, and build positive cultural associations and identity in immigrant adolescents.86-88

Selected resources: For immigrant adolescents

A list of community services for immigrant youth is available in this resource.

Selected resources: For health professionals

References

  1. WHO. Health topics. Adolescent health.
  2. Statistics Canada. Leading Causes of Death in Canada, 2009. Table 1-3. Ten leading causes of death by selected age groups, by sex, Canada — 15 to 24 years. Ottawa, ON: Statistics Canada, 2010.
  3. Public Health Agency of Canada. The Chief Public Health Officer’s Report on the state of public health in Canada, 2011, Chapter 3: The health and well-being of Canadian youth and young adults.
  4. Hamilton HA, Noh S, Adlaf EM. Adolescent risk behaviours and psychological distress across immigrant generations. Can J Public Health 2009;100(3):221-5.
  5. Smith A, Poon C, Stewart D, et al; McCreary Centre Society. Making the right connections: Promoting positive mental health among B.C. youth. Vancouver, B.C.: McCreary Centre Society, 2011.
  6. Hilario CT, Vo DX, Johnson JL, et al. Acculturation, gender, and mental health of Southeast Asian immigrant youth in Canada. J Immigr Minor Health 2014;16(6):1121-9.
  7. Berman H, Mulcahy GA, Forchuk C, et al. Uprooted and displaced: A critical narrative study of homeless, Aboriginal, and newcomer girls in Canada. Issues Ment Health Nurs 2009;30(7):418-30.
  8. Crooks VA, Hynie M, Killian K, Kyle K, et al. Female newcomers’ adjustment to life in Toronto, Canada: Sources of mental stress and their implications for delivering primary mental health care. GeoJournal 2011;76:139-49.
  9. Pearson C, Janz T, Ali J; Statistics Canada, 2013. Health at a glance: Mental and substance use disorders in Canada. Cat. No. 82-624-X.
  10. Smith A, Stewart D, Poon C, et al. From Hastings Street to Haida Gwaii: Provincial results of the 2013 B.C. Adolescent Health Survey. Vancouver, B.C.: McCreary Centre Society, 2014.
  11. Patel V, Flisher AJ, Hetrick S, et al. Mental health of young people: A global public-health challenge. Lancet 2007;369(9569):1302-13.
  12. Kirmayer LJ, Narasiah L, Munoz M, et al. Common mental health problems in immigrants and refugees: General approach in primary care. CMAJ 2011;183(12):E959-67.
  13. Ali J; Statistics Canada, 2002. Mental health of Canada’s immigrants. Supplement to Health Reports. Cat. No. 82-003.
  14. Hansson E, Tuck A, Lurie S et al; Mental Health Commission of Canada, 2010. Improving mental health services for immigrant, refugee, ethno-cultural and racialized groups: Issues and options for service improvement.
  15. Pottie K, Dahal G, Georgiades C, et al. Do first generation immigrant adolescents face higher rates of bullying, violence and suicidal behaviours than do third generation and native born? J Immigr Min Health 2014; Sep 24 [Epub ahead of print DOI: 10.1007/s10903-014-0108-6
  16. Tousignant M, Habimana E, Biron C, et al. The Quebec Adolescent Refugee Project: Psychopathology and family variables in a sample from 35 nations. J Am Acad Child Adolesc Psychiatry 1999;38(11):1426-32.
  17. Centre for Addiction and Mental Health, 2007. Best practice guidelines for mental health promotion programs: Children and youth: www.porticonetwork.ca/web/camh-hprc/resources/best-practice-guidelines-for-mental-health-promotion-programs
  18. Beiser M, Ogilvie L, Rummens JA, et al. The new Canadian children and youth study: Research to fill a gap in Canada’s children’s agenda. Canadian Issues/Thèmes Canadiens 2005;21-4.
  19. Ngo H, Schleifer B. Immigrant children and youth in focus. Canadian Issues/Thèmes Canadiens 2005:29-33.
  20. Salehi R. Intersection of health, immigration, and youth: A systematic literature review. J Immigr Minor Health 2010;12(5):788-97.
  21. Shakya Y. Determinants of mental health for newcomer youth: Policy and service implications. Canadian Issues/Thèmes Canadiens 2010:98-102.
  22. Trickett E J, Jones CJ. Adolescent culture brokering and family functioning: A study of families from Vietnam. Cultur Divers,Ethnic Minor Psychol 2007;13(2):143-50.
  23. Khanlou N. (2010). Immigrant mental health. Canadian Issues/Thèmes canadiens 2010:9-16.
  24. Beiser MN, Hou F. Ethnic identity, resettlement stress and depressive affect among Southeast Asian refugees in Canada. Soc Sci Med 2006;63(1):137-50.
  25. Kia-Keating M, Dowdy E, Morgan ML, et al. Protecting and promoting: An integrative conceptual model for healthy development of adolescents. J Adolesc Health 2011;48(3):220-8.
  26. Boivin M; Royal Society of Canada/CAHS Expert panel reports, 2012. Early Childhood Development.
  27. Hertzman C. The significance of early childhood adversity. Paediatr Child Health 2013;18(3):127-8.
  28. Nguyen H, Rawana JS, Flora DB. Risk and protective predictors of trajectories of depressive symptoms among adolescents from immigrant backgrounds. J Youth Adolesc 2011;40(11): 1544-58.
  29. van Bergen DD, Eikelenboom M, Smit JH, et al. Suicidal behavior and ethnicity of young females in Rotterdam, The Netherlands: Rates and risk factors. Ethn Health 2010;15(5):515-30.
  30. Juang LP, Alvarez AA. Discrimination and adjustment among Chinese American adolescents: Family conflict and family cohesion as vulnerability and protective factors. Am J Public Health 2010;100(12):2403-9.
  31. Park MS. The factors of child physical abuse in Korean immigrant families. Child Abuse  Negl 2001;25(7):945-58.
  32. Cho YB, Haslam N. Suicidal ideation and distress among immigrant adolescents: The role of acculturation, life stress, and social support. J Youth Adolesc 2010;39(4):370-9.
  33. Kim SY, Wang Y, Orozco-Lapray D, et al. Does “tiger parenting” exist? Parenting profiles of Chinese Americans and adolescent developmental outcomes. Asian Am J Psychol 2013;4(1):7-18.
  34. Kim SY. Defining tiger parenting in Chinese Americans. Human Development 2013;56(4):217-22.
  35. Wong ST, Homma Y, Johnson JL, et al. The unmet health needs of East Asian high school students: Are homestay students at risk? Can J Public Health 2010;101(3):241-5.
  36. Tse JKH, Waters JL. Transnational youth transitions: Becoming adults between Vancouver and Hong Kong. Global Networks 2013;13(4):535-50.
  37. Kim SY, Chen Q, Wang Y, et al. Longitudinal linkages among parent-child acculturation discrepancy, parenting, parent-child sense of alienation, and adolescent adjustment in Chinese immigrant families. Dev Psychol 2013;49(5):900-12.
  38. Unger JB, Ritt-Olson A, Wagner KD, et al. Parent-child acculturation patterns and substance use among Hispanic adolescents: A longitudinal analysis. J Prim Prev 2009;30(3-4):293-313.
  39. Wang Y, Kim SY, Anderson ER, et al. Parent-child acculturation discrepancy, perceived parental knowledge, peer deviance, and adolescent delinquency in Chinese immigrant families. J Youth Adolesc 2012;41(7):907-19.
  40. Schwartz SJ, Unger JB, Des Rosiers SE, et al. Substance use and sexual behavior among recent Hispanic immigrant adolescents: Effects of parent-adolescent differential acculturation and communication. Drug Alcohol Depend 2012;125(Suppl 1):S26-34.
  41. Yu J. Young people of Chinese origin in western countries: a systematic review of their sexual attitudes and behaviour. Health Soc Care Community 2010;18(2):117-28.
  42. Kao TS. Ask the expert. Sexual health education disparities in Asian American adolescents. J Spec Pediatr Nurs 2006;11(1):57-60.
  43. Trejos-Castillo E, Vazsonyi AT. Risky sexual behaviors in first and second generation Hispanic immigrant youth. J Youth Adolesc 2009;38(5):719-31.
  44. Flores G, Brotanek J. The healthy immigrant effect: A greater understanding might help us improve the health of all children. Arch Pediatr Adolesc Med 2005;159(3):295-7.
  45. McDonald JA, Manlove J, Ikramullah EN. Immigration measures and reproductive health among Hispanic youth: Findings from the national longitudinal survey of youth, 1997-2003. J Adolesc Health 2009;44(1):14-24.
  46. Santelli JS, Abraido-Lanza AF, Melnikas AJ. Migration, acculturation, and sexual and reproductive health of Latino adolescents. J Adolesc Health 2009;44(1):3-4.
  47. Homma Y, Saewyc EM, Wong ST, et al. Sexual health and risk behaviour among East Asian adolescents in British Columbia. Can J Hum Sexuality 2013;22(1):13-24.
  48. Lindemann C, Scott W. The fertility related behavior of Mexican American adolescents. J Early Adolesc 1982;2(1):31-8.
  49. Reynoso TC, Felice ME, Shragg GP. Does American acculturation affect outcome of Mexican-American teenage pregnancy. J Adolescent Health 1993;14(4):257-61.
  50. Kuo WH, St Lawrence JS. Sexual behaviour and self-reported sexually transmitted diseases (STDs): Comparison between White and Chinese American young people. Cult Health Sex 2006;8(4):335-49.
  51. Ryan C, Huebner D, Diaz RM, et al. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics 2009;123(1):346-52.
  52. Bui HN. Racial and ethnic differences in the immigrant paradox in substance use. J Immigr Minor Health 2013;15(5):866-81.
  53. Chien LY, George MA, Armstrong RW. Country of birth and language spoken at home in relation to illicit substance use. Can J Public Health 2002;93(3):188-92.
  54. Georgiades K, Boyle MH, Duku E, et al. Tobacco use among immigrant and nonimmigrant adolescents: Individual and family level influences. J Adolesc Health 2006;38(4):443.e1-7.
  55. Di Cosmo C, Milfont TL, Robinson E, et al. Immigrant status and acculturation influence substance use among New Zealand youth. Aust N Z J Public Health 2011;35(5):434-41.
  56. Prado G, Huang S, Schwartz SJ, et al. What accounts for differences in substance use among U.S.-born and immigrant Hispanic adolescents? Results from a longitudinal prospective cohort study. J Adolesc Health 2009;45(2):118-25.
  57. Wong SK. Acculturation, peer relations, and delinquent behavior of Chinese-Canadian youth. Adolescence 1999;34(133)107-19.
  58. Edge S, Newbold B. Discrimination and the health of immigrants and refugees: Exploring Canada’s evidence base and directions for future research in newcomer receiving countries. J Immigr Minor Health 2013;15(1):141-8.
  59. Rousseau C, Hassan G, Measham T, et al. Prevalence and correlates of conduct disorder and problem behavior in Caribbean and Filipino immigrant adolescents. Eur Child Adolesc Psychiatry 2008;17(5):264-73.
  60. Kilbride KM, Anisef P, Baichman-Anisef E, et al. Between two worlds: The experiences and concerns of immigrant youth in Ontario. Joint Centre of Excellence for Research on Immigration and Settlement – Toronto, 2003.
  61. Soriano FI, Rivera LM, Williams KJ, et al. Navigating between cultures: The role of culture in youth violence. J Adolesc Health 2004;34(3):169-76.
  62. Le TN, Stockdale G. Acculturative dissonance, ethnic identity, and youth violence. Cultur Divers Ethnic Minor Psychol 2008;14(1):1-9.
  63. Vo DX, Pate OL, Zhao H, et al. Voices of Asian American youth: Important characteristics of clinicians and clinical sites. Pediatrics 2007;120(6):e1481-93.
  64. Ford CA, Bearman PS, Moody J. Foregone health care among adolescents. JAMA 1999;282(23):2227-34.
  65. Ford CA, English A, Sigman G. Confidential Health Care for Adolescents: Position paper for the society for adolescent medicine. J Adolesc Health 2004;35(2):160-7.
  66. Ginsburg KR, Slap GB, Cnaan A, et al. Adolescents’ perceptions of factors affecting their decisions to seek health care. JAMA 1995;273(24):1913-8.
  67. Ginsburg KR, Menapace AS, Slap GB. Factors affecting the decision to seek health care: The voice of adolescents. Pediatrics 1997;100(6):922-30.
  68. Harrison C; CPS Bioethics Committee.  Treatment decisions regarding infants, children and adolescents. Paediatr Child Health 2004;9(2):99-103.
  69. Ginsburg KR. Setting the stage for a trustworthy relationship. In: Ginsburg KR, Kinsman SB, eds. Reaching Teens: Strength-based Communication Strategies to Build Resilience and Support Healthy Adolescent Development. Elk Grove Village, IL: American Academy of Pediatrics, 2014.
  70. Klein DA, Goldenring JM, Adelman WP. HEEADSSS 3.0: The psychosocial interview for adolescents updated for a new century fueled by media. Contemp Pediatr 2014;31(1):16-28.
  71. Ginsburg KR. Engaging adolescents and building on their strengths. Adolesc Health Update 2007;19(2):1-8.
  72. Ginsburg KR. The SSHADESS screen: A strength-based psychosocial assessment. In: Ginsburg KR, Kinsman SB, eds. Reaching Teens: Strength-based Communication Strategies to Build Resilience and Support Healthy Adolescent Development. Elk Grove Village, IL: American Academy of Pediatrics, 2014.
  73. Lewis V, et al.  Cultural humility.  In: Ginsburg KR, Kinsman SB, eds. Reaching Teens: Strength-based Communication Strategies to Build Resilience and Support Healthy Adolescent Development. Elk Grove Village, IL: American Academy of Pediatrics, 2014.
  74. Vo DX. Reaching immigrant youth. In: Ginsburg KR, Kinsman SB, eds. Reaching Teens: Strength-Based Communication Strategies to Build Resilience and Support Healthy Adolescent Development. Elk Grove Village, IL: American Academy of Pediatrics, 2014.
  75. Berry JW, Phinney JS, Sam DL, et al. Immigrant youth, acculturation, identity, and adaptation. Applied Psychol: Internat Rev 2006;55(3):303-32.
  76. Lee E, 1988 “Ten Principles on Raising Chinese-American Teens”: www.evelynlee-mentalhealth.org/ten_principles.asp
  77. Catalano RF, Hawkins JD, Berglund ML, et al. Prevention science and positive youth development: Competitive or cooperative frameworks? J Adolesc Health 2002;31(6 Suppl):230-9.
  78. Kia-Keating M, Dowdy E, Morgan ML, et al. Protecting and promoting: An integrative conceptual model for healthy development of adolescents. J Adolesc Health 2011;48(3):220-8.
  79. Vo DX, Park MJ. Racial/ethnic disparities and culturally competent health care among youth and young men. Am J Mens Health 2008;2(2):192-205.
  80. Pittman KJ. Promoting youth development: Strengthening the role of youth-serving and community organizations. Washington, DC: Center for Youth Development and Policy Research, Academy for Educational Development, 1991.
  81. Lerner JV, Phelps E, Forman Y, et al. Positive youth development. In: Lerner RM, Steinberg L, eds. Handbook of Adolescent Psychology, 3rd edn. Hoboken, NJ: Wiley, 2009.
  82. Ginsburg KR, Carlson EC. Resilience in action: An evidence-informed, theoretically driven approach to building strengths in an office-based setting. Adolesc Med State Art Rev 2011;22(3):458-81.
  83. Ginsburg KR, Kinsman SB, eds. Reaching Teens: Strength-Based Communication Strategies to Build Resilience and Support Healthy Adolescent Development. Elk Grove Village, IL: American Academy of Pediatrics, 2014.
  84. Gunnestad A. Resilience in a cross-cultural perspective: How resilience is generated in different cultures. J Intercultural Communication 2006;11.
  85. Catalano RF, Fagan AA, Gavin LE, et al. Worldwide application of prevention science in adolescent health. Lancet 2012;379(9826):1653-64.
  86. Ngo HV. Patchwork, sidelining and marginalization: Services for immigrant youth. J Immigr Refugee Stud 2009;7(1):82-100.
  87. Oscós-Sánchez MÁ, Lesser J, Oscós-Flores LD. High school students in a health career promotion program report fewer acts of aggression and violence. J Adolesc Health 2013;52(1):96-101.
  88. Roffman JG, Suarez-Orozco C, Rhodes JE. Facilitating positive development in immigrant youth: The role of mentors and community organizers. In: Villarruel, FA, Perkins DG, Borden LM, et al eds. Community Youth Development: Programs, Policies, and Practices. Thousand Oaks, CA: Sage, 2003.

Editor(s)

Dzung Vo, MD
Carla Hilario, RN, MSN, PhD Candidate
Kevin Pottie, MD

Last updated: November, 2016

Also available at: http://www.kidsnewtocanada.ca/culture/adolescent-health-guidance-for-clinicians
© 2017 Canadian Paediatric Society.
All rights reserved.
Privacy Policy | Sitemap

Caring for Kids New to Canada is a resource for health professionals. The information here is not a substitute for medical advice, nor does it indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

Back to top
<<<<<<< HEAD ======= >>>>>>> develop