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• W2059586337 abstract "The United States faces a rapidly changing demographic and cultural landscape, with its population becoming increasingly multiracial and multicultural. In consequence, cultural and racial factors relating to mental illness and emotional disturbances deserve closer attention and consideration. This Practice Parameter outlines clinical applications of the principle of cultural competence that will enable child and adolescent mental health clinicians to better serve diverse children, adolescents, and their families. The United States faces a rapidly changing demographic and cultural landscape, with its population becoming increasingly multiracial and multicultural. In consequence, cultural and racial factors relating to mental illness and emotional disturbances deserve closer attention and consideration. This Practice Parameter outlines clinical applications of the principle of cultural competence that will enable child and adolescent mental health clinicians to better serve diverse children, adolescents, and their families. The rapidly changing demographics of the United States are largely the result of 3 major factors: progressive aging and low birth rate of the European-origin population, younger mean ages and increasing birth rates in non-European minority groups, and a significant increase in immigration from non-European countries, especially from Latin America, Asia, and Africa. By 2050, European Americans will no longer constitute the majority, and this will happen by 2030 among children younger than 18 years and is already true among children younger than 8 years.1US Census. United States population projections: 2000 to 2050. 2009. http://www.census.gov/population/www/projections/analytical-document09.pdf. Accessed June 22, 2011.Google Scholar The process of evaluating and treating culturally diverse children and youth and their families can be complex and requires special expertise and unique approaches. Thus, this parameter can be useful for clinicians and, ultimately, for the children and families they serve. Principles in this parameter apply to culturally diverse children and youth younger than 18 years. In PubMed, the Medical Subject Heading (MeSH) terms culture, Hispanic, Latino, African American, Asian American, American Indian, child psychiatry, child psychology, adolescent psychiatry, adolescent psychology, and United States were searched. The initial search yielded 2,970 results. Then, the results were limited to English, human, all child (0 to 18 years), and 1990 through December 2011. Additional limits included classical article, clinical trial, comparative study, controlled clinical trial, evaluation studies, guideline, historical article, meta-analysis, practice guideline, multicenter study, randomized controlled trial, review, twin study, and validation studies. The refined PubMed search yielded 2,268 articles. In the PsycINFO database subject headings (focused), the keywords culture, Latino, Hispanic, African American, Asian American, American Indian, and mental health were searched. The initial search returned 40,167 articles and then was limited to English, articles in the United States, childhood: birth to age 12 yrs, adolescence: age 13-17 yrs, peer reviewed journal, and 1990 through December 2011. The refined PsycINFO search yielded 2,240 articles. In the Cochrane Database of Systematic Reviews, keywords of culture and mental health were searched without additional limits. The Cochrane search yielded 80 articles. An additional 953 articles were retrieved from the CINAHL database, after excluding Medline articles, by searching culture, Latino, Hispanic, African American, Asian American, American Indian, mental health, and United States and limiting to childhood and adolescence, peer-reviewed articles, English language, and 1990 through December 2011. A total of 5,461 articles were identified. After removing duplicate references, the resulting yield from the comprehensive search was 4,391 articles. The titles and abstracts of all articles were reviewed. Studies were selected for full-text review based on their place in the hierarchy of evidence (e.g., randomized controlled trials), quality of individual studies, and generalizability to clinical practice. The search was augmented by a review of articles nominated by expert reviewers and further search of article reference lists and relevant textbook chapters. A total of 163 articles were selected for full-text examination. Principles were identified from the consensus of the American Academy of Child and Adolescent Psychiatry (AACAP) Diversity and Culture Committee and informed by the literature review articles and the Cultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Populations.2Four Racial/Ethnic PanelsCultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Populations. Center for Mental Health Services, Substance Abuse and Mental Health Administration, US Department of Health and Human Services, Rockville, MD1999Google Scholar •Culture: Integrated pattern of human behaviors including thoughts, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social nature.•Cultural competence: Set of congruent behaviors, attitudes, and policies found in a system, agency, or professionals that enables them to work effectively in a context of cultural difference.3Cross T. Bazron B. Dennis K. Issac M. Towards a Culturally Competent System of Care. CASSP Technical Assistance Center, Georgetown University Child Development Center, Washington, DC1989Google Scholar•Acculturation: Process of change in the cultures of 2 or more groups of individuals from different cultures, resulting from their continuous first-hand contact.4Rothe E.M. Tzuang D. Pumariega A.J. Acculturation, development and adaptation.Child Adolesc Psychiatr Clin N Am. 2010; 19: 681-696Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar•Race: Social classification system based on a set of external physical characteristics that are socially significant within a specific culture.•Ethnicity: Common historical or geographic heritage shared by a group of people.•Immigrant: Someone who intends to reside permanently in a new land. The recent demographic changes in the United States are highly significant for child mental health services. First, the acceptability and use of mental health services are governed strongly by cultural attitudes, beliefs, and practices. Second, the current science base of psychiatric diagnosis and treatment is derived from research primarily involving European-origin populations, so its validity for these emerging populations is not fully established. Third, minority populations face many increasing challenges around mental illness, including different sources of stressors, changing patterns of psychopathology, less access to services and evidence-based treatments, and greater burdens of morbidity and possibly mortality than Euro-Americans. For example, Latino and African American youth have significantly higher rates of suicidal ideation and attempts compared with Euro-Americans.5Eaton D. Kann L. Kinchen S. et al.Youth risk behavior surveillance–United States 2009.MMWR Surveill Summ. 2010; 59 (Accessed June 22, 2011): 1-142http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdfPubMed Google Scholar The current health care system does not effectively address the needs of culturally diverse populations. The recognition of racial and ethnic disparities in general health care has led to increasing recognition of similar disparities in mental health care.6Institute of MedicineUnequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, Washington, DC2002Google Scholar, 7US Office of the Surgeon GeneralMental Health: Culture, Race, and Ethnicity. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, Rockville, MD2001Google Scholar Obvious examples of mental health disparities are the child welfare and juvenile justice systems. More than 50% of children and youth in the child welfare system are African American, Latino, and American Indian children, and more than 65% of the children and youth in the juvenile justice system are African American and Latino.1US Census. United States population projections: 2000 to 2050. 2009. http://www.census.gov/population/www/projections/analytical-document09.pdf. Accessed June 22, 2011.Google Scholar, 8Alegria M. Vallas M. Pumariega A. Racial and ethnic disparities in pediatric mental health.Child Adolesc Psychiatr Clin. 2010; 19: 759-774Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar These systems also serve disproportionate numbers of mentally ill children, and their racial ethnic disparities are associated with a lack of early access to mental health services to prevent such outcomes. At the same time, in response to these mounting challenges, cultural competence became one of the core principles of the children’s community-based systems-of-care movement.3Cross T. Bazron B. Dennis K. Issac M. Towards a Culturally Competent System of Care. CASSP Technical Assistance Center, Georgetown University Child Development Center, Washington, DC1989Google Scholar Principle 1. Clinicians should identify and address barriers (economic, geographic, insurance, cultural beliefs, stigma, etc.) that may prevent culturally diverse children and their families from obtaining mental health services. Non-Hispanic white families are twice as likely as minority families to seek mental health treatment for their children9Angold A. Erkanli A. Farmer E. et al.Psychiatric disorder, impairment, and service use in rural African-American and white youth.Arch Gen Psychiatry. 2002; 59: 893-901Crossref PubMed Scopus (340) Google Scholar, 10Cuffe S. Waller J. Cuccaro M. Pumariega A. Race and gender differences in the treatment of psychiatric disorders in young adolescents.J Am Acad Child Adolesc Psychiatry. 1995; : 341536-341543Google Scholar, 11Pumariega A. Glover S. Holzer C. Nguyen N. Utilization of mental health services in a tri-ethnic sample of adolescents.Community Mental Health J. 1998; 34: 145-156Crossref PubMed Scopus (79) Google Scholar despite evidence suggesting the prevalence of psychiatric disorders in children does not appear to vary greatly by race or ethnicity.12Costello E. Pescosolido B. Angold A. Burns B.J. A family network-based model of access to child mental health services.Res Community Mental Health. 1998; 9: 165-190Google Scholar When minorities seek treatment, they may not remain engaged in outpatient services or use as many service units.10Cuffe S. Waller J. Cuccaro M. Pumariega A. Race and gender differences in the treatment of psychiatric disorders in young adolescents.J Am Acad Child Adolesc Psychiatry. 1995; : 341536-341543Google Scholar, 11Pumariega A. Glover S. Holzer C. Nguyen N. Utilization of mental health services in a tri-ethnic sample of adolescents.Community Mental Health J. 1998; 34: 145-156Crossref PubMed Scopus (79) Google Scholar Multiple systemic and logistical barriers that interfere with timely access to services are disproportionately experienced by racially/ethnically diverse families. These include financial needs, location of services and transportation, lack of adequate insurance, poorly understood bureaucratic procedures, and lack of linguistic support. Even when minority children and families receive services, these are often interrupted prematurely by these barriers.13Snowden L. Yamada A. Cultural differences in access to care.Annu Rev Clin Psychol. 2005; 1: 143-166Crossref PubMed Scopus (209) Google Scholar Although many traditional cultural values and beliefs are a source of strength and support for diverse children and families, some can act as barriers to mental health services. For example, a survey of Latinos found that factors such as perceptions of mental illness (including stigma and beliefs about causality), fatalism, spirituality, “familism” (in which the family is considered the primary unit of identification and allegiance3Cross T. Bazron B. Dennis K. Issac M. Towards a Culturally Competent System of Care. CASSP Technical Assistance Center, Georgetown University Child Development Center, Washington, DC1989Google Scholar and leads to keeping problems within the family), cultural commitment (e.g., to using only culturally sanctioned helping approaches), and language proficiency14Kouyoumdjian H. Zamboanga B. Hansen D. Barriers to community mental health services for Latinos: treatment considerations.Clin Psychol Sci. 2003; 10: 394-422Crossref Google Scholar affect their treatment. Abe-Kim et al.15Abe-Kim J. Takeuchi D. Hong S. et al.Use of mental health–related services among immigrant and US-born Asian Americans: results from the National Latino and Asian American study.Am J Public Health. 2007; 97: 1-8Crossref Scopus (448) Google Scholar found that rates of mental health–related service use, subjective satisfaction, and perceived helpfulness of services varied by birthplace and generation; United States–born Asian Americans used services at higher rates than their immigrant counterparts; and third-generation or later individuals had the highest (62.6%) rates of service use in the previous year. Stigma can be a powerful barrier to timely access to treatment. In many cultures, mental illness has major negative connotations, leading to the fear of double discrimination (as a result of being culturally different and perceived as “crazy”), which prevents minority families from accessing services. These perceptions can then become self-reinforcing when emergency services are needed owing to the traumatic impact of suddenly receiving a more restrictive level of care and/or their involuntary nature.16Freedenthan S. Stiffman A. “They might think I was crazy”: young American Indians’ reasons for not seeking help when suicidal.J Adolesc Res. 2007; 22: 58-77Crossref Scopus (74) Google Scholar Families may mistrust mental health service agencies given their histories of discrimination and disregard for cultural needs.17Suite D. LaBril R. Primm A. Harrison-Ross P. Beyond misdiagnosis, misunderstanding and mistrust: relevance of the historical perspective in the medical and mental health treatment of people of color.J Natl Med Assoc. 2007; 99: 879-885PubMed Google Scholar Culturally diverse families are more vulnerable to perceived or actual power differentials in their encounters with health care professionals. Diverse families should be educated to improve their understanding of diagnosis and treatment, empower decision making, expose myths, and improve treatment outcomes.2Four Racial/Ethnic PanelsCultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Populations. Center for Mental Health Services, Substance Abuse and Mental Health Administration, US Department of Health and Human Services, Rockville, MD1999Google Scholar Clinicians should address the realities and perceptions of power differentials that may interfere with therapeutic relationships.8Alegria M. Vallas M. Pumariega A. Racial and ethnic disparities in pediatric mental health.Child Adolesc Psychiatr Clin. 2010; 19: 759-774Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar It is not uncommon for minority children and adolescents to engage in mental health treatment for troubling behaviors identified by the school or the court, rather than by their parents.13Snowden L. Yamada A. Cultural differences in access to care.Annu Rev Clin Psychol. 2005; 1: 143-166Crossref PubMed Scopus (209) Google Scholar One explanation is that minority families tend to have a higher threshold for disruptive behaviors and to not seek professional intervention until the situation becomes unmanageable.18Napoles-Springer A. Santavo J. Houston K. Perez-Stable E. Stewart A. Patients’ perceptions of cultural factors affecting the quality of their medical encounters.Health Expect. 2005; 8: 4-17Crossref PubMed Scopus (112) Google Scholar Yeh et al.19Yeh M. McCabe K. Hurlburt M. et al.Referral sources, diagnoses, and service types of youth in public outpatient mental health care: a focus on ethnic minorities.J Behav Health Serv Res. 2002; 29: 45-60Crossref PubMed Google Scholar reported that children and adolescents of ethnic and racial minorities are referred for mental health treatment from involuntary sources such as the child welfare and juvenile justice systems more often than their white counterparts, with rates of self-referral to community services that are lower than those for whites. Although socioeconomic class can contribute to these disparities, they affect minority youth at higher rates than white youth even when controlling for socioeconomic status. Principle 2. Clinicians should conduct the evaluation in the language in which the child and family are proficient. Language-based communication is critical in obtaining accurate clinical information and establishing a therapeutic alliance. Many immigrants, however, are not fluent in English and thus may be unable to fully participate in the clinical process. In these situations, translation and interpretation are critical to effective care. Limited English proficiency is a significant barrier to accessing mental health services for adults and children from different ethnic origins, resulting in significantly lower utilization of mental health services.11Pumariega A. Glover S. Holzer C. Nguyen N. Utilization of mental health services in a tri-ethnic sample of adolescents.Community Mental Health J. 1998; 34: 145-156Crossref PubMed Scopus (79) Google Scholar, 14Kouyoumdjian H. Zamboanga B. Hansen D. Barriers to community mental health services for Latinos: treatment considerations.Clin Psychol Sci. 2003; 10: 394-422Crossref Google Scholar, 20Sentell T. Shumway M. Snowden L. Access to mental health treatment by English language proficiency and race/ethnicity.J Gen Intern Med. 2007; 22: 289-293Crossref PubMed Scopus (224) Google Scholar Lack of appropriate linguistic ability or interpreter support has been associated with misdiagnosis and adverse clinical outcomes.21Malgady R. Constantino G. Symptom severity in bilingual Hispanics as a function of clinician ethnicity and language of interview.Psychol Assess. 1998; 10: 120-127Crossref Scopus (61) Google Scholar, 22Flores G. Laws M. Mayo S. et al.Errors in medical interpretation and their potential clinical consequence in pediatric encounters.Pediatrics. 2003; 111: 6-14Crossref PubMed Scopus (509) Google Scholar In these cases, clinicians should obtain linguistic support through qualified interpreters or possess demonstrable proficiency in the target language. Unfortunately, translation and interpretation are often considered menial or informal tasks in the clinical process, as reflected by using untrained interpreters or translators without regard to impact on family relations, family members, siblings, or the child.2Four Racial/Ethnic PanelsCultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Populations. Center for Mental Health Services, Substance Abuse and Mental Health Administration, US Department of Health and Human Services, Rockville, MD1999Google Scholar Language brokering, the common practice of having children act as interpreters between parents and medical and school authorities, should be avoided, particularly when the patient is the language broker. An association has been identified between high language-brokering contexts and higher levels of family stress, lower parenting effectiveness, poorer adjustment in academic functioning, higher Child Behavior Checklist internalizing scores, and substance use in adolescents.23Martinez C. McClure H. Eddy J. Language brokering contexts and behavioral and emotional adjustment among Latino parents and adolescents.J Early Adolesc. 2009; 29: 71-98Crossref PubMed Scopus (117) Google Scholar Telephonic interpretation services enable 24-hour access and a wide range of available languages but are not ideal owing to their lack of ability to convey nonverbal communication. Interpreters should have proper training in the skill of interpretation and the content area being discussed. They should serve as integral members of the clinical team, serve as cultural consultants when they have understanding of the family’s culture, and interpret all verbal, nonverbal, and implicit communications from the child and family rather than provide summaries.24Pumariega A. Rothe E. Rogers K. Cultural competence in child psychiatric practice.J Am Acad Child Adolesc Psychiatry. 2009; 48: 362-366Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar If live translation services are not available, clinicians may have to use alternatives (telephonic interpreter services, individuals with dual-language abilities, or someone the family or child identifies), but efforts should be made to obtain the consent of the individuals using written or nonverbal means. Any educational materials and rating or diagnostic instruments should be translated to the language of the family member or child, and their reliability and validity in the target cultural group should be established using well-accepted reverse translation and psychometric methodologies. In the event materials or instruments have not been formally translated or validated, practitioners should access translation services from trained professionals or from bilingual child mental health professionals. Clinicians should be cautious about clinical interpretations based on diagnostic instruments not properly translated or validated with the population in question.2Four Racial/Ethnic PanelsCultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Populations. Center for Mental Health Services, Substance Abuse and Mental Health Administration, US Department of Health and Human Services, Rockville, MD1999Google Scholar, 24Pumariega A. Rothe E. Rogers K. Cultural competence in child psychiatric practice.J Am Acad Child Adolesc Psychiatry. 2009; 48: 362-366Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Principle 3. Clinicians should understand the impact of dual-language competence on the child’s adaptation and functioning. An estimated 20% of American children 18 years and younger grow up exposed to 2 languages. Learners of English as a “second language” (defined as any language learned after 3 years of age, which is the end of the critical period for rapid language acquisition) constitute the majority of dual-language children in America. After English, the most common home language in the United States is Spanish.25Toppelberg C. Munir K. Nieto-Castañon A. Spanish-English bilingual children with psychopathology: language deficits and academic language proficiency.Child Adolesc Ment Health. 2006; 11: 156-163Crossref PubMed Scopus (11) Google Scholar, 26Toppelberg C. Collins B. Language, culture and adaptation in immigrant children.Child Adolesc Psychiatr Clin N Am. 2010; 19: 697-717Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Grammatical and other language errors made by a child learning a second language (or a second English dialect, such as standard American English for a speaker of Black English) should not be confused with the grammatical or lexical abnormalities of language disorders. In contrast, deficits associated with psychiatric and language disorders (such as auditory-verbal working memory deficits) may slow the acquisition of a second language. Specialized consultation and assessment over time by a speech/language pathologist with expertise in dual-language children may be necessary to differentiate normal from disordered language acquisition.26Toppelberg C. Collins B. Language, culture and adaptation in immigrant children.Child Adolesc Psychiatr Clin N Am. 2010; 19: 697-717Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar There is evidence that maintaining the first (home) language is important in accessing family and community protective factors and other benefits. Despite this evidence, there has been a poorly substantiated practice of recommending to parents that they discontinue speaking the home language to a child who is facing language, cognitive, or other delays. This practice has little or no empirical support, and the limited research conducted in this area suggests that children with language impairment can be healthily exposed to and learn 2 languages with no significant detrimental effects.26Toppelberg C. Collins B. Language, culture and adaptation in immigrant children.Child Adolesc Psychiatr Clin N Am. 2010; 19: 697-717Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Although it may be true that certain children with linguistic or other deficits may become overwhelmed by the additional cognitive and linguistic demands of dual-language learning, recommendations to discontinue learning the home language may have potentially serious consequences and should not be made lightly. Rather, such decisions should ideally involve full assessment by a speech/language pathologist with appropriate expertise, consultation with the parents and others who know the child well, and an informed decision process by the parents with consideration of the family’s plans for the future.26Toppelberg C. Collins B. Language, culture and adaptation in immigrant children.Child Adolesc Psychiatr Clin N Am. 2010; 19: 697-717Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar For example, a child whose family speaks only a minority language may need to maintain and learn that language. Sudden language immersion may be stressful, depending on the child’s temperament and availability of supports. Children who are suddenly immersed in a second language environment with no knowledge of the language may go through a normal “nonverbal period.” This should not be confused with selective mutism, which has a higher prevalence among immigrant dual-language children. Thus, it is important that clinicians be familiar with features that differentiate the normal nonverbal period from selective mutism, which typically lasts much longer.27Toppelberg C. Tabors P. Coggins A. Lum K. Burger C. Differential diagnosis of selective mutism in bilingual children.J Am Acad Child Adolesc Psychiatry. 2005; 44: 592-595Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Principle 4. Clinicians should be cognizant that cultural biases might interfere with their clinical judgment and work toward addressing these biases. Adult and pediatric psychiatry literatures provide evidence for cultural and racial disparities in diagnostic assessment, treatment measures, and quality of received health care.8Alegria M. Vallas M. Pumariega A. Racial and ethnic disparities in pediatric mental health.Child Adolesc Psychiatr Clin. 2010; 19: 759-774Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar, 10Cuffe S. Waller J. Cuccaro M. Pumariega A. Race and gender differences in the treatment of psychiatric disorders in young adolescents.J Am Acad Child Adolesc Psychiatry. 1995; : 341536-341543Google Scholar, 28Kilgus M. Pumariega A. Cuffe S. Influence of race on diagnosis in adolescent psychiatric patients.J Am Acad Child Adolesc Psychiatry. 1995; 34: 67-72Abstract Full Text PDF PubMed Scopus (65) Google Scholar Stereotyping, biases, and uncertainties in health care providers can lead to unequal treatment.6Institute of MedicineUnequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, Washington, DC2002Google Scholar, 29Van Ryn M. Research on the provider contribution to race/ethnicity disparities in medical care.Med Care. 2002; 40: 140-151Crossref PubMed Google Scholar When the patient’s presentation or diagnosis is unclear, physicians may inadvertently over-rely on behavioral or clinical stereotypes of specific groups at the expense of focusing on the patient’s unique experience, clinical presentation, or sociocultural context. Stereotyping is defined as the process by which people use social categories (e.g., race, sex) to acquire, process, and retrieve information about others. Because stereotyping can be a subtle cognitive phenomenon resulting from virtually universal social categorization processes, it also occurs, often unconsciously, among people who strongly endorse egalitarian principles and truly believe that they are not prejudiced.30Sue D. Capodilupo C. Torino G. et al.Racial microaggressions in everyday life: implications for clinical practice.Am Psychol. 2007; 62: 271-286Crossref PubMed Scopus (2417) Google Scholar In the United States, there is considerable empirical evidence that well-meaning people who are not overtly biased and do not believe they are prejudiced typically demonstrate implicit (i.e., unconscious) negative racial attitudes and stereotypes.31Dovidio J. Brigham J. Johnson B. Gaertner S. Stereotyping, prejudice, and discrimination: another look.in: Macrae N. Stangor C. Hewstone M. Stereotypes and Stereotyping. Guilford Press, New York1996: 276-319Google Scholar Prejudice is defined in psychology as an unjustified negative attitude based on a person’s group membership.31Dovidio J. Brigham J. Johnson B. Gaertner S. Stereotyping, prejudice, and discrimination: another look.in: Macrae N. Stangor C. Hewstone M. Stereotypes and Stereotyping. Guilford Press, New York1996: 276-319Google Scholar Although in general me" @default.
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• W2059586337 title "Practice Parameter for Cultural Competence in Child and Adolescent Psychiatric Practice" @default.
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