Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied Refugee Minors

Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied... This article explores migration trauma among Mexican and Central American unaccompanied refugee minors (URM) with the purpose of developing an understanding of migration as a tripartite process consisting of: pre-migration exposure to traumatic stressors, in-journey stressors, and post-migration stressors. The migration experience of these youth may be sub- jectively different depending on a wide range of factors. The complexities of migration are explored as a traumatic, tripartite process. These three salient components of migration may act as precursors, often resulting in psychological sequelae such as: post-traumatic stress disorder (PTSD), anxiety, and depression. Of all migrant groups, URM are more likely to develop psychiatric symptoms. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Cognitive Behavioral Intervention for Trauma in Schools (CBITS), and Mental Health for Immigrants Program (MHIP) are among the most effective interventions in the treatment of PTSD, anxiety, and depression in refugee minors. Social workers in schools are in unique positions to provide mental health services to URM. A case example illustrating a cultural adaptation of TF-CBT in an urban public high school is included. Clinical implications of culturally responsive and trauma-informed treatment of URM in schools will be discussed. Additionally, this article will emphasize the importance of bridging the gap between research and culturally responsive, trauma-informed interventions for URM in schools. Keywords Immigration · Minors · Trauma · Unaccompanied refugees · Schools The literature pertaining to the migration process of unac- (PTSD) and other psychological sequelae such as depres- companied refugee minors (URM) from Mexico and Central sion and anxiety as a result of forced exile and exposure to America, explores the tripartite process, consisting of: (1) traumatic events before, during, and after migration (Adel- pre-migration exposure to traumatic stressors, (2) in-journey man & Taylor, 2015; Fortuna, Porche, & Alegria, 2008; stressors, and (3) post-migration stressors, as adverse events, Rasmussen, Crager, Baser, Chu, & Gany, 2012; Smid, when approached through a trauma-informed perspective Lensvelt-Mulders, Knipscheer, Gersons, & Kleber, 2011; (Fazel & Stein, 2002; Kirmayer et al., 2011; Perez-Foster, Unterhitzenberger et al., 2015; Yearwood, Crawford, Kelly, 2001; Pine & Drachman, 2005; Sullivan & Simonson, 2016). & Moreno, 2007). Therefore, the unique needs of URM call Although most of the literature acknowledges the connec- for awareness and action by school-based social workers and tion between migration and trauma, an in-depth discussion educators in tailoring services that meet their complex needs on migration trauma as a tripartite process and as a clinical after migration. framework for assessment and treatment is inconsistent and Immigrant minors are youth under the age of 18, who often missing. When compared to other migrants, URM are migrate to the United States from their countries of origin at a higher risk of developing post-traumatic stress disorder because of varied, complex dynamics known in the litera- ture as push and pull factors (Kandel et al., 2014; Lee, 1966; Meyer, Margesson, Ribando Seelke, & Taft-Morales, 2016). * Diana Franco Push factors are described as forces that cause migrants to flee Dfranco04@me.com their countries and/or play into the decision-making process New York University Silver School of Social Work, 92-31 to migrate to the United States. Push factors originate in the 57th Avenue, Apt. 4A, Elmhurst, NY 11373, USA migrants’ native country, for instance war, poverty, and perse- New York University Silver School of Social Work, cution (Lee, 1966). Pull factors are influences that originate New York, NY 10003, USA Vol.:(0123456789) 1 3 552 D. Franco in the resettlement country, such as reunification with family, Literature Review that urge URM to migrate specifically to the US (Kandel et al., 2014; Meyer et al., 2016). Although migrant groups may differ Mexican and Central American Unaccompanied in levels of exposure to traumatic events (Pumariega, Rothe, Refugee Minors: Who are They? & Pumariega, 2005), pre-migration stressors, “in-journey” trauma-exposure, and post-migration stressors, are elements According to the 2016 United Nations (UN) Global Trend in the composition of migration trauma that contribute sali- Report, of the world’s 65.3 million people who are forci- ent information to the youth’s psychosocial history (Kirmayer bly displaced, more than half are young people under the et al., 2011). Overall, push and pull factors will continue to age of 18 (UNHCR, 2016). In the United States, almost influence the arrival of URM in the United States in years to 40% of new refugees are minors; although the literature come. posits that these statistics are difficult to monitor because In the US, schools provide most mental health services to URM often lack appropriate identification (Sullivan & minors (Bal & Perzigian, 2013; Beehler, Birman, & Camp- Simonson, 2016). According to a report by U.S. Customs bell, 2012; Burns et al., 1995; Hoagwood & Erwin, 1997; and Border Protection (2018), between October 2016 and Kataoka et al., 2003; Stein et al., 2002; Sullivan & Simonson, September 2017 41,435 unaccompanied youth had been 2016). Overall, social work services in schools contribute to apprehended at the US Southwest border. In 2017, 17% of the reduction in emotional distress and academic challenges these unaccompanied youth were between 0 and 12 years experienced by URM (Dods, 2015). Schools are situated to of age, 13% between 13 and 14 years of age, 37% between shorten the gap in service delivery for undocumented children 15 and 16 years of age, and 32% were 17 years old (Office and families who would not otherwise have access to these of Refugee Resettlement, 2018). The Office of Refugee services as a result of transportation barriers, stigma, and lack Resettlement (2018) notes that in 2017, 68% of the youth of health insurance (Stein et al., 2002; Sullivan & Simonson, apprehended were male and 32% were female. After the 2016). Although the literature (Green, 2003; Krogstad, Bar- surge of unaccompanied minors in 2014, there continues rera, & Lopez, 2014) emphasizes an increasingly steady influx to be a steady, yet increasing influx in rates of immigrant of unaccompanied minors migrating to the US (Pierce, 2015), youth (Pierce, 2015) and URM to the US. This proportion there is a dearth of empirical research (Greenman & Hall, is likely to grow significantly by 2020 (Yearwood et al., 2013; Rasmussen et al., 2012; Yearwood et al., 2007) pertain- 2007). ing to trauma-informed mental health services and culturally URM are youth under the age of 18 who flee their responsive treatment for URM in schools. countries without an adult companion and do not face the The role of pre-migration, in-journey, and post-migration option of returning to their homeland (Fong, 2007). The stressors will be explored as precursors for PTSD and other UN defines URM as youth “who are separated from both psychiatric disorders in URM. The relationship between parents and are not being cared for by an adult who, by trauma-related, psychological sequelae and their effect on law or custom, is responsible to do so” (Unterhitzenberger learning and academic achievement will be discussed. The et  al., 2015, p. 1; UNHCR, 2014). Additionally, fear of necessity for evidence-based interventions such as Trauma- persecution for reasons of race, religion, social or political Focused Cognitive Behavioral Therapy (TF-CBT), Cogni- affiliation, nationality, and lack of protection from country tive Behavioral Intervention for Trauma in Schools (CBITS), of origin, may result in an inability or unwillingness for and Mental Health for Immigrants Program (MHIP) will be URM to return (UNHCR, 1951). Thus, as a migrant group explored. Culturally responsive modifications will be dis- URM are distinct because of the persecution and displace- cussed through a tripartite process of migration framework ment they experience when compared to other migrant to emphasize the importance of making accurate assessments groups (Sullivan & Simonson, 2016). and establishing appropriate supports in schools. The need The term immigrant minors is usually discussed amor- for longitudinal, multimodal, and participatory action research phously in the literature; resulting in broad discussions (Stein et al., 2002) to address the gaps between research and and generalizations about a non-homogenous population culturally response practice with URM will be emphasized. (Bal & Perzigian, 2013). Immigrant minors are charac- terized by diversity that encompasses differences from migratory status, type of migration route utilized, and whether the youngsters migrated unaccompanied by an adult (Fong, 2007). In addition, there are other noted dis- tinctions between voluntary immigrant minors and URM, such as the latter usually being undocumented. Voluntary immigrant minors often embark on migration from their 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 553 countries of origin, to join other family members in the granted formal relief, which grants immigration status of US and seek better life opportunities (Adelman & Taylor, asylum or Special Immigrant Juvenile (SIJ) (Pierce, 2015). 2015; Fong, 2007). Push factors force URM to flee their Migrants from Guatemala and El Salvador have been admit- countries of origin because of political unrest, civil war, ted to the US as refugees since the 1980s, following political gang violence, or persecution (Adelman & Taylor, 2015; unrest in these countries (Greenman & Hall, 2013). Hondu- Fong, 2007). Both groups of migrants leave a great part of ran migrants have qualified for Temporary Protected Status their cultures and loved ones behind and may struggle with (TPS), after hurricanes, floods, and other natural disasters traumatic grief, adjustment, and racism upon arrival to the have affected the area in the 1990s and early 2000s (Green- US (Adelman & Taylor, 2015; Fong, 2007). man & Hall, 2013). Krogstad, Barrera, and Lopez (2014) note that URM from Central America and Mexico are the fastest growing group of immigrants in the United States. From October 1, 2012 to Migration as a Tripartite Process May 31, 2014, 46,932 unaccompanied children were taken into custody by U.S. Customs and Border Protection (Krog- The Impact of Exposure to Pre‑migration Adverse stad et al., 2014). Other research (Pierce, 2015) indicates Events that 102,327 unaccompanied children were apprehended at the US-Mexico border from the start of 2014 (fiscal year) Migration is a tripartite process, consisting of pre-migra- through August 31, 2015. Most URM come to the US from tion, in-journey, and post-migration stressors, that may be Mexico and the Northern Triangle, which refers to El Salva- explored through a trauma-informed perspective (Fazel dor, Guatemala, and Honduras—countries plagued by civil & Stein, 2002; Perez-Foster, 2001; Sullivan & Simonson, wars, gang violence, and severe poverty (Ciaccia & John, 2016). Although each URM report unique migration stories, 2016; Pierce, 2015; Stein et al., 2002; Zatz & Rodriguez, there are commonalities in these narratives that URM expe- 2015). Between 2014 through August 31, 2015, a total of rience as a collective (Murray, Cohen, Ellis, & Mannarino, 76,572 URM from the Northern Triangle were apprehended 2008). Pre-migration events may expose URM to a wide at the US-Mexico border (Pierce, 2015). Furthermore, Cen- array of stressors that widely depend on their country of tral America has the highest homicide rates per country, origin’s political and socioeconomic histories. especially among males ages 15–29 (Ciaccia & John, 2016). Overall, out of all emigrating groups, refugees of all ages In 2012, The Women’s Refugee Commission interviewed are the only group whose exposure to significant pre-migra- 151 URM, 77% of which stated that violence in their home tion violence results in psychiatric symptoms (Yearwood countries was their primary reason for migrating (Ciaccia & et al., 2007). URM, as previously mentioned, are forced to John, 2016). Of the minors interviewed, most reported that if flee from countries and regions plagued with civil unrest, they had the opportunity to “repeat the journey to the United violence, war, and other push factors. These push factors are States,” they would (Ciaccia & John, 2016, p. 1). believed to play a role in exposure to traumatic events prior For the most part, Mexican unaccompanied minors are to migration, increasing the youth’s susceptibility to devel- deported immediately (Pierce, 2015) and few Mexican oping PTSD (Smid et al., 2011). Due to the possibility that it migrants have been granted asylee immigration status in the may take longer for people with PTSD to seek help (Parsons US (Greenman & Hall, 2013). In contrast, migrants from the & Ressler, 2013), it is important for service providers to Northern Triangle are usually admitted to the US as refu- understand pre-migration adverse effects through a trauma gees. If proved eligible, URM can change their legal status to lens. Parsons and Ressler (2013) underscore “that exposure asylee, “a protection granted to foreign nationals already in to trauma in the past, before the ‘index trauma’ associated the United States or at the border who meet the international with PTSD—particularly childhood trauma exposure—is of definition of a refugee” (American Immigration Council, substantial importance” (p. 147). 2017, para. 2; Greenman & Hall, 2013). It is important to Scholars (Sawyer & Márquez, 2017; Tello, Castellon, note the differences between the designations refugee and Aguilar, & Sawyer, 2017) emphasize that gang violence is asylee. Refugees and asylees must both meet the same legal one of the push actors which result in forced migration from definition of having a well-founded fear of persecution due Central America. URM participants in a thematic analysis to race, religion, nationality, or membership in a particular by Tello et  al. (2017) “discussed fleeing to escape gang social group. Refugees receive legal permission to resettle violence and death” (p. 368). One participant in the study in the U.S. before they arrive, whereas asylees must meet the by Tello et al. (2017), reported being forced to flee Central definition of refugee and apply for asylum after they arrive America after losing her parents to gang violence and having in the U.S. (American Immigration Council, 2017). been threatened by a local gang. Similar literature (Garsd, Consequently, in immigration court, Central American 2015) reports that a 15-year-old girl from El Salvador was URM, may contest deportation by requesting that they be shot to death by gang because she was selling tortillas in 1 3 554 D. Franco a rival gang’s territory. Garsd (2015) adds that a different and other reported psychological sequelae include: the 15-year-old girl was shot in the head because her boyfriend physical and emotional effects of poverty, malnourishment, refused to join a gang. Similar gang-related violence is expe- physical and mental health issues, substance/drug abuse, rienced in Guatemala and Honduras. educational achievement, teen pregnancy, grief, personal War, violence, living in unsettled refugee camps, and per- losses (home, family, friends, belongings), leaving countries secution are events that often go hand-in-hand with physi- of origin suddenly without saying good-bye to loved ones, cal and emotional trauma (Adelman & Taylor, 2015; Fong, and being unaccompanied (Fong, 2007; Smid et al., 2011; 2007). When compared to voluntary immigrant youth, URM Yearwood et al., 2007). were more likely to report a higher incidence of trauma related to war and were disproportionally impacted by it Migration “In‑Journey” Stressors and Risk of PTSD (Collier, 2015; Pumariega et al., 2005; Rasmussen et al., and Other Psychological Sequelae 2012). The countries that make up the Northern Triangle have had a long history of violence and civil unrest. El Sal- Previous literature (Rasmussen et al., 2012) underscores dif- vador experienced a civil war throughout the 1980s and ferences in migration histories between URM and voluntary 1990s (Sawyer & Márquez, 2017). As a result, violence and immigrant youth. The most significant difference between persecution spilled into the neighborhoods in the form of these groups is the migration method used by URM to come executions and decapitations (Sawyer & Márquez, 2017). to the US. URM from the Northern Triangle embark on their The military coup of 2009 in Honduras resulted in police journey in many ways. The aid of a coyote, or human smug- corruption and unchecked crime against journalists, people gler, is sought by families who can send money from the US who identify as LGBT, and peasants (Sawyer & Márquez, to pay for the coyote’s services. Human smugglers, unlike 2017, p. 70). A 36-year-long civil war in Guatemala, which human traffickers, transport people across international bor - began in 1960 and ended in 1996, has left a lasting impact on ders who voluntarily seek this service. Nonetheless, human the country (PBS, 2011). Violence, intimidation, and organ- smuggling is a crime (Vargas, 2014). The migration journey ized crime continue to be a problem in Guatemala (PBS, can be treacherous, exposing the URM to being assaulted, 2011), forcing URM to flee their native lands. physically and sexually abused, and sustaining physical inju- Exposure to living in war-affected regions and violent ries. URM also face the risk of dehydration and malnourish- environments has been known to affect the mental health of ment from long periods of traversing through arid terrains, Latino migrants and refugees (Fong, 2007; Fortuna et al., while avoiding government officials. 2008; Yearwood et al., 2007), resulting in PTSD and depres- Many URM take buses, vans, and other methods of trans- sion (Rasmussen et al., 2012). The literature (Barowsky & portation arranged by coyotes (Dominguez Villegas, 2014), McIntyre, 2010; Fong, 2007; Fortuna et al., 2008; Rasmus- as they find their way through Central America and Mexico. sen et al., 2012; Yearwood et al., 2007), shows that depres- However, one method that has attracted attention from US sion and PTSD have been noted in children and adolescent and Mexican policy makers and human rights activists alike, asylum seekers fleeing from civil conflict or war affected is La Bestia (The Beast), freight trains that transport a vari- regions and that there is an average of 9 years, of pre-migra- ety of products to the US (Dominguez Villegas, 2014). Many tion PTSD onset (Rasmussen et al., 2012). PTSD onset has URM who take La Bestia as their method of migration to the been challenging to measure due to migration circumstances US are among the poorest of migrants, however, hitchhiking that make assessment difficult (Smid et al., 2011). Smid, a ride on La Bestia offers a cheaper alternative to paying Lensvelt-Mulders, Knipscheer, Gersons, and Kleber (2011) coyotes (Dominguez Villegas, 2014). Designed for cargo, argue that late-onset PTSD in URM is closely associated La Bestia offers no passenger railcars, forcing URM who with age of migration and lower education levels. This was use this method to ride on top of the freight trains; exposing noted between one to 2 years after resettlement (Smid et al., riders to serious risks (Dominguez Villegas, 2014). 2011). URM aboard La Bestia are vulnerable to a multitude of URM have also reported being exposed to other forms of dangers and traumatic stressors, such as the possibility of pre-migration violence not related to war, such as witnessing falling or being pushed off the freight train, amputation, the violent death of loved ones, community violence, being and death (Dominguez Villegas, 2014). Moreover, URM threatened with a weapon, kidnapping, domestic violence, aboard La Bestia are vulnerable to extortion, theft, or sexual sexual and physical abuse (Fortuna et al., 2008; Rasmus- assault by gangs who may force them to pay “protection” sen et al., 2012; Smid et al., 2011; Yearwood et al., 2007). fees. These gangs have been reported to work with Mexican These pre-migration traumatic events, coupled with severity organized crime groups by threatening and bribing migrants of exposure, may predict future traumatic events and suscep- in return for safe passage (Dominguez Villegas, 2014). In tibility to PTSD (Rasmussen et al., 2012; Smid et al., 2011). a study by Tello et al. (2017), some participants “reported Other pre-migration stressors that may contribute to PTSD being beaten and robbed in Mexico when their train would 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 555 stop at various points” (p. 365). Train conductors, often part stipulation for humane treatment, these detention centers of the smuggling and extortion operations, demand bribes of or “hieleras,” Spanish for iceboxes or freezers (Cantor, families, women, and children (Dominguez Villegas, 2014). 2015), are often extremely cold, overcrowded, with limited Exposure to these extreme conditions, experiencing and/ access to restrooms, medical care, food and water (Cantor, or witnessing death, abuse, and other forms of violence, 2015; Collier, 2015). These conditions serve as pervasive increase susceptibility for the development of PTSD and reminders that the threat of perceived risk to survival is still depression (Yearwood et al., 2007). However, PTSD and present. This notion is supported by Gudiño (2013), posit- other psychological sequelae may result from other losses ing that children with sensitivity to cues that threaten their not related to violence during the migration journey. Mur- survival may experience reinforcement that danger is still ray, Cohen, Ellis, and Mannarino (2008) assert that refu- present when surrounded by a hostile environment after gee populations, among the aforementioned stressors, are resettlement. characterized by loss and traumatic grief. Grieving about Detention centers and shelters have also posed other deceased loved ones, sudden separation from family, friends, threats to URM. It has been reported that URM have been and country of origin may lead to feelings of resentment, sexually and physically abused by detentions’ facility staff anger, and guilt in URM (Murray et al., 2008). However, during their temporary placements (Collier, 2015). Brané irrespective of the migration method used, most URM trave- (2018) adds that “perpetrators have included local police and ling through Central America and Mexico, may have already ICE employees, as well as contract guards and fellow detain- been impacted by violence, poverty, and war in their coun- ees.” It is evident that these statistics are difficult to moni- tries of origin. The exposure to these events only serves to tor as these incidents often go unreported. The Department exacerbate exposure to previous trauma. of Justice (DOJ) declared detention centers exempt from the Prison Rape Elimination Act (PREA) (ACLU, n.d.). Post‑migration Resettlement Stressors The PREA protects people in custody from sexual abuse by setting standards for prevention, detection, and report- The Icebox: US Detention Centers ing (ACLU, n.d.). Without PREA enforcement, there are no laws in place to protect URM in detention centers from The end of migration’s hazardous journey marks the begin- human rights violations and further increasing vulnerability ning of the post-migration phase, which is characterized by and exposure to post migration trauma. a unique set of stressors. Upon crossing the Southern US border, URM are apprehended by US Customs and Border Community Integration Protection (CBP). Consequently, a series of processes that determine the fate of URM in the US begin to unravel. While awaiting court proceedings, URM are released to a According to the William Wilberforce Trafficking Vic- relative, sponsor, or suitable families usually residing in tims Protection Reauthorization Act (TVPRA) of 2008, large Central American communities in the US (Collier, unaccompanied minors from countries other than Mexico 2015; Hennessy-Fiske, 2015; Pierce, 2015). After spon- or Canada cannot be sent back to their countries of origin sors and guardians are fingerprinted and vetted by FBI and without a court hearing (Collier, 2015). This law states Homeland Security, they will be verified to not pose a risk to that unaccompanied minors must be held humanely by the the child’s well-being (Hennessy-Fiske, 2015). Home stud- Department of Health and Human Services (HHS) until the ies are required by ORR only in cases where the URM have Office of Refugee Resettlement (ORR) releases them to a been reported to have a disability, history of abuse, or human sponsor or family found suitable to care for the child(ren) trafficking. However, the homes of many sponsors and/or (Avila, 2014; Collier, 2015; Pierce, 2015). Since March 1, guardians without criminal histories, still may not be appro- 2003, ORR has been responsible for over 175,000 URM, priate placements for these youth. Therefore, when family following requirements set forth by the Flores Agreement in members or sponsors are unavailable, URM are placed in 1997, the Trafficking Victims Protection Act of 2000, and foster care (Crea, Lopez, Taylor, & Underwood, 2017). the TVPRA of 2005 and 2008 (Office of Refugee Resettle- Scholars (Crea et al., 2017; Pine & Drachman, 2005) note ment, n.d.). that URM enter the child welfare system for reasons pertain- Following apprehension, URM must be turned over to ing to migration and resettlement such as migratory status HHS and placed in US detention centers and shelters within and exposure to traumatic events during the pre-migration 72 h (Collier, 2015; Hennessy-Fiske, 2015). Once placed, and in-journey phases. In other cases, URM have reportedly URM must wait at least 21 days after being charged as unau- experienced having food being withheld by relatives, sexual thorized to see an immigration judge for their first hearing abuse, and being forced to work rather than attend school. (Pierce, 2015). In the meantime, URM wait in detention ORR has expressed not having jurisdiction once a child is centers, often in deplorable conditions. Despite the law’s placed and that it is up to local child protective agencies to 1 3 556 D. Franco respond to cases of suspected abuse and neglect (Hennessy- Deferred Action for Childhood Arrivals (DACA) program Fiske, 2015). These circumstances often warrant the support which protected many undocumented youth from being of school social workers to aid in the protection of URM deported, was terminated (Sessions, 2017). In addition, after placement with parents, guardians, and in some cases, a decision to terminate the Temporary Protected Status with foster parents. It is evident that once placed, URM may (TPS) for migrants from El Salvador increased anxiety continue being vulnerable to a host of acute and complex among URM residing with parents or guardians who had stressors. been granted this protection (Nielsen, 2018). The dis- Other post-migration stressors such as acculturative stress mantling of these programs and protections result in the (Cano et al., 2015) and low socio-economic status (SES) disruption of family structures as a result of deportation contribute to emotional distress for URM. After resettle- (Planas & Carro, 2017). The fear of deportation and public ment, the SES of the family or new living arrangement (Smid safety act as ongoing barriers and stressors in the lives of et al., 2011; Yearwood et al., 2007) may be a stressor that URM in the US. continues to exacerbate pre-migration trauma pertaining to poverty, limited opportunities to engage in childhood activi- ties such as play, and having to take on adult responsibilities (Martinez, 2009). URM who arrive between the ages of thir- The Role of Trauma on Learning teen and seventeen often come to the US unaccompanied by and Academic Achievement a parent and face the choice of going to secondary school or directly to work (Allard, 2015). Family circumstances often Fischer (2010) posits that Mexican and Guatemalan chil- pressure students to make financial contributions by forcing dren living in US immigrant communities are vulnerable them to seek jobs after school, in turn resulting in challenges to experiencing challenges in the educational system. The related to studying at home and completing homework literature (Free, Križ, & Konecnik, 2014; Green, 2003, (Abrego & Gonzalez, 2010). Other research concurs that p. 65) reports that the consequences of hardships such as URM arrive to the United States with adult responsibilities poverty, depression, and lack of parental presence in URM such as working and paying bills (Allard, 2015; Martinez, and voluntary immigrant children may result in challenges 2009). Consequently, school attendance for most migrant pertaining to educational mobility and exacerbate issues children is dictated by the financial needs of the family and of illiteracy. Additional research (Collier, 2015; Dods, those needs may change from day to day depending on the 2015; Pumariega et al., 2005) indicates that trauma related general economic condition (Green, 2003). symptomatology may manifest in concentration, learning URM under the age of eighteen must make difficult deci- problems, and academic functioning for URM. Addition- sions between working or going to school and, because of ally, URM, who are particularly at risk among migrant pre-migration factors, consider themselves adults with no groups, have reported higher levels of conduct disorders other alternative (Allard, 2015; Martinez, 2009). Similar and school-related aggressive behaviors, due to prior literature (Lukes, 2014) purports that interrupted school- exposure to war and violence (Pumariega et al., 2005). In ing in Mexican and Central American youth is less related this regard, exposure to trauma can impact “all areas of to a disinterest in school, but rather because of economic a youth’s life” (Dods, 2015, p. 113). This is further sup- reasons pertaining to pre- and post-migration stressors. ported by Dods’ (2015) qualitative case study in which Educators and health providers often do not understand the personal interviews were administered to three youths to complex nature that underlies the balancing act between explore the intersection of trauma, school experiences, and the URM’s academic and work life. The reasons for these their perceptions of the roles schools play. Dods (2015) absences may not always be evident to educators, therefore further emphasized that trauma triggers, such as a loud, placing the onus of school attendance on the parents and/ crowded classroom can contribute to an increase in a stu- or guardians of URM. State mandated reporters find them- dent’s arousal levels. Thus, the student’s behaviors may selves in ethical dilemmas when they question whether or appear oppositional and unpredictable coupled with inat- not the teen is being neglected or improperly supervised, as tention, memory, and motivation challenges. The research schools label this as truancy or educational neglect resulting concluded that “unmet needs and diminished sense of in the involvement of the child welfare system. Additionally, agency” were common themes across participants (Dods, because of fear and lack of trust in authority figures, URM 2015, p.  129). The participants in Dods’ study (2015) will fail to state the reason for the absences, unless they have reported that while in school, they felt guarded and unsafe. established a trusting rapport with someone at the school. When heightened, these feelings may lead to pervasive Additional barriers such as anti-immigration policies PTSD symptoms (Smid et al., 2011) and ongoing disrup- in the US contribute to acute stress after resettlement for tions in academic achievement. URM. Effective September 2017, the program known as 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 557 treatment (Sullivan & Simonson, 2016). Thus, schools are The Necessity for School‑Based situated to shorten the gap in service delivery for families Interventions who would not otherwise have access to these services (Stein et al., 2002; Sullivan & Simonson, 2016). There were approximately 840,000 immigrant students in the US in grades k-12 (Adelman & Taylor, 2015). Fortu- Trauma‑Informed and Culturally Responsive nately, schools have been identified as the primary pro- Interventions in Schools vider of mental health services for all youth, including serving as the first social and institutional space that URM For schools to successfully engage URM in school-based encounter (Bal & Perzigian, 2013; Beehler et al., 2012; mental health services, these interventions are more likely Kataoka et al., 2003; Sullivan & Simonson, 2016). Addi- to be effective when they are evidence-based, trauma- tionally, schools have been noted to be in unique positions informed, and culturally responsive. Evidenced-based, in providing URM school-based mental health services, trauma informed treatment can effectively address the unique thereby contributing to the reduction in emotional dis- mental health issues manifested by URM, especially when tress and academic challenges (Dods, 2015). Most stu- delivered by a culturally responsive provider (Beehler et al., dents, k-12, spend at least 7 hours a day in school. This 2012). Although, “few programs have been rigorously evalu- places school administration and staff in loco parentis, or ated” (Kataoka et al., 2003, p. 311) specifically for URM in place of a parent, of students with diverse academic, and other children belonging to minority groups, the few social-emotional, linguistic, and cultural needs. programs that have been investigated have proven success As with instruction, mental health services are not a in trauma symptom reduction and academic improvement one-size-fits-all model. Therefore, schools are challenged (Nadeem et al., 2011; Unterhitzenberger et al., 2015). Addi- to self-assess to best respond to the complex needs of tionally, Unterhitzenberger et al. (2015) posit that no study URM and voluntary immigrant students (Bal & Perzigian, has explicitly investigated PTSD treatment in URM (p. 2). 2013). As URM enter the U.S. with past or current his- Notwithstanding, there are many trauma-informed modali- tories of PTSD, an increase in awareness about the pres- ties that target the reduction of trauma related symptoma- ence of school-based mental health services has emerged tology in children and adolescents. However, the literature amongst educators and policy makers to promote best (Bal & Perzigian, 2013; Beehler et al., 2012; Kataoka et al., academic and social-emotional outcomes (Bal & Perzi- 2003; Murray et al., 2008; Nadeem et al., 2011; Stein et al., gian, 2013; Dods, 2015; Nadeem, Jaycox, Kataoka, Lang- 2002; Sullivan & Simonson, 2016; Unterhitzenberger et al., ley, & Stein, 2011). Although some literature (Beehler 2015) purports that Cognitive Behavioral Therapy (CBT), et al., 2012; Stein et al., 2002) posits that few studies have Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), explored effectiveness of school-based mental health pro- Cognitive Behavioral Intervention for Trauma in Schools grams, schools with accessible mental health services have (CBITS)—including CBITS in Spanish, and the Mental been effective in demonstrating improvement in students’ Health for Immigrants Program (MHIP) have been evalu- academic achievement, social-emotional functioning, and ated to be most effective in the treatment in URM and other behavior (Nadeem et al., 2011; Unterhitzenberger et al., immigrant minors in schools. 2015). CBT is a therapeutic modality developed by Aaron T. School-based mental health services provide other ben- Beck that uses attention to thoughts, behaviors, and feelings efits for URM, voluntary immigrant students, and their associated with thought distortions and catastrophic thinking families. For example, most URM and voluntary immi- (Beehler et al., 2012; Murray et al., 2008; Sullivan & Simon- grant youths need psychological treatment, however are son, 2016). CBT and adapted CBT techniques and models not receiving it for a variety of reasons that may include currently “have the most empiric evidence” (Cohen, Man- stigma, finances, or lack of health insurance (Beehler et al., narino, Berlinger, & Deblinger, 2000; Murray et al., 2008, 2012; Polk, Page, & Ross DeCamp, 2014; Pumariega et al., p. 588) in treating traumatized youth. Despite the challenges 2005). Families of URM must often prioritize obtaining of time limitations and URM’s potential low writing, read- basic needs over addressing mental health needs (Beehler ing or drawing proficiencies, CBT and adapted CBT models et al.,  2012; Murray et al., 2008). In addition to acces- have also proved to be positive interventions for war trau- sibility, school-based interventions help reduce culturally matized refugee populations (Murray et al., 2008). TF-CBT, assigned stigma to receiving treatment (Pumariega et al., CBITS, and MHIP are among the most common and effec- 2005; Sullivan & Simonson, 2016, p. 508). Since cultural tive school-based interventions that use CBT techniques to and financial factors can be accounted for in a school set- reduce PTSD, depression, and anxiety symptoms in URM. ting, school-based interventions may assist in alleviating TF-CBT was developed using CBT techniques for the some of the obstacles that hinder URM from receiving treatment of children with psychological sequelae of sexual 1 3 558 D. Franco abuse and has expanded to treat other forms of trauma (Bee- To address the gap in effective evidenced-based, trauma- hler et al., 2012, p. 159). This manualized framework is an informed interventions in schools, in 1998 a team of clini- intensive, short-term, and time-limited approach which cian researchers from the RAND corporation, the University usually takes place over 12–16  weeks, once a week, in of California, Los Angeles (UCLA), and the Los Angeles 60–90 min sessions (Beehler et al., 2012; Cohen et al., 2000; Unified School District (LAUSD) collaborated in develop- Sullivan & Simonson, 2016; Unterhitzenberger et al., 2015). ing effective interventions (Nadeem et al., 2011; Stein et al., TF-CBT emphasizes the use of exposure, cognitive process- 2011). The school partners in the development of CBITS ing and reframing, stress management, parental treatment, wanted to offer a program that could effectively be delivered and cross-cultural modification while maintaining fidelity by school staff, in 45-min class periods, to a large number (Cohen et al., 2000, p. 1202; Sullivan & Simonson, 2016; of students in a linguistically and culturally responsive way Unterhitzenberger et al., 2015, p. 2). The acronym PRAC- (Nadeem et al., 2011). In their study, Stein et al. (2011) dem- TICE (P. Psychoeducation and parenting skills, R. Relaxa- onstrated that participants exposed to violence who received tion, A. Affective modulation, C. Cognitive processing, T. CBITS experienced significant improvement, evidenced by Trauma narrative, I. In vivo desensitization, C. Conjoint decrease in PTSD symptoms. In support of this literature, child/parent sessions, E. Enhancing safety and future skills) a randomized controlled study by Ngo et al. (2008) estab- best describes each of the components used in TF-CBT lished a significant decrease in depressive and PTSD symp- (Murray et al., 2008; Unterhitzenberger et al., 2015). toms in Mexican and Central American youth (p. 858). The Unterhitzenberger et al. (2015), purport that TF-CBT is implementation of CBITS in schools has broadened nation- “the best supported therapy for traumatized young people ally (California, Colorado, Louisiana, New Mexico, and at the moment …with proven feasibility for refugee chil- New Jersey) and internationally (Australia, China, Japan, dren” (p. 2). Unterhitzenberger et al. (2015), investigated and Guyana) (Stein et al., 2011). As a result, CBITS is a the feasibility of TF-CBT in a sample of traumatized URM. recommended, effective school-based intervention in treat- The results showed a “clinically significant symptom reduc - ing URM, immigrant youth, and other ethnically and lin- tion at posttest for all cases receiving TF-CBT” (p. 7). For guistically diverse youth in effectively decreasing trauma this reason, CBT and TF-CBT “may be useful in school related symptoms by “integrating cultural-sensitivity and systems serving large populations of refugees” (Sullivan & evidenced-based practice” (Ngo et al., 2008, p. 861; Stein Simonson, 2016, p. 523). Overall, TF-CBT has been proven et al., 2011). to reduce PTSD, internalizing, and externalizing symptoms MHIP is a school-based mental health intervention that in traumatized youth (Murray et al., 2008). Furthermore, incorporates CBT and is based on the CBITS framework CBT and TF-CBT are feasible interventions that can be used (Kataoka et al., 2003; Stein et al., 2002). In the development by school social workers, guidance counselors, school psy- of MHIP, LAUSD Mental Health Services Unit (MHSU) chologists, and other educational and behavioral specialists developed this framework by considering the school and cul- in treating children exposed to violence and complex trauma tural ecologies, to thereby effectively address the needs of (Kataoka et al., 2003; Sullivan & Simonson, 2016, p. 523.) Los Angeles’ large Latino immigrant student body (Kataoka Like TF-CBT, CBITS is a skills-based group interven- et al., 2003; Stein et al., 2002). Hence, program materials tion, developed by using a community-partnered research were made available in Spanish and other languages (Stein model, that uses cognitive behavioral techniques in relieving et al., 2002). In addition to CBT, MHIP also included home depression, anxiety, and PTSD symptoms in trauma exposed visits to meet with parents or guardians and were school- children, ages 10–15 (NCTSN, 2012; Nadeem et al., 2011). based to minimize barriers to service access (Stein et al., It was initially developed to effectively decrease trauma 2002). Services were provided during times when students related symptomatology for ethnically diverse and immi- were both in school and the school was able to provide ade- grant youth in schools (Ngo et  al., 2008). Interventions quate space in order to avoid decline in participation (Stein are delivered in 10, 1-h group sessions composed of 6–8 et al., 2002). Overall, MHIP aimed at reducing PTSD symp- children, once a week. The protocol includes one to three toms for immigrants who had been exposed to violence, individual sessions, two parent sessions, and one teacher sexual abuse, and other traumas (Kataoka et al., 2003). education session (NCTSN, 2012) and teaches participants The study conducted by Kataoka et al. (2003) demon- six cognitive-behavioral techniques: (1) Education about strated that MHIP was associated with a modest reduction reaction to trauma, (2) Relaxation training, (3) Cognitive in symptoms, however, further research is needed to deter- therapy, (4) Real life exposure, 5., Stress or trauma exposure, mine sustainability and replication by other schools. Stein and 6. Social problem-solving (NCTSN, 2012). To account et al. (2002) add that although many challenges in school- for cultural diversity, CBITS programs are available in Span- based mental health research exists, MHIP provided a use- ish and there are efforts being made in adapting CBITS for ful framework to guide program development in the future Native American children (NCTSN, 2012). (p.  324). Stein et  al. (2002) purport that future program 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 559 engagement with recent immigrant parents or guardians of treatment needs are not being met in schools (Sullivan & migrant children would be an asset to MHIP’s development. Simonson, 2016). Often linguistic and cultural barriers, In addition to being trauma-informed, school-based inter- such as stigma about the concept of therapy itself, may pose ventions are increasingly effective when culturally respon- obstacles in identifying URM and families in need (Murray sive modifications are made (Isakson, Legerski, & Layne, et al., 2008; Sullivan & Simonson, 2016). School staff often 2015). misinterpret trauma-triggered behaviors in URM since these may range from irritable outbursts to internalized symptoms Challenges with Implementation in Schools that are less noticeable (Cohen, Mannarino, & Murray, 2011; Sullivan & Simonson, 2016). Some of these symptoms will CBT, TF-CBT, CBITS and MHIP are all models that effec- manifest in a variety of ways including somatic complaints tively target the reduction of trauma symptoms in URM and such as headaches and stomachaches (Cohen et al., 2011; immigrant youth. However, there are some challenges in Isakson et al., 2015; Ngo et al., 2008; Pumariega et al., 2005; implementing these models in schools with this population. Sullivan & Simonson, 2016). In support of this literature, As stated earlier, URM migrate to the U.S. unaccompanied Isakson et al. (2015), assert that “non-Western cultures do by a parent or guardian. In many cases, parents of URM not differentiate between physical and emotional health” migrated to the U.S. when the child(dren) was or were very (p. 4). Therefore, it is important to identify how migration young. Sometimes, URM leave their parents in their coun- trauma presents in URM. Since culture shapes emotional tries of origin and join grandparents, aunts, uncles, or other vocabulary and meaning associated with trauma, neces- family members whom they have never met. Since all of sary steps must be taken so that the school social worker is these models include a parent psychoeducational piece, it speaking the same cultural language as the child (Isakson is important to note that the absence of collaborating with a et  al., 2015, p. 4; Murray et al., 2008, p. 593). By doing parent or guardian who knows the URM well may present a so, school social workers are able to provide a culturally challenge in treatment. Smith, Lalonde, and Johnson (2004) informed understanding of the URM’s behavior to the rest note that staggered patterns of migration, or serial migra- of the school community. tion, when parents migrate to a new country years before Culturally responsive interventions and approaches their children, results in stress for the family and in negative that validate and incorporate the cultural values, norms, effects on the self-esteem and behavior of URM. Although and resilience factors of URM, have resulted in increased there is no available literature on the effect of staggered receptiveness to treatment when compared to models with- migration on treatment in schools, it is possible that these out cultural modifications (Fong, 2007; Isakson et al., 2015). strained family dynamics may require treatment other than Cultural modifications include targeting the unique needs of those mentioned in this article. refugees such as housing, language, emotional and physical CBT, TF-CBT, and CBITS are time limited with regard health (Isakson et al., 2015). For instance, CBT, TF-CBT, to duration of each session as well as the treatment model. CBITS, and MHIP school-based interventions have been These time constraints may pose challenges in schools adapted to working with URM by making linguistic modifi- regarding student schedules and potential inconsistent cations and incorporating customs and rituals from the chil- attendance of URM. As a result, treatment may be inter- dren’s native culture (Ngo et al., 2008; Stein et al., 2002). rupted or subject to sudden programming changes by the Although Spanish is the most commonly spoken language school. in Mexico and Central America, Garifuna and Mayan lan- The aforementioned treatment modalities, also rely on guages such as K’iche’ and Mam are spoken by over 500,000 writing, drawing, and/or reading. In some cases, URM might people in these regions (Carcamo, 2016). Some countries enter the U.S. school system with interrupted education in in Central American use vos, the second person singular their countries of origin, varying levels of cognitive devel- pronoun, instead of the informal command tú when speak- opment, and/or limited writing and reading skills. School ing to family members and close friends (Alvarenga, 2017). social workers may adapt the modalities by using a verbal or As a result, Spanish-speaking service providers may need dramatic form of expression (Murray et al., 2008). to familiarize themselves with variations of spoken Spanish and other languages in the treatment of URM. Cultural Responsiveness: Considerations Other modifications can be evidenced by incorporating in School‑Based, Trauma‑Informed Treatment cultural values and norms when meeting with parents, guard- ians, or family members of URM, such as leveraging the Although schools have been identified as the front-line pro- voice and input from the mother, being mindful of the role viders of mental health services to minors, including URM of spirituality in treatment, and being mindful of somatic and voluntary immigrant youth (Kataoka et al., 2003; Stein complaints in a cultural context. For these reasons, it is et  al., 2002; Sullivan & Simonson, 2016), most URM’s important for school social workers and other school-based 1 3 560 D. Franco mental health staff to familiarize themselves with the culture group was an adaptation of TF-CBT techniques and utilized of each URM’s country of origin. a culturally responsive approach, including group facilitation The Cultural Adjustment and Trauma Services (CATS), is in Spanish. This group focused on trust building, psychoe- a school-based mental health model that uses CBT and TF- ducation, trauma exposure, and consultation with parents. CBT with immigrant youth in two New Jersey school dis- tricts (Beehler et al., 2012). In this model, CBT techniques were used “eclectically as needed in response to clinical Case Example: Yaretzi presentation” (Beehler et al., 2012, p. 159). The manual- ized intervention used, TF-CBT, was discontinued in the Yaretzi is a 16-year-old girl in her sophomore year at a small, CATS model because some students found it challenging New York City public high school. She is originally from to focus on a single trauma narrative or stressor, making a low-income neighborhood in a small town in El Salva- the implementation counterproductive. As previously men- dor. Yaretzi currently lives with her paternal grandmother, tioned, migration trauma is a tripartite process which may be a relative whom she never met or lived with before. Living composed of repeated and prolonged events that may result with her grandmother and her strict rules is one of the many in complex post-traumatic stress disorder (C-PTSD). As a adjustments that pose as stressors for Yaretzi. She arrived in result, adaptable treatments that can be culturally modified the United States, through the US-Mexico border assisted by to the specific experiences of URM are essential. Nonethe- a coyote, as an unaccompanied refugee minor. In El Salva- less, TF-CBT was used to inform other services provided dor, Yaretzi lived with her mother, father, and two younger by the treatment such as family involvement (Beehler et al., siblings. She reported witnessing a lot of gang violence and 2012). often felt unsafe. She remembered that “while aboard the bus Ngo et al. (2008) assert that CBITS was flexibly devel- to school, witnessing a group of gang members board the oped to meet the needs of ethnically and heterogeneous bus, shoot, and kill two fellow classmates.” The gang threat- school districts. Additionally, this intervention was devel- ened the passengers, stating that if the authorities were noti- oped to strike a balance in maintaining the treatment fidel- fied there would be retribution. Yaretzi stated that her “life ity while emphasizing cultural and systems competence. changed after witnessing the murder of the two students,” Because CBITS is not comprised of culturally specific core who allegedly had been gang affiliated. Her father drove her components, clinicians modified psychoeducation, cogni- to school for the next couple of months, but her experience tive-restructuring, and problem-solving, in working with of ongoing fear, nightmares and flashbacks of the event URM who had crossed the US-Mexico border, so that the ultimately interrupted her ability to perform daily tasks, model would be sensitive to migration trauma (Ngo et al., including concentrating on school work. Despite her parents’ 2008, p. 860). Operating under the notion of cultural respon- requests, Yaretzi dropped out of school for a year and stayed siveness, CBITS involves necessary steps to not disregard home out of fear for her safety. Yaretzi expressed that her URM’s family beliefs such as ghosts or other cultural beliefs parents wanted her to “have the opportunity of acquiring an (Ngo et al., 2008, p. 860). Stein et al. (2002), emphasize that education and a better life.” However, she did not know that like CBITS, MHIP providers collaborated in ways to address her parents, in collaboration with family members living in cultural issues that emerged in sessions such as belief in New York City, collected money to finance her journey to ghosts or spirits of deceased family members. the U.S. Yaretzi states that she doesn’t remember much of The models CBT, TF-CBT, CBITS, and MHIP shared the journey, except that she cried the entire time and was additional culturally responsive modifications. All models often told to “shut up” by the coyote. After 11 days, Yaretzi emphasized the use of bicultural and bilingual licensed clini- arrived at the U.S.–Mexico border from El Salvador. She cians to provide services (Beehler et al., 2012; Stein et al., was apprehended in Texas and taken to a detention center. 2002). The literature (Beehler et al., 2012; Murray et al., About 2 months after her admission to the high school, 2008; Ngo et al., 2008; Pumariega et al., 2005; Stein et al., Yarezti’s teachers noted to the school social worker that she 2002) asserts that the use of cultural brokers or liaisons to had been steadily losing weight, missing school days, and the community with cultural knowledge and clinical exper- falling asleep in class. One of her teachers facilitated an tise is crucial in assisting with outreach and in ensuring that introduction to the school social worker. The school social interventions were implemented in a culturally sensitive way. worker introduced the support services offered to URM at The following case example illustrates a cultural adapta- the high school, including group and individual sessions tion of TF-CBT in the treatment of PTSD with a URM in an in Spanish. Yaretzi appeared hesitant to disclose personal urban public high school. Implementation of a manualized information to the teacher and the school social worker in intervention such as TF-CBT and CBITS was not possible at the introductory conversation. However, Yaretzi made an this school setting due to challenges around student program- appointment to speak to the school social worker the next ming and physical space. As a result, this trauma-informed day. Yaretzi was introduced by one of her peers (and group 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 561 members) to the school-based counseling group designed to parents and/or guardians of the group members. These ses- address the needs of URM. sions took place in person or by phone in order to adjust to the families’ work schedules. Engaging the family in discus- Assessment and Interventions: Trauma‑Informed sions pertaining to the group’s purpose, migration trauma, Treatment with Cultural Modifications trauma symptoms and stigma helped parents and guardians feel like stakeholders in the students’ (and their own) healing In the initial individual session (and in subsequent sessions), process. Yaretzi’s grandmother was grateful for the existence the school social worker met with Yaretzi in Spanish. Early of the group on her granddaughter’s life, however, she was in the session, Yaretzi stated concerns about confidentiality. mostly concerned with her academic success and follow- The social worker explained the limits of confidentiality as a ing the rules at home. Cultural understandings around trust, school official. Yaretzi reported to the social worker that she shame, discipline, respect, hierarchy, and family dynamics felt sad on a daily basis, experienced nightmares and inter- are the important values to be aware of in conversations with rupted sleep, and flashbacks of the event on the bus in El families and in treatment with URM. Salvador. She stated having difficulty focusing in class, pri- When the group was ready, they began to explore and marily because much of the content was taught in English. share their trauma narrative—the exposure to trauma related Although she had made a couple of friends, Yaretzi reported memories through narrative. This was done through journal feeling that she “did not belong” here. Yaretzi also stated entries, visual art, songs, acting and story-telling. For exam- that she “hated living with her grandmother because she was ple, the group members engaged in creative ways to help strict and mean.” She added that food in the U.S. tasted “like construct the narrative such as: “What happened the day plastic, artificial. Nothing like mom’s tortillas back at home before you left (country of origin)?”, “What event(s) stands and other tasty food.” The school social worker discussed out about your journey to the U.S.?” and “What do you the migration process with Yaretzi. Yaretzi spend some time remember about the exact moment you arrived in the U.S.?” discussing the negative and positive aspects of her life in El Yaretzi wrote a poem and a story depicting her experiences Salvador, the hardships endured in her journey to the U.S., before, during, and after migration. The trauma narratives and the stressors she had been facing after her arrival to New developed and changed over a few weeks while emerging York City. In the initial session, the school social worker feelings and memories were processed in group. In her nar- assessed for depression and self-harm. At the conclusion of rative, Yaretzi emphasized a longing for “the beauty of her the session, the school social worker invited her to join the country,” her mother’s cooking, the smell of her home in El group. Yaretzi stated that she would think about it. Salvador, the sadness she felt about being “forced to leave,” Yaretzi and one of her peers approached the school social and “living in a strange country.” In the post-migration nar- worker’s office the next day requesting to join. The group rative, Yaretzi expressed feeling “stressed having to balance consisted of five Central American high school girls, ages the role between being a student and having to work full time 15–16, met once a week for 40 min, throughout the 10-month after school.” After a month of participating in the group academic year. As suggested by the literature (Cohen et al., and seeing the school social worker for individual sessions, 2011), when youth may have been exposed to multiple trau- Yaretzi’s effort in class improved, her attendance became mas, as observed in migration’s tripartite process, TF-CBT’s more consistent, and she stopped sleeping in class. Enhancing Safety skill of the PRACTICE model may be introduced before Psychoeducation. Focusing on this skill, the social worker was able to develop an environment of Discussion safety in a group of girls that had faced threatening events in their native countries and in their respective journeys to This case example illustrates the necessity for exploring the U.S. Safety and trust-building was created through group migration trauma as a tripartite process including the pro- activities that encouraged reliance on each other. During vision of school-based, trauma-informed interventions. this process, Yaretzi was often hesitant to participate, but During pre-migration, Yaretzi witnessed the death of peers after encouragement from peers, she joined activities more and was threatened by the gang members that murdered the readily. Yarezti and other group members identified family, youngsters on the school-bound bus. Fearing for her safety church, priests, Santeros, Espiritistas, Curanderas, and other after the shooting, Yaretzi’s education in El Salvador was practitioners of traditional medicine as sources of safety in interrupted, sleep patterns were dysregulated by nightmares, their communities. and capacity to focus on daily tasks became increasingly The school social worker introduced psychoeducation challenging. It is important to note that prior to the shoot- about PTSD, depression, and anxiety symptoms related to ing, Yaretzi was exposed to poverty and other stressors that the migration process and slowly normalizing exposure to accompany low-income families in the Northern Triangle. trauma. Psychoeducational sessions were also held with As noted throughout the literature, stressors that accompany 1 3 562 D. Franco poverty may contribute to PTSD up to 9 years prior to migra- frontline in mental health service provision for minors, tion (Fong, 2007; Rasmussen et al., 2012; Smid et al., 2011; Yaretzi was able to develop a safe, support system in a Yearwood et al., 2007). trusted space. Most importantly, support was delivered in In keeping with this notion, the literature suggests that Yaretzi’s native language and her narrative was understood exposure to gang violence and witnessing the violent death from a culturally responsive, trauma-informed perspective. of someone are pre-migration stressors that increase sus- ceptibility to PTSD (Fortuna et al., 2008; Rasmussen et al., 2012; Smid et al., 2011; Yearwood et al., 2007). In Yarezti’s case, she was exposed to these stressors from birth. Ulti- Practice, Policy, and Research Implications mately, these interruptions and acute stressors acted as push factors that pressured Yaretzi’s family to plan her migra- Practice and Policy Implications tion to the US. Moreover, these events forced Yaretzi out of El Salvador without appropriately saying goodbye to many Although it has been noted that URM have unique needs loved ones in addition to leaving cherished possessions, that call for tailored interventions, most are not receiv- memories, and components of her culture behind. ing the necessary mental health services within schools or Once embarked, Yaretzi did not witness or experience in their respective communities. The literature reviewed violence or physical risks. However, throughout the migra- emphasized the complexity in the treatment of immigrant tion journey, Yaretzi experienced loss, separation, grief, pro- youth, in particular, Mexican and Central American URM. found sadness, and distress. She was met with no support Voluntary immigrant youth and URM have reported differ - while being forced to stifle the expression of emotions by the ences in PTSD prevalence. URM have been identified as coyote. Vargas (2014) explains that “coyotes are well known a vulnerable and high-risk group susceptible for develop- in Central American townships, and the smuggling busi- ing PTSD and other psychological sequelae as a result of ness has traditionally been built on trust. Knowing the right exposure to stressors throughout the migration process. coyote is key to securing a safe journey” (para.7). Although There is a danger in pathologizing symptoms and behav- Yaretzi did not undergo other forms of abuse by the coyote, iors in URM if clinicians in settings that serve URMs, she reported feeling “demeaned” by the coyote’s demands especially in schools, do not assess for trauma as discussed to stop crying. Yaretzi’s trauma narrative as depicted in her in this article. Knowledge of URMs socio-political and story and poem, highlight the anguish she experienced from economic histories, values, norms, and resilience fac- the sudden loss of family, friends, and community. Thus, tors would enhance the delivery of culturally responsive traumatic grief over the unexpected separation from her fam- treatment. ily and birthplace may have added to the complexity of the Therefore, an in-depth exploration of migration’s tri- pre-existing trauma experienced by Yaretzi (Murray et al., partite process as it pertains to trauma and other psy- 2008). chological sequelae may assist mental health providers Yaretzi’s resettlement and adjustment experiences after in school deliver culturally responsive services to these migration also contributed to pre-existing stressors. Post- youth. Additionally, schools would better support URM migration stressors that may have exacerbated her feelings by offering social work services in the student’s native of loss, danger, and grief were the low socio-economic language wherever possible. School staff should make status in the new living arrangement with her grandmother active efforts in understanding the norms and values of and recurrent nightmares and flashbacks about the shoot- the student’s culture and incorporating these into trauma- ing. The literature explains that after re-settlement, pov- informed services. The support of the student’s parents, erty in the new country may act as a continuous stressor guardians, family members, and cultural brokers in the while negatively impacting educational outcomes in URM community should be leveraged as part of the treatment (Collier, 2015; Dods, 2015; Free et al., 2014; Green, 2003; process in schools. Pumariega et al., 2005). Consequently, Yaretzi reported Overall, it is proposed that school-based, mental- appetite loss, change in eating habits, and decrease in health service providers and educators become attuned to energy. As a result, academic achievement, body weight, the unique needs of URM. Therefore, culturally adjust- and capacity to concentrate in and out of school were ing trauma-informed interventions to the complex events directly impacted. Teacher referrals and established sup- experienced by URM throughout the migration process ports such as the school-based, trauma-informed student (Isakson et al., 2015; Murray et al., 2008). Neglecting this group, individual sessions with the school social worker in connection results in learning and adjustment difficulties Spanish, and establishing peer supports allowed for timely that may exacerbate pre-existing PTSD symptoms. identification of possible PTSD symptoms and adjust- ment challenges. Since schools are considered to be at the 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 563 English as a New Language (ENL) classes (formerly Eng- Implications for Research lish as a Second Language) which is where most URM are placed upon admission to US schools. It is important that Because of current gaps in research, longitudinal, multi- modal, and participatory action research (Stein et al., 2002) school district leaders look beyond the students’ academic needs to include social-emotional needs in the form of may help bridge research disparities for the purpose of translating findings into practice. Further research is needed trauma-informed supports. Thus, training must be provided for school social workers, other school-based mental health pertaining to the provision of culturally responsive, trauma informed treatment of URM in schools. Moreover, the litera- staff, teachers, guidance counselors, and administration. ture consistently reports that studies about effective school- Acknowledgements The author gratefully acknowledges Dr. Diane based, trauma treatment of Mexican and Central American Mirabito, Dr. Liliana Goldín, and Dr. Carol Tosone for their feedback URM, are scarce (Beehler et al., 2012; Dods, 2015; Isak- and guidance on earlier versions of this article. son et al., 2015; Murray et al., 2008). This dearth in the literature may be partly due to challenges associated with Compliance with Ethical Standards studying URM as a population (Collier, 2015). For instance, fear of immigration status disclosure and cultural beliefs and Conflict of interest The author declares that the author has no conflict of interest. stigma about mental health services may contribute to these challenges (Collier, 2015; Murray et al., 2008; Sullivan & Ethical Approval This article does not contain any studies with human Simonson, 2016). Other challenges are posed by concerns participants performed by any of the authors. pertaining to translating evidence-based treatment into prac- tice and balancing model fidelity with culturally responsive Open Access This article is distributed under the terms of the Crea- modifications (Kazdin, 2008; Ngo et al., 2008). While CBT tive Commons Attribution 4.0 International License (http://creat iveco and TF-CBT have been reported to be feasible and effective mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- tion, and reproduction in any medium, provided you give appropriate school-based interventions, other literature states that TF- credit to the original author(s) and the source, provide a link to the CBT is less effective in URM with complex trauma as noted Creative Commons license, and indicate if changes were made. throughout the tripartite process of migration (Beehler et al., 2012; Sullivan & Simonson, 2016). References Conclusion Abrego, L. J., & Gonzalez, R. G. (2010). Blocked paths, uncertain futures: The postsecondary education and labor market prospects This article explored migration as a traumatic, tripartite pro- of undocumented Latino youth. Journal of Education for Students cess as it relates to the unique needs of URM and school- Placed at Risk, 15, 144–157. https://d oi.org/10.1080/108224661 0 based services (Fazel & Stein, 2002; Kirmayer et al., 2011; 03635 168. Perez-Foster, 2001; Sullivan & Simonson, 2016). The influx Adelman, H. S., & Taylor, L. (2015). Immigrant children and youth in the USA: Facilitating equity of opportunity at school. Education of URM in the US continues to rise steadily and may con- Sciences, 5, 323–344. tinue to do so in years to come (Pierce, 2015; Yearwood Allard, E. (2015). Undocumented status and schooling for newcomer et al., 2007). URM are reportedly at a higher risk for devel- teens. Harvard Educational Review, 85, 478–501. oping PTSD and other psychological sequelae as a result Alvarenga, D. (2017). Vos vs. tú: 4 Central Americans on proudly reclaiming voseo in the United States. Remezcla. Retrieved from of their migration process when compared to voluntary http://r emez cla.com/lis ts /cultu r e/centr al-amer i cans-r ecla iming migrants. For this reason, schools are in unique positions to -vos-calif ornia /. provide mental health services to URM that are culturally- American Civil Liberties Union (ACLU). (n.d.). Sexual abuse in immi- responsive and trauma informed. CBT, TF-CBT, CBITS, gration detention facilities. Retrieved March 15, 2017 from https:// www.aclu.org/featu re/sexua l-abuse -immig ratio n-deten tion. and MHIP have been effective school-based models in the American Immigration Council. (2017). Asylum in the United States. treatment of URM, although some literature argues that TF- Retrieved July 11, 2017 from https://www .americanim mig rationc CBT is less effective in youth with complex trauma. The ounci l.org/resea rch/asylu m-unite d-state s. effectiveness of these models was enhanced by adopting Avila, J. (2014). 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Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied Refugee Minors

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Psychology; Personality and Social Psychology; Clinical Psychology; Sociology, general
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Abstract

This article explores migration trauma among Mexican and Central American unaccompanied refugee minors (URM) with the purpose of developing an understanding of migration as a tripartite process consisting of: pre-migration exposure to traumatic stressors, in-journey stressors, and post-migration stressors. The migration experience of these youth may be sub- jectively different depending on a wide range of factors. The complexities of migration are explored as a traumatic, tripartite process. These three salient components of migration may act as precursors, often resulting in psychological sequelae such as: post-traumatic stress disorder (PTSD), anxiety, and depression. Of all migrant groups, URM are more likely to develop psychiatric symptoms. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Cognitive Behavioral Intervention for Trauma in Schools (CBITS), and Mental Health for Immigrants Program (MHIP) are among the most effective interventions in the treatment of PTSD, anxiety, and depression in refugee minors. Social workers in schools are in unique positions to provide mental health services to URM. A case example illustrating a cultural adaptation of TF-CBT in an urban public high school is included. Clinical implications of culturally responsive and trauma-informed treatment of URM in schools will be discussed. Additionally, this article will emphasize the importance of bridging the gap between research and culturally responsive, trauma-informed interventions for URM in schools. Keywords Immigration · Minors · Trauma · Unaccompanied refugees · Schools The literature pertaining to the migration process of unac- (PTSD) and other psychological sequelae such as depres- companied refugee minors (URM) from Mexico and Central sion and anxiety as a result of forced exile and exposure to America, explores the tripartite process, consisting of: (1) traumatic events before, during, and after migration (Adel- pre-migration exposure to traumatic stressors, (2) in-journey man & Taylor, 2015; Fortuna, Porche, & Alegria, 2008; stressors, and (3) post-migration stressors, as adverse events, Rasmussen, Crager, Baser, Chu, & Gany, 2012; Smid, when approached through a trauma-informed perspective Lensvelt-Mulders, Knipscheer, Gersons, & Kleber, 2011; (Fazel & Stein, 2002; Kirmayer et al., 2011; Perez-Foster, Unterhitzenberger et al., 2015; Yearwood, Crawford, Kelly, 2001; Pine & Drachman, 2005; Sullivan & Simonson, 2016). & Moreno, 2007). Therefore, the unique needs of URM call Although most of the literature acknowledges the connec- for awareness and action by school-based social workers and tion between migration and trauma, an in-depth discussion educators in tailoring services that meet their complex needs on migration trauma as a tripartite process and as a clinical after migration. framework for assessment and treatment is inconsistent and Immigrant minors are youth under the age of 18, who often missing. When compared to other migrants, URM are migrate to the United States from their countries of origin at a higher risk of developing post-traumatic stress disorder because of varied, complex dynamics known in the litera- ture as push and pull factors (Kandel et al., 2014; Lee, 1966; Meyer, Margesson, Ribando Seelke, & Taft-Morales, 2016). * Diana Franco Push factors are described as forces that cause migrants to flee Dfranco04@me.com their countries and/or play into the decision-making process New York University Silver School of Social Work, 92-31 to migrate to the United States. Push factors originate in the 57th Avenue, Apt. 4A, Elmhurst, NY 11373, USA migrants’ native country, for instance war, poverty, and perse- New York University Silver School of Social Work, cution (Lee, 1966). Pull factors are influences that originate New York, NY 10003, USA Vol.:(0123456789) 1 3 552 D. Franco in the resettlement country, such as reunification with family, Literature Review that urge URM to migrate specifically to the US (Kandel et al., 2014; Meyer et al., 2016). Although migrant groups may differ Mexican and Central American Unaccompanied in levels of exposure to traumatic events (Pumariega, Rothe, Refugee Minors: Who are They? & Pumariega, 2005), pre-migration stressors, “in-journey” trauma-exposure, and post-migration stressors, are elements According to the 2016 United Nations (UN) Global Trend in the composition of migration trauma that contribute sali- Report, of the world’s 65.3 million people who are forci- ent information to the youth’s psychosocial history (Kirmayer bly displaced, more than half are young people under the et al., 2011). Overall, push and pull factors will continue to age of 18 (UNHCR, 2016). In the United States, almost influence the arrival of URM in the United States in years to 40% of new refugees are minors; although the literature come. posits that these statistics are difficult to monitor because In the US, schools provide most mental health services to URM often lack appropriate identification (Sullivan & minors (Bal & Perzigian, 2013; Beehler, Birman, & Camp- Simonson, 2016). According to a report by U.S. Customs bell, 2012; Burns et al., 1995; Hoagwood & Erwin, 1997; and Border Protection (2018), between October 2016 and Kataoka et al., 2003; Stein et al., 2002; Sullivan & Simonson, September 2017 41,435 unaccompanied youth had been 2016). Overall, social work services in schools contribute to apprehended at the US Southwest border. In 2017, 17% of the reduction in emotional distress and academic challenges these unaccompanied youth were between 0 and 12 years experienced by URM (Dods, 2015). Schools are situated to of age, 13% between 13 and 14 years of age, 37% between shorten the gap in service delivery for undocumented children 15 and 16 years of age, and 32% were 17 years old (Office and families who would not otherwise have access to these of Refugee Resettlement, 2018). The Office of Refugee services as a result of transportation barriers, stigma, and lack Resettlement (2018) notes that in 2017, 68% of the youth of health insurance (Stein et al., 2002; Sullivan & Simonson, apprehended were male and 32% were female. After the 2016). Although the literature (Green, 2003; Krogstad, Bar- surge of unaccompanied minors in 2014, there continues rera, & Lopez, 2014) emphasizes an increasingly steady influx to be a steady, yet increasing influx in rates of immigrant of unaccompanied minors migrating to the US (Pierce, 2015), youth (Pierce, 2015) and URM to the US. This proportion there is a dearth of empirical research (Greenman & Hall, is likely to grow significantly by 2020 (Yearwood et al., 2013; Rasmussen et al., 2012; Yearwood et al., 2007) pertain- 2007). ing to trauma-informed mental health services and culturally URM are youth under the age of 18 who flee their responsive treatment for URM in schools. countries without an adult companion and do not face the The role of pre-migration, in-journey, and post-migration option of returning to their homeland (Fong, 2007). The stressors will be explored as precursors for PTSD and other UN defines URM as youth “who are separated from both psychiatric disorders in URM. The relationship between parents and are not being cared for by an adult who, by trauma-related, psychological sequelae and their effect on law or custom, is responsible to do so” (Unterhitzenberger learning and academic achievement will be discussed. The et  al., 2015, p. 1; UNHCR, 2014). Additionally, fear of necessity for evidence-based interventions such as Trauma- persecution for reasons of race, religion, social or political Focused Cognitive Behavioral Therapy (TF-CBT), Cogni- affiliation, nationality, and lack of protection from country tive Behavioral Intervention for Trauma in Schools (CBITS), of origin, may result in an inability or unwillingness for and Mental Health for Immigrants Program (MHIP) will be URM to return (UNHCR, 1951). Thus, as a migrant group explored. Culturally responsive modifications will be dis- URM are distinct because of the persecution and displace- cussed through a tripartite process of migration framework ment they experience when compared to other migrant to emphasize the importance of making accurate assessments groups (Sullivan & Simonson, 2016). and establishing appropriate supports in schools. The need The term immigrant minors is usually discussed amor- for longitudinal, multimodal, and participatory action research phously in the literature; resulting in broad discussions (Stein et al., 2002) to address the gaps between research and and generalizations about a non-homogenous population culturally response practice with URM will be emphasized. (Bal & Perzigian, 2013). Immigrant minors are charac- terized by diversity that encompasses differences from migratory status, type of migration route utilized, and whether the youngsters migrated unaccompanied by an adult (Fong, 2007). In addition, there are other noted dis- tinctions between voluntary immigrant minors and URM, such as the latter usually being undocumented. Voluntary immigrant minors often embark on migration from their 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 553 countries of origin, to join other family members in the granted formal relief, which grants immigration status of US and seek better life opportunities (Adelman & Taylor, asylum or Special Immigrant Juvenile (SIJ) (Pierce, 2015). 2015; Fong, 2007). Push factors force URM to flee their Migrants from Guatemala and El Salvador have been admit- countries of origin because of political unrest, civil war, ted to the US as refugees since the 1980s, following political gang violence, or persecution (Adelman & Taylor, 2015; unrest in these countries (Greenman & Hall, 2013). Hondu- Fong, 2007). Both groups of migrants leave a great part of ran migrants have qualified for Temporary Protected Status their cultures and loved ones behind and may struggle with (TPS), after hurricanes, floods, and other natural disasters traumatic grief, adjustment, and racism upon arrival to the have affected the area in the 1990s and early 2000s (Green- US (Adelman & Taylor, 2015; Fong, 2007). man & Hall, 2013). Krogstad, Barrera, and Lopez (2014) note that URM from Central America and Mexico are the fastest growing group of immigrants in the United States. From October 1, 2012 to Migration as a Tripartite Process May 31, 2014, 46,932 unaccompanied children were taken into custody by U.S. Customs and Border Protection (Krog- The Impact of Exposure to Pre‑migration Adverse stad et al., 2014). Other research (Pierce, 2015) indicates Events that 102,327 unaccompanied children were apprehended at the US-Mexico border from the start of 2014 (fiscal year) Migration is a tripartite process, consisting of pre-migra- through August 31, 2015. Most URM come to the US from tion, in-journey, and post-migration stressors, that may be Mexico and the Northern Triangle, which refers to El Salva- explored through a trauma-informed perspective (Fazel dor, Guatemala, and Honduras—countries plagued by civil & Stein, 2002; Perez-Foster, 2001; Sullivan & Simonson, wars, gang violence, and severe poverty (Ciaccia & John, 2016). Although each URM report unique migration stories, 2016; Pierce, 2015; Stein et al., 2002; Zatz & Rodriguez, there are commonalities in these narratives that URM expe- 2015). Between 2014 through August 31, 2015, a total of rience as a collective (Murray, Cohen, Ellis, & Mannarino, 76,572 URM from the Northern Triangle were apprehended 2008). Pre-migration events may expose URM to a wide at the US-Mexico border (Pierce, 2015). Furthermore, Cen- array of stressors that widely depend on their country of tral America has the highest homicide rates per country, origin’s political and socioeconomic histories. especially among males ages 15–29 (Ciaccia & John, 2016). Overall, out of all emigrating groups, refugees of all ages In 2012, The Women’s Refugee Commission interviewed are the only group whose exposure to significant pre-migra- 151 URM, 77% of which stated that violence in their home tion violence results in psychiatric symptoms (Yearwood countries was their primary reason for migrating (Ciaccia & et al., 2007). URM, as previously mentioned, are forced to John, 2016). Of the minors interviewed, most reported that if flee from countries and regions plagued with civil unrest, they had the opportunity to “repeat the journey to the United violence, war, and other push factors. These push factors are States,” they would (Ciaccia & John, 2016, p. 1). believed to play a role in exposure to traumatic events prior For the most part, Mexican unaccompanied minors are to migration, increasing the youth’s susceptibility to devel- deported immediately (Pierce, 2015) and few Mexican oping PTSD (Smid et al., 2011). Due to the possibility that it migrants have been granted asylee immigration status in the may take longer for people with PTSD to seek help (Parsons US (Greenman & Hall, 2013). In contrast, migrants from the & Ressler, 2013), it is important for service providers to Northern Triangle are usually admitted to the US as refu- understand pre-migration adverse effects through a trauma gees. If proved eligible, URM can change their legal status to lens. Parsons and Ressler (2013) underscore “that exposure asylee, “a protection granted to foreign nationals already in to trauma in the past, before the ‘index trauma’ associated the United States or at the border who meet the international with PTSD—particularly childhood trauma exposure—is of definition of a refugee” (American Immigration Council, substantial importance” (p. 147). 2017, para. 2; Greenman & Hall, 2013). It is important to Scholars (Sawyer & Márquez, 2017; Tello, Castellon, note the differences between the designations refugee and Aguilar, & Sawyer, 2017) emphasize that gang violence is asylee. Refugees and asylees must both meet the same legal one of the push actors which result in forced migration from definition of having a well-founded fear of persecution due Central America. URM participants in a thematic analysis to race, religion, nationality, or membership in a particular by Tello et  al. (2017) “discussed fleeing to escape gang social group. Refugees receive legal permission to resettle violence and death” (p. 368). One participant in the study in the U.S. before they arrive, whereas asylees must meet the by Tello et al. (2017), reported being forced to flee Central definition of refugee and apply for asylum after they arrive America after losing her parents to gang violence and having in the U.S. (American Immigration Council, 2017). been threatened by a local gang. Similar literature (Garsd, Consequently, in immigration court, Central American 2015) reports that a 15-year-old girl from El Salvador was URM, may contest deportation by requesting that they be shot to death by gang because she was selling tortillas in 1 3 554 D. Franco a rival gang’s territory. Garsd (2015) adds that a different and other reported psychological sequelae include: the 15-year-old girl was shot in the head because her boyfriend physical and emotional effects of poverty, malnourishment, refused to join a gang. Similar gang-related violence is expe- physical and mental health issues, substance/drug abuse, rienced in Guatemala and Honduras. educational achievement, teen pregnancy, grief, personal War, violence, living in unsettled refugee camps, and per- losses (home, family, friends, belongings), leaving countries secution are events that often go hand-in-hand with physi- of origin suddenly without saying good-bye to loved ones, cal and emotional trauma (Adelman & Taylor, 2015; Fong, and being unaccompanied (Fong, 2007; Smid et al., 2011; 2007). When compared to voluntary immigrant youth, URM Yearwood et al., 2007). were more likely to report a higher incidence of trauma related to war and were disproportionally impacted by it Migration “In‑Journey” Stressors and Risk of PTSD (Collier, 2015; Pumariega et al., 2005; Rasmussen et al., and Other Psychological Sequelae 2012). The countries that make up the Northern Triangle have had a long history of violence and civil unrest. El Sal- Previous literature (Rasmussen et al., 2012) underscores dif- vador experienced a civil war throughout the 1980s and ferences in migration histories between URM and voluntary 1990s (Sawyer & Márquez, 2017). As a result, violence and immigrant youth. The most significant difference between persecution spilled into the neighborhoods in the form of these groups is the migration method used by URM to come executions and decapitations (Sawyer & Márquez, 2017). to the US. URM from the Northern Triangle embark on their The military coup of 2009 in Honduras resulted in police journey in many ways. The aid of a coyote, or human smug- corruption and unchecked crime against journalists, people gler, is sought by families who can send money from the US who identify as LGBT, and peasants (Sawyer & Márquez, to pay for the coyote’s services. Human smugglers, unlike 2017, p. 70). A 36-year-long civil war in Guatemala, which human traffickers, transport people across international bor - began in 1960 and ended in 1996, has left a lasting impact on ders who voluntarily seek this service. Nonetheless, human the country (PBS, 2011). Violence, intimidation, and organ- smuggling is a crime (Vargas, 2014). The migration journey ized crime continue to be a problem in Guatemala (PBS, can be treacherous, exposing the URM to being assaulted, 2011), forcing URM to flee their native lands. physically and sexually abused, and sustaining physical inju- Exposure to living in war-affected regions and violent ries. URM also face the risk of dehydration and malnourish- environments has been known to affect the mental health of ment from long periods of traversing through arid terrains, Latino migrants and refugees (Fong, 2007; Fortuna et al., while avoiding government officials. 2008; Yearwood et al., 2007), resulting in PTSD and depres- Many URM take buses, vans, and other methods of trans- sion (Rasmussen et al., 2012). The literature (Barowsky & portation arranged by coyotes (Dominguez Villegas, 2014), McIntyre, 2010; Fong, 2007; Fortuna et al., 2008; Rasmus- as they find their way through Central America and Mexico. sen et al., 2012; Yearwood et al., 2007), shows that depres- However, one method that has attracted attention from US sion and PTSD have been noted in children and adolescent and Mexican policy makers and human rights activists alike, asylum seekers fleeing from civil conflict or war affected is La Bestia (The Beast), freight trains that transport a vari- regions and that there is an average of 9 years, of pre-migra- ety of products to the US (Dominguez Villegas, 2014). Many tion PTSD onset (Rasmussen et al., 2012). PTSD onset has URM who take La Bestia as their method of migration to the been challenging to measure due to migration circumstances US are among the poorest of migrants, however, hitchhiking that make assessment difficult (Smid et al., 2011). Smid, a ride on La Bestia offers a cheaper alternative to paying Lensvelt-Mulders, Knipscheer, Gersons, and Kleber (2011) coyotes (Dominguez Villegas, 2014). Designed for cargo, argue that late-onset PTSD in URM is closely associated La Bestia offers no passenger railcars, forcing URM who with age of migration and lower education levels. This was use this method to ride on top of the freight trains; exposing noted between one to 2 years after resettlement (Smid et al., riders to serious risks (Dominguez Villegas, 2014). 2011). URM aboard La Bestia are vulnerable to a multitude of URM have also reported being exposed to other forms of dangers and traumatic stressors, such as the possibility of pre-migration violence not related to war, such as witnessing falling or being pushed off the freight train, amputation, the violent death of loved ones, community violence, being and death (Dominguez Villegas, 2014). Moreover, URM threatened with a weapon, kidnapping, domestic violence, aboard La Bestia are vulnerable to extortion, theft, or sexual sexual and physical abuse (Fortuna et al., 2008; Rasmus- assault by gangs who may force them to pay “protection” sen et al., 2012; Smid et al., 2011; Yearwood et al., 2007). fees. These gangs have been reported to work with Mexican These pre-migration traumatic events, coupled with severity organized crime groups by threatening and bribing migrants of exposure, may predict future traumatic events and suscep- in return for safe passage (Dominguez Villegas, 2014). In tibility to PTSD (Rasmussen et al., 2012; Smid et al., 2011). a study by Tello et al. (2017), some participants “reported Other pre-migration stressors that may contribute to PTSD being beaten and robbed in Mexico when their train would 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 555 stop at various points” (p. 365). Train conductors, often part stipulation for humane treatment, these detention centers of the smuggling and extortion operations, demand bribes of or “hieleras,” Spanish for iceboxes or freezers (Cantor, families, women, and children (Dominguez Villegas, 2014). 2015), are often extremely cold, overcrowded, with limited Exposure to these extreme conditions, experiencing and/ access to restrooms, medical care, food and water (Cantor, or witnessing death, abuse, and other forms of violence, 2015; Collier, 2015). These conditions serve as pervasive increase susceptibility for the development of PTSD and reminders that the threat of perceived risk to survival is still depression (Yearwood et al., 2007). However, PTSD and present. This notion is supported by Gudiño (2013), posit- other psychological sequelae may result from other losses ing that children with sensitivity to cues that threaten their not related to violence during the migration journey. Mur- survival may experience reinforcement that danger is still ray, Cohen, Ellis, and Mannarino (2008) assert that refu- present when surrounded by a hostile environment after gee populations, among the aforementioned stressors, are resettlement. characterized by loss and traumatic grief. Grieving about Detention centers and shelters have also posed other deceased loved ones, sudden separation from family, friends, threats to URM. It has been reported that URM have been and country of origin may lead to feelings of resentment, sexually and physically abused by detentions’ facility staff anger, and guilt in URM (Murray et al., 2008). However, during their temporary placements (Collier, 2015). Brané irrespective of the migration method used, most URM trave- (2018) adds that “perpetrators have included local police and ling through Central America and Mexico, may have already ICE employees, as well as contract guards and fellow detain- been impacted by violence, poverty, and war in their coun- ees.” It is evident that these statistics are difficult to moni- tries of origin. The exposure to these events only serves to tor as these incidents often go unreported. The Department exacerbate exposure to previous trauma. of Justice (DOJ) declared detention centers exempt from the Prison Rape Elimination Act (PREA) (ACLU, n.d.). Post‑migration Resettlement Stressors The PREA protects people in custody from sexual abuse by setting standards for prevention, detection, and report- The Icebox: US Detention Centers ing (ACLU, n.d.). Without PREA enforcement, there are no laws in place to protect URM in detention centers from The end of migration’s hazardous journey marks the begin- human rights violations and further increasing vulnerability ning of the post-migration phase, which is characterized by and exposure to post migration trauma. a unique set of stressors. Upon crossing the Southern US border, URM are apprehended by US Customs and Border Community Integration Protection (CBP). Consequently, a series of processes that determine the fate of URM in the US begin to unravel. While awaiting court proceedings, URM are released to a According to the William Wilberforce Trafficking Vic- relative, sponsor, or suitable families usually residing in tims Protection Reauthorization Act (TVPRA) of 2008, large Central American communities in the US (Collier, unaccompanied minors from countries other than Mexico 2015; Hennessy-Fiske, 2015; Pierce, 2015). After spon- or Canada cannot be sent back to their countries of origin sors and guardians are fingerprinted and vetted by FBI and without a court hearing (Collier, 2015). This law states Homeland Security, they will be verified to not pose a risk to that unaccompanied minors must be held humanely by the the child’s well-being (Hennessy-Fiske, 2015). Home stud- Department of Health and Human Services (HHS) until the ies are required by ORR only in cases where the URM have Office of Refugee Resettlement (ORR) releases them to a been reported to have a disability, history of abuse, or human sponsor or family found suitable to care for the child(ren) trafficking. However, the homes of many sponsors and/or (Avila, 2014; Collier, 2015; Pierce, 2015). Since March 1, guardians without criminal histories, still may not be appro- 2003, ORR has been responsible for over 175,000 URM, priate placements for these youth. Therefore, when family following requirements set forth by the Flores Agreement in members or sponsors are unavailable, URM are placed in 1997, the Trafficking Victims Protection Act of 2000, and foster care (Crea, Lopez, Taylor, & Underwood, 2017). the TVPRA of 2005 and 2008 (Office of Refugee Resettle- Scholars (Crea et al., 2017; Pine & Drachman, 2005) note ment, n.d.). that URM enter the child welfare system for reasons pertain- Following apprehension, URM must be turned over to ing to migration and resettlement such as migratory status HHS and placed in US detention centers and shelters within and exposure to traumatic events during the pre-migration 72 h (Collier, 2015; Hennessy-Fiske, 2015). Once placed, and in-journey phases. In other cases, URM have reportedly URM must wait at least 21 days after being charged as unau- experienced having food being withheld by relatives, sexual thorized to see an immigration judge for their first hearing abuse, and being forced to work rather than attend school. (Pierce, 2015). In the meantime, URM wait in detention ORR has expressed not having jurisdiction once a child is centers, often in deplorable conditions. Despite the law’s placed and that it is up to local child protective agencies to 1 3 556 D. Franco respond to cases of suspected abuse and neglect (Hennessy- Deferred Action for Childhood Arrivals (DACA) program Fiske, 2015). These circumstances often warrant the support which protected many undocumented youth from being of school social workers to aid in the protection of URM deported, was terminated (Sessions, 2017). In addition, after placement with parents, guardians, and in some cases, a decision to terminate the Temporary Protected Status with foster parents. It is evident that once placed, URM may (TPS) for migrants from El Salvador increased anxiety continue being vulnerable to a host of acute and complex among URM residing with parents or guardians who had stressors. been granted this protection (Nielsen, 2018). The dis- Other post-migration stressors such as acculturative stress mantling of these programs and protections result in the (Cano et al., 2015) and low socio-economic status (SES) disruption of family structures as a result of deportation contribute to emotional distress for URM. After resettle- (Planas & Carro, 2017). The fear of deportation and public ment, the SES of the family or new living arrangement (Smid safety act as ongoing barriers and stressors in the lives of et al., 2011; Yearwood et al., 2007) may be a stressor that URM in the US. continues to exacerbate pre-migration trauma pertaining to poverty, limited opportunities to engage in childhood activi- ties such as play, and having to take on adult responsibilities (Martinez, 2009). URM who arrive between the ages of thir- The Role of Trauma on Learning teen and seventeen often come to the US unaccompanied by and Academic Achievement a parent and face the choice of going to secondary school or directly to work (Allard, 2015). Family circumstances often Fischer (2010) posits that Mexican and Guatemalan chil- pressure students to make financial contributions by forcing dren living in US immigrant communities are vulnerable them to seek jobs after school, in turn resulting in challenges to experiencing challenges in the educational system. The related to studying at home and completing homework literature (Free, Križ, & Konecnik, 2014; Green, 2003, (Abrego & Gonzalez, 2010). Other research concurs that p. 65) reports that the consequences of hardships such as URM arrive to the United States with adult responsibilities poverty, depression, and lack of parental presence in URM such as working and paying bills (Allard, 2015; Martinez, and voluntary immigrant children may result in challenges 2009). Consequently, school attendance for most migrant pertaining to educational mobility and exacerbate issues children is dictated by the financial needs of the family and of illiteracy. Additional research (Collier, 2015; Dods, those needs may change from day to day depending on the 2015; Pumariega et al., 2005) indicates that trauma related general economic condition (Green, 2003). symptomatology may manifest in concentration, learning URM under the age of eighteen must make difficult deci- problems, and academic functioning for URM. Addition- sions between working or going to school and, because of ally, URM, who are particularly at risk among migrant pre-migration factors, consider themselves adults with no groups, have reported higher levels of conduct disorders other alternative (Allard, 2015; Martinez, 2009). Similar and school-related aggressive behaviors, due to prior literature (Lukes, 2014) purports that interrupted school- exposure to war and violence (Pumariega et al., 2005). In ing in Mexican and Central American youth is less related this regard, exposure to trauma can impact “all areas of to a disinterest in school, but rather because of economic a youth’s life” (Dods, 2015, p. 113). This is further sup- reasons pertaining to pre- and post-migration stressors. ported by Dods’ (2015) qualitative case study in which Educators and health providers often do not understand the personal interviews were administered to three youths to complex nature that underlies the balancing act between explore the intersection of trauma, school experiences, and the URM’s academic and work life. The reasons for these their perceptions of the roles schools play. Dods (2015) absences may not always be evident to educators, therefore further emphasized that trauma triggers, such as a loud, placing the onus of school attendance on the parents and/ crowded classroom can contribute to an increase in a stu- or guardians of URM. State mandated reporters find them- dent’s arousal levels. Thus, the student’s behaviors may selves in ethical dilemmas when they question whether or appear oppositional and unpredictable coupled with inat- not the teen is being neglected or improperly supervised, as tention, memory, and motivation challenges. The research schools label this as truancy or educational neglect resulting concluded that “unmet needs and diminished sense of in the involvement of the child welfare system. Additionally, agency” were common themes across participants (Dods, because of fear and lack of trust in authority figures, URM 2015, p.  129). The participants in Dods’ study (2015) will fail to state the reason for the absences, unless they have reported that while in school, they felt guarded and unsafe. established a trusting rapport with someone at the school. When heightened, these feelings may lead to pervasive Additional barriers such as anti-immigration policies PTSD symptoms (Smid et al., 2011) and ongoing disrup- in the US contribute to acute stress after resettlement for tions in academic achievement. URM. Effective September 2017, the program known as 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 557 treatment (Sullivan & Simonson, 2016). Thus, schools are The Necessity for School‑Based situated to shorten the gap in service delivery for families Interventions who would not otherwise have access to these services (Stein et al., 2002; Sullivan & Simonson, 2016). There were approximately 840,000 immigrant students in the US in grades k-12 (Adelman & Taylor, 2015). Fortu- Trauma‑Informed and Culturally Responsive nately, schools have been identified as the primary pro- Interventions in Schools vider of mental health services for all youth, including serving as the first social and institutional space that URM For schools to successfully engage URM in school-based encounter (Bal & Perzigian, 2013; Beehler et al., 2012; mental health services, these interventions are more likely Kataoka et al., 2003; Sullivan & Simonson, 2016). Addi- to be effective when they are evidence-based, trauma- tionally, schools have been noted to be in unique positions informed, and culturally responsive. Evidenced-based, in providing URM school-based mental health services, trauma informed treatment can effectively address the unique thereby contributing to the reduction in emotional dis- mental health issues manifested by URM, especially when tress and academic challenges (Dods, 2015). Most stu- delivered by a culturally responsive provider (Beehler et al., dents, k-12, spend at least 7 hours a day in school. This 2012). Although, “few programs have been rigorously evalu- places school administration and staff in loco parentis, or ated” (Kataoka et al., 2003, p. 311) specifically for URM in place of a parent, of students with diverse academic, and other children belonging to minority groups, the few social-emotional, linguistic, and cultural needs. programs that have been investigated have proven success As with instruction, mental health services are not a in trauma symptom reduction and academic improvement one-size-fits-all model. Therefore, schools are challenged (Nadeem et al., 2011; Unterhitzenberger et al., 2015). Addi- to self-assess to best respond to the complex needs of tionally, Unterhitzenberger et al. (2015) posit that no study URM and voluntary immigrant students (Bal & Perzigian, has explicitly investigated PTSD treatment in URM (p. 2). 2013). As URM enter the U.S. with past or current his- Notwithstanding, there are many trauma-informed modali- tories of PTSD, an increase in awareness about the pres- ties that target the reduction of trauma related symptoma- ence of school-based mental health services has emerged tology in children and adolescents. However, the literature amongst educators and policy makers to promote best (Bal & Perzigian, 2013; Beehler et al., 2012; Kataoka et al., academic and social-emotional outcomes (Bal & Perzi- 2003; Murray et al., 2008; Nadeem et al., 2011; Stein et al., gian, 2013; Dods, 2015; Nadeem, Jaycox, Kataoka, Lang- 2002; Sullivan & Simonson, 2016; Unterhitzenberger et al., ley, & Stein, 2011). Although some literature (Beehler 2015) purports that Cognitive Behavioral Therapy (CBT), et al., 2012; Stein et al., 2002) posits that few studies have Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), explored effectiveness of school-based mental health pro- Cognitive Behavioral Intervention for Trauma in Schools grams, schools with accessible mental health services have (CBITS)—including CBITS in Spanish, and the Mental been effective in demonstrating improvement in students’ Health for Immigrants Program (MHIP) have been evalu- academic achievement, social-emotional functioning, and ated to be most effective in the treatment in URM and other behavior (Nadeem et al., 2011; Unterhitzenberger et al., immigrant minors in schools. 2015). CBT is a therapeutic modality developed by Aaron T. School-based mental health services provide other ben- Beck that uses attention to thoughts, behaviors, and feelings efits for URM, voluntary immigrant students, and their associated with thought distortions and catastrophic thinking families. For example, most URM and voluntary immi- (Beehler et al., 2012; Murray et al., 2008; Sullivan & Simon- grant youths need psychological treatment, however are son, 2016). CBT and adapted CBT techniques and models not receiving it for a variety of reasons that may include currently “have the most empiric evidence” (Cohen, Man- stigma, finances, or lack of health insurance (Beehler et al., narino, Berlinger, & Deblinger, 2000; Murray et al., 2008, 2012; Polk, Page, & Ross DeCamp, 2014; Pumariega et al., p. 588) in treating traumatized youth. Despite the challenges 2005). Families of URM must often prioritize obtaining of time limitations and URM’s potential low writing, read- basic needs over addressing mental health needs (Beehler ing or drawing proficiencies, CBT and adapted CBT models et al.,  2012; Murray et al., 2008). In addition to acces- have also proved to be positive interventions for war trau- sibility, school-based interventions help reduce culturally matized refugee populations (Murray et al., 2008). TF-CBT, assigned stigma to receiving treatment (Pumariega et al., CBITS, and MHIP are among the most common and effec- 2005; Sullivan & Simonson, 2016, p. 508). Since cultural tive school-based interventions that use CBT techniques to and financial factors can be accounted for in a school set- reduce PTSD, depression, and anxiety symptoms in URM. ting, school-based interventions may assist in alleviating TF-CBT was developed using CBT techniques for the some of the obstacles that hinder URM from receiving treatment of children with psychological sequelae of sexual 1 3 558 D. Franco abuse and has expanded to treat other forms of trauma (Bee- To address the gap in effective evidenced-based, trauma- hler et al., 2012, p. 159). This manualized framework is an informed interventions in schools, in 1998 a team of clini- intensive, short-term, and time-limited approach which cian researchers from the RAND corporation, the University usually takes place over 12–16  weeks, once a week, in of California, Los Angeles (UCLA), and the Los Angeles 60–90 min sessions (Beehler et al., 2012; Cohen et al., 2000; Unified School District (LAUSD) collaborated in develop- Sullivan & Simonson, 2016; Unterhitzenberger et al., 2015). ing effective interventions (Nadeem et al., 2011; Stein et al., TF-CBT emphasizes the use of exposure, cognitive process- 2011). The school partners in the development of CBITS ing and reframing, stress management, parental treatment, wanted to offer a program that could effectively be delivered and cross-cultural modification while maintaining fidelity by school staff, in 45-min class periods, to a large number (Cohen et al., 2000, p. 1202; Sullivan & Simonson, 2016; of students in a linguistically and culturally responsive way Unterhitzenberger et al., 2015, p. 2). The acronym PRAC- (Nadeem et al., 2011). In their study, Stein et al. (2011) dem- TICE (P. Psychoeducation and parenting skills, R. Relaxa- onstrated that participants exposed to violence who received tion, A. Affective modulation, C. Cognitive processing, T. CBITS experienced significant improvement, evidenced by Trauma narrative, I. In vivo desensitization, C. Conjoint decrease in PTSD symptoms. In support of this literature, child/parent sessions, E. Enhancing safety and future skills) a randomized controlled study by Ngo et al. (2008) estab- best describes each of the components used in TF-CBT lished a significant decrease in depressive and PTSD symp- (Murray et al., 2008; Unterhitzenberger et al., 2015). toms in Mexican and Central American youth (p. 858). The Unterhitzenberger et al. (2015), purport that TF-CBT is implementation of CBITS in schools has broadened nation- “the best supported therapy for traumatized young people ally (California, Colorado, Louisiana, New Mexico, and at the moment …with proven feasibility for refugee chil- New Jersey) and internationally (Australia, China, Japan, dren” (p. 2). Unterhitzenberger et al. (2015), investigated and Guyana) (Stein et al., 2011). As a result, CBITS is a the feasibility of TF-CBT in a sample of traumatized URM. recommended, effective school-based intervention in treat- The results showed a “clinically significant symptom reduc - ing URM, immigrant youth, and other ethnically and lin- tion at posttest for all cases receiving TF-CBT” (p. 7). For guistically diverse youth in effectively decreasing trauma this reason, CBT and TF-CBT “may be useful in school related symptoms by “integrating cultural-sensitivity and systems serving large populations of refugees” (Sullivan & evidenced-based practice” (Ngo et al., 2008, p. 861; Stein Simonson, 2016, p. 523). Overall, TF-CBT has been proven et al., 2011). to reduce PTSD, internalizing, and externalizing symptoms MHIP is a school-based mental health intervention that in traumatized youth (Murray et al., 2008). Furthermore, incorporates CBT and is based on the CBITS framework CBT and TF-CBT are feasible interventions that can be used (Kataoka et al., 2003; Stein et al., 2002). In the development by school social workers, guidance counselors, school psy- of MHIP, LAUSD Mental Health Services Unit (MHSU) chologists, and other educational and behavioral specialists developed this framework by considering the school and cul- in treating children exposed to violence and complex trauma tural ecologies, to thereby effectively address the needs of (Kataoka et al., 2003; Sullivan & Simonson, 2016, p. 523.) Los Angeles’ large Latino immigrant student body (Kataoka Like TF-CBT, CBITS is a skills-based group interven- et al., 2003; Stein et al., 2002). Hence, program materials tion, developed by using a community-partnered research were made available in Spanish and other languages (Stein model, that uses cognitive behavioral techniques in relieving et al., 2002). In addition to CBT, MHIP also included home depression, anxiety, and PTSD symptoms in trauma exposed visits to meet with parents or guardians and were school- children, ages 10–15 (NCTSN, 2012; Nadeem et al., 2011). based to minimize barriers to service access (Stein et al., It was initially developed to effectively decrease trauma 2002). Services were provided during times when students related symptomatology for ethnically diverse and immi- were both in school and the school was able to provide ade- grant youth in schools (Ngo et  al., 2008). Interventions quate space in order to avoid decline in participation (Stein are delivered in 10, 1-h group sessions composed of 6–8 et al., 2002). Overall, MHIP aimed at reducing PTSD symp- children, once a week. The protocol includes one to three toms for immigrants who had been exposed to violence, individual sessions, two parent sessions, and one teacher sexual abuse, and other traumas (Kataoka et al., 2003). education session (NCTSN, 2012) and teaches participants The study conducted by Kataoka et al. (2003) demon- six cognitive-behavioral techniques: (1) Education about strated that MHIP was associated with a modest reduction reaction to trauma, (2) Relaxation training, (3) Cognitive in symptoms, however, further research is needed to deter- therapy, (4) Real life exposure, 5., Stress or trauma exposure, mine sustainability and replication by other schools. Stein and 6. Social problem-solving (NCTSN, 2012). To account et al. (2002) add that although many challenges in school- for cultural diversity, CBITS programs are available in Span- based mental health research exists, MHIP provided a use- ish and there are efforts being made in adapting CBITS for ful framework to guide program development in the future Native American children (NCTSN, 2012). (p.  324). Stein et  al. (2002) purport that future program 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 559 engagement with recent immigrant parents or guardians of treatment needs are not being met in schools (Sullivan & migrant children would be an asset to MHIP’s development. Simonson, 2016). Often linguistic and cultural barriers, In addition to being trauma-informed, school-based inter- such as stigma about the concept of therapy itself, may pose ventions are increasingly effective when culturally respon- obstacles in identifying URM and families in need (Murray sive modifications are made (Isakson, Legerski, & Layne, et al., 2008; Sullivan & Simonson, 2016). School staff often 2015). misinterpret trauma-triggered behaviors in URM since these may range from irritable outbursts to internalized symptoms Challenges with Implementation in Schools that are less noticeable (Cohen, Mannarino, & Murray, 2011; Sullivan & Simonson, 2016). Some of these symptoms will CBT, TF-CBT, CBITS and MHIP are all models that effec- manifest in a variety of ways including somatic complaints tively target the reduction of trauma symptoms in URM and such as headaches and stomachaches (Cohen et al., 2011; immigrant youth. However, there are some challenges in Isakson et al., 2015; Ngo et al., 2008; Pumariega et al., 2005; implementing these models in schools with this population. Sullivan & Simonson, 2016). In support of this literature, As stated earlier, URM migrate to the U.S. unaccompanied Isakson et al. (2015), assert that “non-Western cultures do by a parent or guardian. In many cases, parents of URM not differentiate between physical and emotional health” migrated to the U.S. when the child(dren) was or were very (p. 4). Therefore, it is important to identify how migration young. Sometimes, URM leave their parents in their coun- trauma presents in URM. Since culture shapes emotional tries of origin and join grandparents, aunts, uncles, or other vocabulary and meaning associated with trauma, neces- family members whom they have never met. Since all of sary steps must be taken so that the school social worker is these models include a parent psychoeducational piece, it speaking the same cultural language as the child (Isakson is important to note that the absence of collaborating with a et  al., 2015, p. 4; Murray et al., 2008, p. 593). By doing parent or guardian who knows the URM well may present a so, school social workers are able to provide a culturally challenge in treatment. Smith, Lalonde, and Johnson (2004) informed understanding of the URM’s behavior to the rest note that staggered patterns of migration, or serial migra- of the school community. tion, when parents migrate to a new country years before Culturally responsive interventions and approaches their children, results in stress for the family and in negative that validate and incorporate the cultural values, norms, effects on the self-esteem and behavior of URM. Although and resilience factors of URM, have resulted in increased there is no available literature on the effect of staggered receptiveness to treatment when compared to models with- migration on treatment in schools, it is possible that these out cultural modifications (Fong, 2007; Isakson et al., 2015). strained family dynamics may require treatment other than Cultural modifications include targeting the unique needs of those mentioned in this article. refugees such as housing, language, emotional and physical CBT, TF-CBT, and CBITS are time limited with regard health (Isakson et al., 2015). For instance, CBT, TF-CBT, to duration of each session as well as the treatment model. CBITS, and MHIP school-based interventions have been These time constraints may pose challenges in schools adapted to working with URM by making linguistic modifi- regarding student schedules and potential inconsistent cations and incorporating customs and rituals from the chil- attendance of URM. As a result, treatment may be inter- dren’s native culture (Ngo et al., 2008; Stein et al., 2002). rupted or subject to sudden programming changes by the Although Spanish is the most commonly spoken language school. in Mexico and Central America, Garifuna and Mayan lan- The aforementioned treatment modalities, also rely on guages such as K’iche’ and Mam are spoken by over 500,000 writing, drawing, and/or reading. In some cases, URM might people in these regions (Carcamo, 2016). Some countries enter the U.S. school system with interrupted education in in Central American use vos, the second person singular their countries of origin, varying levels of cognitive devel- pronoun, instead of the informal command tú when speak- opment, and/or limited writing and reading skills. School ing to family members and close friends (Alvarenga, 2017). social workers may adapt the modalities by using a verbal or As a result, Spanish-speaking service providers may need dramatic form of expression (Murray et al., 2008). to familiarize themselves with variations of spoken Spanish and other languages in the treatment of URM. Cultural Responsiveness: Considerations Other modifications can be evidenced by incorporating in School‑Based, Trauma‑Informed Treatment cultural values and norms when meeting with parents, guard- ians, or family members of URM, such as leveraging the Although schools have been identified as the front-line pro- voice and input from the mother, being mindful of the role viders of mental health services to minors, including URM of spirituality in treatment, and being mindful of somatic and voluntary immigrant youth (Kataoka et al., 2003; Stein complaints in a cultural context. For these reasons, it is et  al., 2002; Sullivan & Simonson, 2016), most URM’s important for school social workers and other school-based 1 3 560 D. Franco mental health staff to familiarize themselves with the culture group was an adaptation of TF-CBT techniques and utilized of each URM’s country of origin. a culturally responsive approach, including group facilitation The Cultural Adjustment and Trauma Services (CATS), is in Spanish. This group focused on trust building, psychoe- a school-based mental health model that uses CBT and TF- ducation, trauma exposure, and consultation with parents. CBT with immigrant youth in two New Jersey school dis- tricts (Beehler et al., 2012). In this model, CBT techniques were used “eclectically as needed in response to clinical Case Example: Yaretzi presentation” (Beehler et al., 2012, p. 159). The manual- ized intervention used, TF-CBT, was discontinued in the Yaretzi is a 16-year-old girl in her sophomore year at a small, CATS model because some students found it challenging New York City public high school. She is originally from to focus on a single trauma narrative or stressor, making a low-income neighborhood in a small town in El Salva- the implementation counterproductive. As previously men- dor. Yaretzi currently lives with her paternal grandmother, tioned, migration trauma is a tripartite process which may be a relative whom she never met or lived with before. Living composed of repeated and prolonged events that may result with her grandmother and her strict rules is one of the many in complex post-traumatic stress disorder (C-PTSD). As a adjustments that pose as stressors for Yaretzi. She arrived in result, adaptable treatments that can be culturally modified the United States, through the US-Mexico border assisted by to the specific experiences of URM are essential. Nonethe- a coyote, as an unaccompanied refugee minor. In El Salva- less, TF-CBT was used to inform other services provided dor, Yaretzi lived with her mother, father, and two younger by the treatment such as family involvement (Beehler et al., siblings. She reported witnessing a lot of gang violence and 2012). often felt unsafe. She remembered that “while aboard the bus Ngo et al. (2008) assert that CBITS was flexibly devel- to school, witnessing a group of gang members board the oped to meet the needs of ethnically and heterogeneous bus, shoot, and kill two fellow classmates.” The gang threat- school districts. Additionally, this intervention was devel- ened the passengers, stating that if the authorities were noti- oped to strike a balance in maintaining the treatment fidel- fied there would be retribution. Yaretzi stated that her “life ity while emphasizing cultural and systems competence. changed after witnessing the murder of the two students,” Because CBITS is not comprised of culturally specific core who allegedly had been gang affiliated. Her father drove her components, clinicians modified psychoeducation, cogni- to school for the next couple of months, but her experience tive-restructuring, and problem-solving, in working with of ongoing fear, nightmares and flashbacks of the event URM who had crossed the US-Mexico border, so that the ultimately interrupted her ability to perform daily tasks, model would be sensitive to migration trauma (Ngo et al., including concentrating on school work. Despite her parents’ 2008, p. 860). Operating under the notion of cultural respon- requests, Yaretzi dropped out of school for a year and stayed siveness, CBITS involves necessary steps to not disregard home out of fear for her safety. Yaretzi expressed that her URM’s family beliefs such as ghosts or other cultural beliefs parents wanted her to “have the opportunity of acquiring an (Ngo et al., 2008, p. 860). Stein et al. (2002), emphasize that education and a better life.” However, she did not know that like CBITS, MHIP providers collaborated in ways to address her parents, in collaboration with family members living in cultural issues that emerged in sessions such as belief in New York City, collected money to finance her journey to ghosts or spirits of deceased family members. the U.S. Yaretzi states that she doesn’t remember much of The models CBT, TF-CBT, CBITS, and MHIP shared the journey, except that she cried the entire time and was additional culturally responsive modifications. All models often told to “shut up” by the coyote. After 11 days, Yaretzi emphasized the use of bicultural and bilingual licensed clini- arrived at the U.S.–Mexico border from El Salvador. She cians to provide services (Beehler et al., 2012; Stein et al., was apprehended in Texas and taken to a detention center. 2002). The literature (Beehler et al., 2012; Murray et al., About 2 months after her admission to the high school, 2008; Ngo et al., 2008; Pumariega et al., 2005; Stein et al., Yarezti’s teachers noted to the school social worker that she 2002) asserts that the use of cultural brokers or liaisons to had been steadily losing weight, missing school days, and the community with cultural knowledge and clinical exper- falling asleep in class. One of her teachers facilitated an tise is crucial in assisting with outreach and in ensuring that introduction to the school social worker. The school social interventions were implemented in a culturally sensitive way. worker introduced the support services offered to URM at The following case example illustrates a cultural adapta- the high school, including group and individual sessions tion of TF-CBT in the treatment of PTSD with a URM in an in Spanish. Yaretzi appeared hesitant to disclose personal urban public high school. Implementation of a manualized information to the teacher and the school social worker in intervention such as TF-CBT and CBITS was not possible at the introductory conversation. However, Yaretzi made an this school setting due to challenges around student program- appointment to speak to the school social worker the next ming and physical space. As a result, this trauma-informed day. Yaretzi was introduced by one of her peers (and group 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 561 members) to the school-based counseling group designed to parents and/or guardians of the group members. These ses- address the needs of URM. sions took place in person or by phone in order to adjust to the families’ work schedules. Engaging the family in discus- Assessment and Interventions: Trauma‑Informed sions pertaining to the group’s purpose, migration trauma, Treatment with Cultural Modifications trauma symptoms and stigma helped parents and guardians feel like stakeholders in the students’ (and their own) healing In the initial individual session (and in subsequent sessions), process. Yaretzi’s grandmother was grateful for the existence the school social worker met with Yaretzi in Spanish. Early of the group on her granddaughter’s life, however, she was in the session, Yaretzi stated concerns about confidentiality. mostly concerned with her academic success and follow- The social worker explained the limits of confidentiality as a ing the rules at home. Cultural understandings around trust, school official. Yaretzi reported to the social worker that she shame, discipline, respect, hierarchy, and family dynamics felt sad on a daily basis, experienced nightmares and inter- are the important values to be aware of in conversations with rupted sleep, and flashbacks of the event on the bus in El families and in treatment with URM. Salvador. She stated having difficulty focusing in class, pri- When the group was ready, they began to explore and marily because much of the content was taught in English. share their trauma narrative—the exposure to trauma related Although she had made a couple of friends, Yaretzi reported memories through narrative. This was done through journal feeling that she “did not belong” here. Yaretzi also stated entries, visual art, songs, acting and story-telling. For exam- that she “hated living with her grandmother because she was ple, the group members engaged in creative ways to help strict and mean.” She added that food in the U.S. tasted “like construct the narrative such as: “What happened the day plastic, artificial. Nothing like mom’s tortillas back at home before you left (country of origin)?”, “What event(s) stands and other tasty food.” The school social worker discussed out about your journey to the U.S.?” and “What do you the migration process with Yaretzi. Yaretzi spend some time remember about the exact moment you arrived in the U.S.?” discussing the negative and positive aspects of her life in El Yaretzi wrote a poem and a story depicting her experiences Salvador, the hardships endured in her journey to the U.S., before, during, and after migration. The trauma narratives and the stressors she had been facing after her arrival to New developed and changed over a few weeks while emerging York City. In the initial session, the school social worker feelings and memories were processed in group. In her nar- assessed for depression and self-harm. At the conclusion of rative, Yaretzi emphasized a longing for “the beauty of her the session, the school social worker invited her to join the country,” her mother’s cooking, the smell of her home in El group. Yaretzi stated that she would think about it. Salvador, the sadness she felt about being “forced to leave,” Yaretzi and one of her peers approached the school social and “living in a strange country.” In the post-migration nar- worker’s office the next day requesting to join. The group rative, Yaretzi expressed feeling “stressed having to balance consisted of five Central American high school girls, ages the role between being a student and having to work full time 15–16, met once a week for 40 min, throughout the 10-month after school.” After a month of participating in the group academic year. As suggested by the literature (Cohen et al., and seeing the school social worker for individual sessions, 2011), when youth may have been exposed to multiple trau- Yaretzi’s effort in class improved, her attendance became mas, as observed in migration’s tripartite process, TF-CBT’s more consistent, and she stopped sleeping in class. Enhancing Safety skill of the PRACTICE model may be introduced before Psychoeducation. Focusing on this skill, the social worker was able to develop an environment of Discussion safety in a group of girls that had faced threatening events in their native countries and in their respective journeys to This case example illustrates the necessity for exploring the U.S. Safety and trust-building was created through group migration trauma as a tripartite process including the pro- activities that encouraged reliance on each other. During vision of school-based, trauma-informed interventions. this process, Yaretzi was often hesitant to participate, but During pre-migration, Yaretzi witnessed the death of peers after encouragement from peers, she joined activities more and was threatened by the gang members that murdered the readily. Yarezti and other group members identified family, youngsters on the school-bound bus. Fearing for her safety church, priests, Santeros, Espiritistas, Curanderas, and other after the shooting, Yaretzi’s education in El Salvador was practitioners of traditional medicine as sources of safety in interrupted, sleep patterns were dysregulated by nightmares, their communities. and capacity to focus on daily tasks became increasingly The school social worker introduced psychoeducation challenging. It is important to note that prior to the shoot- about PTSD, depression, and anxiety symptoms related to ing, Yaretzi was exposed to poverty and other stressors that the migration process and slowly normalizing exposure to accompany low-income families in the Northern Triangle. trauma. Psychoeducational sessions were also held with As noted throughout the literature, stressors that accompany 1 3 562 D. Franco poverty may contribute to PTSD up to 9 years prior to migra- frontline in mental health service provision for minors, tion (Fong, 2007; Rasmussen et al., 2012; Smid et al., 2011; Yaretzi was able to develop a safe, support system in a Yearwood et al., 2007). trusted space. Most importantly, support was delivered in In keeping with this notion, the literature suggests that Yaretzi’s native language and her narrative was understood exposure to gang violence and witnessing the violent death from a culturally responsive, trauma-informed perspective. of someone are pre-migration stressors that increase sus- ceptibility to PTSD (Fortuna et al., 2008; Rasmussen et al., 2012; Smid et al., 2011; Yearwood et al., 2007). In Yarezti’s case, she was exposed to these stressors from birth. Ulti- Practice, Policy, and Research Implications mately, these interruptions and acute stressors acted as push factors that pressured Yaretzi’s family to plan her migra- Practice and Policy Implications tion to the US. Moreover, these events forced Yaretzi out of El Salvador without appropriately saying goodbye to many Although it has been noted that URM have unique needs loved ones in addition to leaving cherished possessions, that call for tailored interventions, most are not receiv- memories, and components of her culture behind. ing the necessary mental health services within schools or Once embarked, Yaretzi did not witness or experience in their respective communities. The literature reviewed violence or physical risks. However, throughout the migra- emphasized the complexity in the treatment of immigrant tion journey, Yaretzi experienced loss, separation, grief, pro- youth, in particular, Mexican and Central American URM. found sadness, and distress. She was met with no support Voluntary immigrant youth and URM have reported differ - while being forced to stifle the expression of emotions by the ences in PTSD prevalence. URM have been identified as coyote. Vargas (2014) explains that “coyotes are well known a vulnerable and high-risk group susceptible for develop- in Central American townships, and the smuggling busi- ing PTSD and other psychological sequelae as a result of ness has traditionally been built on trust. Knowing the right exposure to stressors throughout the migration process. coyote is key to securing a safe journey” (para.7). Although There is a danger in pathologizing symptoms and behav- Yaretzi did not undergo other forms of abuse by the coyote, iors in URM if clinicians in settings that serve URMs, she reported feeling “demeaned” by the coyote’s demands especially in schools, do not assess for trauma as discussed to stop crying. Yaretzi’s trauma narrative as depicted in her in this article. Knowledge of URMs socio-political and story and poem, highlight the anguish she experienced from economic histories, values, norms, and resilience fac- the sudden loss of family, friends, and community. Thus, tors would enhance the delivery of culturally responsive traumatic grief over the unexpected separation from her fam- treatment. ily and birthplace may have added to the complexity of the Therefore, an in-depth exploration of migration’s tri- pre-existing trauma experienced by Yaretzi (Murray et al., partite process as it pertains to trauma and other psy- 2008). chological sequelae may assist mental health providers Yaretzi’s resettlement and adjustment experiences after in school deliver culturally responsive services to these migration also contributed to pre-existing stressors. Post- youth. Additionally, schools would better support URM migration stressors that may have exacerbated her feelings by offering social work services in the student’s native of loss, danger, and grief were the low socio-economic language wherever possible. School staff should make status in the new living arrangement with her grandmother active efforts in understanding the norms and values of and recurrent nightmares and flashbacks about the shoot- the student’s culture and incorporating these into trauma- ing. The literature explains that after re-settlement, pov- informed services. The support of the student’s parents, erty in the new country may act as a continuous stressor guardians, family members, and cultural brokers in the while negatively impacting educational outcomes in URM community should be leveraged as part of the treatment (Collier, 2015; Dods, 2015; Free et al., 2014; Green, 2003; process in schools. Pumariega et al., 2005). Consequently, Yaretzi reported Overall, it is proposed that school-based, mental- appetite loss, change in eating habits, and decrease in health service providers and educators become attuned to energy. As a result, academic achievement, body weight, the unique needs of URM. Therefore, culturally adjust- and capacity to concentrate in and out of school were ing trauma-informed interventions to the complex events directly impacted. Teacher referrals and established sup- experienced by URM throughout the migration process ports such as the school-based, trauma-informed student (Isakson et al., 2015; Murray et al., 2008). Neglecting this group, individual sessions with the school social worker in connection results in learning and adjustment difficulties Spanish, and establishing peer supports allowed for timely that may exacerbate pre-existing PTSD symptoms. identification of possible PTSD symptoms and adjust- ment challenges. Since schools are considered to be at the 1 3 Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied… 563 English as a New Language (ENL) classes (formerly Eng- Implications for Research lish as a Second Language) which is where most URM are placed upon admission to US schools. It is important that Because of current gaps in research, longitudinal, multi- modal, and participatory action research (Stein et al., 2002) school district leaders look beyond the students’ academic needs to include social-emotional needs in the form of may help bridge research disparities for the purpose of translating findings into practice. Further research is needed trauma-informed supports. Thus, training must be provided for school social workers, other school-based mental health pertaining to the provision of culturally responsive, trauma informed treatment of URM in schools. Moreover, the litera- staff, teachers, guidance counselors, and administration. ture consistently reports that studies about effective school- Acknowledgements The author gratefully acknowledges Dr. Diane based, trauma treatment of Mexican and Central American Mirabito, Dr. Liliana Goldín, and Dr. Carol Tosone for their feedback URM, are scarce (Beehler et al., 2012; Dods, 2015; Isak- and guidance on earlier versions of this article. son et al., 2015; Murray et al., 2008). This dearth in the literature may be partly due to challenges associated with Compliance with Ethical Standards studying URM as a population (Collier, 2015). For instance, fear of immigration status disclosure and cultural beliefs and Conflict of interest The author declares that the author has no conflict of interest. stigma about mental health services may contribute to these challenges (Collier, 2015; Murray et al., 2008; Sullivan & Ethical Approval This article does not contain any studies with human Simonson, 2016). Other challenges are posed by concerns participants performed by any of the authors. pertaining to translating evidence-based treatment into prac- tice and balancing model fidelity with culturally responsive Open Access This article is distributed under the terms of the Crea- modifications (Kazdin, 2008; Ngo et al., 2008). While CBT tive Commons Attribution 4.0 International License (http://creat iveco and TF-CBT have been reported to be feasible and effective mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- tion, and reproduction in any medium, provided you give appropriate school-based interventions, other literature states that TF- credit to the original author(s) and the source, provide a link to the CBT is less effective in URM with complex trauma as noted Creative Commons license, and indicate if changes were made. throughout the tripartite process of migration (Beehler et al., 2012; Sullivan & Simonson, 2016). References Conclusion Abrego, L. J., & Gonzalez, R. G. (2010). Blocked paths, uncertain futures: The postsecondary education and labor market prospects This article explored migration as a traumatic, tripartite pro- of undocumented Latino youth. 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Child and Adolescent Social Work JournalSpringer Journals

Published: May 29, 2018

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