Separated Children in Immigrant Shelters Suffering From Extreme Mental Health Distress, OIG Says

A report released by the Office of Inspector General (OIG) of HHS Wednesday paints a picture of severely traumatized children and overwhelmed mental health clinicians in US shelters where immigrant children, many of whom were removed from the custody of their parents, are being held by authorities.

Perhaps not surprisingly, the children’s mental health issues worsened the longer they were in US custody, the report noted.

The Trump administration began deterring border crossings in 2017 by forcibly removing children from their refugee parents and housing them separately, and it formally instituted the policy in May 2018; the policy was curtailed the following month by executive order and by order of the judge in Ms. L v ICE, a class action lawsuit. Previously, the “unaccompanied minors” program had been largely been used to care for teenagers crossing the border alone or in cases where a parent or guardian had a criminal history or was carrying contraband.

The OIG said it conducted site visits at 45 facilities funded by the Office of Refugee Resettlement (ORR), which falls under the Administration for Children and Families (ACF) within HHS. All ORR-funded facilities are required to provide counseling for children and to arrange for specialist mental health care when needed.

The OIG visits were conducted a year ago and included interviews with 100 mental health clinicians, medical coordinators at each facility, leadership at each facility, and 28 ORR field specialists. The OIG asked facility staff to choose up to 3 cases that represented the issues they were facing.

Trauma was created in multiple ways, the report said. Children experienced “intense trauma” in their home countries, on their trip to the United States, and once inside the United States.

Staff in multiple facilities recounted how children had been kidnapped, tortured, or raped in their home countries; were held in captivity; or had witnessed the rape and murder of their family members before fleeing.

In one case, a child was abducted by a gang and held for ransom while attempting to cross from Guatemala to Mexico.

Once in the United States, the children experienced new trauma when they were unexpectedly separated from the parent or guardian, the report said. Children who were separated from their parents suffered higher levels of mental anguish; some believed their parents had abandoned them and were angry and confused, while others had feelings of fear or guilt.

Children with longer stays experienced more stress, anxiety, and behavioral issues; one clinician told investigators that even children who had thus far been resilient and coping started getting more frustrated at around the 70th day in care.

The report traced the longer stays in care to new fingerprinting requirements put in place in 2018, which made it more difficult to identify sponsors willing to take the children in. The length of stay hit a high of 93 days in November 2018 and fell to 48 days by April 2019 after HHS ended the requirement for fingerprint background checks for most parents or legal guardians.

Given the extreme levels of trauma experienced by the children, mental health clinicians expressed concerns that they were not able to address the children’s significant mental health issues. Some of this stemmed from the fact that no one knew how long a child would be held in a facility, which prevented long-term, meaningful therapeutic progress from taking place.

In addition, an unexpected increase in children 12 years or younger created challenging circumstances to provide age-appropriate mental health care, the report said.

The issues were compounded by clinicians struggling with high caseloads. Although the required facilitywide staffing ratio is 1 mental healthcare clinician for every 12 children, in some shelters, clinicians had caseloads of more than 25 children. Clinicians also reported having difficulties accessing external mental health specialists.

ACF said it agreed with the OIG’s 6 recommendations to minimize harm and improve the care of children in its custody, which include:

• Identifying and disseminating evidence-based approaches to addressing trauma and short-term therapy
• Developing and implementing strategies to assist facilities in overcoming obstacles to hiring and retaining qualified mental health clinicians
• Assessing whether to set maximum caseloads for individual clinicians
• Improving access to mental health specialists
• Increasing therapeutic placement options for children who need more intensive mental health care

Lastly, the OIG said those responsible should “take all reasonable steps to minimize the time the children remain in custody.” The report said the ORR “should establish procedures to ensure that future policy changes prioritize child welfare considerations and do not inadvertently increase the length of time a child remains in ORR custody.”

In a separate but related report examining employee hiring in the facilities, OIG found a mix of screening and hiring practices. Some facilities did not have evidence of background results and did not always ensure that out-of-state background checks were conducted. Over half of the 45 facilities allowed workers to begin employment before receiving the results of background checks. In addition, HHS granted 6 facilities a waiver from conducting a child protective services background check. Overall, the facilities “generally” conducted background checks, the report said.