Introduction

As increasing numbers of immigrants and refugees become a part of the fabric of the United States, pediatric and adolescent mental health services have needed to adapt and respond to the demand for culturally appropriate services. Mental health services must also respond to the specific social stressors and mental health needs encountered by immigrant youth; in addition to a base rate of psychopathology, the specific circumstances of migration and resettlement may contribute to some immigrant and refugee children being at higher risk for certain disorders. Some immigrants and refugees have experienced or witnessed violence or atrocities in their home country or faced significant danger and adversity during the migration process. All immigrant youth must face the challenges of adjusting to a new culture and navigating the sometimes pro-found cultural divide between their family’s culture and the culture of their new home. Stressors both prior to leaving the home country and after resettlement can contribute to an increased risk for a variety of disorders, in particular post-traumatic stress disorder and depressive disorders. This chapter will briefly review the prevalence of mental health problems in child and adolescent immigrants and refugees and then present current treatment modalities and special treatment considerations in working with this population.

Mental Health of Child and Adolescent Immigrants and Refugees

Studies of refugee youth suggest that they are at heightened risk for developing mental health problems.¹ In a recent study of 300 children ages 5–18 attending schools in the UK, 100 of whom were refugees, more than 25% of refugee children reported experiencing significant psychological disturbance – more than three times the national average and significantly greater than non-refugee students surveyed.² Studies of refugee youth resettled in the United States show rates of post-traumatic stress disorder (PTSD) ranging from 25% to 50%.^3,⁴ What little longitudinal work has been done suggests that PTSD, in particular, remains relatively persistent in refugee youth over time.^4,⁵ Sack and colleagues⁴ assessed Cambodian adolescents four times over a period of 12 years, with the first assessment occurring a few years after resettlement; they found that at initial assessment and 3 years later around half of the youth met criteria for PTSD (50% and 48%, respectively), and 12 years later this remained as high as 35%. Depression has also been found to be of significance in refugee and immigrant child and adolescent populations, though somewhat less frequently than post-traumatic stress disorder.^3,⁴

Studies of immigrant children, in contrast, have shown mixed findings. Several studies report no difference in rates of psychopathology in immigrants compared to non-immigrants.^6,⁷ Exposure to particular risk factors, such as trauma, increases the likelihood that an immigrant child will experience mental health problems following resettlement.⁸ A recent study by Jaycox and colleagues found that immigrant children and adolescents were at risk for both violence exposure and the development of PTSD, with 32% of 1004 immigrant schoolchildren surveyed reporting symptoms in the clinical range.⁹

In light of the extremely high rates of trauma that have been identified within many refugee and immigrant communities, the fact that many of these children do not develop mental health problems points to a great resilience among some children and families. Indeed, within the child refugee field, scholars have pointed out the need to avoid overpathologizing refugees and the importance of not assuming that the experience of trauma necessarily leads to disturbances in mental health.¹⁰ For the subset of children who do present with symptoms of mental health problems, however, the provision of culturally consonant, trauma-informed mental healthcare is critical.

Mental Health Interventions for Immigrant and Refugee Youth

Before embarking on a discussion of models of intervention for immigrant youth, the following questions must be addressed: who is receiving the intervention, what is the problem to be targeted, and within what service system will the intervention be delivered?

For whom is the intervention?

This question, while seemingly basic, addresses several fundamental variables that must be considered in choosing an intervention approach. On one level, the interventionist must decide whether the intervention is for the individual child, the family, or even more broadly for a whole community. Appropriate conceptualization of mental health, illness, and healing among diverse cultural groups is important for ensuring the relevance and effectiveness of interventions.¹¹ For example, in many of the regions from which today’s immigrants and refugees originate, more emphasis is placed on the community and collective relationships rather than on the individual, which is common in Western cultures.^12,¹³ In this light, cultural views of mental health, trauma, and healing may be quite different from those in Western host countries, which place a great deal of emphasis on the self as a focal point for treatment. Sensitivity to how a given culture thinks about individuality versus collectivity can also be applied to improve the structure and delivery of mental health services for different immigrant groups. For example, individual therapy approaches may not be the most comfortable starting point for some groups, whereas interventions that integrate psychoeducation into existing community-based activities may be more palatable and can provide a pathway for those needing a higher level of care to be screened and introduced to other forms of services. Interventions that overlook such fundamental cultural differences may be counterproductive for treating multicultural immigrant and refugee populations and fail to tap existing resources to promote mental health and healing.

Once the level of intervention has been decided, additional cultural or historical factors may influence the intervention approach. Culture can greatly influence a family’s willingness to engage in treatment, perceptions of mental health services, and explanatory models regarding the child’s problems and path to healing.¹⁴ Within some cultures, such as Central Americans, a family therapy model has been identified as particularly consonant with cultural values and practices.¹⁵ Other factors that may influence the treatment approach relate to the historical experience of a child. Recently immigrated families may best benefit from a treatment that focuses on initial adjustment, orientation, and an establishment of safety and security.¹⁶ Indeed, given the many pressing logistical challenges for new arrivals, families may prefer not to engage in treatment soon after arrival despite identified mental health problems.¹⁷ Mental health service providers may find that providing initial case management and linking families to other needed services may present important opportunities for building a treatment alliance. Thus, before identifying an appropriate treatment approach, these factors must be assessed.

What is the problem to be targeted?

Refugee and immigrant children may present to treatment with any of a variety of mental health or adjustment problems. As detailed above, experiences of loss and trauma have been linked to an increased rate of depressive disorders and post-traumatic stress disorder. However, one must be cautious not to assume the presence of these problems in immigrant children without a diagnostic assessment. A careful assessment of the child’s social and developmental history, trauma exposure, and current mental health presentation is essential in order to determine the primary problem in need of treatment. Challenges in acculturation can sometimes confuse the assessment, as in the example of a recently arrived young refugee boy who frequently gets into fights. This behavioral problem could be a manifestation of a mental health problem such as PTSD, in which the child becomes easily emotionally dysregulated and hyperaroused, or could be the result of a learned survival skill within a resource-poor setting such as a refugee camp. Assessing the timeline of the course of the problem, the child’s functioning within multiple contexts, the specific antecedents to a behavior, cultural understandings of the problem, as well as behavioral observations can all contribute to a more accurate diagnosis. In particular, mental health providers must avoid equating forced migration experience, particularly that of refugees, with trauma. At times, issues related to grief, loss, and subsequent adjustment issues may be the most appropriate framework for capturing a client’s experience. Without question, many immigrants and refugees can and do encounter physical and emotional hardship and exposure to violence that may lead to traumatic reactions during all phases of migration. However, a focus on trauma as an issue in treatment must be established following careful and sensitive assessment, rather than assumed.

A careful approach to trauma-focused treatment is particularly indicated in light of research demonstrating that interventions which encourage the ventilation or retelling of traumatic events at the urging of a therapist, such as critical-incident debriefing may do more harm than good.¹⁸ Furthermore, anthropological evidence has indicated that in some cultures the discussion of past traumatic events may be imbued with very different cultural meanings. Research among war-affected populations in Southern Mozambique found that many people viewed discussion of past traumas as inviting evil spirits to be enlivened.¹² Even if clinical judgment indicates that processing of past traumatic events is indicated for treatment to be successful, the timing, pace, and mechanism by which these memories are engaged must be given careful consideration and planning when working within any cultural group.

Within what service system will the intervention be delivered?

Many refugee and immigrant families do not seek specialized mental healthcare services for their children.^7,¹⁹ This may be the result of the stigma associated with mental illness in many cultures, unfamiliarity with mental health services within the US, or problems identifying a given presenting problem as related to mental health.

Mental health service providers have addressed this challenge in a variety of ways. Some mental health programs have expanded their services such that mental healthcare becomes part of a broader service package. Partnering with existing service systems that have pre-established relationships with refugee children is another means of facilitating the provision of mental health services. Two service systems that have been identified in the literature as key areas for mental health intervention delivery for immigrant and refugee youth are schools and pediatric primary care settings. Collaboration with resettlement agencies and local mutual assistance organizations also presents a possibility for expanding opportunity to bring refugee children into care.

Given the numerous considerations regarding who and what the treatment is for, as well as where the treatment is delivered, there is no single model to be followed in providing mental healthcare for immigrant children and adolescents. In addition, despite the demonstrated need for effective mental health interventions with immigrant and refugee youth, relatively few empirical studies have been conducted that elucidate the best treatment modalities for this population.²⁰ Despite these challenges, the field has begun to provide some models for consideration in treating immigrant and refugee children. These models, along with the specific populations and treatment targets for which they have been used, are described here.