Professional Documents
Culture Documents
Adversity in Child
Immigrants and Their Families
Shawn S. Sidhu, MD, FAPA, DFAACAP
Twitter: @shawnsidhumd.
Associate Professor, UNM Department of Psychiatry
Training Director, UNM Child and Adolescent Psychiatry Fellowship Program
DISCLOSURES: Shawn Sidhu
Source Research Advisor/Cons Employee Speaker Travel Book In Kind Stock Honorarium
UNM X X
AACAP X X X
What Next Step Are You Willing To Take?
How Can We Help You Take It?
Objectives
Upon completion of this session, the participant will be able to:
1) Describe the Scope of the Refugee Crisis Worldwide
2) Identify Psychosocial Adversities in Child Immigrant Populations
Seen Clinically
3) Apply Information to the Clinical Care of Child Immigrant
Populations
4) Explore Options for Getting Involved, Including Forensic
Assessments, Clinical Care, and Advocacy
Child Immigrant Populations
Child Immigrant Populations
Asylee/Refugee DREAMer
5. Which form of humanitarian relief applies to immigrants who can
demonstrate torture and/or persecution on the bases if their race,
religion, nationality, political opinion, or social group which occurred in
their country of origin by governmental, military, or police entities (or
in the case of gangs, that the government was unwilling and/or unable
to protect its citizens from organized crime)?
A. Green card.
B. Political asylum.
C. T‐Visa.
D. U‐Visa.
E. Violence Against Women Act.
Why Does This Topic Matter to Child
Psychiatrists?
Immigrants as a Percentage of the Population (Lopez & Bialik
2017)
1970: 4.7 %
2015: 13.4 % (46.6 million immigrants)
4.7 million children in U.S. have at least 1 undocumented
parent, vast majority born in U.S. (PEW Research Center, 2016)
7‐9% of all children born in the U.S. between 2003 and 2014
had at least one undocumented parent
(PEW Research Center, 2014)
DISCRIMINATION/BULLYING
Why Does This Matter to Child and
Adolescent Psychiatrists?
Immigrant children, regardless of background (Migration Policy Institute 2015):
↑Discrimina on
↓ Educa onal, Psychological, Social Outcomes vs. Peers.
Specific Stressors: (Gulbas 2014)
Difficulty Communicating with Friends
Negative Perceptions of Parents’ Home Country
Financial Struggles
Loss of Supportive School Networks
Stressed Relations with Parents
Community Violence
Most of Life Outside U.S.
Asylees/Refugees
What is the current status of people displaced by persecution,
conflict, violence, and human rights violations?
A. Improved after Operation Iraqi Freedom and Operation
Enduring Freedom (Iraq and Afghanistan Wars).
B. Worse, but not as bad as World War II.
C. Worst ever since World War II.
D. Stable and steady.
E. There is insufficient data to answer this question.
10 million
child
refugees
worldwide
20102016: 450% ↑ in unaccompanied minors
How bad would things have to be for you to send one of your only
children on a trip hundreds of miles long with a complete stranger and
the near certain trauma, all for the potential hope of a better life?
How powerless would you have to feel as a parent to do this?
11 million.
3x
The homicide rate per capita is highest in which of the
following areas of the world?
A. African Great Lakes (Rwanda, Kenya, Uganda, Republic of
the Congo).
B. Brazil (Rio De Janeiro slums).
C. Myanmar (Rohingya genocide).
D. Syria (Syrian Civil War)
E. The Northern Triangle (Guatemala, El Salvador, Honduras).
El Salvador Gang &
& Cartel
Honduras Members
Outnumber
Police
(Restrepo
2014)
Murder Rate Per Capita: Honduras 1st, El Salvador 4th, Guatemala 5th
True or False: Border crossings are at an all time high?
A) True
B) False
Which segment of the population crossing the border has
increased drastically in recent years?
A. Criminals.
B. Single men.
C. Single women.
D. Unaccompanied minors.
2x: MDD.PTSD.Psychosis.
-WHO
2015-2016: >50% of refugees “showing signs of mental illness” (Germany).
Children Parents
Living in the U.S. with an Undocumented Parent
Born In the U.S. or DREAMers
POVERTY.
POVERTY
• Undocumented immigrants often paid below minimum wage
(Bernhardt 2009), increasing risk for food insecurity, poor nutrition,
and poor health in children
• Undocumented immigrants are ineligible for public assistance
programs such as welfare, which exacerbates poverty and makes it
difficult to come out of poverty
• Taking public assistance can disqualify immigrants from legal
immigration (so‐called “Public Charge Rule” for Green Card
applicants)
• Poverty is correlated to negative cognitive and emotional outcomes in
low‐income children (Johnson 2010, Yoshikawa 2008)
HOUSING.
HOUSING
• Undocumented Immigrants are ineligible for housing assistance
• Overcrowding in homes: 40% of undocumented farmworker
households report more multiple adults per room and lower rates of
washers and dryers than matched rural counterparts (Early 2006)
• Impact on children Overcrowding has been associated with low
academic achievement, high blood pressure, and increased
behavioral problems at school (Evans 1998)
EDUCATION.
EDUCATIONAL/DEVELOPMENTAL OUTCOMES
• The children of Mexican undocumented parents had higher overall
levels of developmental risk than U.S.‐born Caucasian children (as
measured by language, health, and socioemotional domains)
• The children of Mexican parents have also reported lower reading
and math skills at school entry than other ethnic groups matched for
poverty, immigrant, and minority status (Crosnoe 2007, Fuller 2009,
Han 2006)
EDUCATIONAL/DEVELOPMENTAL OUTCOMES
• Undocumented immigrants are less likely than other ethnic groups to send
their children to preschool (Crosnoe 2006, Hernandez 2008, Kalil & Crosnoe
2009, Magnuson 2006, Matthews 2006)
• The children of Mexican and Central American immigrants, ages 3‐5, are far
less likely to enroll in preschool than other ethnic groups (Matthews 2006),
despite a parental preference that their children attend (Garcia 2007)
• Preschool is of significant benefit to the cognitive development of young
children, especially those from low‐income families (Gormley 2005)
HEALTHCARE.
ACCESS to HEALTHCARE
• Low‐income undocumented immigrant families have been covered by
health insurance at increasingly lower rates since 1996 (Kalil and Ziol‐
Guest 2009, Kaushal 2005, Lurie 2008)
• Lower rates of health care utilization and continuity of care in
undocumented immigrant families (Ortega 2007).
• Undocumented immigrants are less likely to be aware of or fully
understand eligibility requirements of community programs and
health services than matched peers, even when their children were
born in the U.S. and are citizens (Shields & Behrman 2004, Capps
2002, Yu & Kogan 2005)
WORKPLACE RAIDS
WORKPLACE RAIDS
• Study of 900 undocumented adults who were arrested at their
workplace (Chaudry 2010)
• 500 had children who were affected, and 66% of these children were
under 5 years of age
• Immediate Effects:
• Loss of childcare
• Dramatic loss of income
• Reluctance to go to agencies for emergency assistance
• Difficulty obtaining basic needs for children (food, diapers, formula and
clothing)
WORKPLACE RAIDS
• In weeks and months that followed, the remaining caregivers
reported
• Social isolation
• Depressive symptoms
• Suicidal ideation
• In weeks and months that followed, the remaining children reported
symptoms of:
• Anxiety
• Depression
• PTSD
DEPORTATION.
Impact of Deportation on Children
Parental Deportation linked to future emotional and behavioral
problems, including substance abuse, unemployment, and
interpersonal difficulties with family members (Zuniga & Hamann
2006, Brabeck 2014)
50% of the children of undocumented parents are directly affected by
parental deportation or detention, and 30% meet probably criteria for
depression (Gulbas 2014)
Deported
Parent:
-Behavioral
Disturbance
-Sleep &
Appetite
Problems
-Excessive
Crying
-Fear
-Aggression
or
Withdrawn
Behavior
Impact of Deportation on Children
• Children who experience parental deportation report (Gulbas 2014):
• A greater burden of stressors than those not affected by parental deportation
• Consider parental deportation to be a major life trauma which either
generated or exacerbated stressors
• Even when separated voluntarily, children separated from their
parents are at greater risk for anxiety and depression than non‐
separated children (Suarez‐Orozco 2011)
Impact of Deportation on Parents
• Parents report that their own vulnerability to deportation affects
their (Brabeck 2010):
• Emotional adjustment
• Ability to support their children financially
• Their relationships with their children
• Their children’s emotional wellbeing
• Their childrens school performance
• Parental stress results in parenting practices that are harsher and less
warm, impacting the socio‐emotional development of children
(Yoshikawa)
Behavioral Health Issues in the Children of
Undocumented Parents
Children who experience multiple immigration‐related stressors, such
as parental deportation, immigration raids, or detention are at
increased risk for the development of depression, anxiety, and PTSD
The children of undocumented parents suffer from a greater burden of
anxiety and depression, attention problems, social withdrawal, and
rule‐breaking behaviors (Suarez‐Orozco 2010, Suarez‐Orozco 2011,
Allen 2013, Dreby 2014)
Why Does Deportation Matter?
SDSU Study (2014‐2015): At least 83 individual reports of people being
murdered shortly upon return to their country of origin from 2014‐
2015.
Other individuals have reported being kidnapped, raped, enslaved and
sex‐trafficked upon return.
Those who are not deported can be detained for 6‐9 months, and
families are usually separated in detention
Why Should I Get Involved?
This is not a political issue. It’s a matter of:
(1) our Hippocratic Oath and (2) due process.
Hippocratic Oath
I will remember that I do not treat a fever chart, a cancerous
growth, but a sick human being, whose illness may affect the
person's family and economic stability. My responsibility
includes these related problems, if I am to care adequately
for the sick.
I will remember that I remain a member of society, with
special obligations to all my fellow human beings, those
sound of mind and body as well as the infirm.
“Our lives begin to
end the day we
become silent
about things that
matter.”
-MLK
How Can I Get Involved
1) Asylum Evaluations (Pre‐Adjudication)
A) Physicians for Human Rights (PHR)
B) Workshops at National Conferences
C) Individual Mentorship
2) Clinical Care and Treatment
3) Advocacy
Asylum Evaluations
• Any Medical Provider, including Physicians, Advanced Practitioners, Nurses
WHO • Any Mental Health Provider, Including Psychiatrists, Psychologists, Therapists
• A Thorough Diagnostic Interview with an Asylum‐Seeking Immigrant/Translator
WHAT • A Modified Mental Health Evaluation (“H&P”) Write‐Up for Court (Affidavit)
• In Immigration and Customs Enforcement (“ICE”) Detention Centers
WHERE • In the Community (potentially in other countries as well with telehealth)
• At a Time Benefitting Both Evaluator and Detainee
WHEN • Some Requests Are Time Sensitive and Must Be Done Quickly
• Rate of Asylum Granted Improves By 30‐50% With a Mental Health Evaluation (PHR)
WHY • Evaluations Help Client Prepare for Court, Evaluators Can Explain Trauma to Court
Clinical Care of Child Immigrant Populations
Special Considerations
• Inquiring About Immigration Status
• Many Don’t
• Others do in a very sensitive way
• Explain Rationale: to obtain additional services and make referrals
• Only if the child and family feel comfortable
• Immigration status is protected under HIPPA
• No legal mandate to report this information
• Many do not document immigration status in case medical records are
subpoenaed by a court
Clinical Care of Child Immigrant Populations
Special Considerations
• Some cannot provide a forensic mental health evaluation, but can write
letters to the court which are better than nothing
• Listen empathically to experiences of family, normalize while taking
families seriously, and provide psychoeducation on migration stress and
trauma (“Anyone who went through what you have would be feeling awful,
so you’re not strange for having these feelings, and yet I can see how much
this is impacting you and your family”).
• High quality interpreter services are a must, avoid using children
• Undocumented families (especially those with U.S.‐born children) may
qualify for services, such as special school programming, healthcare,
housing, case management, transportation, and other supports
• Connect families to non‐profit grassroots organizations, immigrant law
centers, churches, and local immigrant communities
How To Get Involved: Clinical Care
Trauma‐
Informed
Multi‐ Culturally‐
Generational Sensitive
Clinical Care of Child Immigrant Populations
Special Considerations
• Family Centered
• Much of the trauma experienced may be multi‐generational
• Family can utilize one another as supports with difficult transitions
• Trauma‐Informed
• Warm and welcoming clinical space and staff
• Avoid re‐traumatization and/or triggering of patients
• Culturally‐Sensitive
• Mental health providers seek to understand
• Highlight shared beliefs when present
• May be experiencing discrimination at school or in the community
Clinical Care of Child Immigrant Populations
Special Considerations
• Great advantage for clinics to be located in areas with high
concentrations of undocumented immigrants and/or asylees/refugees
• Improves community relationships with local providers, stakeholders,
and families
• Improves trust and visibility of mental health services
• Flyers can inform patients in native language that they are safe to
receive care, and to provide education
Our Role as Advocates
• Child immigrants and their families may refrain from speaking out for
fear of retaliation
• Especially in areas where immigration raids, arrests, detention, and
deportation are more prevalent
• AACAP, APA, AAP, and AMA all have policy statements against recent
executive orders and the separation of immigrant children from their
families
• Op‐Eds for AACAP News, Psychiatric News, local newspapers
• Local news interviews
• Meeting with local, state, and national representatives
U.S. Congresswoman Veronica
Escobar (D‐Texas)
Fabiola Eckleberry (President,
Professional Counselors of El
Paso)
“A jug fills drop by drop. Likewise,
the wise man, gathering it little by
little, fills himself with good.”
-Buddha
What Next Step Are You Willing To Take?
How Can We Help You Take It?
Thank You!
shawnsidhu@gmail.com