Impact of COVID-19 on Unaccompanied Immigrant Minors and Families: Perspectives from Clinical Experts and Providers

ABSTRACT

The number of unaccompanied immigrant minors (UIMs) and families from Central America seeking asylum in the U.S. continues to rise. This growth, combined with restrictive government policies, led to crowded and suboptimal conditions in Customs and Border Patrol and non-governmental organization facilities. COVID-19 further taxed facilities and exacerbated uncertainty surrounding length of detention, basic human rights, and family reunification. The current project features testimonies from the authors who work as clinical experts and providers in Texas – a top destination for Central American immigrants. In collaboration with a deputy director of a not-for-profit human rights organization, volunteer psychologists, and the director of a humanitarian respite center, we describe challenges faced by administrators and clinical staff in addressing the mental health needs of immigrant children and families during the COVID-19 pandemic. The primary themes identified were anti-immigrant policies that occurred concurrently with COVID-19; difficulty implementing COVID-19 protocols alongside scarcity of supplies and volunteers; increased mental health needs among UIMs and immigrant families; and challenges in UIM placement upon release from custody. Strategies for addressing clinical challenges in the near- and long-term and opportunities for improvement in care systems to immigrant youth, including correcting anti-immigrant policies, addressing ongoing COVID-19 protocols and challenges, meeting mental and physical health needs, facilitating release and reunification for unaccompanied immigrant minors, and maximizing youth resilience through trauma-informed interventions, are presented.

Resumen

El número de menores inmigrantes no acompañados (UIM) y familias de Centroamérica que buscan asilo en los EE. UU. continúa aumentando. Este crecimiento, combinado con políticas restrictivas, crearon hacinamiento y condiciones subóptimas en las instalaciones de la Aduana y la Patrulla Fronteriza y de organizaciones no gubernamentales. La pandemia de COVID-19 agravó aún más las condiciones de estas instalaciones y exacerbó la incertidumbre con respecto a la duración de la detención, los derechos humanos básicos, y la reunificación familiar. El proyecto actual presenta testimonios de los autores, que trabajan como expertos clínicos y proveedores de servicios para migrantes en Tejas, un destino principal para los inmigrantes centroamericanos en EE.UU. En colaboración con un subdirector de una organización de derechos humanos, psicólogos voluntarios, y el director de un centro de descanso humanitario, describimos los desafíos que enfrentan los administradores y el personal clínico para abordar las necesidades de salud mental de los niños y familias inmigrantes durante la pandemia de COVID-19. Los temas principales identificados fueron políticas antiinmigrantes que ocurrieron simultáneamente con la pandemia; dificultad para implementar los protocolos COVID-19 junto con la escasez de suministros y voluntarios; mayores necesidades de salud mental entre los UIM y las familias inmigrantes; y desafíos en la colocación de UIM al ser puestos en libertad. Se presentan estrategias para abordar los desafíos clínicos a corto y largo plazo y oportunidades para mejorar los sistemas de atención a los jóvenes inmigrantes, incluyendo la corrección de las políticas antiinmigrantes, abordando los protocolos y desafíos actuales de COVID-19, satisfaciendo las necesidades de salud mental y física, facilitando la liberación y la reunificación de menores inmigrantes no acompañados, y maximizado de la resiliencia de los jóvenes a través de intervenciones focalizadas en el trauma.

The number of unaccompanied immigrant minors (UIMs) entering the U.S. from Central America skyrocketed in 2014 and recently exceeded the levels observed in that initial surge (Greenberg, 2021)—a crisis compounded by the simultaneous influx of many Central American families seeking asylum in the U.S. Record breaking levels of child migration in 2019 rapidly exceeded the Office of Refugee Resettlement’s (ORR) shelter capacity, leaving children in crowded and suboptimal Customs and Border Patrol (CBP) facilities and spilling over into temporary youth-only facilities (Greenberg, 2021). Large numbers of asylum-seeking families also overcrowded respite facilities run by non-governmental organizations (NGOs). Prior to the global pandemic, existing anti-immigration policies, like the “Remain in Mexico” policy—part of the Migrant Protection Protocols that required asylum-seeking migrants to await U.S. immigration court hearings in Mexico rather than in the U.S.— created new obstacles for migrants and increased the risk of trauma exposure for children and families seeking asylum (Garcini et al., 2020). The COVID-19 pandemic further taxed under-suitable CBP and under-resourced NGO facilities and exacerbated uncertainty surrounding length of stay, basic human rights, and family reunification (Garcini et al., 2020). Though the crisis was temporarily assuaged by a sharp decrease in migration in the early months of the pandemic, arrivals rose precipitously in October-December 2020 and have remained high, reaching record-breaking levels in Spring 2021 (Greenberg, 2021).

There is reason to believe that the effects of the COVID-19 pandemic on UIMs and immigrant families will be particularly pronounced (Walker et al., 2022). Indeed, during the COVID-19 pandemic, young Latinx children have experienced disparity in cognitive and social-emotional domains compared with other racial and ethnic groups (Yipp, 2020)—with this disparity being referred to as a “a pandemic within a pandemic” (Schmit et al., 2020). Of note, Latinx mothers in Texas have been disproportionately exposed to COVID-19 hardships (Padilla & Tomson, 2021), indicating that their children are likely to be the most vulnerable to disparate developmental outcomes. Indeed, more than 29% of Latinx families report experiencing 3+ COVID-19-related hardships; these hardships are expected to have implications for child development and health (Padilla & Tomson, 2021). Further, Latinx children have experienced disproportionate delay in cognitive development and achievement compared to White peers (i.e. 3-5 months behind compared with 1-3 months behind for White peers), and Latinx children are the most likely of any racial/ethnic group to have experienced complete disruption in educational placement and the least likely to have live access to educators (Dorn et al., 2020). As the pandemic has worn on, improvement in the cognitive and social-emotional functioning of young children has been noted among White families, whereas adverse outcomes have persisted over time for young children of color (Center for Translational Neuroscience [CTN], 2020; Dorn et al., 2020). For many of these families, anti-immigrant policies compounded COVID-19 stressors by creating fear of detention, deportation, or other adverse enforcement actions that would separate them (Garcini et al., 2020). The impact of family separation due to immigration policies (like those enacted under the Trump administration that forcibly separated parents and children) or immigration enforcement actions (i.e. deportation or detention) is clear: “separations are linked with increased attachment insecurity and other difficulties in the parent-child relationship as well as detriments to child well-being including increased emotional and behavioral problems,” (see Venta, Cuervo, 2022 for a review, p. 4). Together, the aforementioned literature suggests a need to document the challenges facing UIMs, immigrant families, and the agencies that serve them amidst the COVID-19 pandemic and overlapping immigration policy changes.

In this manuscript, we comment on the experiences of key informants and frontline mental and physical healthcare workers in meeting the needs of UIMs and immigrant families during the surge in migration that was compounded by the COVID-19 pandemic. Our aim was to describe our experiences and perspectives in the interest of answering two key questions: (a) what were the major challenges faced in serving immigrant minors and families on the front lines during the COVID-19 pandemic and (b) how can we improve the situation for immigrant youth and families during and beyond the current pandemic? As a descriptive piece, we elaborate the main challenges and needs that front-line workers encountered and continue to face while grappling with large numbers of immigrants and the ongoing pandemic. The primary themes identified were anti-immigrant policies that occurred concurrently with COVID-19; difficulty implementing COVID-19 protocols alongside scarcity of supplies and volunteers; increased mental health needs among UIMs and immigrant families; and challenges in UIM placement upon release from custody. Strategies for addressing clinical challenges in the near- and long-term and opportunities for improvement in care systems, including maximizing youth resilience through trauma-informed interventions, are discussed. Both challenges and solution-focused strategies described are summarized in Table 1. We close with policy and practice implications to improve the situation for immigrant youth and families during and beyond the current pandemic.

Table 1. Summary of challenges observed and solutions proposed.

Challenge Observed	Solution-Focused Strategy
Anti-immigrant policies occurring concurrently with COVID-19	Correcting anti-immigrant policies Rescind “Remain in Mexico” Develop collaborations between policy makers and immigrant serving organizations
Difficulty implementing COVID-19 protocols and scarcity of supplies and volunteers	Addressing COVID-19 protocols and scarcity of supplies, volunteers, and staff Reliable access to PPE Vaccination efforts Reduce staff burnout
Increased mental health needs	Meeting mental health needs in the COVID-19 era Telehealth equipment and platforms Adapting services to unique client needs Hybrid service delivery Specialized staff training
Challenges in UIM placement upon release from custody	Facilitating UIM release and reunification Limit duration of stay even during emergency protocols Educate UIM about process and expectations Educate staff to recognize distress Ensure safety for UIM sponsors

Clinical Experts & Providers

The current project features testimonies from the authors who work as clinical experts and providers in Texas – a top destination for Central American immigrants (Babich & Batalova, 2021) and a popular migratory entry point for UIMs and immigrant and refugee families seeking asylum in the U.S. In collaboration with a deputy director of a not-for-profit human rights organization, volunteer psychologists, and the director of a respite center serving families released by CBP, we describe challenges faced by administrators, clinicians, and direct care staff in addressing the mental health needs of immigrant children and families in government custody during the COVID-19 pandemic. Specifically, we describe the experiences of Sister Norma Pimentel, director of the Catholic Charities Humanitarian Respite Center in McAllen, Texas, which houses migrant families upon immediate release from CBP custody; Kathryn Hampton, deputy director of the asylum program for Physicians for Human Rights, a not-for profit human rights NGO; Dr. Alfonso Mercado, a clinical psychologist who, during the COVID-19 pandemic, volunteered on the front lines on the U.S. Mexico border conducting clinical research and leading efforts to assure trauma informed care was available for unaccompanied minors and families seeking asylum; Dr. Luz Garcini, a clinical psychologist who, during the pandemic, provided volunteer support, resources, and consultation to address the mental health needs of UIMs in government custody; and Dr. Amanda Venta, a clinical psychologist who conducted mental health assessments with UIMs before and during COVID-19.

Gaps in Knowledge

Emerging research has begun to accumulate regarding the experiences of immigrant youth and families during COVID-19 from the perspective of front-line workers and yet significant gaps remain which we sought to address. Two important works have been published by Lovato and colleagues. First, Lovato, Finno-Velasquez, 2022 authored a large-scale descriptive study which featured qualitative interviews with 31 child welfare agency practitioners across 11 states centered on how the pandemic and immigration policies challenged child welfare agencies. Notably, no providers from Texas were included in their research – despite the importance of this state both as an entry point for Central American immigrant youth and families and a hotbed of anti-immigrant state policies and rhetoric. More research is needed on conditions other than child welfare environments, which only a subset of Latinx immigrant families will encounter (Dettlaff et al., 2009). Still, their research highlights how considering the perspectives of front-line workers allows for a deeper examination of children and families’ needs (Lovato, Finno-Velasquez, 2022). Second, Lovato, Ramirez, 2022 conducted semi-structured interviews with social service providers in Los Angeles with the aim of assessing the stressors faced by Latinx immigrants due to both COVID-19 and restrictive immigration policies. Just as we focus on the unique and practically important context of Texas, Lovato, Ramirez, 2022 focused on Los Angeles, which is densely populated with Latinx immigrants, to address a notable gap in the empirical literature – that the perspectives and experiences of service providers are largely omitted from existing research on the Latinx community. Indeed, the perspectives of clinical experts and service providers are often ignored in empirical research, producing a scientific literature that is divorced from the daily realities and practical barriers faced by service providers, negatively impacting Latinx communities as a result. In drawing attention to the perspectives of clinical experts and service providers, we hope to focus readers and scholars on the immediate, high-priority areas wherein future research and extramural funding can have the highest impact. Moreover, we seek to identify strategies for addressing clinical challenges that are practical and feasible from the perspective of service providers. In doing so, we recognize that serving any clients – including UIMs – requires more than mastery of available empirical facts, theories, and knowledge (Tanenbaum, 1999) because the empirical literature does not always align directly with client needs (Kazdin et al., 1986); adequately addressing existing challenges requires both empirical research and clinical expertise (Overholser, 2010).

Additionally, a mixed-methods study of 43 community health workers serving low-income Latinx communities conducted by Garcini et al. (2022) emphasized the vulnerability of these communities during the COVID-19 pandemic by documenting pronounced mental health stressors related to economic difficulties, immigration, misinformation, family stress, health, and social isolation. This study is important in highlighting two prominent gaps in knowledge that we sought to address in the present manuscript. First, immigration-related stress, including undocumented or temporary immigration legal status and variation in acculturation, was noted as a prominent stressor type among Latinx immigrant communities residing in South Texas by Garcini et al. (2022) and, yet, little is known about how these stressors operate for very new or hopeful immigrants to the U.S.— including those continuing to reside in Mexico while awaiting immigration proceedings and those just arrived in the U.S. and released from CBP custody. To date, the experiences of migrants forced to Remain in Mexico and the challenges faced by service providers attempting to meet their most pressing needs are largely absent from the scientific literature (Mercado et al., 2021). Second, changes in family dynamics and loss and separation from family emerged as significant stressors and yet, the perspectives of providers serving unaccompanied children were not included in their sample. Indeed, the perspectives of providers serving unaccompanied immigrant minors are often absent from the empirical literature because they work for federal agencies that prohibit participation in research or because the policies of confidentiality and non-disclosure mandated by their employers effectively silence both their voices and those of the children they serve (Feu & Venta, 2021).

Finally, the present study is unique in the range of clinical experts and providers who participated in sharing their perspectives. In doing so, we build upon the work of Falicov et al. (2020), mental health professionals who shared their experiences working with immigrant families during COVID-19. They identified several mental health and daily living challenges facing immigrant families served by their mental health clinics in San Diego and described problem-solving approaches that supported their clients during the pandemic. We add to their important work by featuring the perspectives of several clinical psychologists operating at the Texas-Mexico border and working with ORR during COVID-19. We add depth to these clinical perspectives by sharing the testimonies of NGO frontline workers and those working with immigrants at the very point of entry to the U.S. including on the Mexico-side of the border while immigrants await entry. To our knowledge, no published research includes the perspectives of service providers interfacing with immigrants so early in the asylum-seeking process during the Remain in Mexico policy and very little literature exists on the experiences of practitioners working with ORR (Feu & Venta, 2021).

Challenge 1: Anti-Immigrant Policies Occurring Concurrently with COVID-19

Context

We identified policies that increased distress and have affected their ability to meet the needs of UIMs and families during the COVID-19 pandemic. One policy particularly damaging to efforts to help UIMs and families is Title 42, a public health order that grants the government the power to prohibit the entry of people and property to stop a contagious disease from spreading in the U.S. Likewise, the government has argued that Title 42 allows for the expedited removal of immigrants, often just a few hours after being in custody, to northern Mexico or their country of origin; this application of public health law is currently under litigation. In 2021, U.S. CBP reported a total of 1,071,075 Title 42 expulsions, of which 133,974 included individuals in family units, accompanied minors, and UIMs (U.S. Customs and Border Protection, 2022). Indeed, it must be noted that UIMs were not immune from Title 42 expulsions. This policy has magnified the obstacles that frontline workers face when trying to provide aid to immigrants during the pandemic. For example, there was an initial decrease in the number of forensic evaluations conducted by Physicians for Human Rights for asylum seekers to use as expert evidence in their immigration cases following the start of the pandemic. However, this was not due to a decreased need for services but instead resulted from Title 42 making it complicated for attorneys to find and represent clients who were removed from the U.S. quickly after being taken into custody. From the perspective of our eighth author, Title 42 has made it difficult for organizations such as Physicians for Humans Rights to offer social services since most of their services are based in the U.S.

“Throughout the U.S. there are immigration attorneys, there are social service agencies, there are nonprofits that work [with immigrants], and it is extremely difficult when everyone is expelled to northern Mexico because all the services can’t relocate thousands of miles to where migrants are forced to be. The most critical thing is admitting [immigrants] to the U.S. where they can be safe and further access a variety of services and be reunified with friends and family.” (Kathryn Hampton, Physicians for Human Rights)

In addition to preventing immigrants from accessing services, Title 42 has also contributed to ongoing family separations, and therefore an increased number of UIMs in the U.S. at the border. In practice, this policy has targeted spouses with children and minors accompanied by relatives who are the children’s primary caregivers, even though they may not be their biological parent.

“A lot of family members were separated, especially spouses with children, so they would send the mother off with one child and the father off with another child and then separate them. Sometimes, they would fly them hundreds or thousands of miles away from each other … Sometimes, people had primary custody of a nephew or a granddaughter, and the U.S. government was not recognizing those relationships and separating them from their primary caregiver, and that is extremely traumatizing and increases the number of UIMs in the U.S.” (Kathryn Hampton, Physicians for Human Rights)

Strategy: Correcting Anti-Immigrant Policies

It is evident that the COVID-19 pandemic has shed light on preexisting healthcare inequalities with people of color specifically the Latinx population. Anti-immigrant policies enacted concurrently with the pandemic have made it much harder for immigrants and families to seek refuge in the U.S. and anti-immigration rhetoric and policies continue to exacerbate trauma exposure and abuse, while also increasing health risk (Mercado et al., 2021). It is critical for change that professionals and advocates leverage science that can inform advocacy and policy to reduce risk and prevent further harm among immigrant youth and family in government custody. For instance, it is now known that the Remain in Mexico policy places families and children at risk of trauma (Mercado et al., 2021) above and beyond what is already embedded in the pre-migration and migration experiences of UIMs and immigrant families (DeBrabander & Venta, 2022). Rescinding this policy would allow migrants to await immigration court hearings in a safe environment where they can access existing immigration support agencies. Rescinding this policy would also avoid the concentration of migrants in need at the U.S.-Mexico border, reducing the burden on local providers who cannot currently meet the needs of the large immigrant population awaiting entry to the U.S.

Also, developing collaboration and support between community organizations, interdisciplinary providers and government agencies is essential for emergency preparedness and policies that make this collaboration difficult – like the executive order barring the transportation of immigrants by non-federal agents – must be eliminated. For instance, collaboration across the aforesaid organizations and government agencies in the provision of medical and mental health screening services, health resources and information to protect from infectious diseases (e.g. COVID-19) and other health conditions should be prioritized. Indeed, the provision of services and resources needs to include care at immigration processing facilities, during shelter placement, and post-release, with policies facilitating, rather than complicating, collaboration among these agencies.

Challenge 2: Difficulty Implementing COVID-19 Protocols & Scarcity of Supplies and Volunteers

Context

Although there was an initial decrease in migration due to the pandemic, migration to and across the U.S. -Mexico border reached its highest level in 2021 (Gramlich & Noe-Bustamante, 2019). Prior to the pandemic, charity organizations already struggled to house, feed, and provide for (e.g., clean clothes) incoming immigrants, challenges that were exacerbated within the context of the pandemic. For instance, the Humanitarian Respite Center, which is run by a small permanent staff plus many volunteers and operates with donations, found itself without volunteers or sufficient supplies. Empty grocery shelves meant fewer available food and hygiene donations; people afraid to leave their houses meant fewer volunteers and fewer drop-offs of gently used clothing and toys, leftover diapers, and other essentials. The few available volunteers and staff provided only the most critical services – food and medicine disbursement – leaving other important areas of care unstaffed. With fewer volunteers available, it was difficult to hold recreational activities for children that could serve as distractions to ameliorate distress while the children endured hardship from the migration process, leaving them bored and unstimulated. Donated clothing grew scarce and, what was available, went unsorted, without volunteers to do the sorting, stalling the process of providing clean clothes to immigrants. CBP often removes migrants’ shoelaces and belts as a safety precaution. Without access to donated and sorted clothing items, immigrants walked around the respite center holding up their pants and with the tongues of their sneakers sticking out. Children wore blankets as clothing because garments in their size had not been located. Even a year into the pandemic, scarcity in personal protective equipment (PPE) persisted, and volunteers at the Humanitarian Respite Center and paid staff at UIM shelters struggled to find masks to protect themselves as they served immigrant communities. Immigrants requested masks and hand sanitizer at rates that could not be met due to limited supply and the reality that previously, such items were not needed by immigrant serving organizations.

Paid staff in immigrant service organizations also grew scarce, with many falling ill and others absent due to concerns about the pandemic or burnout. To meet the demands of thousands of immigrants, agencies had to recruit, hire, and train new employees and volunteers while continuing to serve immigrants with reduced direct care staff. The first author, Dr. Venta, saw strains on clinical staff responsible for the care of UIMs in the custody of the ORR during the early days of the pandemic. UIMs were isolated at nonprofit shelters (where they reside after being released from CBP custody and before being reunified with an immigration sponsor in the U.S.) because the scarcity of providers meant a bottleneck in the usual reunification process.

With the courts closed and many professionals – like lawyers, physicians, and mental health care providers – suspending or limiting their practice, minors were stuck in limbo with their care staff unable to coordinate the services they needed for release. At the same time, the kids themselves were isolated from one another due to concerns about the spread of COVID-19 and insufficient access to masks due to increased demand for PPE. Staff members weren’t coming to work, afraid for their own health because they couldn’t get masks. (Dr. Amanda Venta, clinical service provider for the Office of Refugee Resettlement)

Immigrant serving institutions were not immune to the large-scale employee resignation seen across the U.S. Direct care staff, who provide therapy and supervision to UIMs, moved into administrative positions that allowed for remote work at the same agencies or switched industries altogether, like many Americans (Fox, 2022). “This compounded the problem” said Dr. Venta, noting that remaining staff were then responsible for more UIMs with less staff and administrative support – and still without sufficient PPE – leading to greater burnout and resignation.

The implementation of COVID-19 protocols disrupted care as usual for all immigrant-related organizations. In addition to physical distancing, hand washing, and mask protocols, shelters had to implement a new protocol to reduce virus transmission. At the Humanitarian Respite Center, no individual who tested positive was allowed to enter the shelter. Those who did test positive were placed in hotel rooms for isolation where they remained until they tested negative or needed to be transported for treatment. These hotel rooms were not readily available, and they were quick to fill up; the cost of hotels posed financial stress for immigrant serving organizations that already operate with tight budgets and limited resources. At one point during the pandemic, there were so many immigrants that the respite center considered rejecting immigrants with positive COVID-19 status. To avoid turning away immigrants, Sister Norma contacted the city mayor for aid. “I called him and told him, ‘If you don’t open space for me, positive cases will be sleeping in the streets tonight’ … that night, he opened space for me,” she said (Sister Norma Pimentel, Humanitarian Respite Center). This example highlights the important role that community leaders and organizations can have in advocating for immigrant health and safety in the face of challenges such as the implementation of COVID-19 protocols.

Strategy: Addressing COVID-19 Protocols & Scarcity of Supplies, Volunteers, & Staff

In the short-term, difficulties implementing COVID-19 protocols must be mitigated and strategies for addressing scarcity of supplies and volunteers are needed. The continued emergence of COVID-19 variants compels immediate action steps to increase security and reduce health risk among staff, providers, UIMs, and immigrant families. Observations and narratives from the front lines emphasize the prevalence of fear, anxiety, and grief among staff, UIMs, and their families, as everyone navigated increased contamination fears and the loss of predictability and routine in daily life. Reliable access to quality PPE for staff and youth at immigrant-serving institutions is essential. The delays in production and distribution of supplies further challenged an already burdened workforce. Although vaccines have mitigated the risk of contracting the virus and experiencing serious illness, the availability of PPE such as masks, gowns, gloves, and other related items is essential to provide a peace of mind and trust in the organizations. Vaccination must become an international effort that can reach immigrants on both sides of the U.S. -Mexico border and their care providers. Maximizing a sense of physical safety will facilitate necessary social contact and engagement among staff and youth.

Moreover, staff and volunteers must feel psychologically safe and supported in order to continue serving immigrants and mitigate the challenges associated with resignation as well as hiring and training a new workforce. Equipping direct care staff and volunteers with the skills to meet the mental and physical health of immigrants – either themselves or through collaboration with healthcare providers and other agencies – is essential in reducing burnout. In addition to training, staff wellness must also be prioritized. One example of an organizational initiative to target staff wellness comes from United We Dream (UWD), the largest immigrant-youth led network in the United States. UWD has partnered with psychologists from the National Latinx Psychological Association to develop no-cost webinars, guidelines, rapid response teams, and mental health support for their staff.

Challenge 3: Increased Mental Health Needs

Context

The COVID-19 pandemic increased physical health needs among immigrants who had encountered or contracted the virus, produced valid fears of becoming ill, and made it more difficult to receive medical attention for other common ailments including malnutrition, exhaustion, dehydration, and physical injury during migration (DeBrabander & Venta, 2022). Despite initially expecting high numbers of COVID-19 illness due to overcrowding and unsanitary conditions in CBP custody and transportation, rates were not as high as initially predicted. In fact, according to the Hidalgo County Health and Human Services Department, the rates of positive COVID-19 cases in Hidalgo County Texas (border county of South Texas and Mexico) far exceeded the positive rates of immigrants crossing the border (Hidalgo County, 2020). Still, even with lower rates than expected, the high volume of immigrants in northern Mexico alone (due to an increase in migration and Title 42 expulsions) was enough for many medical clinics to lack the capacity to meet the increased demand for health services (Physicians for Human Rights, 2021a). “They saw many more immigrants [than they were used to] trapped in northern Mexico without access to medical services,” commented Kathryn Hampton (Physicians for Human Rights). Put simply, immigration policies that concentrated immigrants at the U.S. -Mexico border did not concentrate health service providers or medical supplies at the border, leading to unmet needs. The fifth author (Dr. Mercado) visited immigrant tent encampments in Mexico.

What was most concerning were families at the refugee camps in Matamoros, Tamaulipas, Mexico. Basic hygiene necessities were not readily available, and we knew that when COVID arrived in the tent encampments, it would spread like wildfire. This caused Mexican authorities to encourage families to return to their countries and offer a free bus ride to the border of Mexico and Guatemala – asking migrants to return to the place they feared most. Some families returned, many did not. (Dr. Mercado, volunteer psychologist at the U.S./Mexico border)

Dr. Mercado also witnessed an overwhelming need for medical screening personnel on the U.S. side of the border, particularly through volunteer work at the Humanitarian Respite Center. He said, “Recently arrived immigrant families were not tested for COVID-19 at immigration processing centers thus giving the burden and cost to the respite center to test every person and separate those families who tested positive, which was approximately 1 of 100 families being released, and assuring they were isolated and healthy before traveling to their sponsor destinations.” The demands of testing, treating, and isolating COVID-19 patients compounded the already pressing physical health demands of immigrants and exacerbated difficulties meeting those needs that existed even prior to the pandemic.

Mental health professionals around the world have noted increased mental health needs because of COVID-19. These increased needs were compounded for Latinx immigrant communities which were affected by anti-immigrant policies, job losses, financial hardship, and illness/death at higher rates than other demographic groups (Garcini et al., 2020; Venta, Bick, et al., 2021). At the U.S.- Mexico border, Physicians for Human Rights has found high rates of major mental health diagnoses among immigrants, especially posttraumatic stress disorder (PTSD; Physicians for Human Rights, 2021b). At a youth shelter for more than 5,000 UIMs, the third author (Dr. Garcini) saw a full range of mental health experiences “from sadness and irritability and uncertainty to some severe cases like non-suicidal self-injury and social withdrawal.” Concerningly, immigrants are reporting traumas related to the migration process and as a result of delays in migrant processing that translate to longer periods of detainment – which may be especially challenging for UIMs.

A big source of stress for UIMs at the shelters was the length of time that they had to spend at the shelter before being release to their hosting families. Many children spent more than 60 days in crowded shelters without many opportunities to spend time outside in daylight. This was particularly difficult for the kids who came from a life in the farms or near the ocean and were used to spending a lot of time outdoors. (Dr. Luz Garcini, volunteer psychologist).

“They start scratching the walls until they feel pain,” said the seventh author (Sister Norma Pimentel) of children at the Humanitarian Respite Center, echoing Dr. Garcini’s sentiment. The fifth author (Dr. Mercado) and his students also witnessed significant anxiety and depressive symptoms in children. It was evident that children were experiencing multiple pandemics, including one of mental health characterized by more pronounced mental health concerns than previously witnessed.

We have seen the cases referred for evaluation growing more and more severe. We see presenting problems including psychosis, suicide-related thoughts and behaviors, and intense behavioral disruption more frequently than we did before. Psychological evaluations are more difficult to conduct, and rapport is more difficult to establish because we rely on tele-health platforms. And the kids are unhappy, often having to quarantine in their rooms due to COVID-19 concerns or spend long periods of time masked. (Dr. Amanda Venta, clinical service provider for the Office of Refugee Resettlement)

The first author (Dr. Venta) also emphasized that there was a delay in providing evaluations for UIMs as both she and the shelter staff sorted out the technology needed for remote service delivery.

Responding to the mental health toll of COVID-19 isolation and compounded stressors has been taxing for staff and providers working at immigrant shelters and service organizations. “They [volunteers and direct care staff] are all feeling very drained and exhausted, and that makes it difficult for us to keep up with the demand,” said the eighth author (Kathryn Hampton; Physicians for Human Rights). The sentiment of exhaustion is shared among clinical staff at ORR shelters who, first author Dr. Venta reports, have resigned at higher rates during the COVID-19 pandemic. She recalled clinical staff “growing accustomed to working remotely during the early days of the pandemic and not wanting to return to face-to-face services without available vaccines and PPE.” Although some organizations implemented practices such as quarterly wellness sessions, as done by Physicians for Human Rights for their staff, many mental health professionals and other frontline workers are left to deal with their emotional wellbeing on their own. Among staff at the Humanitarian Respite Center, not being able to provide immediate care to all immigrants was overwhelming. Although most immigrants are only at the respite center for about 24 hours, the stress, anxiety, and desperation that immigrant children and families were facing was evident to staff.

Strategy: Meeting Mental Health Needs in the COVID-19 Era

Beyond PPE, the availability of HIPAA compliant telehealth equipment has proven critical to timely and responsive services. From a practice stance, telehealth has become a necessity in health care, and emerged as a useful approach to care delivery. Studies evaluating the delivery of care through virtual platforms with vulnerable populations (e.g., immigrants, asylum seekers, refugees) have found telephonic and video psychiatric evaluations to be comparable to those conducted in person (Bayne et al., 2019; Mishori et al., 2021; Mucic, 2009). Immigrant-serving institutions varied in their ability to offer and maintain technology for staff and youth. Consequently, much needed evaluations that could be offered through virtual platforms were delayed. Promoting low-cost or free options to these organizations can increase the availability of quality services that are necessary to expedite processing for immigrant youth. In addition to facilitating access to evaluations and communication with legal representatives, virtual platforms may promote emotional wellness through online counseling, education resources such as tutoring, and peer-led support groups.

While telehealth has previously been found to be effective with vulnerable populations, it is important to recognize that a one-size-fits-all approach is invalidating, inappropriate, and unethical (Drake et al., 2022). Therefore, it is imperative to adapt services to the local context and situation, and to consider the role of trauma and trauma histories. Moreover, organizations may consider the use of a hybrid (telehealth and in person) model of service delivery (Augusterfer et al., 2018), which can assist with efficiency and the reallocation of resources. A hybrid approach can enhance staff flexibility (e.g., scheduling), therefore, expediting timely care and number of individuals who can be helped.

Further, training staff to assess for trauma symptoms and possible dissociation activated by the pandemic can aid service providers in their ability to accurately recognize signs of trauma-related distress, including PTSD. A helpful resource for staff and providers on how to address and work with trauma via teleservices can be found at the Oxford Center for Anxiety Disorders and Trauma (OxCADAT). The guidelines developed by OxCADAT have been found helpful in the adaptation of services and to front line providers (OxCADAT Resources, 2020). In addition to guidelines, staff and providers are encouraged to utilize clinical consultation to identify and work through ethnical concerns related to remote approaches to trauma services. The challenge moving forward is determining how to best address the ethical considerations for delivering services to vulnerable populations with histories of trauma.

Challenge 4: Challenges in UIM Placement Upon Release from Custody

Context

Prior to the pandemic, family reunification efforts were already difficult due to a lack of contact information for parents, people in hiding because of danger in their home countries, and people’s mistrust of the U.S. government. Following implementation of harsh immigration policies like the Remain in Mexico policy and zero-tolerance policies that resulted in family separation, many undocumented immigrants in the U.S. who might have otherwise served as sponsors for UIMs became afraid to do so. The first author (Dr. Venta) recalled, “In the last few years I have seen many more children who lose an immigration sponsor because that person is afraid to collaborate with the U.S. government. For children who were separated from the parent that they traveled with, there is often no sponsor available. Moms and dads that brought their children with them and then got separated at the border did not prepare for their child to be alone in the U.S. They didn’t have a sponsor ready and willing to take the child. They didn’t intend for their child to need a sponsor at all.” For years, there was no existing government entity working to address family separation, but following a backlash in 2018, a Family Reunification Task Force was created. Still, COVID-19 protocols have made it difficult for the Task Force to conduct reunification efforts. For example, the Task Force worked on identifying immigration sponsors while navigating physical distancing mandates and fear due to anti-immigrant rhetoric and actions. Immigrant organizations were also limited in their ability to provide services across different locations and settings during various points of the COVID-19 pandemic. Although not much is known about the impact of delayed family reunification due to the pandemic, our eight author highlights the lasting negative impact of family separations that occurred prior to the pandemic.

We followed parents 3–4 years after being separated from their children and deported by the U.S. government and [found] high levels of trauma even 3 to 4 years later … In the case of one little boy, the father said that even following reunification, his son was having nightmares several times a week, and 2 years following reunification, he was having nightmares once a month … that’s a concrete example of how long it takes symptom severity to decrease. (Kathryn Hampton, Physicians for Human Rights, referencing report Physicians for Human Rights, 2022)

The third author (Dr. Garcini) witnessed many challenges in the reunification of UIMs with family members and/or sponsors in the U.S.

A salient problem faced by immigrant shelters to UIMs was to locate sponsor families for placement once the children were released from government custody. Also, for UIMs with family in the U.S., the challenges were many. Many of these children had been separated from their parents or families for many years … in some cases the children did not even remember what their parents looked like … so there were a lot of concerns about reunification and how to prepare these families for the encounter in the short and long-term. (Dr. Luz Garcini, volunteer psychologist)

Challenges in family reunification following migration-related separation are beginning to be increasingly highlighted in the psychological literature for their deleterious mental health and attachment consequences (Venta et al., 2020, Venta, Bailey, etal., 2021). Professional and policy resources for mitigating these challenges are few: “our organization was asked for resources to try to facilitate conversations pertaining to reunification with these families, but a lot of time passed before the resources could be delivered to the families,” said the third author (Dr. Garcini), stressing “This continues to be a salient problem with no easy solution. Guidelines are needed to ensure that children are released into safe environments and that families are equipped with knowledge and skills to face the many challenges, such as coping with feelings of guilt, shame, and anger that stemmed from family separation.”

The first author (Dr. Venta) observed that difficulties associated with family separation and reunification were made more complex by COVID-19. In her provision of psychological services to UIMs in ORR custody, she witnessed, “kids couldn’t be reunified, even if they and their sponsors wanted to be, because COVID-19 slowed everything down. Home studies couldn’t be conducted on time. Even my evaluations, which are sometimes needed prior to reunification, couldn’t happen as quickly because my team was working remotely, we were dealing with technology challenges, and we were having to collaborate with direct care staff that was working remotely or maybe even out sick.” She added, “sponsors also seemed to drop out more frequently as COVID-19 started to affect their livelihoods. Maybe they realized they wouldn’t be able to provide the financial or housing stability the child would need. Or maybe they realized they would have a child who they’d have to educate remotely and care for full-time in the home.”

Strategy: Facilitating UIM Release and Reunification

Although the long-term goal of eliminating family separations and detention remains, if UIMs or children separated from immigrant parents are to be housed temporarily, there should be clear limits to the duration of the stay in these facilities and a concrete plan that details the release and placement. In addition, finding ways to improve communication and transparency with youth about what they can expect as part of their immigration proceedings is recommended. This will require training and support for staff who are the first line for the immigrant youth and families. Teaching staff to accurately recognize signs of distress among the youth, communicate with empathy, and deescalate high risk behaviors are all important components of staff wellness. Lacking attention to these training gaps risks perpetuating staff burnout, demoralization, and a sense of defeat and hopelessness among all parties.

Reunification efforts have largely returned to pre-COVID operations with more providers (e.g., lawyers, psychologists) returning to practice face-to-face or implementing telehealth delivery systems. Still, sponsors remained frightened of interaction with ORR and other government organizations. Aforementioned policy changes as well as community building and rhetoric changes are needed to assuage the aforementioned fears. Furthermore, ORR must prioritize support services for family reunification. The science is now clear – families and UIMs struggle after reunification with trauma, attachment disruption, guilt, and mental health problems challenging reunification (Berger Cardoso et al., 2022; Venta, Brabeck et al., 2021). Evidence based interventions for enhancing family cohesion and addressing pronounced mental health problems in UIMs and their caregivers must be built into the reunification process.

Limitations & Future Research Directions

Our aim was to describe our experiences and perspectives in the interest of answering two key questions: (a) what were the major challenges faced in serving immigrant minors and families on the front lines during the COVID-19 pandemic and (b) how can we improve the situation for immigrant youth and families during and beyond the current pandemic? Several important limitations to fully addressing these questions must be noted and serve as a springboard for future research. First, none of the authors is an employee of the federal government and we therefore cannot represent the challenges faced by CBP and public officials during the COVID-19 pandemic. While we take a humanitarian lens and view immigration policy and enforcement actions as punitive and damaging to immigrant well-being, the perspectives of those responsible for ensuring public safety, securing borders, and interpreting/enacting U.S., state, and local laws are not reflected here. As we encourage policy changes and interdisciplinary collaboration, it is essential to include policymakers and enforcers in future research and cooperation. Second, our perspectives, while valuable and unique in an empirical literature that does not often hear from service providers, should not be taken as reflective of the voices of UIMs or immigrant families. These voices are silenced for a multitude of reasons (Feu & Venta, 2021) and our efforts to describe our own experiences should not be interpreted as silencing or speaking on behalf of marginalized groups, rather, we aim to use the power of our own voices to draw attention to ongoing difficulties in meeting the needs of UIMs and immigrant families. Still, future research must endeavor to showcase the experiences of UIMs and immigrant families through their first-hand narratives through community based participatory research and anonymous research that can mitigate barriers to participation (Feu & Venta, 2021). Finally, our contribution is descriptive – compiled by a diverse group with combined decades of service to the UIM and immigrant family communities – and addresses existing gaps in knowledge but does so from a relatively narrow perspective. Future research, both qualitative and quantitative, is needed to gather information on challenges facing UIMs and immigrant families, sources of resilience in these groups, and directions for growth and improvement from service providers on a large scale that is capable of representing many regions, perspectives, employment settings, etc. Critically, prospective longitudinal research with UIMs is needed to determine how they adjust into adolescence and adulthood and identify both sources of risk and resilience.

Conclusions

This project uncovered serious challenges in meeting the needs of UIMs and immigrant families during the COVID-19 era. Our observations highlight several primary challenges including anti-immigrant policies that occurred concurrently with COVID-19; difficulty implementing COVID-19 protocols alongside scarcity of supplies and volunteers; increased mental health needs among UIMs and migrant families; and challenges in UIM placement upon release from custody. Our experience and expertise highlighted deleterious anti-immigrant policies that made their work more difficult, traumatized immigrants, and taxed the already overburdened care systems available to immigrants. Compounding these challenges, staff resignation, scarcity of supplies and volunteers, and difficulties implementing COVID-19 protocols were prominent during the early pandemic and, to some extent, continue. Amid these difficulties in caring for immigrants, UIMs and arriving families appeared to present with increased mental healthcare needs that remain pressing, despite growing service provision through telehealth modalities. Family separations and difficulties in UIM reunification with immigration sponsors continue, albeit without the media attention seen previously, and UIMs that are reunified with a family member do not receive the needed support and intervention.

Alongside these challenges, sources of resilience including gratitude, selflessness, and spirituality were noted and must be capitalized upon in addressing ongoing and future challenges for immigrant serving organizations. The pandemic highlighted opportunities to identify and implement sustainable strategies that lead to resilient systems of care. Organizations that can adjust to changing conditions, including public health recommendations, and continue to provide needed clinical services, are an important component of individual and staff wellness. Understanding the parallel experience between staff and the youth they care for can help to inform strategies for improvement. For example, at the staff level, consistent and clear communication on expectations can build confidence, and in turn, promote a sense of stability among the youth seeking direction from the adults charged with caring for them. Lacking clarity, inconsistent messaging, and little direction is likely to heighten anxiety and the vulnerability for emotional distress. This is important to note as beyond the obvious loss of language, culture, and home, youth and families served at these organizations have often experienced multiple traumatic events and are therefore at risk of mental health symptoms. Therefore, attention to the physical environment and the promotion of trauma-informed interventions that increase the opportunity for reconnection and success are imperative. We witnessed selflessness, gratitude, and spirituality as sources of resilience in immigrants. Indeed, UIM and immigrant family resilience is pronounced and seemingly impervious to the challenges we observed, and difficulties associated with COVID-19. All of these sources of resilience – as well as cultural values, personal strength, and other sources of resilience – should be attended to by healthcare providers as well as frontline workers. Policy changes, government and NGO collaboration, emergency preparations, international vaccine efforts, staff training programs, trauma informed care, and new standards of care for UIM and family reunification are needed. But policy changes, intervention development, and any other efforts to mitigate the challenges described in this manuscript will fall short if they do not leverage the fountain of resilience found in immigrants themselves. These changes will be most effective when they leverage immigrants’ fortitude and resilience.

Positionality Statement

As in all research, it is helpful to understand our positionality and, therefore, the lens we use in interpreting extant literature and current events. All of the authors interface with immigrant and Latinx communities through service, clinical care, teaching, and/or scholarship. We belong to the immigrant and Latinx communities to differing extents. The first seven authors identify as Latinx and many of us identify as immigrants, though our countries of origin, immigration histories, and generational statuses differ. All authors were educated at least in part in the U.S. We worked as a team to describe and synthesize our experiences serving the immigrant community during the COVID-19 pandemic, guided by our collective cultural knowledge and expertise.

Acknowledgments

This article is part of the special issue ‘Understanding the Impact of the COVID-19 Pandemic on the Mental Health of Latinx Children, Youth, and Families: Clinical Challenges and Opportunities’ edited by José M. Causadias and Enrique W. Neblett, Jr.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Time commitment for this study was partially supported by a grant from the National Institutes of Health, National Heart, Lung, and Blood Institute (NHLBI) (K01HL150247; PI: Garcini).