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Key points
- Cultural differences can affect the diagnosis and treatment of child and adolescent psychosis.
- There is a stigma associated with mental health disorders in many countries, making treatment challenging.
Sarper Taskiran is a senior child and adolescent psychiatrist in the Psychopharmacology Center at the Child Mind Institute, with extensive experience diagnosing and treating the full range of psychiatric disorders, including child psychosis.
Originally from Türkiye, he completed his medical training in Ankara and then his residency in the United States at Yale, NYU, and Bellevue, where he observed key differences in diagnosing children with psychosis in different countries and cultures.
Following is an interview with Taskiran on the cultural differences in diagnosing and treating psychosis in Türkiye and the United States.
Sarah An Myers: Could you tell me about your multicultural medical training and background?
Sarper Taskiran: I was born and raised in Türkiye. I went through college and medical school in Ankara, where my first use of medicine was formed in the Turkish system. The medical center I trained adopted an American curriculum. Early on, I was able to see some of the differences between some of the descriptions in the textbooks.
Following my graduation, I came to the United States and spent some time doing research in psychiatry prior to going to residency, where I ultimately ended up at Yale. There, I saw a lot of adolescent and child psychosis and then moved to NYU and Bellevue, where I saw a lot of different demographics, including immigrants, displaced war refugees, Haitian refugees, people from the Middle East, children of illegal immigrants, and more—a demographic which was under a lot of stress. I went back to Türkiye following my residency for five years and saw a lot of the same demographics and children with various physical and sexual traumatic injuries.
SM: What are the differences between psychosis in Türkiye and in the United States?
ST: Psychosis in children is a rare disorder. Children with this disorder have impaired thinking that causes them to lose touch with reality and impaired emotional regulation. They have changes in their speech, motivation, socialization, and cognition. When we're talking about true psychosis, such as very early onset schizophrenia, that is 1 percent of 1 percent of people with schizophrenia. However, if we consider adolescence, 30 percent of adults with schizophrenia have had some symptoms that started before age 18.
When we are evaluating psychosis, we are evaluating thoughts and beliefs. We evaluate the organization of someone's thought process and the content of their thoughts. Additionally, we look at their behavioral functioning, how they're presenting in school, relatedness to their peers, and engagement in activities. In order to evaluate behavior, we tend to look for social withdrawal and low motivation, and we can truly gauge these things when we have a good understanding of their baseline, meaning how they functioned before the symptoms started.
This baseline is established and shaped by the cultural group they belong to. For migrants and refugees, these children are clearly not in the environment they're used to. So it's hardly realistic to expect them to be engaged and be overly motivated and be prosocial with peers when they don't understand the lay of the land and culture of their new country.
We sometimes have teachers tell us about red flags, saying they're exhibiting strange behavior, but when we talk to their families with a translator, often a different picture will be painted. Evaluation of psychosis needs a clear picture of what is normal in their culture and their own understanding of their own cultural beliefs.
For example, practicing in Türkiye, I saw a lot of patients who were scared of djinns, which are demonic beings vastly engrained in Turkish culture. Most kids describe them akin to the dementors in Harry Potter—beings that suck your soul. The kids reported seeing them, hearing them say God's name, etc., but when I dug deeper to examine what is normal for their community, then I realized this was the baseline of everyone in the culture, and that alone did not qualify them for a psychosis diagnosis.
SM: What is the difference between the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its structure in the United States versus diagnostic criteria in Türkiye?
ST: What the DSM does cleverly is that it says seemingly delusional beliefs only qualify for a diagnosis if the symptoms are "out of the norm” and they are discordant with beliefs accepted by one’s culture. In order to correctly evaluate psychosis in children, one needs to be very familiar with the culture in which they come from and to be able to see if the symptoms are acceptable within societal norms. If the psychiatrist isn't familiar, a good interview with parents can clear things up to understand what is shared and normative in their family vs. what stands out.
Also, the diagnosis of schizophrenia in children is never just about having delusions or hallucinations; these should be together with displays of bizarre, uncharacteristic behavior, a decrease in academic functioning, adaptive skills markedly reduced, and also cognitive decline. In the absence of those, you can't make a diagnosis.
SM: What is the difference between child and adolescent psychosis and adult psychosis?
ST: Childhood psychosis is much rarer. It is more common in males, and the process is not sudden but insidious. And there is almost always a marked academic and functional decline prior to the onset of psychotic symptoms. It has a worse prognosis because overall functioning in the future really depends on the amount of time the individual spends in psychosis. When it starts in childhood and is not treated well, it accumulates over time.
The diagnosis is usually confused with behavioral disorders because children who are suffering from psychosis have erratic behaviors, which can be confused with willful behavior. However, once the psychotic symptoms are established, such as delusions, hallucinations, and disorganized thinking, it's actually hard to miss.
SM: What is the treatment for child psychosis?
ST: The most effective treatment is early intervention. We need to get these individuals seen even before the positive psychotic symptoms, such as delusions or hallucinations, start. We call these prodromal symptoms. Some signs of this condition are that they might look depressed, withdrawn, or apathetic, or start having difficulty with mood regulation, concentration, and attention.
Cognitive remediation is a treatment to improve the skills they are losing. We also try to get the individual and the family supportive treatments as well to go against the disease itself. We try to push more social interactions to preserve these social skills that might be disappearing due to the onset of psychosis.
Another intervention we do is start antipsychotic medications early to attenuate the level of psychosis when it starts. If they have less severe psychotic episodes and spend less time being psychotic, then the overall prognosis is better.
SM: Are there any issues you run into while facing cultural differences between patients and their families?
ST: When a child is having psychotic symptoms, treatment requires consent from the parents. Sometimes there is reason for pushback with immigrant families, refugee families, etc., who understandably come in with an apprehensive approach to the healthcare system in general and concerns with deportation, so they do not agree with hospitalization.
Most families come with a preconceived idea that the system is not approaching their treatment in their best interests. Sometimes, they feel like the system is trying to put a wedge between the child and the family. Sometimes, in their own denial, they say, "He's just a kid," or "He's an adolescent, he's acting differently now, but it's probably going to pass," things like that. They're trying to chalk it up to cultural differences or due to the distrust in the system.
And there is also this idea that it's a Western idea that mental health disorders should be treated. This is very different in other cultures. Mental disorders are denied or untreated because once a person is mentally ill, they won't get better in their minds.
In the U.S., it's taken years to come to this acceptance, and it's taking a lot of work. I think outpatient care is more normalized now. Less developed countries have not gone through that mental health reform or destigmatizing movement, so a lot of people are holding onto their beliefs, and it takes a lot of effort in each individual country to combat that stigma.
SM: What do you want people to know about child and adolescent psychosis?
ST: If you leave a child with psychosis untreated, their whole life is going to be affected by psychosis. I always want to convey to the parents that this is a biological condition with a clear genetic origin that includes neurodevelopmental and neurodegenerative changes. These individuals are born with vulnerability, and life stressors such as physical, emotional, or sexual trauma or a big transition such as refugee status or immigration can unearth this vulnerability and trigger a psychotic reaction in the brain. During the time when their prefrontal cortices are still developing, I reiterate that there are gross gray matter changes happening that contribute to the physical deterioration of the brain.
Generally, I always get MRI imaging done on a child to rule out any other organic conditions, such as brain tumors or infections, which are not done in adults.
