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Immigration and Latin American child refugees through the lens of trauma Underexplored Territories in Trauma Education: Charting Frontiers for Clinicians and Researchers Yvette Maria Güereca, MA & Elana Newman, PhD University of Tulsa December 10th, 2014 Learning Objectives Express three facts about Latin American child refugees and/or immigrants Describe typical trauma-related issues for Latin American child refugees/immigrants Specify three ways to adapt treatment for this specific population Introduction and Relevance Immigrant children given many labels (i.e., unaccompanied minors, refugee, asylum-seeking, separated, trafficked, forced) Recent influx of immigrant children from Latin American countries presents a need which clinicians should be prepared to address Immigrant children are one of the most vulnerable groups in need of adequate services Backus, 2014; Boothby, 1994; Kaplan, 2009; Levinson, 2011; National Child Traumatic Stress Network, 2012; Tobia, 2014 Increase in Immigration Violence is main cause for the increase Immigration Policy Center, 2014; Krogstad, et al., 2014; Pew Research Center, 2014; Tobia, 2014; Wong, 2014 Immigrant Children Immigration affects children: Left behind by one or both parents who migrate Accompany their migrating parents Migrate alone (independently of parents and adult guardians) Undocumented and unaccompanied minors are potentially at greater risk for harmful situations, traumatic stress, and PTSD Kraut, 1994; McLeigh, 2013 Unaccompanied Minors Unaccompanied minors “Are defined in statute as children who lack lawful immigration status in the United States, are under the age of 18, and are without a parent or legal guardian in the United States or no parent or legal guardian in the United States is available to provide care and physical custody.” - U.S. Citizenship and Immigration Services (USCIS) U.S. Department of Homeland Security, USCIS Questions and Answers, 2013 Unaccompanied Minors The Journey: On La Bestia Approximately 1500 miles Tulsa, OK Boston, MA = 1583 miles Travel for a week to several months Amnesty International, 2010; Immigration Policy Center, 2014; Migration Policy Institute, 2014 The Journey: On La Bestia The Journey: Fort Sill, OK Approximately 1800 children passed through the state Reunited with family Permanent shelters Removal proceedings 241 unaccompanied minors still living with sponsors in OK Removal proceedings for many < 1/3 have attorneys 90% deported Local groups provide aid TU’s Immigrant Rights Project Catholic Charities Putnam, 2014 Immigrant Children and Trauma 1004 recent immigrant schoolchildren; 8-15 years old 16%: Depression symptoms 32%: PTSD symptoms High levels of violence exposure (personal victimization & witnessing violence) in previous year and lifetime Boys and older children more likely to have experienced violence Girls higher prevalence of PTSD and depression PTSD symptoms were predicted by both recent and lifetime violence exposure, even when depressive symptoms and gender were controlled However, not specific to Latin American populations and languages Jaycox, et al., 2002 Refugee Children and Trauma Refugee children display a high prevalence of PTSD symptoms: Rates between 50-90% Wide range of traumatic events: 20% war exposure 14% forced displacement Also display symptoms of: Anxiety Depression Nightmares Insomnia Behavior problems Academic difficulty Somatic problems How does this relate to Latin American immigrant children? Boothby, 1994 ; Lustig et al., 2004 Latino Children and Trauma Latino/Hispanic Children prevalence rates: Complex trauma, 72% Exposure to domestic violence, 53% Impaired caregiver, 47% Emotional abuse, 42% Traumatic loss, 42% Physical abuse, 33% Sexual abuse, 29% Neglect, 27% Community violence, 22% When compared to White/Caucasian controls: Higher Domestic violence, impaired caregiver, community violence 3 Times Higher Community violence Taken together, findings for trauma symptomology in Latin American immigrant children are unclear Lustig et al., 2004 ; National Child Traumatic Stress Network, 2012 Trauma Conceptualization: The Refugee Experience Trauma Exposure Disruption to schooling Exposure to violence Traumatic loss Preflight Individual factors Displacement Migration & Loss Acculturation Camps/ detention Separation from caregivers Flight Family functioning and presence of caregivers RISK FACTORS Access to education Economic insecurity Resettlement Availability of appropriate services (formal and informal) Community acceptance PROTECTIVE FACTORS Adapted from: Betancourt & Frounfelker, 2013; Boothby, 1994; Kaplan, 2009; National Child Traumatic Stress Network, 2013 Assessment and Treatment Considerations Provider Barriers Knowledge about Immigration Language Cultural Competency and Awareness How and/or why child came here Fluency in child’s language Child’s conceptualization of mental illness Child’s current state of distress and needs Applicability of assessments Understanding child’s culture Betancourt, 2013; Gosh Ippen, 2011; National Child Traumatic Stress Network, 2012; Refugee Health, 2011 Addressing Barriers Knowledge about Immigration Language Cultural Competency and Awareness Self-education and community involvement Interpreters and cultural brokers Cultural brokers and ongoing self-education Implications of immigration policy Regular communication and teamwork Diversity-informed approach Betancourt, 2013; Gosh Ippen, 2012; Hodes, 2002; National Child Traumatic Stress Network, 2012; Refugee Health, 2011 Assessment Reassure the child he or she is not in trouble! Consider child’s linguistic skills Consider child’s developmental level Build rapport with the child: Describe your role as a helper Explain what mental health treatment is about Explain purpose of the assessment process Discuss the rationale for confidentiality and what it is Let the child know they are in control – can stop the interview at any time Emphasize that assessment process can be spread out over multiple sessions Betancourt, 2013; National Child Traumatic Stress Network, 2013; Hodes, 2002 Assessment Spanish versions: Diagnostic Interview for Children and Adolescents–Acute Stress Disorder Child PTSD Symptom Scale (CPSS) UCLA Posttraumatic Stress Disorder Reaction Index for DSMIV* More research is needed Ideal to use comprehensive, individualized, and culturallyinformed trauma assessment Family history Acculturation Risk and resiliency factors Ongoing exposure to trauma Culturally-specific trauma symptoms (e.g., somatic complaints) Betancourt, 2013; de Arrellano, 2006; Friedman, Keane, & Resick, 2014; Hodes, 2002; Kassam‐Adams, 2013; Steinberg, 2013; National Child Traumatic Stress Network, 2013 Treatment Best to employ individualized and comprehensive treatment plan Trauma-Informed Cognitive Behavioral Interventions Ongoing psychoeducation Family-focused Community and group school-based Primary health care provider Settings reduce stigma and increase access to care Emphasize the utility of informal services in the community Psychopharmaceutical interventions have not been thoroughly evaluated in these groups Birman, et al., 2005; Briere & Scott, 2013; de Girolamo, 1994; Friedman, Keane, & Resick, 2014; Ghosh Ippen, 2012; Kinzie, et al., 2006 Conclusions Identify issues related to trauma in treatment and assessment with immigrant children Strive to be educated on the differences and similarities between immigrant children and other populations susceptible to trauma Engage in continuous self-education to increase cultural awareness when working with special populations in need Resources The National Child Traumatic Stress Network: Refugee Services Toolkit (RST) learn.nctsn.org/course/view.php?id=62 2-1-1 Helpline 211oklahoma.org Community Service Council www.csctulsa.org Immigration: Migration Policy Institute www.migrationpolicy.org Immigration Policy Center: American Immigration Council www.immigrationpolicy.org Cultural Sensitivity/Awareness: Bridging Refugee Youth and Children’s Services (BRYCS) www.brycs.org Cultural Orientation Resource Center www.culturalorientation.net QUESTIONS? References Amnesty International. April 10, 2010. “Invisible Victims: Migrants on the Move in Mexico.” http://www.amnesty.org/en/library/asset/AMR41/014/2010/en/8459f0ac-03ce-4302-8bd2-3305bdae9cde/amr410142010eng.pdf Backus, S. September 17, 2014. “Fort Sill officially released from unaccompanied minor mission.” http://www.koco.com/news/fortsill-officially-released-from-unaccompanied-immigrant-minor-mission/28113904 Betancourt, T. S. & Frounfelker, R. (2013). “Best Practices in Screening and Assessment of Refugee Youth.”. Refugee Services Toolkit. The National Child Traumatic Stress Network. http://www.nctsn.org/nctsn_assets/pdfs/mediasite/10302013_slides.pdf Boothby, N. (1994). Trauma and violence among refugee children. In A. J. Marsella, T. Bornemann, S. Ekblad, J. Orley (Eds.) , Amidst peril and pain: The mental health and well-being of the world's refugees (pp. 239-259). American Psychological Association. doi:10.1037/10147-012 Birman, D., Ho, J., Pulley, E., Batia, K., Everson, M. L., Ellis, H., Betancourt, T. S., & Gonzalez, A. (2005). Mental health interventions for refugee children in resettlement white paper II. National Child Traumatic Stress Network. Briere, J. N., & Scott, C. (2013). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (2nd ed., revised and expanded) Sage Publications, Inc, Thousand Oaks, CA. Brody, E. (1994). The mental health and well-being of refugees: Issues and directions. In A. J. Marsella, T. Bornemann, S. Orley (Eds.) Amidst peril and pain: The mental health and well-being of the world's refugees (pp. 33-56). American Psychological Association. doi:10.1037/10147-020 De Arellano, M. (2006). Trauma among Hispanic/Latino populations. A presentation as part of the Master Speaker Series Teleconference. www.nctsn.org/masters. de Girolamo, G. (1994). Primary health care of refugees. In A. J. Marsella, T. Bornemann, S. Ekblad, J. Orley (Eds.) , Amidst peril and pain: The mental health and well-being of the world's refugees (pp. 263-274). American Psychological Association. doi:10.1037/10147-013 Fessler, P. August 08, 2014. “Trauma Plagues Many Immigrant Kids in U.S. Illegally.” http://www.npr.org/2014/08/08/338606412/trauma-plagues-many-immigrant-kids-in-u-s-illegally Foster, R. P. (2001). When immigration is trauma: Guidelines for the individual and family clinician. American Journal of Orthopsychiatry, 71(2), 153-170. doi:http://dx.doi.org/10.1037/0002-9432.71.2.153 Friedman, M. J., Keane, T. M., & Resick, P. A. (2007). Handbook of PTSD: Science and practice. Guilford Press. Immigration Policy Center: American Immigration Council. May 21, 2014. “Mexican and Central American Asylum and Credible Fear Claims: Background and Context.” http://immigrationpolicy.org/special-reports/mexican-and-central-american-asylum-andcredible-fear-claims-background-and-context Ghosh Ippen, C. (2012). Integrating a diversity-informed approach into evidence-based practice. Trauma therapy in context: The science and craft of evidence-based practice. (pp. 29-50) American Psychological Association, Washington, DC. doi:http://dx.doi.org/10.1037/13746-002 References Hodes, M. (2002). Three key issues for young refugees' mental health. Transcultural Psychiatry, 39(2), 196-213. doi:http://dx.doi.org/10.1177/136346150203900206 Immigration Policy Center. http://www.immigrationpolicy.org/ Jaycox, L. H., Stein, B. D., Kataoka, S. H., Wong, M., Fink, A., Escudero, P., & Zaragoza, C. (2002). Violence exposure, posttraumatic stress disorder, and depressive symptoms among recent immigrant schoolchildren. Journal of the American Academy of Child & Adolescent Psychiatry, 41(9), 1104-1110. doi:http://dx.doi.org/10.1097/00004583-200209000-00011 Kaplan, I. (2009). Effects of trauma and the refugee experience on psychological assessment processes and interpretation. Australian Psychologist, 44(1), 6-15. doi:10.1080/00050060802575715 Kassam‐Adams, N., Gold, J. I., Montaño, Z., Kohser, K. L., Cuadra, A., Muñoz, C., & Armstrong, F. D. (2013). Development and psychometric evaluation of child acute stress measures in spanish and english. Journal of Traumatic Stress, 26(1), 19-27. doi:http://dx.doi.org/10.1002/jts.21782 Kinzie, J. D., Cheng, K., Tsai, J., & Riley, C. (2006). Traumatized refugee children: The case for individualized diagnosis and treatment. Journal of Nervous and Mental Disease, 194(7), 534-537. doi:http://dx.doi.org/10.1097/01.nmd.0000224946.93376.51 Kraut, A. (1994). Historical aspects of refugee and immigration movements. In A. J. Marsella, T. Bornemann, S. Ekblad, J. Krusteva, A., & Brown, E. L. (2013). Migrants and Refugees : Equitable Education for Displaced Populations. Charlotte, NC: Information Age Publishing, Inc. Krogstad, J. M., Gonzalez-Barrera, A., & Hugo, M. July 22, 2014. “Children 12 and under are fastest growing group of unaccompanied minors at U.S. border.” http://www.pewresearch.org/fact-tank/2014/07/22/children-12-and-under-are-fastest-growing-group-of-unaccompanied-minorsat-u-s-border/ Levinson, A. January 24, 2011. “Unaccompanied Immigrant Children: A growing phenomenon with few easy solutions.” Migration Policy Institute. http://www.migrationpolicy.org/article/unaccompanied-immigrant-children-growing-phenomenon-few-easy-solutions Lustig, S., Kia-Keating, M., Grant-Knight, W., Geltman, P., Ellis, H., Birman, D., et al. (2003). Review of Child and Adolescent Refugee Mental Health. White Paper from the National Child Traumatic Stress Network Refugee Trauma Task Force. Boston, Massachusetts McLeigh, J. D. (2013). Children in migration require greater protection from violence, exploitation, and discrimination. Child Abuse and Neglect, 37, 1056-1068. National Child Traumatic Stress Network. http://www.nctsn.org/ Pew Research Center. http://www.pewresearch.org/ Putman, C. September 9, 2014. “The kids are out of Fort Sill. Now what?” Oklahoma Policy Institute. http://okpolicy.org/kids-fort-sill-now Steinberg A.M,. Brymer M.J., Kim S., Ghosh C., Ostrowski S.A., Gulley K., Briggs, E.C., Pynoos, R.S. (2013). Psychometric properties of the UCLA PTSD Reaction Index: Part 1, Journal of Traumatic Stress, 26, 1-9. Tobia, P. J. June 20, 2014. “No country for lost kids.” PBS News Hour. http://www.pbs.org/newshour/updates/country-lost-kids/ U.S. Department of Homeland Security, 2013. “USCIS Questions and Answers.” http://search.dhs.gov/search?utf8=%E2%9C%93&affiliate=dhs&query=unaccompanied+minor+definiton Wong, T. K. July 8, 2014. “Statistical Analysis Shows that Violence, Not Deferred Action, Is Behind the Surge of Unaccompanied Children Crossing the Border.” Center for American Progress. https://www.americanprogress.org/issues/immigration/news/2014/07/08/93370/statistical-analysisshows-that-violence-not-deferred-action-is-behind-the-surge-of-unaccompanied-children-crossing-the-border/ Risk of Persistent Trauma Pre-migration: History of trauma prior to leaving Community violence Poverty Neglect Abuse Resources (what does the literature say?) Migration: Exposure to trauma during transit to new country Sexual abuse Crime Trafficking Method of transportation (i.e., La Bestia) Asylum-seeking and/or relocation: Ongoing experiences as part of the process Racism and discrimination Legal and foster system Amnesty International, 2010; Briere & Scott, 2013; Segura & Zavella, 2011
