Child Immigration: Mental health issues

~ by Amy Cohen, MD, child psychiatrist

“CRISTIAN OMAR REYES, an 11-year-old sixth grader in the neighborhood of Nueva Suyapa, on the outskirts of Tegucigalpa, tells me he has to get out of Honduras soon — “no matter what.”

In March, his father was robbed and murdered by gangs while working as a security guard protecting a pastry truck. His mother used the life insurance payout to hire a smuggler to take her to Florida. She promised to send for him quickly, but she has not.

Three people he knows were murdered this year. Four others were gunned down on a nearby corner in the span of two weeks at the beginning of this year. A girl his age resisted being robbed of $5. She was clubbed over the head and dragged off by two men who cut a hole in her throat, stuffed her panties in it, and left her body in a ravine across the street from Cristian’s house.

“I’m going this year,” he tells me.

- from “The Children of the Drug Wars” by Sonia Nazario   The New York Times 7/11/14

 

Who are the children and why have they come?

As has been widely reported, the past three years have witnessed an explosion – a “surge” – in the number of unaccompanied minors fleeing, particularly, countries of the “Northern Triangle” of Central America: Honduras, Guatemala and El Salvador and, to a lesser extent, Mexico. Many of these children have landed in the United States. Prior to 2012, children arrived unaccompanied in the US at a steady pace of about 6,800 per year. In 2012, this number jumped to 13,000. In 2013 more than 24,000 arrived and this year the number is expected to be near 70,000.

This “surge” has also brought a demographic shift – more young children (as young as 3) and more female children, some of them pregnant as a result of rape either in their home countries or on their journey to safety.

These children arrived into a heated debate over illegal immigration. But are they illegal immigrants or refugees? What is our country’s obligation to them? Some facts may be helpful:

• More than half of these minors would qualify for sanctuary asylum as refugees and would be in this country legally if properly adjudicated
• The United Nations High Commission for Refugees (UNHCR) defines refugees as those “in need of international protection”: people fleeing from:
  •  pervasive and extreme violence
  • Imminent risk to life
• A state system unable to provide protection to its citizens

A UNHCR study concluded over half of the unaccompanied minors qualify for asylum. Here are the reasons the children are fleeing:

• A coordinated American-Columbian effort to disrupt the flow of drugs through the Caribbean (thus shifting the route to the Northern Triangle of Central America) combined with the deportation of many gang members from the U.S. back to Central America.

• Honduras is statistically the most-violent country in the world. The three countries of the Northern Triangle (from which nearly all of these children travel) comprise three of the five most violent countries on earth.

• Over half of the children witnessed the murders of young peers and family members and themselves having faced rape, violence and continuous threats on their lives and those of their families if they refuse to join gangs and drug cartels.

Drugs cartels, gangs, violence in schools, school bombings, home situations that might include dead or missing family members; there is much to fear. Much like the “lost boys” of what is now South Sudan they are driven to flee with the hope of safety, sometimes deciding on their own, sometimes encouraged by peers or sent away by terrified parents. Some have already been victims of the dangers and violence of the journey itself, and some have been turned back, only to risk their lives again to flee the nightmare of their home cities and villages.

US Arrival of Child Immigrants

Once apprehended at the border, children arriving from Central America undergo a dizzying series of moves from one detention center to another as they come under the jurisdiction of a progression of agencies of the Department of Homeland Security. The priority is to place them within 45 days with someone who can serve as a sponsor.

Some are sent to more institutional settings. Others land with those claiming to be relatives, foster parents with other children who may or may not speak Spanish, smaller group homes with a diverse population of children who may regard them with suspicion or hostility.   Some may be placed with other children like themselves while others may be more isolated from anyone who understands the terrible things they endured. Shame and fear make it likely that they will keep their stories to themselves, increasing their experience of isolation.

Public Health Implications

These refugee children are victims of psychological trauma, and many suffer from Post Traumatic Stress Disorder. Their consequent symptoms impact not only the children themselves, but also the broader systems with which these children intersect: border patrols, temporary and longer term facilities, caregivers, peers, schools, communities. The need for public education, community and family supports, and professional preparedness is enormous.

Symptoms of PTSD

The DSM V updated the diagnosis of PTSD. Full descriptive criteria can be found here:

PTSD requires exposure to a traumatic event (direct or indirect) and at least one symptom from each of the four symptom clusters:

• Intrusion symptoms
•  Avoidance
•  Negative alterations in cognition and mood
•  Alterations in arousal and reactivity

In addition, symptoms must have persisted for at least one month and must have “functional significance”, either impacting negatively on daily function or creating significant symptom-related distress. In addition, two specifiers further define the disorder as “delayed” (onset in excess of six months) and “with or without dissociative symptoms” (depersonalization or derealization).

All children defined as qualifying for refugee status will meet the criteria of exposure to a traumatic event. PTSD symptoms differ depending on the resiliency of the child and type of exposure to trauma. A child who is constitutionally more vulnerable will require less exposure and manifest more symptoms.

Specific symptoms for any given child include the following:

INTRUSION SYMPTOMS:

• Recurrent, involuntary and intrusive memories (sometimes expressed through play)
• Traumatic nightmares and other sleep disturbances
• Flashbacks and other dissociative reactions
• Intense or protracted distress after exposure to traumatic reminders
• Marked physiologic reactivity (e.g. rapid pulse and breathing, vomiting or diarrhea) following exposure to trauma-related stimuli

AVOIDANCE SYMPTOMS:

• Trauma-related thoughts or feelings
• Trauma-related external reminders (e.g. events or people who may trigger thoughts or feelings)

NEGATIVE CHANGES IN COGNITION AND MOOD:

• Inability to recall key features of traumatic event
• Persistent negative beliefs about oneself or the world
• Distorted blaming of oneself or others for having caused the event
• Persistent trauma-related negative emotions (e.g. fear, anger, guilt)
• diminished interest in activities previously significant activities
• detachment or estrangement from others
• persistent inability to experience positive emotions

ALTERATIONS IN AROUSAL AND REACTIVITY:

• Irritable or aggressive behavior
• Self-destructive or reckless behavior
• Hypervigilance
• Exaggerated startle response
• Concentration problems
• sleep disturbances

It is not unusual for PTSD symptoms to be delayed by weeks or even months before nightmares begin to establish themselves. These are child “survivors” who – by dint of making it successfully on their own to the US – have demonstrated a capacity for determination and fortitude. Once immediate danger has passed, and fortitude is no longer required, symptoms are likely to emerge. So all caregivers should be alert to the possible evolution of symptoms and ready to step in and shift strategies as needed.

Families, school systems and communities may all be profoundly challenged by these refugee children – their emotional, interpersonal and behavioral issues. Education and support are key to offering schools and communities a clear perspective on what they may expect, and what resources to access when problems do come to pass.

Interventions

A public health response in this population must include coordinated services between mental health professionals, physicians, schools and the community. To facilitate the transition of these children into healthy and productive lives, they must be “held” by a “net” of responsible adults who are knowledgeable about PTSD, and able to communicate with each other to initiate or revise treatment as needed.

Mental health professionals should be at the center of care for these children. They should be trained and experienced in trauma and trauma-directed therapies.   Functions should include:

•  Coordination of all mental health services
• Thorough and careful, trauma-based evaluation of each child
• The development of an initial treatment plan, including:
  • further psychological testing if necessary
  • group and individual psychotherapy (trauma-based CBT should be included)
  • medication evaluation
  • family therapy where indicated
• Regular follow-up to assess progress and evaluate for the emergence of new symptoms
• Education of and ongoing consultation to parents or parent surrogates, schools and community organizations to assist them in better understanding PTSD Collaboration with pediatricians and family physician.

These children may speak little English and are likely to have difficulty sharing their stories and symptoms with strangers. Ideally, therapists should be Spanish speaking. Group therapy with other children with similar histories will help them feel connected and respond to treatment better. When possible, regional centers should be established to bring these children together for treatment and support.

I once worked with parents who had two biological children but had decided to pursue a domestic adoption. They’d been persuaded to take in two sisters but had never been told that these girls had witnessed terrible domestic violence that had ended in murder. When the girls began to act out in destructive ways, the family was mystified and unprepared. Ultimately, they chose to place them in a distant group setting in order to save their family, but not before havoc had reigned, and intensive family treatment was required to repair the damage to the parents and their other children. Honest information and appropriate resources could have spared this family terrible confusion, distress and guilt and might have enabled them to keep and raise their girls. It would have spared their biological children their own trauma and their adopted children additional isolation and rejection.

As is illustrated by this story, it is not only the children who require help in dealing with the aftermath of terrible trauma, but also the caregivers. They need education on the symptoms of PTSD, as well advocacy training on behalf of the children in their communities, schools and with health care workers. These can be very challenging children to raise and caregivers deserve to be prepared for the required commitment of time and effort.

Schools are often places where these children become symptomatic. Educators need help in recognizing the warning signals of a struggling child. They should have support in strategies for dealing with problems within the school setting, as well as resources for outside referral.

As examples, children may exhibit the following:

• Frank learning problems due to issues with focus and concentration
• Extremes of aggressiveness or timidity with adults and peers
• Chronic fearfulness with overt phobias, clinging to adults, difficulty with transitions, need for constant reassurance, misinterpretation of the actions or words of others
• Overt mood disorders, with depressive or even hypomanic or manic symptoms
• Bizarre behavior that could be the consequence of flashbacks or dissociative episodes
• Difficulty following rules or directions
• A tendency to isolate or gravitate only to those with similar histories

They may demonstrate significant peer problems as they struggle with their new social environment and may misinterpret or respond poorly to social cues. This may result in more social isolation, scapegoating and fights in and outside of the classroom.

Mental health professionals should be available to schools to:

• Educate teachers and administrators about PTSD
• Be available for regular meetings with teachers and administrators to monitor progress
• Develop specific treatment plans for children requiring them within school setting
• Offer emergency consultations when necessary

Communities require education in understanding the histories of these children, the rationale for their need for asylum and the ways in which the community might support them. First responders, such as the police and fire departments may benefit from their own educational sessions and the availability of mental health providers to answer their questions. Local emergency rooms should have numbers to call should these children present with emotional or behavioral issues.

 

Conclusion

Americans are, for the most part, unaccustomed to seeing child victims of the ravages of war. Efforts to address this new surge of children must occur on many fronts. International efforts must certainly focus on the conditions in the nations of the Northern Triangle that have led to this mass exodus and which – if rectified – could allow these children to go home.

The statistics suggest that at least 35,000 children will qualify for asylum if properly processed through our borders. While this is unfamiliar and distressing to many Americans, it may be useful to place this in some perspective. As one example, countries bordering Syria have taken in nearly three million people, with Jordan alone accepting in two days what the United States has received in a month during the apex of this surge. We would be railing at Asian or African or European countries that heartlessly expelled lone children escaped from war zones, and we should expect no less of ourselves.

The question of how to properly identify and logistically manage the burden of our child refugees represents a significant challenge, some of which falls upon our mental health system. While we await a longer-term solution to the issues plaguing Central America, we must do our best to support these children and the communities that have reached out to host them.

Bio:

Dr. Amy Cohen is a child, adolescent adult and family psychiatrist currently working with high risk, inner city youth in the Bay Area of San Francisco. Her interest in the effects of trauma on children date back to the 1970s when she was an active member of the domestic violence group at Boston Children’s Hospital. She traveled to South Sudan to address the trauma needs of children newly released from slavery in the north following their protracted exposure to violence and torture. Dr. Cohen obtained her medical degree from the University of Pennsylvania. She received her postgraduate adult and child training at The Cambridge Hospital and McLean Hospital, respectively – both within the Harvard system. She has applied her clinical, administrative, program development and teaching skills to both inpatient and outpatient settings over her 25 years of practice.

SOURCES

1.  UNHCR report: “Children on the Run” http://www.unhcrwashington.org/children/reports
2. “The Surge of Unaccompanied Children from Central America http://www.americanprogress.org/issues/immigration/report/2014/07/24/94396/the-surge-of-unaccompanied-children-from-central-america-root-causes-and-policy-solutions/
3. Step-by Step Guide on Apprehension and Detention of Juveniles in the United States http://www.womensrefugeecommission.org/resources/document/1035-step-by-step-guide-on-apprehension-and-detention-of-juveniles-in-the-united-states
4. “Not in my backyard: Communities protest surge of immigrant kids” http://www.cnn.com/2014/07/15/politics/immigration-not-in-my-backyard/
5.  “The Children of the Drug Wars” http://www.nytimes.com/2014/07/13/opinion/sunday/a-refugee-crisis-not-an-immigration-crisis.html?_r=0
6.  Unaccompanied Children http://www.womensrefugeecommission.org/programs/migrant-rights/unaccompanied-children