Sharing the university’s expertise with the local community, psychiatry residents and faculty at the University of Puerto Rico in San Juan have been able to teach the parents of violent and troubled youth to recognize the early warning signs of mental illness and find appropriate mental health services.
The psychiatric professionals were part of a communitywide effort to stem a flood of youth violence in recent years—which accounted for the majority of adolescent deaths on the island in 1999.
"Due to the impact that violence has in terms of emotional cost to victims and their families, as well as the health and safety of citizens," said Luz Colón de Marti, M.D., associate professor of psychiatry and residency training director at the University of Puerto Rico, "we decided we needed to address prevention and early intervention in violent behavior."
The residents and faculty have reached more than 1,000 parents, teachers, and other school staff through workshops all over the island on the prevention of youth violence, according to Colón de Marti, who spoke about the project at the annual meeting of the American Association of Psychiatric Residency Training Directors in March.
To reach the community, the university joined forces with the Violence Prevention Project at the Asociación de Padres Pro Beinestar de Ninos Impedidos Inc. (APNI) and the Association of Parents for the Welfare of Children With Disabilities.
APNI is a nonprofit organization founded in 1977 by a group of parents to improve educational services for children with disabilities.
The organization received a two-year grant in 2000 from the U.S. Department of Education to educate the community about violence and mental health issues. Colón de Marti said that when the grant is renewed, the university will continue its collaboration with APNI.
At the day-long workshops, anywhere from 30 to 150 parents and school staff gathered in various places in the community—police buildings, city halls, and health clinics, for instance.
Working together to stop youth violence are (from left) Wanda Santos, APNI project coordinator; Luz Colón de Marti, M.D., associate professor and residency training director at the University of Puerto Rico; Gloria Suau, M.D., resident; Iris Rodriguez, M.D., resident; and Leslis Nazario, M.D., residency training director for the child and adolescent psychiatry program.
In the mornings, according to Wanda Santos, APNI project coordinator, APNI staff and nonpsychiatric mental health professionals from the university equipped attendees with certain parenting skills, for instance. "We taught the parents how to relax and to control their anger so that they could better deal with their children" when the children were having problems, Santos said.
University psychiatry faculty then spoke to parents and school staff about risk factors for violent behavior, which can range from undiagnosed mental illness to poverty to unsupervised television or Internet use.
"We also taught attendees about how violence can be a problem in children with certain psychiatric disorders or organic medical conditions," said Leslis Nazario, M.D., the training director at the University of Puerto Rico’s child psychiatry residency training program.
So that attendees became savvy to the possibility of mental illness in youngsters, faculty members taught them the warning signs associated with psychiatric illnesses such as attention-deficit/hyperactivity disorder, depression, substance abuse, and posttraumatic stress disorder.
But the majority of learning—and sharing—took place when psychiatry residents, under supervision by faculty, divided the workshops into smaller groups and discussed clinical vignettes with attendees.
The children at risk for violence in the sample vignettes were not unlike the children in the parents’ and teachers’ lives, the residents noted.
The group exercise—to identify some of the risk factors for violence in the vignettes—often developed into candid discussions of someone’s child who was combative at school, belonged to a gang, or was bullied by other children in the classroom.
Bullying was a frequent theme of these discussions, Colón de Marti noted. "One of the parents began crying when she read the vignette because she believed we were writing about her child."
The mother came to the workshop to learn more about how to help her daughter, who suffered from a congenital disease that caused her to look different from other children. The girl had long been the victim of merciless bullying at the hands of her classmates.
The residents instructed the mother about how to get help for herself and her daughter and provided the teachers in the group with strategies to stop the bullying in the classroom.
According to psychiatry resident Gloria Suau, M.D., who led some of the smaller group sessions, "The workshops not only helped us to understand our role in the community, but also helped the community to understand the role of mental health professionals and the different mental health services available to them."
Some didn’t know the difference between a psychologist and a psychiatrist, for instance, or under what conditions inpatient hospitalization as opposed to outpatient care was warranted for a child with mental health problems, Suau said.
At each workshop, residents and faculty came armed with a list of local agencies, hospitals, and psychiatrists and mental health professionals that the parents and teachers could turn to for children in need of help.
Sometimes, the faculty and residents were the ones who helped the children through their crises.
Suau shared one particularly rewarding experience that came out of the workshops. There, she met the mother of a young girl with mood swings and frequent and explosive temper tantrums. She was teased by her schoolmates because of her obesity.
Suau evaluated the girl and found that she had Prader-Willi syndrome, a genetic disorder characterized by short stature, below-average intelligence, aggressive tendencies, obesity, and obsessive behavior often involving food.
At the university’s outpatient clinic under supervision of faculty, Suau began behavior and medication therapy. She then referred the child to a number of specialists, including a nutritionist, who helped her control her eating, and an endocrinologist, who started the girl on a growth hormone—growth hormone has the double benefit of facilitating growth and controlling mood swings. Another specialist treated her for sleep apnea. In addition, Suau created a brochure to educate children about Prader-Willi syndrome and united parents of other children with the syndrome, who went on to launch a support group.
"The child rarely has temper tantrums, and her mood swings are under control," Suau said. "She is more alert and does better in school."
The psychiatry residents have benefited as well from the experience. "The workshops have improved our professional skills and enriched our training. It’s been an excellent learning experience," Suau said. ▪