Mental Health

Immigrants in the United States are a vastly growing, diverse group of both documented and undocumented individuals that consist of approximately 13.6% of the United States population.¹ Substantial numbers of foreign-born youth and their families have been displaced from their homes by political, economic, and environmental crises around the world.² Immigrant youths and their families face aggravated and unique health and mental health challenges, exacerbated by increasingly restrictive immigration policies in the United States.^3,4 These include, but are certainly not limited to the following:

• Repeated exposure to traumatic events such as natural disasters, community violence, persecution by governments, human trafficking, crime, neglect, deprivation, kidnapping, fear of deportation, discrimination/prejudice, and traumatic grief all compound the mental health of immigrants.^5,6,7,8
• Significant cultural, financial, legal, and linguistic barriers while trying to navigate the complex mental health system in the United States.^9,10
• Immigrant youth and their families are more likely to live at the poverty-level and are more vulnerable to physical, emotional, and behavioral health challenges.^11,12,13,14
• Prolonged detention can subsequently increase their risk of developing psychiatric illnesses such as post-traumatic stress disorder, anxiety, depression, and somatoform disorders.^15,16 Separation from their caregivers at the border can substantially elevate risk in immigrant youth for lifelong trauma and stress reactions, exacerbated by the abhorrent conditions under which they are held in detention at the border.^17,18,19

These are only a few of the distressing challenges that immigrant youth and their family face. To meet these pressing needs, we have collated a comprehensive set of mental health resources for providers hoping to assist their clients/patients to identify accessible and affordable services to help combat the mental health challenges that often accompany immigration-related stressors. In addition, below are a set of professional organization recommendations from the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Psychological Association (APA).

As summarized by the American Academy of Pediatrics, immigrant children are overall well adjusted. However, immigrant children, especially  unaccompanied minors and refugees, are at particular risk for traumatic exposure and should be screened for trauma during any medical or mental health assessment. As the youth departs from the country of origin, they may have lost significant support from extended family networks as well as connection to their cultural traditions. The changing social support structure and experiences of separation from caregivers should be considered during assessment. 

The influence of acculturation is also crucial in the clinical care setting and should be evaluated over three generations. First generation immigrants (parents and children born in the country of origin) may be reluctant to seek mental health services despite more recent trauma due to cultural expectations or perceived risk of deportation. On the contrary, the Second generation children (Americans born of immigrant parents) have been shown to use mental health services at a higher rate than those who immigrate as children. They often have more emotional and behavioral concerns associated with persistent poverty, societal prejudice, and intergenerational conflicts. Third generation immigrants (both parents and children born in the US) are considered native by many researchers, and found to experience the cumulative risk and chronic stressors common to life in poor and/or violent neighborhoods. The cumulative childhood adverse experiences is strongly associated with adult chronic illness and a shorter lifespan.

Lastly, it is important to take in consideration the family dynamic and resiliency. Family functioning mediates the effects of poverty on emotional and behavioral health for all children. Children are found to be better adjusted with resilient parents and interpersonal connectedness among family members . 

Risk factors to be considered:

• Pre-existing cognitive, emotional or physical disorders
• Children of isolated and  linguistically-challenged families
• Unaccompanied children and young immigrant adolescents 
• Disrupted family composition by death and parental mental illness
• Persistent poverty, housing and food insecurity
• Cultural prejudice and limited educational opportunities 

Protective factors that should be discussed and encouraged:

• High family cohesion
• Interpersonal support and communication
• Being part of an engaging community of fellow immigrants 
• Perceived acceptance in receiving communities
• Safety in schools
• Strong work ethics and aspirations

For more information, please refer to the Mental and Emotional Health section of the Immigrant Child Health Toolkit by the American Academy of Pediatrics.

As summarized by the American Academy of Pediatrics, immigrant children and their families face unique challenges in receiving mental health treatment. Families with mixed legal status may be fearful of referrals due to the risk of detection or deportation. Referral for mental health treatment carries a stigma in many communities and may conflict with cultural values. There may be a shortage of mental health providers with cross-cultural experience in many regions of the US, and few interpreters are trained in mental health care that include subtleties in communication and ethics. In addition, the payment for mental health care may be cost prohibitive for immigrant and uninsured families. 

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 are receptive to immigrant families.

For more information, please refer to the Mental and Emotional Health section of the Immigrant Child Health Toolkit by the American Academy of Pediatrics. 

As summarized by the American Academy of Pediatrics, 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. There are 4.5 million children who are US citizens living with one or more parents or guardians who are undocumented.  Another million children who live in mixed status families are themselves undocumented. As a result of the constant anxiety of detection and fear of deportation, up to 40% of children in mixed status families had not seen a doctor in the previous year. Living with this constant anxiety is associated with poor school performance and a rate of school drop-out higher than children in a more secure family status. 

In 2012, over 150,000 children were affected by deportation of one or more family members, with the majority of them 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.

There has been an increase in US citizen children in long-term foster care as a consequence of deportation. In 2001, it is estimated that 5,100 children are living in foster care 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.

For more information, please refer to the Mental and Emotional Health section of the Immigrant Child Health Toolkit by the American Academy of Pediatrics. 

Unaccompanied minors and asylum seekers are at particular risk for traumatic exposure and should be screened for trauma as recommended by the American Academy of Pediatrics. 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 important information for pediatricians to understand the legal process of applying for asylum.

For more information, please refer to the Mental and Emotional Health section of the Immigrant Child Health Toolkit by the American Academy of Pediatrics. 

As summarized by the American Academy of Pediatrics, 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. 

For more information, please refer to the Mental and Emotional Health section of the Immigrant Child Health Toolkit by the American Academy of Pediatrics. 

• The American Academy of Child and Adolescent Psychiatry (AACAP), a medical association dedicated to the health of children and families around the globe, strongly advocates for the provision of developmentally, culturally, and linguistically appropriate, trauma-informed services for children and families, including the availability of evidence-based, trauma-focused treatment for children who develop significant trauma responses. 
• The American Psychological Association, the national organization representing psychology, currently supports the efforts and public policies to increase the availability of and access to educational, health, mental health, and social services for immigrant children, youth, and families. Immigrants are at increased risk of psychological harm, especially when facing the threats of deportation and deportation-related family separation. (APA Official Resolution)  
• The American Psychiatric Association (APA), the national organization representing psychiatric physicians, currently opposes separation of children from parents at the border. It also recommends the Department of Homeland Security (DHS) hold detainment centers accountable to the maximum safety and compliance requirements. APA currently holds the following positions:

1. No child should be forcibly separated from their parents or caregivers as a consequence of immigration policies. For children who undergo forcible separation, trauma-informed, culturally, linguistically, developmentally and structurally competent qualified health professionals should be readily available to provide for their needs.
2. All children must have the right to live in a healthy environment free from violence and with access to evidence-based, trauma-informed, physical and mental health care services.
3. Effective partnerships between the APA and immigration agencies and affiliated relief and aid organizations should be developed to address gaps in providing trauma-informed, culturally, linguistically, developmentally and structurally competent care for these children.
4. Immigration agencies should collaborate with medical societies and with key stakeholders to address gaps in providing trauma-informed, culturally, linguistically, developmentally and structurally competent care for these children and their parents or caregivers.
5. Resources should be developed to promote best practices in prevention and early intervention for immigrant children and adolescents by making relevant screening instruments and other resources publicly available.

(APA Official Actions)

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19. Baum, J. , Jones, R. , & Barry, C. ( 2010). In the child’s best interest? The consequences of losing a lawful immigrant parent to deportation. Berkeley, CA: University of California, Berkeley, School of Law & University of California, Davis, School of Law. Retrieved from https://www.law.berkeley.edu/files/Human_Rights_report.pdf