An insidious prison

As the number of migrant children in US government custody has risen to its highest level in history, mental health experts and lawyers are increasingly voicing their concerns about the psychological and social consequences of detention and prolonged separation from primary caregivers.

Most individuals can understand that it is extremely stressful and anxiety provoking for a child of any age to be detained in a foreign country and separated from their caregiver. What is less understood by the wider public is the anxiety experienced by US born and raised children whose caregivers live under chronic threat of deportation. These children also live in a prison, albeit a less sensational and more insidious one. Instead of being built of metal and concrete, their prison is built of fear.

US-born children of undocumented parents have experienced years of heightened symptoms of stress and pervasive fear as an indirect result of deportation policies, which were introduced under President Bill Clinton and tightened under the administrations of George H.W. Bush and Barack Obama. As mental health professionals working with such children in the New York Tri-State area, we have observed a sharp increase in levels of distress and anxiety ever since the start of President Donald Trump's highly publicised crackdown on illegal immigration. With the administration's focus on immigration from Central America and Mexico, our clinical findings indicate that these symptoms are especially pronounced among Hispanic children.

According to the most recent estimates available from the Migration Policy Institute, 4.1 million U.S. citizen under the age of 18 live with at least one undocumented parent. The majority of these undocumented individuals were born in Mexico, Guatemala, El Salvador and Honduras. In the past ten years, we have evaluated hundreds of Hispanic children of undocumented parents for immigration proceedings. Their childhood is almost always overshadowed by fear and anxiety about their family's future. We have observed how this uncertainty hinders a child's ability to forge meaningful and long-lasting relationships, and make plans for the future. Our extensive clinical experience corroborates the findings of several studies [1] that also show that the lingering possibility of deportation of parents deeply affects children, leaving them with clinical levels of distress, anxiety, and attachment and trust issues. These symptoms interfere with their socioemotional and intellectual development and contribute to academic underachievement. We found that their already debilitating mental health issues are further intensified by identity struggles, increased school bullying, and related social isolation.

Children of immigrants often find themselves caught between two cultures and the challenge of navigating between the two can lead to questions and even shame associated with their self-identity, which poses a significant stressor in a child's life. At home, most parents speak Spanish, though the majority of the patients we evaluate are not fluent and struggle communicating in that language beyond basic conversation. For this reason, many children prefer to speak English, both at home and at school. For some this is a choice informed by a longing to fit in; others feel societal pressure to speak only English.

While they might identify themselves as "American," children of Spanish-speaking parents are likely to be labeled by school records and fellow students as "Hispanic," "Spanish-speakers," or "Latino." Since the start of Trump's presidential campaign, they report being increasingly subjected to racial epithets and threats by their peers. Bullies, perhaps emboldened by the President's coarse language and racist rhetoric when describing Hispanic immigrants, single out children of Spanish speaking parents. We've heard numerous reports of children being subjected to taunts such as "go back to Mexico" and "you and your family are going to be deported". Many studies have confirmed the relationships between perceived racism and behavioral and mental health issues among Hispanic youth, including anxiety, acting out, social withdraw, self-esteem issues, substance abuse, difficulty concentrating, depression, and suicidal ideation [2].

Bullying and racist taunts are not confined to the school yard. According to a recent PEW report, 37 per cent of Hispanics experienced discrimination in the past year while more than half that it has become more difficult to be Hispanic in recent years. Of those surveyed, two-thirds blame the Trump administration's policies for their worsening situation.

While jeers and mockery can be ignored, the reality faced by undocumented immigrants cannot. Children of undocumented immigrants are confronted with almost daily news messages about immigration raids, and hear about peers whose Hispanic immigrant parents are arrested and deported. Not surprisingly, children become extremely fearful that their parents could be next. They report rumination, fear, and helplessness. Many children panic when they see professionals in uniform, and some develop panic symptoms. Others cannot fall asleep until they're assured their parents are home and safe. Young children fear for their and their parent's welfare and these fears hinder their ability to concentrate in school, which in turn affects their academic performance. The younger children we work with are especially prone to develop separation anxiety disorder as a result of these fears. They do not want to go to school, and if they do attend, they want to go home as soon school is out instead of playing sports, engaging in extracurricular activities, or socialising with friends.

Children's fear of deportation is not without merit. Between 2011 and 2013, an estimated 500,000 US citizen children experienced the apprehension, detention, and deportation of at least one parent, according to the American Immigration Council. As deportations of those already living in the United States have increased significantly since President Trump took office, the number of US children affected by parental deportation has increased too.

We observed how children's uncertainty about their family's future in the United States can lead to a lack of aspiration and motivation in terms of higher education. Many are reluctant to accrue the debt of pursuing a college degree when there is the real possibility of not remaining the United States. This bleak realisation often follows years of hard work in middle school and early high school when children were less acutely aware of the implications of their parents' undocumented status. Others end up not attending college, because submitting the necessary information for applications, financial aid, and scholarships could risk exposing their parents' immigration status.

A child's fear of parental deportation is not only related to losing the only life they have known – they are also terrified of the possibility of uprooting to their parents' native communities, which are all too often characterised by gang-related violence, poor healthcare and education, human rights issues, extreme poverty, and widespread corruption.

Many children have witnessed firsthand what life is like in these communities during visits to relatives. Children describe similar experiences during these trips – their grandparents, uncles, and aunts keep them indoors the majority of the time to ensure their safety. When they do leave their relatives' homes, children are told they are not safe, and along with this acute sense of danger, they are confronted with poverty and a lack of medical services. As violence further escalates in countries of origin, anxiety about possible deportation increases.

In cases where only one parent is undocumented, children are often emotionally consumed with the consequences of familial separation. When one parent is deported, those who remain behind struggle financially [3], since most families need two incomes to afford basic needs. Additionally, the absence of one parent can have serious implications in terms of logistical and emotional support, leaving a gap in the child's support system. Children who endure family separation, are usually cared for by a relative as paid childcare is not cost effective for the remaining parent, in other cases older children are expected to assume care for their younger siblings. Both options are emotionally taxing for everyone involved. Further, the remaining parent [4] has to work more hours to financially sustain his or her household, leaving little time to help children with homework, attend parent-teacher meetings, take children to doctor's appointments, and detect any mental health issues in their children. Since airfare to a parent's native country is likely out of reach, separation – and the grief and loss that comes with it – can become long lasting or permanent.

The other option available to a mixed-status family facing deportation, e.g. uprooting the whole family to the country of origin, is often equally or even more deleterious for the child. As mentioned above, the majority of undocumented immigrants were born in Mexico, Guatemala, El Salvador and Honduras. In these countries, US citizen children are subjected to poverty, high crime rates [5], poor healthcare and education systems, and language barriers that can impede their academic success and chances of gainful employment. In addition, those children with mental health or developmental problems have little to no access to appropriate resources as these services are often sparse and poor in parents' countries of origin. The latter is especially concerning, as children who accompany their deported parents are likely to report emotional problems including negative mood, physical symptoms, and negative self-esteem according to Zayas et al [6]. Their study is one of very few that looks into the experiences of children who were born and raised in the United States but now reside in a developing country. Considering the fact that, in Mexico alone, the number of such children is estimated to be anywhere between 430,000 and 600,000, more studies are warranted.

Suffering in silence

Children's overwhelming fear of deportation, along with day-to-day exposure to discrimination and the inability to participate in modern rites of passage such as attending college, places them at risk for emotional stress and social isolation. In this context, the term "perpetual outsiderhood" was coined by Suárez-Orozco and colleagues in their illuminating article on the developmental implications of unauthorised status [7], to describe the isolated position many children of undocumented parents find themselves in.

Further increasing this sense of social isolation, Hispanic children tend to suffer in silence. They are not telling fellow students or school counselors about their home situation, for fear that sharing information about their parents' undocumented status could lead to their deportation. Other children are unaware or only partly aware of their parents' immigration problems and grow up with a sense of secrecy and silence. They can feel parental stress at home, have pressing questions about their parents' background, but feel uncomfortable obtaining answers. Instead they internalise fear and anxiety that is almost always difficult to label and treat. 

At home, they may confide in their siblings or parents, but oftentimes they don't because they do not want to upset their family members. Instead, children focus on being a source of support to their parents by reassuring them, and also by concealing their own fears. For this reason, many of our young patients who present with chronic mental health problems, have not received any professional treatment nor have they been seen by school counselors. Like their children, parents too, fear that if they would follow up on a referral, they would risk detection and thus deportation.

Hispanic parents and their children also hesitate accessing professional care due to the stigma associated with mental health issues in their ethnic community. Out of fear of social exclusion and being labeled 'crazy', parents often deny the possibility that their children may have emotional or mental problems. Other barriers deterring patients who need treatment from seeking it are the cost of mental health services, and the time that needs to be taken off from work to attend sessions. Undocumented families' finances are greatly impacted by immigration related expenses and low wages, leaving them with little disposable income to cover the costs of therapy. As funding for mental healthcare is limited in most communities, mental healthcare is out of reach especially for those who are uninsured, including the majority of undocumented immigrants. Lastly, it should be noted that in many regions in the United States, there is a shortage of therapists with the necessary language and cultural concordance or cross-cultural experience to adequately assist non-native speakers, according to the American Academy of Pediatrics (AAP).

In order to address some of the above issues, the AAP has developed a toolkit that is geared towards providing community based care coordination to help immigrant families engage in treatment. Central to this toolkit is the idea that comprehensive medical homes that include co-located mental health providers reduce barriers to access, including transportation, financial limitations, limited hours of operation, and stigma. Children's Health Fund, a non-profit that provides health care to children and families on mobile medical clinics throughout the United States, has successfully implemented the enhanced medical home approach in its vision and provides bilingual mental healthcare to Hispanic children all over the country.

However, in light of the sheer scale of the problem, more such initiatives and an expansion of existing initiatives are warranted. For example, school mental health services could be improved by equipping counselors with information about immigration-impacted children and youth, providing flexible office hours so parents who work odd hours can attend, and offering communications in a language understandable to parents. It is also important that parents and their children are made aware of the fact that schools and school counselors are by law (Family Educational Rights and Privacy Act) prohibited from sharing private information with anyone without students' or their parents' consent. When a school district has adopted resolutions affirming that they are welcoming spaces and decline to cooperate with ICE raids, this should be communicated clearly to students and their parents. By doing so, a safe and supportive environment is created where children of undocumented parents can explore their struggles and find ways of coping with their fears.

Beyond the United States

The United States is by no means the only western country where draconian immigration measures have produced an environment of fear, restriction, and exclusion that affects both immigrants and their children. Though in most countries the crackdown on illegal immigration is relatively new and largely associated with the European immigration crisis that began in 2015, our experiences may resonate with our peers in the UK and beyond.

In the UK, the number of recorded hate crimes has more than doubled in recent years. Aside from this escalation in racial tension, living as a migrant in the UK has been made significantly more difficult due to immigration laws introduced by Theresa May that were aimed to create a "hostile environment" for those living in the UK without proper authorisation. Some of these individuals, including migrants who have entered the country illegally, individuals who overstayed their visas, Commonwealth migrants who do not have exactly the right documentation, and asylum seekers whose claims were refused, have resided in the UK for many years and have well-established family ties. The intention of the Immigration Act that came into force in 2016, was to deny these individuals access to basic services – including housing, employment, banking services, driving licenses, and healthcare provision – that make it possible to live a normal life. Thus, unauthorised immigrants and their documented or undocumented children are cut off from society, are unable to socially integrate, and are often forced into a life of destitution.

The ultimate aim of this law is the detention and removal of unauthorised immigrants. The Home Office, however, appears as disabled by bureaucracy as its US equivalent. Asylum and immigration cases, and the appeals that usually follow, can take many years to be concluded. As a result, immigrants and their children live in fear of deportation for prolonged periods of time. With increased media coverage of children separated from parents who have been taken into immigration detention and long-term residents being deported, and bill boards warning illegal immigrants "Go home or Face Arrest", children of undocumented parents in the UK have become painfully aware of their family's precarious situation and the repercussions of a removal, even though the figures of detention and deportation have not increased.

Compared to the United States, May's hardline approach is relatively recent and the mental health consequences of her policies are only just beginning to surface. By looking at the experiences of mental health professionals in a country like the United States, where the crackdown on illegal immigration has been in full force since the 1990s, strategies can be formulated on how to assist these children and their families who are impacted by these policies.  

The public outcry that followed the forced separation of parents and children at the border in 2018 was heartening. The ongoing international concern for those currently in detention centers and shelters in the United States is also a start. But the public needs to realize that for every child held in one of those abhorrent lockups there are thousands of psychologically vulnerable children incarcerated in an invisible prison of fear and anxiety, in the United States and beyond.

- Elke Weesjes Ph.D. is an associate at Paula A. Madrid Psy.D and Associates where she is involved in writing psychological evaluations for immigration proceedings, interviewing adults and children facing the psychological stress of immigration, and reporting on the conditions of countries where immigrants might be sent.

- Paula A. Madrid Psy.D. is a New York State Licensed clinical and forensic psychologist who has a private practice in New York City and serves on the adjunct faculty of the National Center for Disaster Preparedness at Columbia University, and as a consultant to the Children's Health Fund in New York City.

Footnotes

[1] Zayas, L. H., Aguilar-Gaxiola, S., Yoon, H., & Rey, G. N. (2015). The Distress of Citizen-Children with Detained and Deported Parents. Journal of child and family studies, 24(11), 3213-3223.

Dreby, Joanna. (2012). The Burden of Deportation on Children in Mexican Immigrant Families. Journal of Marriage and Family Vol. 74, Issue 4. August 2012. Pages 829-845

Yoshikawa, Hirokazu. 2011. Immigrants Raising Citizens: Undocumented Parents and Their Children. New York: Russell Sage Foundation

Perreira, Krista M., and India J. Ornelas. 2011. "The Physical and Psychological Well-being of Immigrant Children." Future of Children 21(1): 195–218.

Rojas-Flores, L., Clements, M., Hwang, K. J., & London, J. (2017). Trauma, psychological distress and parental immigration status: Latino citizen-children and the threat of deportation. Psychological Trauma: Theory, Research, Practice, and Policy, 9, 352 – 361. dx.doi.org/10.1037/tra0000177

Kalina Brabeck, Qingwen Xu. 2010. The Impact of Detention and Deportation on Latino Immigrant Children and Families: A Quantitative Exploration. Hispanic Journal of Behavioral Sciences. Vol. 32, Issue 3, 2010.

[2] Lopez, W. D., LeBrón, A. M. W., Graham, L. F. & Grogan-Kaylor, A. Discrimination and Depressive Symptoms Among Latina/o Adolescents of Immigrant Parents. Int. Q. Community Health. Educ. 36, 131–140 (2016).

Peskin, M. F., Tortolero, S. R., Markham, C. M., Addy, R. C. & Baumler, E. R. Bullying and Victimization and Internalizing Symptoms among Low-Income Black and Hispanic Students. J. Adolesc. Health 40, 372–375 (2007).

[3] Dreby, J. (2012a). The burden of deportation on children in Mexican immigrant families. Journal of Marriage and Family, 74, 829 – 845. doi:10.1111/j.1741-3737.2012.00989.x

[4] It should be noted that given the gender differences of current deportation trends – men are more likely to be deported than women – psychological studies have found that the eroding Hispanic father-child bond is particularly impacting children's emotional wellbeing. Rojas-Flores, L., Clements, M., Hwang, K. J., & London, J. (2017). Trauma, psychological distress and parental immigration status: Latino citizen-children and the threat of deportation. Psychological Trauma: Theory, Research, Practice, and Policy, 9, 352 – 361. dx.doi.org/10.1037/tra0000177

[5] The U.S. government has issued a negative travel advice for El Salvador and Honduras.

[6] Luis H. Zayas, Sergio AguilarGaxiola, Hyunwoo Yoon, and Guillermina Natera Rey, "The Distress of Citizen Children with Detained and Deported Parents," Journal of Child and Family Studies 24, no. 11 (2015): 3213–23.

[7] Page 459 Harvard Educational Review Vol. 81 No. 3 Fall 2011. Growing up in the Shadows.