Migration or ethnic minority status and risk of autism spectrum disorders and intellectual disability: systematic review

Assessment of Suicide Risk and Cultural Considerations in Forcibly Displaced Migrant Youth

Migrant youth who face forced displacement from their home countries have an emergent mental health burden, placing them at increased suicide risk. As such, it is crucial for pediatric providers to include suicide screening and assessment in their care for this population. Migrant families seek safety but, in many cases, encounter adverse events and psychosocial inequities in the migration journey and in the host community. Factors such as trauma, acculturative stress, and intersectionality influence suicide risk in migrants. Summative traumatic events contribute to the mental health load and worsen suicidal outcomes in migrant youth. Acculturative stress can lead to social marginalization in the host country, further adding to the existing mental health burden. Finally, intersectionality encompasses complex sociocultural influences, which shape the development of cultural identity in migrant youth and influence suicide risk. By examining these factors, the author advances cultural considerations in screening and assessment for suicide risk in migrant youth through evidence-based tools in pediatric clinical practice. Barriers to access to mental health services, stigma, and distrust of the health care system within the host community are also addressed. The author establishes recommendations for early suicide screening and prevention within this population through trauma-informed care, active advocacy, and cultural sensitivity.

Bias in assessment of co-occurring mental disorder in individuals with intellectual disabilities: Theoretical perspectives and implications for clinical practice

Influence from bias is unavoidable in clinical decision-making, and mental health assessment seems particularly vulnerable. Individuals with intellectual disabilities have increased risk of developing co-occurring mental disorder. Due to the inherent difficulties associated with intellectual disabilities, assessment of mental health in this population often relies on a different set of strategies, and it is unclear how these may affect risk of bias. In this theoretical paper, we apply recent conceptualisations of bias in clinical decision-making to the specific challenges and strategies in mental health assessment in intellectual disabilities. We suggest that clinical decision-making in these assessments is particularly vulnerable to bias, including sources of bias present in mental health assessment in the general population, as well as potential sources of bias which may be specific to assessments in this population. It follows that to manage potential bias, triangulating information from multi-informant, multi-method, interdisciplinary assessment strategies is likely to be necessary.

Maternal Migration, Prenatal Stress and Child Autistic Traits: Insights From a Population-Based Cohort Study

OBJECTIVE

There is emerging evidence for an increased prevalence of autism in children of mothers with a migration background. To date, the mechanisms underlying this relationship are poorly understood. We investigated whether prenatal stress exposure mediates the association between maternal migration and child autistic traits, assessing first- and second-generation migrant mothers in the Netherlands and their children.

METHOD

The study was embedded in the prospective population-based Generation R cohort. Of the 4,727 participants, 1,773 mothers (38%) had a migration background. Prenatal stress was assessed using questionnaires related to stressful life events, family functioning, self-esteem, long-lasting difficulties, symptoms of psychopathology, social support, and perceived discrimination. Autistic traits were measured at age 6 years with the parent-reported Social Responsiveness Scale exclusively. Longitudinal multiple mediation analyses were performed. Analyses were stratified by migration origin (Europe and outside Europe) because of differences in migration characteristics.

RESULTS

Maternal migration background was associated with more experienced stress and with higher child autistic trait scores (Europe: mean = 0.42, SD = 0.25; outside Europe: mean = 0.50, SD = 0.24) compared to no migration background (Netherlands: mean = 0.38, SD = 0.23; both p < .01). Prenatal stress, especially perceived discrimination and maternal psychopathology, accounted for up to half of the total effect of maternal migration, which remained after adjusting for sociodemographic factors (Bindirect = 0.035, 95% CI = 0.027, 0.043, Btotal = 0.074).

CONCLUSION

Stress during pregnancy mediated the association between maternal migration status and child autistic traits. Future research should focus on early interventions to assess whether reducing prenatal stress exposure among women with a migration background can result in lower offspring autistic traits.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We actively worked to promote sex and gender balance in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Trauma Informed Best Practices and Resiliency

Children who experience fleeing from their home countries, whether with family members or unaccompanied, almost certainly experience trauma. The response of caring systems should remain grounded in the known principles of trauma-informed care, an understanding of best practices based on evidence-based and informed interventions and the developmental process. In addition, care providers should be working to maximize the safety of the environment in which they are interacting with children and youth and considering the style, approach, and content of interaction to balance the purpose of any interaction with the safety and security needs of each child or youth.

Exploring knowledge of autism, its causes and treatment among immigrant and nonimmigrant parents in Somalia\Somaliland

BACKGROUND

The prevalence of autism spectrum disorders (ASDs) has increased over the recent years; however, little is known about the experience of parents of children with autism in Africa such as Somalia. The aim of this study is to understand the knowledge on autism of Somali parents of children with autism and their perceptions of causes and treatment of ASD.

METHODS

We conducted a qualitative study involving 22 parents of children with autism who lived in Mogadishu and Hargeisa; the two largest cities in Somalia. In-depth interviews were used to collect the data. Of the 22 participants, 9 were returned immigrants and 13 were local people (non-immigrants). Data were analysed using thematic analysis.

RESULTS

The data revealed that most of the parents hold the belief that their children's autism were caused by the measles vaccine. The findings demonstrated that parents sought diagnosis and treatment care from outside Somalia due to the lack of experience of health providers in the diagnosis and treatment of autism. The data also revealed a lack of knowledge about autism among the public with resultant stigma and discrimination against children with autism and their families.

CONCLUSIONS

Efforts to increase public knowledge on autism, its causes and treatments are of paramount importance, while a public health campaign designed to eliminate the stigma subjected to children with autism is necessary to improve the quality of life of children with autism and their caregivers. Finally, to counteract vaccine hesitancy, particularly in response to the measles vaccine, health policy makers should take steps to separate the cooccurrence of the onset of autism symptoms and the provision of the measles vaccine.

Developmental disorders among Norwegian-born children with immigrant parents

BACKGROUND

Risk of being diagnosed with different developmental disorders is found to vary with immigrant background. Knowledge about such differences in Norway are a starting point for equity in health services quality, and for early identification and prevention. Our objective was to assess the risk of receiving diagnoses of developmental disorders among children born in Norway (2006-2017) to two or one immigrant parent compared to children with two Norwegian-born parents.

METHODS

Information on developmental disorders was from the Norwegian Patient Register (NPR) and information on immigrant background, parental country of origin, parental education, and household income from Statistics Norway. We estimated hazard ratios (HR) with Cox proportional hazard regressions. With children with Norwegian background as reference category, we estimated HRs for immigration background and region of origin. All analyses were adjusted for sex, year of birth, parental education, and household income.

RESULTS

Children with two immigrant parents had a lower risk of receiving any developmental disorder diagnosis [HR 0.80 (95% CI 0.77, 0.82)] than children with Norwegian background, and lower risk of being diagnosed with attention deficit hyperactivity disorder (ADHD) diagnosis [HR 0.24 (95% CI 0.22, 0.27)], learning difficulties diagnosis [HR 0.39 (95% CI 0.33, 0.47)], and behavioral and emotional disorders [HR 0.52 (95% CI 0.49, 0.55)]. Children with immigrant parents had higher hazard than Norwegian background children of autism spectrum disorder (ASD) [HR 2.21 (95% CI 2.04, 2.39)], mental retardation [HR 1.84 (95% CI 1.64, 2.07)], language disorders [HR 1.30 (95% CI 1.20, 1.40)], and unspecified developmental disorders [HR 1.22 (95% CI 1.17, 1.28)]. Children with only one immigrant parent had lower risk of diagnoses than children of two immigrants.

CONCLUSION

Risk of receiving a diagnosis of various developmental disorders varied substantially by immigrant background. Understanding the underlying mechanisms of these differences is warranted to ensure equity in health services and timely intervention.

The silent shot: An analysis of the origin, sustenance and implications of the MMR vaccine - autism rumour in the Somali diaspora in Sweden and beyond

This article traces the origin, sustenance and implications of a persistent rumour that is responsible for low measles mumps and rubella (MMR) vaccination uptake in the Somali diaspora in a number of countries across the globe. The rumour stipulates that the MMR vaccine - the silent shot - causes autism spectrum disorder (ASD). Although the association between MMR and ASD is non-causal, and various public health initiatives have promoted health information campaigns, the rumour continues to circulate in the Somali diaspora in many countries, including Sweden. This paper shows that there are valid reasons for this. The findings from this paper draw on a systematic scoping review and qualitative interview data from Sweden. The results show that the Somali community experiences higher than average rates of ASD compared to the general population. Moreover, ASD does not exist in the Somali language or their home country, is considered a Western disease that only affects Somali children in the diaspora, and is a highly stigmatised disease. Also, the Somali diaspora has had negative experiences with ASD diagnosis and care. The rumour has been sustained by the absence of an answer to their ASD fear and through active diaspora networks on social media. The network that surrounds the rumour has arguably further helped to create an epistemic community for a community whose concerns have been silenced.

Overview of Services for Autism Spectrum Disorders (ASD) in Low- and Middle-Income Countries (LMICs) and among Immigrants and Minority Groups in High-Income Countries (HICs)

Autism spectrum disorder (ASD) prevalence is rising [...].

Migration modulates the prevalence of ASD and ADHD: a systematic review and meta-analysis

BACKGROUND

Migration has been implicated as a risk factor for autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), but evidence is still limited and inconsistent. We aim to investigate the relationship between migration status and risk of ASD and ADHD.

METHODS

Electronic databases including PubMed, EMBASE, Web of Science, and PsychINFO were searched to identify observational studies on this topic, from inception to February 2021. Random-effects meta-analysis models were used to pool the summary odds ratio (OR) and 95% confidence interval (95% CI), and subgroup analyses were conducted to detect possible discrepancies in associations. Certainty of evidence was assessed as per the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines.

RESULTS

A total of 13 studies (6,532,546 participants) for ASD, five studies (2,875,070 participants) for ADHD, and six studies (31,158 participants) for hyperactivity were included. Overall, the pooled results indicated that migration was associated with increased risk of ASD (pooled OR: 1.32; 95% CI: 1.07-1.63; P for Z test = 0.010), but no association was found between migration and ADHD (pooled OR: 0.84; 95% CI: 0.53-1.32; P for Z test = 0.452) or hyperactivity (pooled standardized mean difference: -0.073; 95% CIs: - 0.383-0.236; P for Z test = 0.642). Subgroup analyses further demonstrated that maternal migration was ASD risk factor (pooled OR: 1.49; 95% CI: 1.19-1.87), and migrant children were more likely to develop ASD with comorbid intellectual disability (ID) (pooled OR: 1.21, P for interaction = 0.006) than ASD without ID. After standardized the origin of migrants, European migrant children from Americas were at higher risk of ASD and ADHD (pooled OR were 4.13 and 1.26), and increased ASD risk was also observed in African children (pooled OR: 2.72). The GRADE of evidence was very low.

CONCLUSIONS

Maternal migration is a risk factor for ASD, and migrant ASD children are more likely comorbid ID. The role of migration on ADHD remains controversial, more studies are needed to assess the association between migration status and ADHD. Health care practitioners should consider screening and providing extra resources for migrant children.

A Study of the Genomic Variations Associated with Autistic Spectrum Disorders in a Russian Cohort of Patients Using Whole-Exome Sequencing

This study provides new data on the whole-exome sequencing of a cohort of children with autistic spectrum disorders (ASD) from an underexplored Russian population. Using both a cross-sectional approach involving a control cohort of the same ancestry and an annotation-based approach involving relevant public databases, we explored exonic single nucleotide variants and copy-number variation potentially involved in the manifestation of ASD. The study results reveal new potential ASD candidate-variants found in the studied Russian cohort and show a high prevalence of common ASD-associated genomic variants, especially those in the genes known to be associated with the manifestation of intellectual disabilities. Our screening of an ASD cohort from a previously understudied population allowed us to flag at least a few novel genes (IGLJ2, FAM21A, OR11H12, HIP1, PRAMEF10, and ZNF717) regarding their potential involvement in ASD.

Are all children treated equally? Psychiatric care and treatment receipt among migrant, descendant and majority Swedish children: a register-based study

AIMS

Underutilisation of mental health services among migrant youth has been demonstrated repeatedly, but little is known about potential discrepancies in terms of treatment receipt for those who do reach services. This study examines the type and level of care received among migrant children and descendants of migrants, particularly investigating disparities in treatment receipt given a specific diagnosis.

METHODS

We used register data of the total population aged 6-17 years in Stockholm, followed from 2006 to 2015, comprising 444 196 individuals, categorised as refugees, non-refugee migrants, descendants of migrants and Swedish-born. To identify recommended treatments for specific diagnoses we used official clinical guidelines. We report logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) of diagnosis receipt, treatment provision and level of care where a diagnosis was first registered.

RESULTS

Migrant children had a lower likelihood of receiving a wide range of psychiatric diagnoses, including mood disorder (OR 0.58; 95% CI 0.52-0.64), anxiety disorder (OR 0.62; 95% CI 0.57-69) and neurodevelopmental disorder (OR 0.59; 95% CI 0.55-0.63). Moreover, when these diagnoses were set, migrant children had a lower likelihood of receiving the recommended treatments for these conditions compared to the majority individuals with the same diagnosis (OR of receiving psychotherapy for anxiety disorder and depression: 0.71; 95% CI 0.62-0.95 and 0.50; 95% CI 0.33-0.75, respectively; OR for receiving ADHD-medication: 0.49; 95% CI 0.43-0.54).

CONCLUSIONS

Migrant children risk underdiagnosis of various mental health conditions, and, when reaching mental health services, risk not receiving the optimal care available.

Maternal levels of acute phase proteins in early pregnancy and risk of autism spectrum disorders in offspring

Previous research supports a contribution of early-life immune disturbances in the etiology of autism spectrum disorders (ASD). Biomarker studies of the maternal innate (non-adaptive) immune status related to ASD risk have focused on one of the acute phase proteins (APP), C-reactive protein (CRP), with conflicting results. We evaluated levels of eight different APP in first-trimester maternal serum samples, from 318 mothers to ASD cases and 429 mothers to ASD-unaffected controls, nested within the register-based Stockholm Youth Cohort. While no overall associations between high levels of APP and ASD were observed, associations varied across diagnostic sub-groups based on co-occurring conditions. Maternal levels of CRP in the lowest compared to the middle tertile were associated with increased risk of ASD without ID or ADHD in offspring (OR = 1.92, 95% CI 1.08-3.42). Further, levels of maternal ferritin in the lowest (OR = 1.78, 95% CI 1.18-2.69) and highest (OR = 1.64, 95% CI 1.11-2.43) tertiles were associated with increased risk of any ASD diagnosis in offspring, with stronger associations still between the lowest (OR = 3.81, 95% CI 1.91-7.58) and highest (OR = 3.36, 95% CI 1.73-6.53) tertiles of ferritin and risk of ASD with ID. The biological interpretation of lower CRP levels among mothers to ASD cases is not clear but might be related to the function of the maternal innate immune system. The finding of aberrant levels of ferritin conferring risk of ASD-phenotypes indicates a plausibly important role of iron during neurodevelopment.

Mental health service use among migrant and Swedish-born children and youth: a register-based cohort study of 472,129 individuals in Stockholm

PURPOSE

Migrant children underutilize mental health services (MHS), but differences according to age, reason for migration, type of problem, and time have not been thoroughly analyzed. We aimed to explore utilization of MHS among migrant children and youth and to study if the hypothesized lower utilization could be explained by fewer neurodevelopmental assessments.

METHODS

A cohort of the population aged 0-24 years in Stockholm, comprising 472,129 individuals were followed for maximum 10 years, between January 1, 2006 and December 31, 2015. We categorized individuals as accompanied refugee migrants, unaccompanied refugee migrants and non-refugee migrants, or Swedish-born. We used survival and logistic analyses to estimate rates of utilization of MHS.

RESULTS

Migrant children and youth utilized less MHS than the majority population, with hazard ratios ranging from 0.62 (95% CI: 0.57; 0.67) to 0.72 (95% CI: 0.69; 0.76). Refugee and non-refugee children utilized less mental health care than their Swedish peers, apart from the youngest refugees (0-10 years) who had similar utilization as Swedish-born. The lower rates were partly explained by all migrant youths' lower risk of being diagnosed with a neurodevelopmental condition. Time in Sweden had a major impact, such that unaccompanied refugee minors had a higher utilization in their first 2 years in Sweden (OR: 3.39, 95% CI: 2.96; 3.85).

CONCLUSION

Migrant youth use less MHS compared with native-born peers, and this is partly explained by fewer neurodevelopmental diagnoses. Strengthening the awareness about unmet needs, and the referring capacity by professionals in contact with migrant children could help reduce barriers to care.