User login
Care providers encountered significant challenges when addressing the mental health needs of unaccompanied immigrant children in federal custody, including overwhelming caseloads and the deteriorating mental health of some patients, according to a new report by the Office of Inspector General (OIG).
In the report, released Sept. 3, the OIG outlined findings from its analysis of 45 Office of Refugee Resettlement (ORR) facilities between August and September 2018. The U.S. Department of Health & Human Services ORR is the legal custodian of unaccompanied immigrant children in its care who have no parent or legal guardian available. This includes children who arrive in the United States unaccompanied and children who are separated from their parents or guardians by immigration authorities after arriving in the country.
For the analysis, OIG investigators collected data from interviews with mental health clinicians, medical coordinators, facility leadership, and ORR federal field specialists at the 45 selected facilities.
Investigators recorded numerous serious challenges experienced by providers when attempting to provide mental health care to the children. Namely, they cited overwhelming patient caseloads, and difficulty accessing external mental health clinicians and referring children to providers within ORR’s network, according to the OIG’s report.
Mental health clinicians reported that the high caseloads hurt their ability to build rapport with young patients – and allowed less time for counseling and less frequent sessions for children with greater needs. The heavy caseloads were generated by heightened immigration enforcement beginning in 2017, and the separation of many more families at the border and more children being placed in federal custody, according to the report.
In addition, providers reported challenges when addressing the mental health needs of children who had experienced significant trauma before coming into federal custody. This included trauma that occurred while the children lived in the countries of origin, trauma during their journey to the United States, and trauma upon their arrival in the United States.
Separation from parents and a chaotic reunification process added to the trauma that children had already experienced, providers reported, and put extreme pressure on facility staff. Separated children exhibited “more fear, feelings of abandonment, and posttraumatic stress than did children who were not separated,” according to the findings. Separated children also experienced elevated feelings of anxiety and loss as a consequence of unexpected separation from loved ones.
Also, facilities reported that longer lengths of stay resulted in deteriorating mental health for some children and increased demands on staff. Facilities reported that children who stayed in federal custody for longer periods experienced more stress, anxiety, and behavioral issues. According to the facilities, the longer stays resulted in higher levels of defiance, hopelessness, and frustration among children – in addition to more instances of self-harm and suicidal ideation.
It is not surprising that the OIG study reflects that mental health services at facilities for unaccompanied minors are understaffed, undertrained, and overwhelmed, said Craig L. Katz, MD, a clinical professor of psychiatry at Mount Sinai in New York.
“In some sense, this can probably be said for most of the U.S. and definitely the world when it comes to child mental health services,” Dr. Katz said in an interview. “But, what’s especially tough to stomach about this shortfall at these facilities is that they encompass an immensely high-risk population – an inevitably highly, if not multiply traumatized population of children who lack primary caregivers.”
Dr. Katz was coinvestigator of a recent study that assessed the mental health of children held at a U.S. immigration detention center through the Parent-Report Strengths and Difficulties Questionnaire. Among the 425 children evaluated, many demonstrated elevated scores for emotional problems, peer problems, and total difficulties, according to the June 2018 study, published in Social Science & Medicine (2019 Jun; 230:303-8). Younger children (aged 4-8 years) demonstrated more difficulties associated with conduct, hyperactivity, and total difficulties, compared with older children, the study found.
Children who had been forcibly separated from their mothers demonstrated significantly more emotional problems and total difficulties, compared with those who had never been separated. Of 150 children who completed the Posttraumatic Stress Disorder Reaction Index, 17% had a probable diagnosis of PTSD, results found.
Dr. Katz said the OIG reached the same basic conclusion as his quantitative study – that separated minors appear to have even greater mental health problems than do fellow unaccompanied minors.
“In our study, we found that children in family detention had greater mental health problems than [did] American community samples but that formerly separated children who had been reunited with their mothers had even more health problems than their fellow detainees,” Dr. Katz said. “Something about being separated per U.S. policy was especially pernicious, which we knew in our hearts; but now in this study and ours, we know empirically.”
As long as the United States continues to detain children, the psychological harm created by such detainments is likely to continue, said Kim A. Baranowski, PhD, a psychologist and lecturer at Columbia University in New York. At a minimum, unaccompanied minors should have access to highly trained licensed clinicians who can respond to their immediate mental health needs within the initial hours and days following their arrival in the United States, and such children should be released rapidly from government custody and reunited with their families, said Dr. Baranowski, a coauthor of the Social Science & Medicine study.
“We need to effectively support their integration into the community, and connect children and their families with linguistically, culturally, and developmentally appropriate trauma-informed pro bono treatment services that respond to their experiences” of premigration, migration, and postmigration stressors, “as well as potential exposure to trauma,” she said in an interview.
The OIG issued several recommendations for practical steps that ORR can take to assist facilities and better provide mental health care to immigrant children in federal custody. The agency advised that the ORR should provide facilities with evidence-based guidance on addressing trauma in short-term therapy and that the ORR also should develop strategies for overcoming challenges to hiring and retaining qualified mental health clinicians.
The Office of Inspector General also suggested that facilities consider maximum caseloads for individual clinicians. Finally, the OIG recommends that ORR address gaps in options for children who require more specialized treatment and that the office take reasonable steps to minimize the length of time that children remain in custody.
agallegos@mdedge.com
*This article was updated 9/5/2019.
Care providers encountered significant challenges when addressing the mental health needs of unaccompanied immigrant children in federal custody, including overwhelming caseloads and the deteriorating mental health of some patients, according to a new report by the Office of Inspector General (OIG).
In the report, released Sept. 3, the OIG outlined findings from its analysis of 45 Office of Refugee Resettlement (ORR) facilities between August and September 2018. The U.S. Department of Health & Human Services ORR is the legal custodian of unaccompanied immigrant children in its care who have no parent or legal guardian available. This includes children who arrive in the United States unaccompanied and children who are separated from their parents or guardians by immigration authorities after arriving in the country.
For the analysis, OIG investigators collected data from interviews with mental health clinicians, medical coordinators, facility leadership, and ORR federal field specialists at the 45 selected facilities.
Investigators recorded numerous serious challenges experienced by providers when attempting to provide mental health care to the children. Namely, they cited overwhelming patient caseloads, and difficulty accessing external mental health clinicians and referring children to providers within ORR’s network, according to the OIG’s report.
Mental health clinicians reported that the high caseloads hurt their ability to build rapport with young patients – and allowed less time for counseling and less frequent sessions for children with greater needs. The heavy caseloads were generated by heightened immigration enforcement beginning in 2017, and the separation of many more families at the border and more children being placed in federal custody, according to the report.
In addition, providers reported challenges when addressing the mental health needs of children who had experienced significant trauma before coming into federal custody. This included trauma that occurred while the children lived in the countries of origin, trauma during their journey to the United States, and trauma upon their arrival in the United States.
Separation from parents and a chaotic reunification process added to the trauma that children had already experienced, providers reported, and put extreme pressure on facility staff. Separated children exhibited “more fear, feelings of abandonment, and posttraumatic stress than did children who were not separated,” according to the findings. Separated children also experienced elevated feelings of anxiety and loss as a consequence of unexpected separation from loved ones.
Also, facilities reported that longer lengths of stay resulted in deteriorating mental health for some children and increased demands on staff. Facilities reported that children who stayed in federal custody for longer periods experienced more stress, anxiety, and behavioral issues. According to the facilities, the longer stays resulted in higher levels of defiance, hopelessness, and frustration among children – in addition to more instances of self-harm and suicidal ideation.
It is not surprising that the OIG study reflects that mental health services at facilities for unaccompanied minors are understaffed, undertrained, and overwhelmed, said Craig L. Katz, MD, a clinical professor of psychiatry at Mount Sinai in New York.
“In some sense, this can probably be said for most of the U.S. and definitely the world when it comes to child mental health services,” Dr. Katz said in an interview. “But, what’s especially tough to stomach about this shortfall at these facilities is that they encompass an immensely high-risk population – an inevitably highly, if not multiply traumatized population of children who lack primary caregivers.”
Dr. Katz was coinvestigator of a recent study that assessed the mental health of children held at a U.S. immigration detention center through the Parent-Report Strengths and Difficulties Questionnaire. Among the 425 children evaluated, many demonstrated elevated scores for emotional problems, peer problems, and total difficulties, according to the June 2018 study, published in Social Science & Medicine (2019 Jun; 230:303-8). Younger children (aged 4-8 years) demonstrated more difficulties associated with conduct, hyperactivity, and total difficulties, compared with older children, the study found.
Children who had been forcibly separated from their mothers demonstrated significantly more emotional problems and total difficulties, compared with those who had never been separated. Of 150 children who completed the Posttraumatic Stress Disorder Reaction Index, 17% had a probable diagnosis of PTSD, results found.
Dr. Katz said the OIG reached the same basic conclusion as his quantitative study – that separated minors appear to have even greater mental health problems than do fellow unaccompanied minors.
“In our study, we found that children in family detention had greater mental health problems than [did] American community samples but that formerly separated children who had been reunited with their mothers had even more health problems than their fellow detainees,” Dr. Katz said. “Something about being separated per U.S. policy was especially pernicious, which we knew in our hearts; but now in this study and ours, we know empirically.”
As long as the United States continues to detain children, the psychological harm created by such detainments is likely to continue, said Kim A. Baranowski, PhD, a psychologist and lecturer at Columbia University in New York. At a minimum, unaccompanied minors should have access to highly trained licensed clinicians who can respond to their immediate mental health needs within the initial hours and days following their arrival in the United States, and such children should be released rapidly from government custody and reunited with their families, said Dr. Baranowski, a coauthor of the Social Science & Medicine study.
“We need to effectively support their integration into the community, and connect children and their families with linguistically, culturally, and developmentally appropriate trauma-informed pro bono treatment services that respond to their experiences” of premigration, migration, and postmigration stressors, “as well as potential exposure to trauma,” she said in an interview.
The OIG issued several recommendations for practical steps that ORR can take to assist facilities and better provide mental health care to immigrant children in federal custody. The agency advised that the ORR should provide facilities with evidence-based guidance on addressing trauma in short-term therapy and that the ORR also should develop strategies for overcoming challenges to hiring and retaining qualified mental health clinicians.
The Office of Inspector General also suggested that facilities consider maximum caseloads for individual clinicians. Finally, the OIG recommends that ORR address gaps in options for children who require more specialized treatment and that the office take reasonable steps to minimize the length of time that children remain in custody.
agallegos@mdedge.com
*This article was updated 9/5/2019.
Care providers encountered significant challenges when addressing the mental health needs of unaccompanied immigrant children in federal custody, including overwhelming caseloads and the deteriorating mental health of some patients, according to a new report by the Office of Inspector General (OIG).
In the report, released Sept. 3, the OIG outlined findings from its analysis of 45 Office of Refugee Resettlement (ORR) facilities between August and September 2018. The U.S. Department of Health & Human Services ORR is the legal custodian of unaccompanied immigrant children in its care who have no parent or legal guardian available. This includes children who arrive in the United States unaccompanied and children who are separated from their parents or guardians by immigration authorities after arriving in the country.
For the analysis, OIG investigators collected data from interviews with mental health clinicians, medical coordinators, facility leadership, and ORR federal field specialists at the 45 selected facilities.
Investigators recorded numerous serious challenges experienced by providers when attempting to provide mental health care to the children. Namely, they cited overwhelming patient caseloads, and difficulty accessing external mental health clinicians and referring children to providers within ORR’s network, according to the OIG’s report.
Mental health clinicians reported that the high caseloads hurt their ability to build rapport with young patients – and allowed less time for counseling and less frequent sessions for children with greater needs. The heavy caseloads were generated by heightened immigration enforcement beginning in 2017, and the separation of many more families at the border and more children being placed in federal custody, according to the report.
In addition, providers reported challenges when addressing the mental health needs of children who had experienced significant trauma before coming into federal custody. This included trauma that occurred while the children lived in the countries of origin, trauma during their journey to the United States, and trauma upon their arrival in the United States.
Separation from parents and a chaotic reunification process added to the trauma that children had already experienced, providers reported, and put extreme pressure on facility staff. Separated children exhibited “more fear, feelings of abandonment, and posttraumatic stress than did children who were not separated,” according to the findings. Separated children also experienced elevated feelings of anxiety and loss as a consequence of unexpected separation from loved ones.
Also, facilities reported that longer lengths of stay resulted in deteriorating mental health for some children and increased demands on staff. Facilities reported that children who stayed in federal custody for longer periods experienced more stress, anxiety, and behavioral issues. According to the facilities, the longer stays resulted in higher levels of defiance, hopelessness, and frustration among children – in addition to more instances of self-harm and suicidal ideation.
It is not surprising that the OIG study reflects that mental health services at facilities for unaccompanied minors are understaffed, undertrained, and overwhelmed, said Craig L. Katz, MD, a clinical professor of psychiatry at Mount Sinai in New York.
“In some sense, this can probably be said for most of the U.S. and definitely the world when it comes to child mental health services,” Dr. Katz said in an interview. “But, what’s especially tough to stomach about this shortfall at these facilities is that they encompass an immensely high-risk population – an inevitably highly, if not multiply traumatized population of children who lack primary caregivers.”
Dr. Katz was coinvestigator of a recent study that assessed the mental health of children held at a U.S. immigration detention center through the Parent-Report Strengths and Difficulties Questionnaire. Among the 425 children evaluated, many demonstrated elevated scores for emotional problems, peer problems, and total difficulties, according to the June 2018 study, published in Social Science & Medicine (2019 Jun; 230:303-8). Younger children (aged 4-8 years) demonstrated more difficulties associated with conduct, hyperactivity, and total difficulties, compared with older children, the study found.
Children who had been forcibly separated from their mothers demonstrated significantly more emotional problems and total difficulties, compared with those who had never been separated. Of 150 children who completed the Posttraumatic Stress Disorder Reaction Index, 17% had a probable diagnosis of PTSD, results found.
Dr. Katz said the OIG reached the same basic conclusion as his quantitative study – that separated minors appear to have even greater mental health problems than do fellow unaccompanied minors.
“In our study, we found that children in family detention had greater mental health problems than [did] American community samples but that formerly separated children who had been reunited with their mothers had even more health problems than their fellow detainees,” Dr. Katz said. “Something about being separated per U.S. policy was especially pernicious, which we knew in our hearts; but now in this study and ours, we know empirically.”
As long as the United States continues to detain children, the psychological harm created by such detainments is likely to continue, said Kim A. Baranowski, PhD, a psychologist and lecturer at Columbia University in New York. At a minimum, unaccompanied minors should have access to highly trained licensed clinicians who can respond to their immediate mental health needs within the initial hours and days following their arrival in the United States, and such children should be released rapidly from government custody and reunited with their families, said Dr. Baranowski, a coauthor of the Social Science & Medicine study.
“We need to effectively support their integration into the community, and connect children and their families with linguistically, culturally, and developmentally appropriate trauma-informed pro bono treatment services that respond to their experiences” of premigration, migration, and postmigration stressors, “as well as potential exposure to trauma,” she said in an interview.
The OIG issued several recommendations for practical steps that ORR can take to assist facilities and better provide mental health care to immigrant children in federal custody. The agency advised that the ORR should provide facilities with evidence-based guidance on addressing trauma in short-term therapy and that the ORR also should develop strategies for overcoming challenges to hiring and retaining qualified mental health clinicians.
The Office of Inspector General also suggested that facilities consider maximum caseloads for individual clinicians. Finally, the OIG recommends that ORR address gaps in options for children who require more specialized treatment and that the office take reasonable steps to minimize the length of time that children remain in custody.
agallegos@mdedge.com
*This article was updated 9/5/2019.