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Mental and Emotional Health

Mental, Emotional and Behavioral Care


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What considerations should be included in a mental health assessment of immigrant children?

What risk and protective factors should be included in the mental health assessment?

What mental health screening instruments are available for use with children of immigrants?

How can I help children link to mental health treatment?

What are some proven intervention and treatment strategies for children with PTSD and other mental, emotional and behavioral health problems?

What are some high-risk circumstances that may require special attention?



What considerations should be included in a mental health assessment of immigrant children?
Overall, immigrant children are well adjusted and should be treated as all children in the pediatric medical home.  However, the experiences of immigrant children may interfere with critical stages of intellectual, social, emotional and physical development.
 
This section of the toolkit addresses mental health considerations for immigrant children and pediatric assessments for children who may need mental health services. Disruption to families, education, and witnessed traumatic events compound developmental concerns. Assessment of mental health among children in immigrant and refugee families involves several key elements:
  • Screening for trauma
  • The influence of acculturation
  • Consideration of changing social support structure
  • Resilience

Screening for trauma: Immigrants and refugees to the United States may come from regions characterized by violence and extreme poverty, such as Central America, the Caribbean and some Asian and African countries, placing them at high risk for emotional and behavioral health problems. Immigrant children may experience trauma in their country of origin, en route to the United States, upon arrival, or while living the community. Unaccompanied minors and refugees are at particular risk for traumatic exposure.

The influence of acculturation:

The influence of acculturation should be evaluated over three generations:

  • First generation immigrants (parents and children born in the country of origin) may experience more recent trauma but may be reluctant to seek mental health of services because of cultural expectations or, in the case of mixed status or undocumented families, because of the perceived risk of deportation.
  • Second generation children (Americans born of immigrant parents), especially those in families with mixed legal status, often have more emotional and behavioral problems associated with persistent poverty, perceived lack of opportunity, intergenerational conflicts and explicit societal prejudice.  These immigrants have been shown to use mental health services at a higher rate than those who immigrate as children.
  • Third generation immigrants (both parents and children born in the US) experience the cumulative risk and chronic stressors common to life in poor, violent neighborhoods and, by many researchers, are considered native.  Evidence strongly associates cumulative childhood adverse experiences with adult chronic illness and a shorter lifespan.

Consideration of changing social support structure:  At the time of departure from the country of origin, children often lose the direct support of extended family networks, familiar cultural expectations and important intimate relationships such as with extended family members.  During the migration, they may experience separation from caregivers.
 
Resilience: As with all children, family functioning mediates the effects of poverty on emotional and behavioral health.  If families are healthy, characterized by resilient parents and good interpersonal connectedness, children are better adjusted and have fewer difficulties with anxiety, depression and aggression. Biculturalism (and bilingualism) appears to be the most adaptive response retaining important elements for the culture of origin but adopting many values from the new culture.

Learn more:

Abe-Kim, J., Takeuchi, D., Hong, S., et al.  Use of Mental Health-Related Services among Immigrant and US-Born Asian Americans:  Results from the National Latino and Asian American Study.  Am J Public Health. 2007;97:91-98.

Beiser et al. Poverty, Family Process, and the Mental Health of Immigrant Children in Canada.  Am J Public Health. 2002;92:220–227

Fazel, M. and Stein, A. The mental health of refugee children. Arch Dis Child 2002;87:366–370
 
Lustig et al. Review of Child and Adolescent Refugee Mental Health. J. Am. Acad. Child Adolesc. Psychiatry, 2004;43(1):24–36.

Perreira, K. and Ornelas, I. 2011. The Physical and Psychological Well-being of Immigrant Children. The Future of Children. 2011: 21(1) pp.195-218 http://www.princeton.edu/futureofchildren/publications/docs/21_01_09.pdf Pumariega A, Rothe, E and Pumariega J. Mental Health of Immigrants and Refugees . Community Mental Health Journal. 2005;41(5): 581-597

Refugee Resettlement: Chapter 3.3 Investing the Future: Refugee Children and Young People. www.unhcr.org.

Child Trends Data Bank  http://www.childtrends.org/?indicators=immigrant-children#sthash.2MRsiehi.dpuf


What risk and protective factors should be included in the mental health assessment?
A variety of risk factors place immigrant children at risk for emotion, behavioral or relational problems:
  • Children of isolated, linguistically-challenged and depressed families are at high risk for emotional and behavioral problems.
  • Pre-existing cognitive, emotional or physical disorder increases the likelihood of maladaptation.
  • High intelligence and education level does not protect children from post-traumatic disorders.
  • Unaccompanied children and young immigrant adolescents are at high risk for emotional distress and enduring relational difficulties.
  • Disrupted family composition by death or other loss increases risk as do single parent families and parental mental illness.
  • Persistent poverty, particularly associated with housing and food insecurity, are significant cumulative risk factors and many migrant families settle in poor neighborhoods with limited support services.
  • Living in ethnic enclaves isolated from mainstream society may be detrimental for the second and third generation immigrants by slowing acculturation and by provoking intergenerational conflict.
  • Perceived cultural prejudice and either overt or implicit prejudice are all associated with increased risk of poor acculturation and individual symptoms of stress.

Protective factors should be encouraged and discussed by pediatricians with immigrant families:

  • High family cohesion, two-parent families, interpersonal support and communication, in addition to strong work ethics and aspirations are all strongly protective.
  • Being part of an engaging community of fellow immigrants from the same country of origin on arrival also leads to better mental health outcomes.
  • For foster children, a same ethnic origin foster parent may be protective.
  • Perceived acceptance in receiving communities, safety in schools and strong neighborhood connections are protective, buffering many of these children from the negative influences of mainstream society.

Resources for practices:

National Child Traumatic Stress Network: Addressing the Mental Health Problems of Border and Immigrant Youth

American Psychological Association

Chadwick Center: Adaptation Guidelines for Serving Latino Children and Families Affected by Trauma

Learn more:

Fazel et al. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet 2012; 379: 266–82

Griffin, M., Son, M. and Shapleigh, E. Children's Lives on the Border. Pediatrics 2014;133;e1118

Shields, Margie K. Shields, Richard E. Behrman (2002) “Children of Immigrant Families: Analysis and Recommendations”, The Future of Children , Vol. 14, No. 2, Children of Immigrant Families (Summer, 2004), pp. 4-15.


What mental health screening instruments are available for use with children of immigrants?
Many mental health and developmental screening instruments that are normed to the general culture are useful for children in immigrant families with some caveats.  Although some instruments have been translated into Spanish, others are only available in English. It is important that the historian has the literacy level to answer the questions (if the instrument is written) and that a skilled medical interpreter is provided when needed. For a list of instruments, please refer to the Table 1.
Anxiety/ PTSD
Trauma Symptom Checklist for Children and Trauma Symptom Checklist for Young Children (TSCC and TSCYC)

Child PTSD Symptom Scale (CPSS)

Univ. of California at Los Angeles Posttraumatic Stress Disorder Reaction Index  (UCLA-PTSDRI)
Depression
Patient health questionnaire (PHQ-9)
ADHD
Vanderbilt ADHD forms
Relational, emotional and behavioral development in pre-school children
Strengths and Difficulties Questionnaire (SDQ) in many languages

Ages & Stages Questionnaires®: Social Emotional (ASQ:SE) in Spanish
Relational, emotional and behavioral development in school-aged children
Pediatric Symptom Checklist in many languages
Autistic Spectrum Disorders
M-Chat available in many languages
Maternal Depression
The Patient Health Questionnaire-2 (PHQ-2)

Maternal depression screening implementation guide
Intimate partner/family violence
https://www.acog.org/About_ACOG/ACOG_Departments/Violence_Against_Women/Es_Usted_Victima_de_Maltratos

HITS screen in English, Spanish and Creole
Social determinants of health
WE CARE Project
Refugee health
Refugee Health Screener
Table 1: Mental Health and Developmental Screening Instruments and Resources


How can I help children link to mental health treatment?
Linking immigrant children to treatment and facilitating retention in quality mental health care are fraught with obstacles.
  • Families with mixed legal status are fearful of referrals because of the risk of detection or deportation.
  • The referral to a mental health therapist often carries a stigma and may conflict with cultural values that disparage or deny the possibility that children may have emotional or mental problems.
  • In many regions of the US, there may be a shortage of therapists with language and cultural concordance or cross-cultural experience.
  • Few interpreters are trained in mental health care that include subtleties in communication and ethics.
  • Funding for mental health care in most communities is limited and uninsured families find the payments prohibitive.

Developing a multi-disciplinary medical home that provides community-based care coordination can help immigrant families engage in treatment.  Nurses or social workers may perform the full spectrum of activities related to care coordination including maintenance of a centralized medical record.  Often lay members of the immigrant community who are trained as community health workers (e.g. promotores de salud) are able to identify children in need, link them to services and improve engagement in treatment. Enhanced medical homes that include co-located mental health providers can be extremely helpful in reducing barriers to access such as transportation, limited hours of operation and stigma.  If co-location or an integrated model is not practical, primary care pediatricians may develop agreements for facilitated referrals to therapists and psychiatrists in the community who they know will be receptive to immigrant families.

Resources for practices:

American Academy of Child and Adolescent Psychiatry. Facts for Families: Finding Mental Healthcare for Children of Immigrants

Introduction to Community Health Workers/Promotores de Salud

Outreach- direct, one-to-one assistance from persons with similar experiences

Rural Assistance Center Community Health Worker toolkit


What are some proven intervention and treatment strategies for children with PTSD and other mental, emotional and behavioral health problems?
Community pediatricians may be called upon to evaluate and recommend treatment strategies that have proven outcomes.  Many evidence-based treatments are effective for children from various cultural backgrounds without significant adaption except for language. These include:
  • Cognitive-behavioral therapy (CBT) for anxiety and child focused play therapy are examples of therapies that are effective without modification.
  • Functional Family Therapy (FFT) and Multi-Systemic Therapy (MST) for families with adolescents with substance abuse or conduct disturbance have been effect across cultures.
  • Incredible Years and Parent-Child Interaction Therapy have similar outcomes in culturally modified and unmodified forms.

Some treatment strategies have been developed or modified specifically for particular immigrant populations.  These adaptations are often school based in order to increase identification and retention of children who otherwise would be difficult to reach because of lack of health coverage, parental perceptions and unrecognized need for care.

  • Cognitive Behavioral Intervention for Trauma in Schools (CBITS) utilizes bilingual therapy sessions, trauma narratives that use music settings familiar to the children and group treatment that may include faith tradition activities such as forgiveness rituals to improve social problem solving.
  • Group TF-CBT (trauma focused cognitive behavioral therapy) and Functional Family Therapy have both been modified with reliably successful outcomes with Hispanic children.

Learn More:

Kataoka et al. A School-Based Mental Health Program for Traumatized Latino Immigrant Children. J. Am. Acad. Child Adolesc. Psychiatry. 2003, 42(3):311–31
 
Malgady, R.  Treating Hispanic Children and Adolescents Using Narrative Therapy.  In:  Evidence-Based Psychotherapies for Children and Adolescents. 2012 The Guilford Press. New York

McCabe, Kristen and Yeh, May(2009) 'Parent-Child Interaction Therapy for Mexican Americans: A Randomized Clinical Trial', Journal of Clinical Child & Adolescent Psychology. 38: 5, 753 — 759
 
McLaughlin  et al. Trauma Exposure and Posttraumatic Stress Disorder in a National Sample of Adolescents. J. Am. Acad. Child Adolesc. Psychiatry. 2013;52(8):815–830.
 
National Child Trauma Stress Network

Ngo et al. Providing Evidence-Based Practice to Ethnically Diverse Youths: Examples From the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Program. J. Am. Acad. Child Adolesc. Psychiatry. 2008,47(8):858-862
 
Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder. J. Am. Acad. Child Adolesc. Psychiatry. 2010;49(4):414–430.
 
Robbins, M., Horigan, V., Szapocznik, J. and Ucha, J.  Treating Hispanic Youths Using Brief Stategic Family Therapy.  In: Evidence-Based Psychotherapies for Children and Adolescents. 2012 The Guilford Press. New York


What are some high-risk circumstances that may require special attention?
Children living in mixed legal status (at least one undocumented parent), in families affected by deportation and in foster care require special attention during the assessment.

Children living in mixed status families
 
An analysis by The Pew Research Center based on 2009 data estimates that there are 4.5 million children who are US citizens and who are living with one or more parents or guardians who are undocumented.  Another million children who live in mixed status families are themselves undocumented. These families often live in constant anxiety of detection and fear of deportation so consequently use medical and mental health services at a low rate.  In one survey, 40% of children in mixed status families had not seen a doctor in the previous year. Living with constant anxiety about their parents’ future as well as their own is associated with poor school performance and a rate of school drop-out higher than children in a more secure family status.

During the years 2008 through 2012, there was an increase in deportations and, in 2012, over 150,000 children were affected.  The majority of these children were under 10 years of age.  In addition to the trauma to the child of losing a parent, deportation results in an increased risk of poverty, food and housing insecurity as well as depression and social isolation in the remaining members of the household.

Learn More:

Enchautegui, Maria. Broken Immigration Policy: Broken Families.  The Urban Institute 2013 available from

Henderson S and Baily C. Parental Deportation, Families, and Mental Health. J. Am. Acad. Child Adolesc. Psychiatry. 2013;52(5):451-453

Human Impact Partners. June 2013. Family Unity, Family Health: How Family-Focused Immigration Reform Will Mean Better Health for Children and Families. Oakland, CA.

Pew Research Hispanic Trends Project

Immigrant children in foster care
 
One particularly toxic effect of deportation is an increase in US citizen children in long-term foster care.  It is estimated that 5,100 children are living in foster care (2011) due to deportation of a parent.  The current immigration enforcement systems are significant barriers to reunification. The children left by deported parents are often denied placement with extended family members because of issues related to documentation.  The effects of abrupt and total separation from parents and family may have profound effects on the child’s emotional development which may be expressed by withdrawal, anxiety, depression or oppositional defiance.

Resource for practices:
Helping Foster and Adoptive Families Cope with Trauma

Learn More:
Applied Research Center. (2011) Shattered Families: The Perilous Intersection of Immigration Enforcement and the Child Welfare System. Available from: https://www.raceforward.org/research/reports/shattered-families

Unaccompanied Minors and Asylum Seekers

In 2014, a humanitarian crisis involving children occurred at the southern border of the United States.  The Customs and Border Protection (CBP) apprehended over 50,000 children and youth from three Central American countries (Guatemala, Honduras and El Salvador) who arrived without a guardian.  A study by the United Nations High Commissioner on Refugees (UHNCR) found that over half of the unaccompanied minors “were forcibly displaced because they suffered or faced harms that indicated a potential or actual need for international protection.”  The displaced children were often exposed to or threatened by gang violence, abuse in the home or drug cartel related activities.  An additional 15,000 children and youth were Mexican nationals, one-third of whom, according to the UNHCR, had been recruited into human trafficking.  Many children suffered assault, theft and rape as they made their way to the US border.  In addition to the tremendous need for trauma informed mental health care, some children and youth may qualify for asylum status.  Being able to remain in the US, as a refugee would make available appropriate treatment.  The website for Physicians for Human Rights (PHR) contains much important information helpful for pediatricians to understand the legal process of applying for asylum.

Resources for practices:
Physicians for Human Rights training resources

American Bar Association Immigrant Children Assistance Project

Learn More:
Byrne, O. and Miller, E. 2012. The Flow of Unaccompanied Children through the Immigration System: A Resource for Practitioners, Policy Makers and Researchers. New York: Vera Institute of Justice.
http://www.vera.org/sites/default/files/resources/downloads/the-flow-of-unaccompanied-children-through-the-immigration-system.pdf

Southwest Border Unaccompanied Alien Children. U.S. Customs and Border Protection. Department of Homeland Security. http://www.cbp.gov/newsroom/stats/southwest-border-unaccompanied-children

Children on the Run: Unaccompanied Children Leaving Central America and Mexico and the Need for International Protection. A Study Conducted by the United Nations High Commissioner for Refugees Regional Office for the United States and the Caribbean. Washington, D.C. (2014)
http://www.unhcrwashington.org/sites/default/files/1_UAC_Children%20on%20the%20Run_Full%20Report.pdf

Immigrant youth who identify as Lesbian, Gay, Bisexual or Transsexual

Immigrant youth may face additional cultural challenges and discrimination because of sexual orientation or gender identity.  The need for socio-emotional support or mental health treatment may be especially acute if the young person left their country of origin after persecution because of sexual orientation and, upon arrival, experiences isolation, alienation and exploitation at the margins of society in the United States.

Resources for practices:
AAP Committee on Adolescence Technical Report

Immigrant Legal Resource Center
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