Unaccompanied Minors Seeking Refuge in the United States: A Review of the Mental Health Literature

While much of the media attention focusing on the current dilemma of unaccompanied minors seeking refuge in the U.S. has focused on the legal and political issues involved, another important perspective to be considered is the mental health and emotional experiences of these children. While there is limited research on the children seeking asylum at the southern border of our country, there is much to learn from related international experiences of this problem. This issue of the Evidence in Action Research Quarterly provides an annotated bibliography of the available social science research and anecdotal evidence regarding the psychosocial experiences of unaccompanied refugee minors.

A review of these studies suggests that these children have generally experienced numerous traumatic experiences in their countries of origin, along their journey and/or upon arrival and detention in the United States. Because the children are without the moderating effects of parental or familial support and often face other complicating factors such as discrimination and the challenges of abrupt cultural assimilation, they are at significant risk for traumatic stress conditions and frequently require specialized mental health interventions. This is an issue of concern for traumatic stress specialists and child-focused mental health practitioners alike.

Research Studies

Bean, T., Eurelings-Bontekoe, E., Mooijaart, A., & Spinhoven, P. (2006). Factors associated with mental health service need and utilization among unaccompanied refugee adolescents. Administration and Policy in Mental Health and Mental Health Services Research, 33(3), 342-355.

Bean et al's 2006 study compares mental health data of samples of Dutch adolescents and of Unaccompanied Refugee Minors (URM) living in The Netherlands. The data, consisting primarily of CBCL's, TRF's and the Mental Health Questionnaire for Adolescents, was collected from adolescents, their guardians, and their teachers. The study found that roughly 57.8% of the URM population reported a need for mental health care relating to emotional distress, as compared to 8.2% of the Dutch control population. Furthermore, teachers and guardians for the URM population were more likely to report the need for mental health care, and 48.7% of URM respondents reported unmet MHC needs. Only 11.7% reported ever receiving professional MHC. Ultimately, Bean concludes that the number of stressful life events directly correlates with perception of mental health needs. As the URM population's guardians and teachers were not fully informed of their charges' traumatic experiences, this correlation could potentially explain caregivers' lower ratings for perceived mental health needs. Finally, Bean reports that URMs' length of stay in the Netherlands, especially over a year, could make these minors more likely to perceive need and seek mental health services. Furthermore, young age and the shielding effect of having another relative living in the Netherlands seem to represent significant protective factors. A supportive social network has, however, been illustrated to negatively affect use of mental health services. Primary methodological concerns present in Bean et al's study are both the relatively large non-response group (potentially indicative of a large subset of URMs experiencing avoidance or withdrawn behavior who were unwilling to participate in the study), and a diverse URM population. It remains unclear if cultural differences affected URMs' perception of certain questions asked. Ultimately, the study illustrates need for continued mental health screening for Unaccompanied Refugee Minors, as well as the provision of adequate living situations with informed adult involvement.

Derluyn, I., & Broekaert, E. (2007). Different perspectives on emotional and behavioural problems in unaccompanied refugee children and adolescents. Ethnicity and Health, 12(2), 141-162.

Derluyn and Broekaert focus on the unique circumstances contributing to increased incidence of psychiatric disorders among unaccompanied refugee minors as opposed to minor refugees accompanied by a nuclear family. They highlight the compounding influence of being a refugee, being in the middle of one's adolescence, being unaccompanied, and having to reintegrate into a radically different culture in large-scale institutional settings on unaccompanied minors' long term emotional state. They reference Porte and Tourney-Purta's (1987) conclusion that Indochinese unaccompanied refugee adolescents living in white foster or group homes had higher depressive scores than did those living with their families or Indochinese foster homes. In this particular study, the Hopkins Symptom Checklist-37 for Adolescents, a self-report SDQ, and Reactions of Adolescents to Traumatic Stress questionnaire were utilized to investigate emotional/behavioral problems and traumatic experiences in a sample of unaccompanied refugee minors. Social Workers or foster parents filled out the CBCL and SDQ-parent report in order to provide a comparison between self-report and caregiver perception of emotional problems. Unaccompanied youths, in comparison with accompanied refugees and newly-arrived refugees, had a much higher percentage of internalizing and emotional problems, particularly PTS, anxiety, and depression symptoms. Girls and those who had experienced a high number of traumas were found to be even more at risk for developing internalizing problems. In contrast, accompanied refugees reported more conduct problems. Other SDQ subscales such as hyperactivity and peer problems demonstrated little variation between groups. Ultimately, the study pointed to a heightened need for mental health screening and treatment for unaccompanied refugee minors. One limitation present in the study was, as in others, an uncertainty as to the effect of the sample population's diversity on the efficacy of the measures. Another limitation presented due to large sample size: more in-depth clinical interviews could not be conducted to shed light on individual resiliency and coping strategies.

Descilo, T., Greenwald, R., Schmitt, T. A., & Reslan, S. (2010). Traumatic incident reduction for urban at-risk youth and unaccompanied minor refugees: Two open trials. Journal of Child & Adolescent Trauma, 3(3), 181-191.

Descilo et al write about the efficacy of traumatic incident reduction (TIR) for child and adolescent trauma treatment. One of the two trials discussed in the article utilized TIR with a sample of unaccompanied minors from Central America detained in Miami. The authors commented that the detention facility in which the participants resided routinely offered trauma treatment to residents, and that the children were eager to participate in treatment. The TIR, which pairs one trauma memory with one session, averaged 7.5 sessions and correlated, in this case, with the average of 8 trauma memories reported. While questions arose as to the strength of the research findings, the PTSD checklist (PCL) showed reduced scores-from above 30 to below clinical range-in nearly all participants. Girls also showed greater PCL score reduction. According to the authors, this observation is more indicative of higher initial PCL scores rather than better response to TIR.

Fazel, M., Reed, R. V., Panter-Brick, C., & Stein, A. (2012). Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. The Lancet, 379(9812), 266-282.

Fazel et al present a systematic review of research regarding displaced and refugee children and provide a detailed discussion of both the risk and protective factors surrounding emotional and behavioral problems. The authors detail a list of current literature, broken down by focus on exposure to violence, age, sex, education, various family demographics, community integration, social support, ethnic origin, immigration process, and resettlement location as risk/protective factors for emotional and behavioral disturbances (as measured by scores on a variety of trauma-related and behavioral measures). While not specifically about unaccompanied minors, the article focuses on the effect of displacement and subsequent resettlement in a new, high-income country. Exposure to violence prior to migration is linked to heightened psychological disturbance. Unaccompanied children are also mentioned as frequently experiencing more adverse effects than their accompanied counterparts, and accompanied children were at a lower risk for internalizing and PTS symptoms. The authors summarize key risk and protective factors-each validated by at least two studies-for refugee children's mental health: exposure to pre-migration violence, female sex (internalizing), unaccompanied status, perceived discrimination, post-migration violence, several changes of residence in host country, parental exposure to violence, poor financial support, single parent and parental psychiatric problems were primary risk factors, and high parental support/family cohesion, self-reported support from friends, self-reported positive school experience, and same ethnic-origin foster care were primary protective factors. The article was unique in that it provided policy recommendations on individual, family and societal levels in order to mitigate the risk factors discussed above. Key recommendations included reduction in post-migration exposure to violence (including bullying, racism, and interfamily violence), providing access to physical and psychological health care, supporting safe cultural beliefs and practices, prioritizing reunification, providing family support, rapidly resolving asylum claims, and reducing inequalities in access to resources.

Huemer, J., Karnik, N. S., Voelkl-Kernstock, S., Granditsch, E., Dervic, K., Friedrich, M. H., & Steiner, H. (2009). Mental Health Issues in Unaccompanied Refugee Minors. Child and adolescent psychiatry and mental health, 3, 13.

This article presents a review of peer-reviewed journal articles from 1998-2008 detailing mental health issues among unaccompanied refugee minors (URMs). Overall, URMs were found to have higher PTSD levels than both a control population and accompanied refugees. Age and gender also affected PTSD scores. The article documents 5 types of studies: comparing URMs to accompanied minors and/or non-refugees, quantitative studies, follow-up studies, qualitative, intervention and health service studies, and validation of instruments. In all, it was noted that URMs are a highly vulnerable, difficult to locate group, and that female gender and age represent predictive factors for posttraumatic stress symptoms. In studying URM populations, care must be taken to account for extreme diversity of experience within the population, and to select culturally appropriate measures and apply multi-modal and culturally sensitive interventions.

Jakobsen, M., Demott, M. A., & Heir, T. (2014). Prevalence of Psychiatric Disorders Among Unaccompanied Asylum-Seeking Adolescents in Norway. Clinical practice and epidemiology in mental health: CP & EMH, 10, 53.

This study focused on detecting the prevalence of psychiatric morbidity in unaccompanied asylum-seeking children shortly upon arrival in a host country. As a group, the UASCs in this Norwegian study came from a variety of countries, primarily Afghanistan, Somalia and Iran. A majority had experienced life threatening events (82%), physical abuse (78%) or loss of a close relative (78%). 41.9% of participants met diagnostic criteria for a psychiatric disorder, with the most common being PTSD (30.6%), MDD (9.4%), Agoraphobia (4.4%) and GAD (3.8%). Jakobsen et al conclude that, as the levels of psychological stress in participants were relatively stable from time of arrival to time of interview, these psychiatric disorders were not likely a result of the stresses of being an asylum seeker. Rather, they were related to pre-migration experiences. Furthermore, the authors suggest that the high incidence of psychiatric diagnoses in the period shortly upon UASC's arrival contrasts the idea that many refugees experience a period of psychological well-being directly after arrival in a host country. Jakobsen et al also note that that there seemed to be a discrepancy between UASC's self-reported age and official age. An unaccompanied minor's age is frequently determined utilizing x-rays and dental exams. In this study, the mean self-reported age was 16.23 and the mean assessed age was 18.48. The highest self-reported age was 20, and highest assessed age was 28. In addition, the authors observe that male populations are typically easier to recruit for studies, as males comprise a majority of unaccompanied child refugees.

Jaycox, L., Stein, B., Kataoka, S., 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.

This study, while not directly concerned with unaccompanied child refugees, considers the link between exposure to violence and PTSD symptomology in a population of recent immigrants at a Los Angeles school. Jaycox et al utilized a modified Life Events Scale, the Child PTSD Symptom Scale, and the Children's Depression Index to collect data through the MHIP Intervention and Evaluation program. The study found a correlation between higher age, male gender, and increased violence exposure. Girls were more likely to report high levels of depressive symptoms compared with boys. Violence exposure, both pre- and post-migration, did correlate strongly with PTSD symptomology. The authors assert that recent immigrant children are at a high risk for violence exposure due to three reasons: refugee and non-refugee immigrants frequently come from areas characterized by violence and social unrest, many immigrants experience life-threatening violence during the migration process, and many recent immigrant children live in impoverished, stressful settings with an increased risk of violence exposure.

Ní Raghallaigh, M., & Gilligan, R. (2010). Active survival in the lives of unaccompanied minors: coping strategies, resilience, and the relevance of religion. Child & Family Social Work, 15(2), 226-237.

This study proposes to investigate specific coping mechanisms utilized by unaccompanied minors. Raghallaigh and Gilligan point to a growing body of literature that contrasts stressors' effects on unaccompanied minors' mental health with a strong resiliency and ability to employ coping mechanisms. Specific coping skills identified, through qualitative research, include maintaining continuity in a changed context, adjusting by learning and changing, adopting a positive outlook, suppressing emotions and seeking distraction, acting independently, and distrusting those around them. Religion was also noted to play a role in helping unaccompanied minors cope, as it filled in the space of missing families, and represented a familiar institution with which they had grown up. This article pushes for a strengths-based approach to interventions for unaccompanied minors.

Oppedal, B., & Idsoe, T. (2012). Conduct problems and depression among unaccompanied refugees: The association with pre-migration trauma and acculturation. Anales de Psicología, 28(3), 683-694.

This study investigated conduct problems, depression, and acculturation in a population of 566 refugees in Norway. The study population had been living in Norway for an average of 3.7 years at the time of data collection. Oppedal and Idsoe discuss the process of acculturation as having more risk factors than just discrimination. Both in-group demands to maintain a different culture and continued lack of cultural competency add barriers to acculturation. While a majority of study participants (81% of boys and 68% of girls) had experienced pre-migration war, and many still experienced intrusive symptoms, conduct problems were generally low in the population. Mean depression levels, however, were close to clinical cutoff ranges. A majority of respondents scored higher on ethnic than host competence, although both scores were above mid-point. Oppedal and Idsoe indicate that, in spite of the continued depressive symptoms, most respondents showed increased signs of cultural competence. Furthermore, while cultural competence was not correlated to conduct problems, both a sense of continued belonging to an ethnic heritage and increased cultural competence in a host country seem to be protective factors against depressive symptoms. A primary limitation in the article was the extreme diversity in the population of interest, with unclear variation between different cultural influences.

Seglem, K. B., Oppedal, B., & Raeder, S. (2011). Predictors of depressive symptoms among resettled unaccompanied refugee minors. Scandinavian journal of psychology, 52(5), 457-464.

This study presents similar data to Oppedal and Idsoe (2012). Referencing the tendency of previous literature to focus on traumatic experiences and posttraumatic stress reactions, it identifies depression, anxiety, somatization, and behavior problems as psychological conditions also likely to present in populations of unaccompanied minors. Utilizing data from a longitudinal study performed by the Norwegian Institute of Public Health, Seglem et al identified a sample of 414 unaccompanied refugee minors living in Norway. They administered the 20-item Center for Epidemiologic Studies-Depression Scale to generate mean CES-D scores and other depressive symptom data about the population of interest. In general, males reported lower depressive scores than did females, and age correlated with depressive scores. In addition, those minors living with family members, as well as minors from Somalia, reported lower overall depressive scores. Country of origin did seem to correlate with depressive scores. The authors conclude that the high depressive scores exhibited, even after resettlement, indicate increased risk for developing mental health problems.

Sourander, A. (1998). Behavior problems and traumatic events of unaccompanied refugee minors. Child abuse & neglect, 22(7), 719-727.

Sourander documents a study of 46 unaccompanied minors waiting for placement in Finland. The author initially notes that it was difficult to establish trust with the face to face interview participants; many participants were hesitant to discuss traumatic experiences. The development of a warm, empathetic relationship helped overcome such obstacles. In addition to the individual interview, participants' caregivers were also asked to complete a CBCL for each child. 48% of participants scored above the 83rd percentile in CBCL total scores. Furthermore, no significant differences were found in comparisons of sex, nationality, duration of flight, experiences of persecution, or death of parents in regard to CBCL total, internalizing, or externalizing scores. Age did seem to have a correlation, however. Participants ages 14 and younger received significantly higher externalizing, social problems, attention problems and aggressivity scores. The interview process allowed for a more nuanced consideration of individual minors' situations. Many minors' principal concern dealt with relatives' well-being in their home countries. Others were concerned with the long wait times to get permission to stay in the host country. Others described missing trusting adult relationships and lonely, boring experiences in the asylum centers.

Tyrer, R. A., & Fazel, M. (2014). School and community-based interventions for refugee and asylum seeking children: a systematic review. PloS one, 9(2).

Tyrer and Fazel present a review of studies of efficacious school or community-based mental health interventions for refugee or asylum-seeking children. A total of 21 studies were reviewed, with 14 occurring in high-income countries. Eleven of these studies were conducted in schools, and three in community settings. Two broad intervention types were identified: those focusing on the verbal processing of past experiences, and those utilizing creative art techniques. Five studies combined the two approaches. While both interventions reported significant reductions in depression, anxiety, PTSD, functional impairment and peer problems, the authors concluded that a focus on exposure to the event through verbal processing remains important, and is particularly efficacious through CBT. The review also mentions that only roughly half of the studies included monitored treatment fidelity and utilized follow up assessments, control groups, and blind assessments.

Vervliet, M., Lammertyn, J., Broekaert, E., & Derluyn, I. (2014). Longitudinal follow-up of the mental health of unaccompanied refugee minors. European child & adolescent psychiatry, 23(5), 337-346.

Vervliet et al present a longitudinal study of 103 unaccompanied minors in Belgium. The authors utilized SLE, HSCL-37A, RATS and DSSYR at arrival and after 6 and 18 months to document generally high anxiety, depressive, and PTS scores. Little variation was observed over time. These consistently high scores over time led to the hypothesis that daily stressors, as well as trauma exposure, contribute to elevated mental health scores.

Vervliet, M., Meyer Demott, M. A., Jakobsen, M., Broekaert, E., Heir, T., & Derluyn, I. (2014). The mental health of unaccompanied refugee minors on arrival in the host country. Scandinavian Journal of Psychology, 55(1), 33-37.

This study, a counterpart to the longitudinal study described above, utilized the same measures to investigate the mental health status of unaccompanied minors shortly after arrival in Belgium. Similarly elevated scores for anxiety, depression and PTSD symptoms were found, with the number of traumatic events experienced correlating to elevated scores.

Reports

This report, produced by the Women's Refugee Commission, provides an overview of the conditions precipitating the influx of unaccompanied minor immigration to the US from Central America-primarily from El Salvador, Guatemala, Mexico and Honduras. In addition, it discusses potentially traumatic experiences and stressors incurred during the journey, as well as experiences upon arrival and detention in the US. The report details country-specific trauma experienced by children, including gang violence, sexual assault, gender-based violence, severe deprivation and adult/caretaker substance abuse and incapacitation. Excerpts from interviews with children who have made the journey further compound these traumas with those abuses experienced during the dangerous trip to America. Gang members frequent the trains taking children north, looking to recruit and punish those trying to escape. The report continues on to describe conditions unaccompanied minors face as they await foster placement and legal decisions regarding their refugee status. It offers detailed recommendations regarding HHS, DHS and DOJ protocols.

Luis Flores, M. A., Executive Vice President, S. C. A. N., & Kaplan, A. (2009). Addressing the Mental Health Problems of Border and Immigrant Youth.

This report, produced by NCTSN, is not specific to unaccompanied minors. Rather, it addresses the need for culturally competent mental health care in immigrant communities. The report addresses mental health professionals working in Latino communities, and highlights the importance of addressing misconceptions and knowledge gaps regarding mental health problems and subsequent treatment. NCTSN reports a high occurrence of trauma-related substance use in the border region. It posits that such use is potentially linked to feelings of insecurity and uncertainty and exposure to violence. The report also notes higher rates of mood disorders for US-born Mexican Americans as compared to their foreign-born counterparts, endorsing the idea that "traditional cultural retention may be a protective factor of the mental health of individuals of Mexican descent." Furthermore, Latino immigrants face significant barriers to mental health care. Those without legal status are hesitant to seek out care or are not able to access care. Those who do try to seek care might be intimidated by a system with which they are unfamiliar, or might be forced to prioritize other necessities over securing mental health care. Finally, NCTSN points out that there is not only a general shortage of mental health professionals in the border region, but also a profound lack of Latino mental health providers. Solutions offered to address such barriers and enhance mental health services in the border region include providing culturally-relevant care, overcoming language barriers, preparing families to receive services, integrating culturally-modified EBPs, achieving biculturalism, and encouraging inter-agency coalitions and outreach.

Lustig, S. L., Kia-Keating, M., Knight, W. G., Geltman, P., Ellis, H., Kinzie, J. D., & Saxe, G. N. (2004). Review of child and adolescent refugee mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 43(1), 24-36.

This report, published by the Refugee Trauma Task Force, provides an overview of both the phases of the refugee experience (preflight, flight and resettlement) and the stresses affecting children during each stage (combat experience, separation from caregivers, refugee camps, detention centers, acculturation, and stigma). The report highlights the psychopathological outcomes from such stressors, and devotes the final section to a discussion of interventions for refugee children and their families. Due to underutilization, stigma, language barriers, and the prioritizing of other pressing needs, traditional Western mental health approaches are not always efficacious with immigrants and refugees. Therefore, interventions must be adapted to fit target populations. Broadly, such interventions should focus on prevention, consultation, outreach, and trauma treatment. Within this framework, intervention settings must be adapted, caregivers must be involved in the treatment, and service providers must exhibit linguistic and cultural competency. Eleven recommendations are offered for clinicians working with refugee populations. These recommendations include addressing social needs early, facilitating cultural support, utilizing counselors familiar with or from a child's culture, remaining cognizant of developmental vulnerabilities, remaining aware of stigma surrounding mental health care, referring refugees to other medical practitioners to treat problems that may exacerbate mental health conditions, accounting for somatization as a common presentation for underlying psychopathology, identifying coping strategies refugees might have utilized in the past, encouraging alternatives to "talk therapy," remembering that talking about traumatic events may not be seen as valuable by refugees from cultures with different psychological models, and accounting for ongoing traumatic triggers.

Analytical/Case Studies

Aldarondo, E., & Becker, R. (2011). Promoting the Well-Being of Unaccompanied Immigrant Minors. In Creating Infrastructures for Latino Mental Health (pp. 195-214). Springer New York.

This article focuses on unaccompanied Latino minors in the US. It estimates that 85% of unaccompanied minors in the United States have arrived from Honduras, Guatemala or El Salvador. 74% are males between the ages of 15 and 18 years. Many report making the journey to the US to either escape harmful situations in their home countries or to reunite with relatives already in the US, and one-fifth of all youth interviewed reported being abused at some point on their journey. Common risks during the journey include being smuggled for domestic servitude or sex work or encountering violence and abuse by strangers, smugglers, or Border Patrol. The article provides a discussion of trauma experience and resiliency/coping skills present in populations of UAM's around the world, and also concisely summarizes the US government's response to unaccompanied minors. While the Office of Refugee Resettlement has, according to the authors, made improvements to the detention and resettlement process, the non-profit detention centers contracted by the ORR to house unaccompanied minors do not always meet the standards of care put in place. The United States' system is described in comparison with other countries as having "frequently detained youth for longer periods of time and under harsher conditions." In contrast, the Australian system is described as the most progressive response to the unaccompanied minor situation. Australia's Unaccompanied Humanitarian Minor Program provides protection to all unaccompanied minors, regardless of legal status, and offers permanent protection visas that ensure access to a full range of government services and benefits. Finally, while Aldarondo and Becker assert that much more than local community responses are necessary to improve unaccompanied minors' situation in the US, they describe one local partnership that has successfully advocated for South Florida unaccompanied minors' legal and mental health care needs. ICLASP, the Immigrant Children Affirmative Network Program, is a university-community partnership focusing on "the creation and dissemination of an integrated, child-centered model of expert legal counsel and advocacy, trauma-oriented mental health services, resilience-building youth development programming, and professional development of staff caring for UIMs in local detention facilities." Its implementation is described in some detail and is encouraged as a format for other community organizations to adopt.

Braein, M., & Christie, H. J. (2011). Therapy with Unaccompanied Refugees and Asylum-Seeking Minors. Today's Children are Tomorrow's Parents, 30, 31, 102-116.

Braein and Christie present two case studies detailing different treatment courses for two unaccompanied minors with different trauma experiences. An initial discussion of trauma experience by unaccompanied minors indicates that complex PTSD or Developmental Trauma Disorder might be more satisfactory characterizations of minors' experiences and condition, as opposed to a PTSD diagnosis. Repeated exposure to war, poverty, neglect, and abuse has been shown to correlate to chronically high pulse rates and levels of noradrenaline and adrenaline that persist for months after a child has been placed in a safe environment. Unaccompanied minors, lacking the parental support that has been shown to mitigate such effects, are particularly vulnerable. These youth should ideally be placed in situations that will allow them to form lasting close relationships. Furthermore, adolescent coping strategies and trauma symptoms have been shown to vary by culture, and treatment must therefore reflect a level of cultural sensitivity and creativity. The authors suggest a phase-oriented treatment model (stabilization and symptom reduction, processing of traumatic memories, and personality integration and rehabilitation), within which may be incorporated TF-CBT and narrative exposure therapy. Within this framework, they stress the importance of recognizing culturally-ingrained avoidance of unpleasant topics and a refusal to discuss openly. Such reticence may be further compounded by fear of political or social repercussions. An emphasis on openness as an encouraged trait in the culture in which the treatment is taking place may help mitigate some of these fears. Art therapy is also stressed as a means of allowing flexibility and providing an ideal medium through which a shy child might feel comfortable expressing himself.

Carlson, B. E., Cacciatore, J., & Klimek, B. (2012). A risk and resilience perspective on unaccompanied refugee minors. Social work, 57(3), 259-269.

Carlson et al acknowledge that the dearth of US-based research on unaccompanied refugee minors (URMs) presents an obstacle for developing evidence-based programs through which to support this vulnerable population. They also indicate that research performed in Europe might not have direct application for situations in the US. In a discussion of such research, however, the authors indicate that the most common risk factors for precipitating psychiatric disorders in URMs include loss of a parent, separation from family, exposure to multiple traumas, and post-migration stressors such as unfamiliar language, frequent moves, and discrimination. The fact that not all children exposed to such risk factors develop adverse outcomes can then be explained due to the presence of protective factors. The factors are presented in detail in three categories: individual protective factors include intelligence, good coping skills and female gender; family protective factors include close parental supervision, support and stability; societal protective factors include close attachments to other adults and prosocial institutions. The authors progress to an in-depth case study of Jany, a Sudanese refugee. Utilizing his story, they decompress each protective factor and discuss the ways in which unaccompanied refugee minors can be systemically connected to such factors.

Eshuis, L. (2012). Unaccompanied Minors: Their Journey from Central America to West Michigan.

This undergraduate honors thesis provides a descriptive summary of the journey unaccompanied minors must undertake from Central America to the US. Much emphasis is placed on the trauma experienced prior to and during migration. Eshuis relies upon case studies and personal interviews published in existing literature to document a diversity of experiences among unaccompanied minors. The report concludes with a case study of Bethany Christian Services in Michigan, exploring the ways in which case workers respond to unaccompanied minors and form partnerships to connect with more resources. Gaps in the services provided for unaccompanied minors, particularly education and trauma counseling, are highlighted as well.

Kholi, R. & Mather, R. (2003). Promoting Psychosocial Well-Being in unaccompanied Asylum Seeking Young People in the United Kingdom. Child and Family Social Work, 2003(8), 201-212.

The article authors discuss particular challenges faced by unaccompanied asylum seeking young people. These minors, united by a desire to get away from harmful situations, experience a three-fold fracturing-past, present, and future-in their sense of belonging. Not only are unaccompanied asylum seekers typically trying to escape from a traumatizing family or political situation, but they are faced with navigating a complex, confusing infrastructure upon arrival in another country. They are further isolated by the sense of an uncertain future and uncertain citizenship. This instability in personal identity and connectedness robs these children of the social nurturing that typically facilitates healing from the multiple additional traumas experienced. Kholi and Mather continue on to highlight the unique vulnerability characterizing the UACs. Summarizing existing research, they indicate that unaccompanied refugee children are troubled by repetitive, intrusive thoughts, flashbacks and nightmares. They also have difficulty concentrating, grasping new material and remembering old skills, and experience survivor's guilt or find it difficult to plan for the future. Despite these vulnerabilities, unaccompanied asylum seeking children exhibit an intense resiliency that makes certain types of interventions quite productive. Such interventions focus on belonging, thinking, agency, and cultural integration. Specifically, the young asylum seekers program (YAS) in the United Kingdom is highlighted as a way to help UACs recovery from isolation, learn to utilize skills and promote talents, learn new skills and connect with helpful people. Helping youth form personal and social connections with their own ideas and with the society in which they now live remains a focus throughout the article. Quoting an earlier article (Howe et al, 1999), the authors assert that: "the complex interplay between the past and the present, the psychological inside and the social outside, is the dance that practitioners have to understand if they are to make sense of what is going on and intervene appropriately and effectively."

Concept Papers

Derluyn, I., & Broekaert, E. (2008). Unaccompanied refugee children and adolescents: The glaring contrast between a legal and a psychological perspective. International Journal of Law and Psychiatry, 31(4), 319-330.

This article highlights the tension between a legal and psychological perspective in regard to unaccompanied refugee children. Derluyn and Broekaert detail the effects of exposure to type II prolonged trauma, particularly as it is compounded by both the loss of family and the acculturation process. They review existing literature on the psychological outlooks for unaccompanied refugee children. Much of the article is devoted to Belgium's legal system as it defines and relates to unaccompanied minors. While such discussion of the specific political classification and treatment of unaccompanied refugee children in Belgium is perhaps not relevant to the US, the overarching tension between whether access to mental health care should be secured by demonstrated psychological need or limited by political definition summarizes a debate emerging in the US as well. The authors conclude that not only does the legal perspective currently heavily outweigh psychological considerations in care decisions for unaccompanied minors, but that the largely circumstantial decision to seek asylum upon entry into Belgium strongly influences an unaccompanied minor's subsequent access to care.

Fortuna, L., & Porche, M. (2013). Clinical Issues and Challenges in Treating Undocumented Immigrants. Psychiatric Times, special reports.

This article, written by a psychiatrist regularly treating undocumented immigrants in the US, describes the double-edged sword that is mental health care for undocumented immigrants. The author reports a number of psychosocial stressors for the population, including trauma experienced during migration, financial and legal burdens in the US, and the pressure of constant fear and vigilance. Such stressors may lead to an increase in psychological problems. Undocumented immigrants are not in a position, however, to seek mental health care for such problems. Fear of being deported, limited access to care, and barriers to care such as language barriers all contribute to reduced treatment options. Therefore, social support systems must be implemented in concert with culturally relevant mental health interventions. Considerations such as providing for bilingual clinicians, introducing brief, solution-oriented treatments, and partnering with churches or other community organizations to provide a sense of belonging must be taken in to account

Helping Unaccompanied Asylum-seeking Children. (2008, April 16). Retrieved July 17, 2014, from http://www.communitycare.co.uk/2008/04/16/helping-unaccompanied-asylum-seeking-children-2.

This webpage describes a rough outline for a multi-agency intervention in the UK targeted at improving unaccompanied minors' emotional well-being and decreasing isolation. While little detail is provided, the document points to a core theory regarding the mental health and emotional needs of unaccompanied minors shortly upon arrival in a different country.

Kennedy, E. G. (2013). Unnecessary Suffering: Potential Unmet Mental Health Needs of Unaccompanied Alien Children. JAMA pediatrics, 167(4), 319-320.

This article focuses on the mental health implications of an unaccompanied alien child's uncertain legal status in the US. UACs, as opposed to unaccompanied refugee minors, are not entitled to comprehensive medical care while in custody. Whereas refugee minors receive care until the age of 21, UACs lose access to any care opportunities upon release from detention facilities. Within 72 hours of arriving at traditional detention facilities, UACs are transferred to Office of Refugee Resettlement (ORR) care. Kennedy observes that, while certain mental health care provisions are in place at these facilities, a wider effort to implement comprehensive mental health screening and treatment could present a cost-effective, efficacious option. Many UACs, upon release from the ORR detention facilities, will have limited access to healthcare. Therefore, their time at the ORR provides an ideal setting for diagnosis and treatment to hopefully ameliorate symptoms from previous trauma and to protect against the development of increased symptomatology upon release into the stresses of a hostile society with little access to services.

Rodriguez, A. (2013). The Migration of Unaccompanied Children from Central America to the United States: Social Causes and Psychological Effects. Sabiduría, 2-4.

This article provides a concise summary of the current unaccompanied minor influx in the US. It provides detail as to why children choose to leave their home countries, as well as the traumas faced along the way that can compound psychological problems. In many cases, the smugglers paid to bring children to the US mistreat and abuse their charges. Other children make the extremely dangerous journey atop freight trains.