Annotated Bibliography: The Impact of Trauma among Undocumented Immigrant Children

Psychological Practice With Unaccompanied Immigrant Minors: Clinical and Legal Considerations

Amanda NeMoyer Massachusetts General Hospital, Boston,

Massachusetts, and Harvard Medical School

Trinidad Rodriguez Massachusetts General Hospital, Boston,

Massachusetts

Kiara Alvarez Massachusetts General Hospital, Boston, Massachusetts, and Harvard Medical School

Among youth who migrate to the United States from Latin America, unaccompanied immigrant minors (UIMs)—traveling without a parent or caregiver—are a unique subpop- ulation facing substantial challenges before, during, and after migration. UIMs often migrate as a result of traumatic experiences in their home countries but are also vulnerable to experiencing trauma pre- and postmigration. These experiences are compounded by the impact of prolonged separation from caregivers who migrated earlier (premigration) and caregivers who were left behind (postmigration). Once in the United States, UIMs are typically considered undocumented and often do not have the legal representation necessary to successfully navigate immigration proceedings in a system designed for adults. Further, they often live in areas with increased rates of poverty and community violence and can face stigmatization and exclusion from important protective activities. UIMs are therefore at risk for psychological distress, including depression, anxiety, and posttraumatic stress. This article provides an overview of typical experiences for UIMs, discusses the accom- panying legal and clinical implications, and offers recommendations for psychological practice at the level of providers, training programs, and child-serving systems. For example, providers might incorporate family-based and trauma-focused interventions to enhance resilience and psychological well-being, in addition to support in navigating interactions with the legal system. Clinical training programs can provide education about the experiences of UIMs, while clinicians can advocate at the systems level to promote social integration of UIMs into school systems and a more humane immigration system focused on meeting the needs of these vulnerable children.

What is the significance of this article for the general public? Unaccompanied immigrant children and adolescents from Latin America leave their home countries to escape traumatic and difficult experiences but remain vulnerable to continued trauma upon arrival to the United States. Psychologists and other mental health providers can support this group of youth by considering their unique circum- stances, providing clinical services that address their distinct needs, and advocating that child-serving systems best facilitate these youths’ long-term health and resilience.

Keywords: immigrant youth, unaccompanied immigrant minors, trauma, mental health, resilience

Amanda NeMoyer, Disparities Research Unit, Depart- ment of Medicine, Massachusetts General Hospital, Bos- ton, Massachusetts, and Department of Health Care Policy, Harvard Medical School; Trinidad Rodriguez, Disparities Research Unit, Department of Medicine, Massachusetts General Hospital; Kiara Alvarez, Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School.

Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award K23MH112841 and T32MH019733.

Correspondence concerning this article should be addressed to Kiara Alvarez, Disparities Research Unit, Department of Medi- cine, Massachusetts General Hospital, 50 Staniford Street, 8th Floor, Suite 830, Boston, MA 02114. E-mail: kalvarez2@mgh .harvard.edu

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Translational Issues in Psychological Science © 2019 American Psychological Association 2019, Vol. 5, No. 1, 4 –16 2332-2136/19/$12.00 http://dx.doi.org/10.1037/tps0000175

4

Migration to the United States by Latin American youth traveling without a parent or guardian reached a peak in 2014, drawing na- tional attention. Between October 2013 and 2014, immigration officials encountered more than 67,000 unaccompanied youth (American Immigration Council, 2015), most of whom em- igrated from Mexico, Guatemala, Honduras, and El Salvador (Seghetti, Siskin, & Wasem, 2014). Though the rate of migration has de- clined, nearly 150,000 more unaccompanied youth have been detained at the U.S./Mexico border since October 2014 (U.S. Customs & Border Protection, 2017). Upon apprehension and detention, youth are identified as “unac- companied alien children” by agents of the U.S. Department of Homeland Security if they: are less than 18 years of age, have no lawful U.S. immigration status (i.e., are “undocumented”), and have no parent or guardian able to provide immediate care and physical custody in the United States1 (Manuel & Garcia, 2016; Ooi, 2011). In this article, we refer to these children as unaccompanied immigrant minors (UIMs).

Unaccompanied children have many motiva- tions for leaving their countries of origin. Com- mon reasons include: fleeing violence, gang ac- tivity, abuse, extortion, or poverty, and seeking family reunification (Ooi, 2011; Seghetti et al., 2014; Valdez, Valdez, & Sabo, 2015). In par- ticular, increased rates of violence and homicide in Guatemala, Honduras, and El Salvador have been directly linked to an increase in the num- ber of UIMs entering the United States (Amer- ican Immigration Council, 2015). After appre- hension and detainment at the border, many UIMs are released to family members or other sponsors to undergo immigration proceedings. During this time, UIMs may seek or be referred to mental health services (e.g., Baily et al., 2014; Grace & Roth, 2015; Schapiro, Gutierrez, Blackshaw, & Chen, 2018). Psychologists and other mental health providers that serve these children should appreciate the often-traumatic journey they have undertaken before presenting for care. Further, basic awareness of immigra- tion proceedings and potential options for legal relief can give needed context for best providing mental health services to this vulnerable popu- lation.2 In this review, we discuss common ex- periences of unaccompanied youth prior to, dur- ing, and after migration, with a focus on family context and unique stressors and resilience fac-

tors. We also review the legal issues these young people often face, and close with recom- mendations for psychologists and other mental health providers in clinical practice, training programs, and at the systems level.

Experiences Before, During, and After Migration

Premigration

Before emigrating from their countries of or- igin, UIMs frequently experience physical and emotional abuse, poverty, and exposure to ex- treme violence (Chavez-Dueñas, Adames, & Goertz, 2014; Schapiro, Kools, Weiss, & Brin- dis, 2013). Substantial proportions of migrating youth report experiencing and fearing vio- lence—in one study, 58% of respondents re- ported personally experiencing or fearing “seri- ous harm of a nature that raises international protection concerns” from state actors, transna- tional criminal organizations, community mem- bers, or even family members (United Nations High Commissioner for Refugees, 2014, p. 25). Children often report fleeing to avoid recruit- ment and exploitation by human smugglers, gangs, and drug cartels (United Nations High Commissioner for Refugees, 2014). For young girls in these regions, sexual violence serves as a leading motive for migration, as female UIMs frequently report being victims of rape (United Nations High Commissioner for Refugees, 2014). Interviews conducted with volunteers serving migrants in Arizona similarly found that adult immigrants from Central America are of- ten fleeing to escape gang violence, sexual vi- olence, extortion, and kidnapping, some with harrowing stories of gang violence toward chil- dren as a way of threatening the family (Valdez et al., 2015). A study of 234 immigrant adults

1 If a child is apprehended with no parent or guardian and cannot be reunited with such an adult within several hours, they will frequently be treated as an unaccompanied alien child, even if an adult willing to assume care of the child can eventually be located within the United States (Manuel & Garcia, 2016).

2 For the purposes of this review, we focus on clinical assessment and service delivery. Psychologists may also be involved in forensic assessments for immigrant youth want- ing to document circumstances that may qualify them for relief from deportation; however, discussion of this topic is beyond the scope of the current paper.

5PRACTICE WITH UNACCOMPANIED IMMIGRANT MINORS

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from Salvador, Honduras, and Guatemala found that half of the participants had experienced death threats, about a third experienced extor- tion, and more than one fifth experienced do- mestic violence (Keller, Joscelyne, Granski, & Rosenfeld, 2017).

For many immigrant families, migration oc- curs in a “stepwise” fashion, such that parents first travel to the United States to secure em- ployment and, eventually, children migrate to reunite with their family (Suárez-Orozco, Bang, & Kim, 2011; Zentgraf et al., 2012). During stepwise migration, children left behind in their countries of origin may feel proud of their par- ents—particularly if they migrated for safety reasons or to improve the family’s financial status— or they may feel abandoned (Schapiro et al., 2013). Children may be more likely to see their family’s migration as a stressor when they are not included in the family’s decision- making process (Potochnick & Perreira, 2010). Of note, children of different ages often respond differently to separation from their parents (Dreby, 2007). For example, preadolescents might become more attached to remaining care- givers (e.g., grandparents), withdraw from their biological parents, and express more reluctance to join their parents via migration. In contrast, although adolescents might initially act out, ap- pear more resentful of their parents, and have more difficulties in school, as they grow older, they tend to have more interest in joining their parents (Dreby, 2007). Other studies have found that separation from mother and/or father due to migration may result in a child experiencing significant distress, which can manifest as de- pressive symptoms, nervios,3 medical condi- tions, and other emotional and behavioral prob- lems (Heymann et al., 2009; Pribilsky, 2001; Suárez-Orozco, Todorova, & Louie, 2002).

Migration

Compounding premigration traumatic expe- riences, migration itself likely exposes youth to further trauma. The journey to the United States from Central America is perilous, entails cross- ing multiple borders through different means of transport, and can take almost two months to complete (Chavez-Dueñas et al., 2014). In ad- dition to traveling via cars, buses, and boats, many migrants cross Mexico on the top and sides of a freight train known as “La Bestia [The

Beast],” a free but dangerous alternative to other forms of transportation. During their jour- ney on “La Bestia,” migrants are sometimes mutilated or killed from falling off the train due to exhaustion (Vogt, 2013). Survivors report witnessing and experiencing assaults, robberies, and sexual violence during the journey (Infante, Idrovo, Sánchez-Domínguez, Vinhas, & González-Vázquez, 2012; Valdez et al., 2015; Vogt, 2013).

Travel is often arranged through use of “coy- otes,” migrant guides who typically receive payment from families hoping to ensure their child is safely brought to the United States (Vogt, 2016). Coyotes frequently have estab- lished social networks for transporting individ- uals from shelter homes along the migration route to contacts on the U.S. side of the border. However, hiring a guide to navigate the migra- tion process does not necessarily protect chil- dren from extortion, kidnappings, and violence. Coyotes themselves might be responsible for violent acts against children they were hired to transport. Vogt (2016) described coyotes as both “perpetrator and protector” (p. 367), as they risk their lives to guide youth but can also take advantage of the vulnerable. Migrants vic- timized by their coyotes have been abandoned, have been kidnapped to demand more money from family members, and, in some cases, have died due to intolerable and inhumane traveling conditions (Infante et al., 2012; Palacios, 2015; Vogt, 2013).

Postmigration

Shortly after entering the United States, UIMs are typically apprehended and detained by Customs and Border Protection (CBP) agents (American Immigration Council, 2015).

3 Nervios directly translated means “nerves,” but here it refers to a cultural idiom of distress among Latinos that has been observed and validated in epidemiologic studies. Also known as ataque de nervios, symptoms of this syndrome can include attacks of crying, shaking, shouting, or being physically aggressive; individuals experiencing nervios fre- quently report feeling a loss of control (Guarnaccia et al., 2010). There is overlap between symptoms of nervios and a variety of psychiatric symptoms, including depression and anxiety (Guarnaccia et al., 2010; Pribilsky, 2001).

6 NEMOYER, RODRIGUEZ, AND ALVAREZ

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UIMs who do not undergo “voluntary return”4

to their country of origin (Seghetti et al., 2014) remain at CBP holding facilities before transfer to the Department of Health and Human Ser- vices Office of Refugee Resettlement (ORR) (Cantor, 2015). Although federal law states that youth should be transferred to an ORR facility within 72 hr, children have reported remaining in CBP facilities for nearly two weeks while await- ing transfer (Women’s Refugee Commission, 2012). Conditions in CBP facilities— often called hieleras, Spanish for iceboxes— have been de- scribed as extreme and inhumane, as detainees must often sleep on concrete floors in freezing temperatures while lights remain on all day and night; these facilities have also been characterized by a lack of adequate food, water, and medical care (Cantor, 2015).

Upon transfer to ORR, youth are typically housed in state-licensed, private facilities with one of three security levels: shelter, staff-secure, and secure (Hill, 2011). Federal law requires that youth be held in the least restrictive setting necessary to meet their best needs, and youth may only be held in secure placement if they are determined to be a danger to themselves or others and/or have been charged with commit- ting a criminal or delinquent offense (Hill, 2011). Youth in ORR custody may be held for days, months, and sometimes years during the removal process: from 2008 to 2010, youth spent between 1 and 710 days in custody, ap- proximately 61 days on average; in 2016 the average length of custody was 34 days (Kandel, 2017). Regardless of security level, these facil- ities are typically in remote areas, thereby lim- iting youths’ accessibility to family members, legal counsel, educators, and medical providers (Hill, 2011). Further, instances of physical and sexual mistreatment by staff have been reported in several facilities (Hill, 2011).

Although they continue to lack lawful immi- gration status until the conclusion of formal immigration proceedings, an estimated 85% of UIMs are released from ORR custody to await those proceedings (Seghetti et al., 2014). Spe- cifically, ORR may release youth to “a family member, legal guardian, or other entity willing to ensure the child’s well-being and timely ap- pearance in immigration court” as appropriate (Ooi, 2011). Prior to releasing a child, ORR should conduct background checks of the po- tential sponsor to identify previous arrests and

convictions; they may also consult with the child, his or her family, and/or the consulate from the child’s country of origin (Seghetti et al., 2014). However, after several children were released to human traffickers posing as distant relatives or family friends of each child (Van- Sickle, 2016), a Senate Subcommittee investi- gation of ORR policies and practices regarding sponsor approval and child release revealed sev- eral concerning shortcomings (U.S. Senate, Committee on Homeland Security and Govern- mental Affairs, Permanent Subcommittee on In- vestigations, 2016). Specifically, the Subcom- mittee took issue with ORR’s unreliable methods of verifying alleged relationships be- tween UIMs and potential sponsors, ORR’s fail- ure to perform background checks on all adults in a potential sponsor’s household, the lack of home studies performed prior to placing UIMs with sponsors, and limited postrelease follow up (U.S. Senate, Committee on Homeland Security and Governmental Affairs, Permanent Subcom- mittee on Investigations, 2016). These short- comings place UIMs at heightened risk for traf- ficking and other forms of abuse upon their release from custody.

After release, UIMs frequently move with their sponsors to major metropolitan areas with large Central American immigrant communi- ties, including but not limited to Los Angeles, Miami, Houston, Washington, DC, and New York City (Pierce, 2015). There, these youths may encounter additional risk factors for nega- tive outcomes, including discrimination, pov- erty, acculturation difficulties, and community violence (Yoshikawa, Suárez-Orozco, & Gon- zales, 2017). For example, a survey of 164 Latino adolescents in California revealed that immigrant youth experienced more violence in the United States than in their home countries; immigrant youths also reported more exposure to weapon-related violence in the United States compared to their U.S.-born peers (Gudiño, Na- deem, Kataoka, & Lau, 2011). Additionally, given their exclusion from many public services

4 Voluntary return, in this context, is a specific process for children from Canada or Mexico who: do not have a possible asylum claim; are not potential victims of traffick- ing; and can make an independent decision to voluntarily return to their home country. If they meet these criteria they undergo “voluntary return” to their country without stan- dard immigration proceedings (Seghetti et al., 2014).

7PRACTICE WITH UNACCOMPANIED IMMIGRANT MINORS

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(e.g., public health insurance, TANF, federal college loans) and the recent rise of anti- immigrant policies and sentiment, many UIMs feel excluded from typical adolescent activities and stigmatized by peers and school personnel, impeding successful adjustment to school, so- cial involvement, educational success, and other important protective factors (Gonzales, Suárez- Orozco, & Dedios-Sanguineti, 2013; Roth & Grace, 2015).

Clinical Considerations

In addition to recognizing the challenging experiences UIMs may face before, during, and after migration, when developing treatment plans, clinicians should consider several indi- vidual- and family-level risk and protective fac- tors. A risk and resilience framework acknowl- edges that human development over time is impacted by external stressors and traumas, as well as by personal assets and external re- sources that may promote healthy adaptation in the context of these events (Fergus & Zimmer- man, 2005; Ungar, 2015).

Mental Health Risk and Protective Factors

Substantial research has demonstrated the impact of cumulative adversity, meaning the impact of multiple traumatic experiences and severe stressors, in impacting mental health across the life span (Turner & Lloyd, 1995). In one study of a nationally representative sample of U.S. youth, exposure to more types of vic- timization and adversity (also called polyvic- timization) was associated with higher levels of both depression and anger/aggression (Turner, Finkelhor, & Ormrod, 2006). In another study examining the impact of adverse childhood ex- periences on young adult health outcomes in an urban population, cumulative adversity was as- sociated with a greater number of poor out- comes (Mersky, Topitzes, & Reynolds, 2013). Thus, cumulative adversity puts youth at risk not only for specific mental health conditions such as posttraumatic stress disorder (PTSD), but potentially for multiple mental health con- ditions and other forms of impairment in their adult life.

In the general youth population, individual risk factors for developing PTSD include expo- sure to violence and other traumatic events;

existing mental health or developmental vulner- abilities; the meaning attributed to events, ex- ternal locus of control, and exposure to daily stressors. Family factors include family conflict, separation from parents, the loss of a parent or experiencing the threat of losing a parent, and poor parent mental health and coping (Bonanno & Mancini, 2008). UIMs disproportionately ex- perience many of these risk factors compared to accompanied immigrants and other youth. As noted earlier, rates of exposure to violence, other trauma, and daily stressors are high in this population (Chavez-Dueñas et al., 2014). Sim- ilarly, key family risk factors are commonly experienced by UIMs, given their prolonged family separation and the trauma and stress that may have been experienced by their parents (Suárez-Orozco et al., 2010; Suárez-Orozco, Yoshikawa, Teranishi, & Suárez-Orozco, 2011).

The stress of migration and postmigration experiences, including discrimination, may also represent a risk factor for this population. In a study of immigrant Latino youth, 24% reported experiencing a stressful experience while mi- grating, which was associated with increased anxiety (Potochnick & Perreira, 2010); preva- lence of stressful migration experiences is likely higher among UIMs. In a study of migrant youth (both unaccompanied and accompanied) screened at a school-based health center in the United States, 44% of youth were referred to behavioral health services; the most common diagnoses were adjustment disorder, depressive disorders, and anxiety disorders (Schapiro et al., 2018). Given few studies documenting the ex- perience of unaccompanied minors in the United States, European studies can provide a useful reference point. For example, a study of unaccompanied minors in Belgium found high rates of depression, anxiety, and PTSD symp- toms, with a quarter or more youth reporting severe depression and anxiety scores and more than 40% reporting severe PTSD at three time points over 18 months (Vervliet, Lammertyn, Broekaert, & Derluyn, 2014). The number of traumatic experiences and daily stressors re- ported by youth in this study were linked to higher levels of depression, anxiety, and PTSD at later time points (Vervliet et al., 2014).

It is important to note that not all youth exposed to trauma develop PTSD. In fact, some researchers note that many trauma-exposed in-

8 NEMOYER, RODRIGUEZ, AND ALVAREZ

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dividuals display resilience, experiencing few disruptions to typical functioning or improving without intervention in the years following the trauma event (Bonanno & Mancini, 2008). This research implicates the value of allowing natu- ral coping processes to unfold and using tar- geted interventions for individuals with greater need. However, other researchers have argued that such recovery is not as common as some studies report and note that a focus on natural resilience might impede investment in needed trauma-informed interventions (Infurna & Lu- thar, 2016). For example, one study suggested that youth who appear psychologically resilient to high levels of stress in early adolescence may still experience long-term biological impact, as measured by stress hormones, blood pressure, and body mass index at age 19 (Brody et al., 2013). Another study suggested that exposure to some adversity (as compared to either no expe- rience of adversity or exposure to high levels of adversity) resulted in higher levels of resilience among children (Seery, Holman, & Silver, 2010). Ungar (2015) emphasizes that among children exposed to high levels of adversity, features of the social context (e.g., supportive relationships and safe environments) are more critical to promoting resilience than individual traits. Overall, these studies highlight the im- portance of clinical assessment of resilience and positive adaptation at the level of both individ- uals and systems, as well as attention to the costs and benefits of different intervention ap- proaches.

Very little research has examined resilience among UIMs; however, we can extrapolate from studies of refugee youth, who have fled their countries (often with family members) for fear of persecution, war, or violence, and thus, experience stressors similar to those UIMs ex- perience. Studies of refugee children emphasize the following individual protective factors: cop- ing skills, adaptability, and positive emotions/ optimism. Family and societal protective factors include family adaptability and cohesion, social support, community integration, experience of safety and security, and school belonging and connectedness (Ehntholt & Yule, 2006; Fazel, Reed, Panter-Brick, & Stein, 2012; Miller & Rasmussen, 2010). Schools may also represent an understudied protective factor for UIMs: a study of resettled refugee adolescents found that greater feelings of school belonging were asso-

ciated with less depression and greater self- efficacy (Kia-Keating & Ellis, 2007). Among adolescent refugees in New York City, a caring school environment was identified as a key ex- perience that counteracted the psychological ef- fects of trauma exposure (Davies, 2008).

Family Context

Because many families with UIMs present to care after reunification—particularly if that pro- cess becomes challenging—providers should understand the effects migration can have on familial relationships. Migrant families are of- ten called “transnational” because they undergo frequent separation and reunification as family members migrate and return (Suárez-Orozco et al., 2010). Adapting to this cycle, families fre- quently adopt parenting strategies that contrast with concepts of small nuclear families; for example, biological parents who migrate may transfer caretaking duties to other family mem- bers or friends while remaining in contact with their children from afar (Falicov, 2011; Suárez- Orozco et al., 2002). Thus, children become part of extended families that cross national borders.

For children separated from their parents by migration, longer separations can create more challenging reunifications. In one study of im- migrant youth, children who had previously been separated from their mothers or from both parents for four years or more reported signifi- cantly higher depressive and anxiety symptoms than those who experienced no separation; how- ever, in a follow-up four years later, there were no differences in depression and anxiety symp- toms between groups (Suárez-Orozco et al., 2002). This study suggests that the psycholog- ical effects of separation may not persist over time. However, longer periods of separation may contribute to difficulty establishing parent– child relationships and reluctance to adhere to biological parents’ rules and norms. Many chil- dren have ambivalent feelings toward reunify- ing with their family, especially if they are leaving behind long-term caretakers to join im- mediate family members they no longer know. Youth may face changes in family makeup, including family members they have never met (e.g., stepparents and siblings born after parents migrated; Suárez-Orozco et al., 2010). Such challenges may result in feelings of ambiguous loss (Gindling & Poggio, 2012), as youth in

9PRACTICE WITH UNACCOMPANIED IMMIGRANT MINORS

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both the premigration and postmigration phases have family members who are available at a distance but not physically present.

Legal Considerations

Given their lack of lawful immigration status, UIMs must undergo formal, adversarial pro- ceedings before an immigration judge that could result in their deportation (Manuel & Gar- cia, 2016). Although existing guidelines en- courage immigration judges to accommodate the unique capabilities of children (e.g., by us- ing simple, straightforward questions), the pro- cedures and legal standards applied to these removal proceedings mimic those of adult pro- ceedings (Somers, Herrera, & Rodriguez, 2010) and do not typically apply the “best interest of the child” standard usually applied to questions of a child’s welfare (Manuel & Garcia, 2016; Ooi, 2011). Further, because federal law pro- hibits the use of government funds to provide counsel for immigrants during removal pro- ceedings, youth have no right to government- appointed legal representation during this pro- cess and must frequently rely on available pro bono representation, which cannot serve all youth in need of counsel (Hill, 2011). Thus, more than half of UIMs face complicated im- migration proceedings with no adult advocate, significantly reducing their chances at success- fully remaining in the country (Hill, 2011; Ooi, 2011).

Despite their young age, UIMs are not cate- gorically protected from deportation; however, each child can apply for one of several options for relief from removal as appropriate (Manuel & Garcia, 2016). These opportunities include: asylum, special immigrant juvenile status, T Visas, and U Visas (Somers et al., 2010), each of which is discussed further below. As they wait for their case to be heard and decided— which can take months or even years—youth may experience significant fear and anxiety about their uncertain fate (Teranishi, Suárez- Orozco, & Suárez-Orozco, 2015).

Asylum

Youth seeking asylum in the United States must meet the same standard applied to adults seeking asylum: they must be unable or unwill- ing to return to their home country because of a

“well-founded fear of persecution on account of race, religion, nationality, political opinion, or membership in a particular social group” (Man- uel & Garcia, 2016). However, given their age, developmental level, limited knowledge of sta- tus in their country of origin, and other relevant factors, children often struggle to explain how they fit into one of the groups eligible for asy- lum— especially when required to prove that their country’s government was unwilling or unable to protect them (Ooi, 2011). Addition- ally, although many UIMs travel to the United States to escape violence, potential gang recruit- ment, retaliation for opposing gang activities, and even police brutality toward “street chil- dren,” these groups are not explicitly identified in asylum guidelines and, therefore, asylum ap- plications based on these realities are frequently unsuccessful (Manuel & Garcia, 2016). In fact, former child soldiers and former gang members often face the most difficulty in obtaining relief given negative perceptions of their past ac- tions— despite their attempts to flee continued involvement in such organizations (Ooi, 2011).

Special Immigrant Juvenile Status (SIJS)

Youth meet criteria for SIJS when they are unmarried; under 21; identified as dependent on a juvenile court or legally committed to state custody; and unable to reunite with one or both parents because of abuse, neglect, or abandon- ment, as long as an administrative proceeding finds that returning to their previous country would not be in their best interest (Manuel & Garcia, 2016; Ooi, 2011). Obtaining SIJS pro- vides youth with a path to citizenship (Ooi, 2011). However, only 25% of the 5,000 avail- able SIJS opportunities are awarded each year, suggesting it is particularly difficult to obtain (Ooi, 2011). For example, youth seeking SIJS must work within two systems (the federal im- migration system and the juvenile court system) whose requirements do not always align (e.g., SIJS allows for youth to be under 21 years of age but jurisdiction for many juvenile systems ends at 18 years of age) and whose procedures often include uncomfortable, potentially retrau- matizing experiences for youth, such as inter- rogative interviews and adversarial procedures (Ooi, 2011). Further, SIJS is only available to youth who can prove that they were abused, neglected, or abandoned— children who have

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experienced other forms of trauma are not eli- gible.

T Visas and U Visas

Both T Visas and U Visas may be available forms of relief for youth who were victims of specific criminal activity. Youth under 18 years of age who came to the United States as a victim of a “severe form of trafficking in persons” who would suffer hardship upon removal may qual- ify for a T Visa (Ooi, 2011). Additionally, U Visas are available for individuals who have suffered “substantial physical or mental abuse” after experiencing serious criminal activity (e.g., domestic violence, rape, kidnapping), as long as they have information about the crimi- nal activity and will assist in the investigation or prosecution of the activity (Manuel & Garcia, 2016). Both forms of relief are available to individuals of any age (additional requirements apply for T Visa applicants older than 18 years of age) and allow an individual to live in the United States for up to four years; holders of T and U Visas may also apply for permanent resident status after three years (Manuel & Gar- cia, 2016).

Recommendations

Clearly, UIMs face significant challenges be- fore, during, and after their migration to the United States. Consequently, providing clinical services to these youths can also present many challenges, especially to clinicians with little prior exposure to this population. Below, we offer several recommendations to individuals and systems that provide services to UIMs.

Provider-Specific Recommendations

Service providers who work with youth should familiarize themselves with the typical process and procedures for newly arrived youth with no lawful immigration status. Even clini- cians who work in regions of the country that are relatively removed from international bor- ders should do so, as many UIMs apprehended by CBP officers are later released to family members or other guardians throughout the country. Becoming familiar with these proce- dures can increase clinicians’ understanding of the challenges a child has experienced before

initiating services and the challenges they will likely face during subsequent immigration pro- cedures. Depending on the nature of services provided, clinicians may find it appropriate to help youth prepare for interfacing with various systems, including schools and legal systems. For example, youth experiencing anticipatory anxiety about meeting with school and/or im- migration administrators might benefit from sessions aimed at addressing this issue. How- ever, clinicians should be cognizant of their roles and goals as service providers and avoid taking on responsibilities associated with guardians ad litem or legal representation.

It may also be helpful for providers to de- velop relevant resources for UIMs and their family members, including educational infor- mation about potential opportunities for re- moval relief and a list of law firms and organi- zations that may provide pro bono legal representation to UIMs. Kids In Need of De- fense (KIND; https://supportkind.org) and the Young Center for Immigrant Children’s Rights (https://www.theyoungcenter.org), organiza- tions dedicated to advocating for unaccompa- nied immigrant and refugee children, operate throughout the United States and may have use- ful information for clinicians developing such resources.

Clinicians providing services to UIMs should consider incorporating family-based services into an ongoing treatment plan as appropriate. Providing psychoeducation to parents and UIMs about common challenges faced by fam- ilies reunifying after migration can be a way to validate their experiences and help them navi- gate obstacles over time (for an in-depth over- view of these challenges, see Suárez-Orozco et al., 2010 and Falicov, 2011). Incorporating par- ents, caregivers, and other family members into therapy should be considered, including ways to include family members living in other coun- tries. The complexities of transnational families (e.g., ecological context of both the home and receiving communities; family constellation in both the home country and in the United States; periods of family separation; changes in family or household composition during separations; quantity and quality of interactions with family members who are not physically present) should be considered in both assessment and intervention. Working with parents and children to complete migration narratives may be a way

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to facilitate communication about their respec- tive experiences, particularly during separa- tions. However, given the likelihood of having experienced trauma before/during migration and the emotional difficulty of discussing fam- ily separations (Suárez Orozco et al., 2011), such an approach should be incorporated care- fully and with appropriate supervision or con- sultation.

Though there is a dearth of evidence on the effectiveness of specific evidence-based ther- apies with UIMs, Trauma-Focused Cognitive Behavioral Therapy (Cohen & Mannarino, 2008) and Cognitive Behavioral Intervention for Trauma in Schools (Kataoka et al., 2003) have both been adapted for use with Latino immigrant children. Trauma Systems Ther- apy, which has been adapted for Somali ref- ugee youth (Ellis et al., 2013), represents another potential intervention approach— particularly within systems that have the re- sources to implement multilevel interven- tions. In general, trauma-informed care approaches fit well in schools, health care settings, and organizations serving immigrant youth populations. Psychologists may provide consultation on the integration of these ap- proaches within a given setting.

Recognizing the limited time and resources with which mental health providers fre- quently operate, it may prove challenging to implement these recommendations. For ex- ample, limitations related to billing and reim- bursement might not allow for out-of-session time to focus on immigration needs with youth clients. Additionally, incorporating families in treatment might prove difficult if family members feel mistrustful of the health care system (Rhodes et al., 2015) or have demanding and unpredictable work sched- ules. In such cases, providers may need to work creatively and flexibly—that might in- clude reserving in-session time to focus on tasks that could be helpful for youth navigat- ing the immigration process; allowing family members to engage in whatever capacity they can, even sporadically; and conducting out- reach to families over the phone. Clinicians should also identify what forms of instrumen- tal support may be useful to families, such as medical documentation regarding appoint- ments for employers and collateral contacts with attorneys. Finally, given the intensity of

common trauma experiences within a UIM population and the increased challenge of working within multiple complicated sys- tems, an additional barrier may arise if clini- cians providing services to these youth expe- rience overload and/or burnout. Thus, it is particularly important for individuals working with UIMs to regularly seek consultation and/or supervision from providers with exper- tise in this area, obtain support from provider peers, and engage in self-care strategies to reduce the likelihood of burnout.

Training Program Recommendations

Clinicians with little to no foundational knowledge about UIMs will likely experience anxiety about and/or face difficulty providing services to this population. As a result, graduate psychology training programs may do their stu- dents a significant disservice if they do not incorporate some information about UIMs into their curriculum. Programs may address this issue through formal means (e.g., providing in- struction about UIMs in relevant courses), or more informal means (e.g., inviting experts to speak to students and faculty). Programs that lack faculty with the necessary expertise to fa- cilitate this learning opportunity might utilize teleconferencing technology and/or collaborate with other programs within the university (i.e., Latino/a Studies programs). Students can also play a role in raising awareness; for example, they might organize meetings to discuss rele- vant journal articles or host a movie screening so that students can become more familiar with the experiences of UIMs and consider how cli- nicians might best serve these youth. Students interested in this idea might screen and discuss Which Way Home, a documentary depicting several unaccompanied children traveling to the United States through Mexico.

System-Specific Recommendations

Upon their arrival to the United States, UIMs must interface with several systems, including legal systems, medical systems, and school sys- tems, which can all improve the ways in which they serve UIMs. For example, school systems with an appreciable UIM population should identify trusted adults that could work directly with these youth, help them navigate the sys- tem, and advocate on their behalf as appropri-

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ate. Some schools have established welcome centers that assist with school enrollment and referral to resources for English Language Learners. In addition to providing instrumental support, these centers can facilitate social inte- gration and inclusion of UIM and their families by providing orientation to expectations in the school system, points of contact, and outside resources for families.5

Given the deficit of available pro bono legal representation, lawmakers might consider alter- ing current restrictions on government-provided attorneys during immigration removal proceed- ings, at least as applied to youth. Doing so would significantly reduce the number of chil- dren without representation expected to mount their own legal arguments for relief, despite no legal training. Even if current restrictions re- main, they should not prevent the provision of guardians ad litem and other youth advocates within youths’ immigration proceedings. Re- searchers should investigate the feasibility and benefits of implementing programs that provide this needed service to UIMs facing removal. Although substantial political barriers impede such changes in policy, developing the evidence base for these services may demonstrate long- term benefits for agencies seeking additional funding and lawmakers seeking strategies to better support UIMs and other immigrant youth.

Conclusion

The migration of thousands of unaccompa- nied Latin American youth, and the barriers they subsequently face in the United States, represents a humanitarian crisis with no signs of abatement. Although the legal and policy con- text for UIM immigration cases is complex, psychologists can play an important role in serving these youth by applying evidence to clinical intervention, training other profession- als to work with these youth, consulting with schools and health care settings, and advocating for a more just and humane immigration sys- tem.

5 For detailed strategies to engage immigrant families in schools, see Breiseth, Robertson, and Lafond (2011). Ad- ditionally, The Center for Health and Health Care in Schools (n.d.) hosts a website with a compilation of re- sources to assist school administrators in serving immigrant and UIM students.

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Received January 2, 2018 Revision received September 2, 2018

Accepted September 6, 2018 �

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