Immigrant Adolescent Health, Part 2: Guidance for clinicians

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

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.

Psychosocial stressors and mental health

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:

• Mental Health Promotion
• Depression in children and youth
• Post-traumatic Stress Disorder
• Substance Use and Immigrant Youth

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 suicide and suicidal ideation 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 suicidal 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).

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

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 may 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 Caucasian 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, transgender, queer and two spirit (LGBTQ2S) 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.

Clinicians can provide culturally safe 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

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 strategies^82,83 

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

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

• Canadian Paediatric Society, Adolescent Health Committee, Position statements and clinical guidance on adolescent health issues, including harm reduction, sexual orientation and eating disorders.
• Contemporary Pediatrics, “The adolescent psychosocial history: HEEADSSS 3.0 and SSHADESS.” Articles and videos on adolescent psychosocial assessments.
• 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.
• Harrison C; CPS, Bioethics Committee. Treatment decisions regarding infants, children and adolescents. Paediatr Child Health 2004;9(2):99-103.
• Kelty Mental Health Resource Centre. Families, together: Supporting the mental well-being of culturally diverse families, children and youth [video and discussion guide]. Several resources are available in French and other languages.
• Kelty Mental Health Resource Centre. Mindfulness.  Text, video, and audio resources for mindfulness with children and youth.
• Ngo H, Schleifer B. Immigrant children and youth in focus. Canadian Issues/Thèmes Canadiens 2005:29-33.
• Smith A, Stewart D, Peled M, et al; McCreary Centre Society. A picture of health: Highlights of the 2008 British Columbia adolescent health survey. Vancouver, B.C.: McCreary Centre Society; 2009.
• Fresh Voices Youth Advisory Team. Fresh Voices Report, 2013:
• Family Acceptance Project.  Multilingual resources, publications, and videos for clinicians and families to help support LGBT youth.

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