Twenty years ago, Hami Torres fled Mexico at age 13, her 11-year-old brother in tow. Terrified, they trekked for hours with a group of older strangers through desert scrub that slashed Hami's bare legs bloody. Then the two children were folded into the spare-tire compartment of a car for the drive across the border.
The Torres children had left their home country to reunite with their mother and stepfather, who had entered the United States three months before. Yet once the children made it to this country, the ordeal wasn't over. They lived in a crime-ravaged neighborhood where Hami was expected to join a gang for protection. She constantly feared being found by immigration authorities, always looking over her shoulder for officials who might find out she was undocumented.
Eventually, Hami was able to build a new life for herself. Though her brother dropped out of high school at 16, Hami graduated, went on to college and earned her citizenship. Today, she is a cardiovascular surgical intensive care nurse, married with three children.
Last year, thousands of unaccompanied minors like the Torres children surged across the Mexican border, most from Central America. Some as young as 5, most in their teens, they turned themselves in to authorities, seeking asylum and giving horrifying accounts of violence they'd either been victim to or witnessed — beatings, rapes, murders and drug gang intimidation — both in their home countries and on their journey to the United States.
Since unaccompanied children from countries other than Mexico or Canada can't be deported without a hearing due to a 2008 law aimed at stopping human trafficking, these children were placed in U.S. detention centers and shelters. For some, the trauma continued. They endured unheated facilities, limited food and water, and lack of access to bathrooms and showers. Some have reported being abused physically and sexually by facility personnel (a complaint was filed in June 2014 by the American Civil Liberties Union on behalf of 116 unaccompanied immigrant children).
After processing in detention facilities, these unaccompanied minors are typically placed either with families or in foster homes or other government-sponsored facilities while they wait for immigration hearings, which can take a year or more. They may start school, not knowing the language or whether they will be allowed to stay.
As psychologists' research has documented, children who have experienced trauma, fear, separation from family and isolation are subject to a variety of psychological stressors and mental health challenges. Studies have shown some develop anxiety, depression, post-traumatic stress disorder (PTSD) or other conditions. Armed with that data, psychologists and other mental health professionals are developing interventions to help these children heal and thrive.
The fears that cause them to flee
From September 2013 to September 2014, about 68,000 unaccompanied minors were apprehended by U.S. border patrol. That's a 77 percent increase from the nearly 39,000 detained the previous year. About 75 percent came from Guatemala, Honduras and El Salvador — ranked among the most violent countries in the world, even including active war zones.
The violence in these countries "impacts youth disproportionately," says Elizabeth Kennedy, a former Fulbright fellow and doctoral student at San Diego State University and the University of California at Santa Barbara. Kennedy worked from November 2013 through September 2014 interviewing unaccompanied minors at a migrant return center in El Salvador.
The 700-plus children she's spoken with have been deported from Mexico; almost all were trying to get to the United States and many said they will try again.
Why do these children risk the treacherous journey? Kennedy says the chief reason they give is fear of gangs, violence and insecurity. More than half (58 percent) of the 322 children she studied recently reported living in neighborhoods with a gang presence. A third attended schools with gangs inside. Kennedy says 109 children told her they had been directly threatened to join the gang or be killed, with 22 assaulted on multiple occasions.
As a result, 70 children quit school because they didn't feel safe; 32 became prisoners in their own homes, staying in day and night out of fear. Four of those children suffered psychological breakdowns severe enough that their parents took them for emergency care and were told by emergency room doctors to get the child out of the country.
Caregivers tell Kennedy their children can't sleep through the night, that they sometimes shake and tremble. But since so many other children have these symptoms, the caregivers think it is normal, she says.
In addition to fear of violence, the second most common reason children give for migrating is to be reunited with parents or other family members. More than 90 percent have a family member — usually a parent — in the United States already, says Kennedy.
The children know the dangers they face trying to get to the United States, she says. "They tell me, ‘I could be raped, I could be maimed, I could be kidnapped, I could be disappeared, I could be beaten,' but the reality is those risks are lesser, they feel, than the ones they run if they stay."
Resilient, but often traumatized
Despite what they've endured, many immigrant children are remarkably strong and resilient, says Andrés Consoli, PhD, associate professor at the University of California, Santa Barbara and past president of the National Latino/a Psychological Association (NLPA). Nonetheless, having experienced such traumatic situations puts them at risk for depression and anxiety, he says.
Exactly how many of these children suffer mental health problems is unclear. "This is a difficult population to study," says Nayeli Chavez-Dueñas, PhD, associate professor at the Chicago School of Professional Psychology and a clinical psychologist who works with immigrant children. "A lot of people are uncomfortable sharing their status."
Research indicates that unaccompanied refugee minors experience greater risk of mental illness than general populations, whether they are "border children" coming into the United States from Central America in recent years or children in other parts of the world. A 2008 review of 22 papers covering unaccompanied refugee minors from 1998 to 2008 found higher levels of PTSD symptoms for unaccompanied minors than either norm populations or accompanied refugee minors (Child and Adolescent Psychiatry and Mental Health, 2009).
Most research on psychological issues faced by unaccompanied refugee minors comes from researchers outside the United States. For example, a 2012 study examined 222 males ages 13 to 18 who were from Afghanistan and were seeking asylum in the United Kingdom. The study found one-third were likely to have PTSD, based on self-reports (Journal of Traumatic Stressopens in new window, 2012). Another study of unaccompanied refugee minors in Belgium followed 103 children for 18 months after their arrival. It found that their generally high levels of anxiety, depression and PTSD did not dissipate over that time period (European Child and Adolescent Psychiatryopens in new window, 2014).
The impact of separation from parents for these unaccompanied children can also be profound. In her research, Carola Suarez-Orozco, PhD, found that immigrant children who were separated from their mothers and/or fathers experienced higher levels of anxiety and depression than those who weren't, although the effects waned within five years of reunification (Journal of Adolescent Researchopens in new window, 2011).
Those who have not been reunited once in the United States, or who were without parents for a long time, "have issues of separation, issues of neglect, issues of attachment," says Jose Hidalgo, MD, a Boston psychiatrist who works with immigrant youth.
The high rates of victimization and exposure to trauma that unaccompanied refugee children experience, combined with limited access to mental health treatment services, is likely to put them at higher risk for a host of long-term consequences, such as PTSD, says Ernestine Briggs-King, PhD, who directs the Trauma Treatment and Research Program at the Center for Child and Family Health and is a professor at Duke University. Unaccompanied minors are likely to have "more of a complex presentation of PTSD symptoms," she says, including difficulty regulating emotions and behaviors, which may manifest as difficulty with rage, fear, shame, substance abuse and/or self-injury. They also may experience difficulty concentrating, learning problems, dissociation and low self-esteem.
Symptoms may vary with age, says Briggs-King. Young children may be clingy, fearful of new situations, frightened and difficult to console, while older kids may display problems with aggression and impulsivity. Many have difficulty sleeping. Gender also can play a role in how children react, researchers say. "More than likely, you will see boys who are more ‘closed,' and they will not share as much as girls," says Ivelisse Torres Fernandez, PhD, an assistant professor in the department of counseling and education at New Mexico State University.
Children may be disconnected from their feelings and may list somatic complaints. "They'll say things like, ‘When I think about it, it hurts in my heart or it hurts in my tummy, and I cannot sleep at night and I miss my mommy,'" Torres Fernandez says. Both boys and girls will have somatic complaints but in her experience, boys are also more reserved with these.
Alisa Miller, PhD, a research associate at the Refugee Trauma and Resilience Center at Boston Children's Hospital, notes that those who work with unaccompanied immigrant children describe them as "little men and little women" because they've had many adult responsibilities from a young age and they have the goals of adults — to work and support their families. To suddenly have to sit in a classroom and discuss the War of 1812 can seem irrelevant to them, given that they've had to deal with life-and-death situations or adult responsibilities, such as finding food and shelter for themselves and family members. Other educational challenges include the language barrier — most don't speak English — and being placed in classrooms based on age, rather than academic skill level, where they may be well behind. Some may also experience bullying, teasing and shaming over their lack of language fluency.
Public schools can, however, be a way for undocumented children to get social services, including mental health counseling, especially since they typically do not qualify for Medicaid and couldn't otherwise afford treatment. However, psychologists point out, school systems are not always prepared to deal with the influx of these children since they may be serving high-need populations already and have trouble just affording the basics of education, much less counseling services.
"That is the challenge," says Chavez-Dueñas. "The school is the perfect setting, but many children go to schools that are very poorly funded, where they may not have even one counselor or social worker who can advocate for their needs."
Treatment strategies
How are practicing psychologists helping? One key is building trust with these children. However, undocumented children often find it difficult to let their guard down, partly due to trauma and partly due to barriers of culture and language.
Torres Fernandez recently spoke with a Latina colleague who had counseled two El Salvadoran children at a school in Virginia. When her colleague met the children, they opened up — finally seeing a face that looked like theirs and encountering someone who knew their language.
"She said it was like an open wound — that the children were bleeding, telling her all this stuff," says Torres Fernandez.
Not only is it important for those working with immigrant children to know the language, or have an interpreter available, but "cultural brokers" are needed, too — people with an intimate understanding of both the child's culture and the culture of the community he or she is entering, says Miller.
For example, mental illness is stigmatized in many cultures, says Miller, including the Somali and Bhutanese cultures with which she works. Latina/o culture has a similar bias, says Torres Fernandez. So, she never uses the words "therapy" or "counseling" with children.
"I just tell them, ‘I'm going to come and visit you and we're going to play games,'" she says.
For the past eight years, Etiony Aldarondo, PhD, associate dean for research at the School of Education and Human Development at the University of Miami, has worked with the Immigrant Children's Legal and Service Partnership in Miami-Dade to promote the human rights and well-being of undocumented, unaccompanied children through legal, social, advocacy and mental health services. Aldarondo and his team of psychology graduate students and community partners help train and support staff at shelters that serve immigrant youth. They help shift typical shelter culture to be more communal, child-centered and evidence-based.
As part of this initiative, Aldarondo and his team developed the Immigrant Children Affirmative Network, or ICAN, which aims to help foster resiliency and hope in unaccompanied minors. Two innovative parts of ICAN are the youths' creation of a "book of life" to help them reclaim different aspects of their identity and the "Toma el Paso" board game, through which they learn about the legal system and the various obstacles and choices they will encounter as undocumented, unaccompanied children in the United States.
In Boston, Hidalgo developed a psychosocial group program called PATHS to Resilience that has been used with children in some detention facilities. Since unaccompanied minors may be hypervigilant and suspicious due to their exposure to different types of trauma, Hidalgo says it is important to help them develop trust and safe connections to others. His program helped to build this through collaborative, teamwork-building games among the children and between staff and children.
Psychologists are also helping these children through the National Child Traumatic Stress Networkopens in new window, established by Congress in 2000 and funded by the Center for Mental Health Services, part of the Substance Abuse and Mental Health Services Administration. The network is made up of institutions and mental health providers nationwide that work to raise the standard of care and improve access to services for traumatized children, their families and communities. The network offers training and education on childhood trauma, a wealth of resources and ways to get immediate help for children at onlineopens in new window or by calling the National Child Abuse Hotline at (800) 4-A-Child.
Future directions
With the large influx of unaccompanied minor children dropping from summertime peaks, media and public attention has moved on. But the humanitarian crisis is far from over, says Kennedy. Migrant rates could soar again next year, while children and adolescents who are already here — but not receiving needed psychological and other services — are at risk for dropping out of school, being unemployed and possibly winding up in prison.
So what's needed? Funding, for one, both for schools and school-based services as well as for direct immigrant services through the U.S. Department of Health and Human Services, say experts. Early last year, President Obama requested an additional $1.8 billion to help care for unaccompanied minors, but Congress did not pass the request.
More counselors trained in these children's special needs and cultures are also needed. The NLPA, under the leadership of Consoli, Chavez-Dueñas and Torres Fernandez, has developed guidelines for detention center workers and mental health professionals to better help unaccompanied minors, which will be published on the NLPA siteopens in new window. Some keys: making sure unaccompanied minors receive mental health screenings once in U.S. custody and having culturally responsive assessments. The guidelines include a variety of interventions and therapeutic approaches to use with these children, such as narrative therapy or allowing children to process their grief and loss through a memorial wall.
Consoli hopes that as the spotlight on the border kids has shifted, attention won't similarly pass without necessary measures being taken.
"Even though right now it's a really hot issue, it is a longstanding issue," he says. "We're hoping that it won't peak and pass — that it will get the actions that are needed."
Lorna Collier is a journalist in Chicago.
