Measuring the Mental Toll of Child Separation
Date Published: July 29, 2019
Migrant children who were separated from their mothers at the border experience significant psychological distress. In fact, researchers from the Icahn School of Medicine at Mount Sinai report in Social Science & Medicine that the prevalence of probable post-traumatic stress disorder in the study population was 17 percent, four times more than in the overall U.S. population.
Dr. Katz and co-author Priscilla Agyeman, MPH, a clinical research coordinator at the Icahn School of Medicine at Mount Sinai, appear on the latest episode of Road to Resilience to discuss their findings and migrants’ need for comprehensive mental health care.
You're listening to Road to Resilience. I'm Jon Earle. Last May, just as news was breaking that the government was separating migrant children from their parents, researchers from the Icahn School of Medicine at Mount Sinai arrived at an immigration detention center near the border. Over the next two months, they interviewed more than 400 migrant mothers about their children’s mental health. Did their kids seem happy? Were they having behavioral problems? And so forth. The researchers’ findings were published last month in the journal Social Science and Medicine. It's the first large, empirical study to look at the mental health of children in U.S. immigration detention, and it raises important questions, including about the mental toll of the child separation policy.
Today on the podcast, I'm joined by two co-authors of the study, Dr. Craig Katz and Priscilla Agyeman. Dr. Katz is a psychiatrist at Mount Sinai, and a Co-director of the Mount Sinai Human Rights Program. Priscilla is a clinical research coordinator and a recent graduate of the Icahn School of Medicine, where she studied public health.
Now, this is a podcast about resilience. So why are we doing an episode about this study? Two reasons: first, no matter where you stand on immigration, I think we can agree that the current crisis contains within it a massive resilience challenge. We're talking about millions of people fleeing their homes. Thousands of children moving through federal custody, often alone. The sheer scale of it is hard to wrap your mind around. Which leads me to reason No. 2: If you're looking for resilience stories, examples of survival and sheer toughness, look no further. Migrants are some of the most resilient people you will ever meet. In the conversation that follows, Priscilla and Dr. Katz talk about what it was like to visit this particular detention center, what they found, and what it means for all of us. Thank you both for being here.
Priscilla Agyeman: 01:50
Dr. Craig Katz: 01:51
Thank you for having us.
Okay. So, Dr. Katz, can you start off by talking a little bit about the human rights program and what it does here at Mount Sinai?
Dr. Craig Katz: 01:58
Yeah Mount Sinai has had a long-standing involvement doing human rights work and the clinic goes back in different incarnations a number of years now and our main focus is on providing asylum evaluations for asylum seekers, and that mission is really driven by the understanding the evidence that if you have a medical professional who has written in an affidavit, that's that in support of the trauma that you describe having on undergone in your home country that having an affidavit like that greatly increases your chances of being granted asylum quite a bit actually like 90 percent Grant rates composed as opposed to maybe like 30 percent. So it makes a huge difference.
So is this the first type of study that the human rights program has worked on?
Dr. Craig Katz: 02:50
This is I believe our first detention-based study. Yeah, we've definitely done some other studies over the years and have a lot of other ones cooking right now. But this is definitely the first in detention.
So where does the story begin? How did the study come about?
Dr. Craig Katz: 03:07
So a resident and I—as part of our global health track, one of the residents opted to go to a family detention center with me and do some work and this was in January 2018. So we went to the family detention center in Texas and did quite a few on-site evaluations, the kinds we would do here. We just did a bunch, just banging them out one after the other. And one thing that struck us, of course, was that this was a family detention center. So this was mothers and kids. And it just struck us that that was something that we wanted to draw some attention to--the fact that, of course, the sheer fact that there are kids being detained, right, and what you know many would call being basically imprisoned, but also to explore what's going on with them mentally, because most of the evaluations we did were in their mothers. And so we also knew the literature, the scientific literature, there wasn't anything on this, and so we thought this would be an enormous contribution to medical literature and especially for advocacy purposes depending upon what we found.
Priscilla, what was the facility like?
Priscilla Agyeman: 04:15
So the facility is, for lack of a better word set up like kind of like a concentration camp. Like there are a lot of, it’s—there's a visitation trailer that we were you know able to go through every day and that was the only location that we were able to visit. We were prohibited from going anywhere else on the "campus" I guess you can say. But the way that it was set up was the women would come in to the visitation trailer to see their lawyers or, you know, the other volunteers that were working on their asylum cases, and so that's where we were on a daily basis, um—
So, so you're in this visitors trailer, right, you're working with the lawyers, you approach one of these women and you say, "Hi, I'm so-and-so and we're doing this study, would you like to participate?" And what were--I understand you had one of several questionnaires that you would use—
Priscilla Agyeman: 05:06
Right, so we use two different surveys. The first one was the Strengths and Difficulties Questionnaire, which is a widely used tool to assess behavioral—
Dr. Craig Katz: 05:16
General mental health symptoms and behaviors and conduct in kids.
Priscilla Agyeman: 05:21
Right, so we used that. And both of the surveys were in Spanish. And then the other survey that we used was the PTSD, Post-traumatic Stress Disorder Reaction Index for children, the UCLA version. So this was a specific survey that measured, you know, the levels of PTSD presentation, I guess you could say, that they had by way of if they had reoccurring nightmares or dissociation, certain psychiatric, I guess, symptoms that you would look for in children to assess PTSD.
The woman were overwhelmingly open to talking about their children and their mental health. I think it was, you know, probably a moment of reflection for them because if you're going through that much trauma and distress, it can be really easy to forget that or not notice that your child is quieter than usual or they're having nightmares, or maybe they're peeing in the bed a lot and they're not at the age where they should be doing that. So I think that them talking to us, or what they expressed, was that them talking to this to us was actually in some way therapeutic. So that was basically how we approached the study. And we did a total of 425 of these in eight weeks.
Wow. What was that like?
Priscilla Agyeman: 06:49
Hard. Difficult. Challenging. Stressful. It felt like such an enormous responsibility as—I'm a child of immigrants myself. My parents didn't go through what these women and children were going through, but I felt very responsible to try my best to show up. Even if I didn't feel like it, even if I was tired or burnt out or dealing with compassion fatigue, which I think both Sarah and I definitely felt. However, it felt like we were doing something important and we're doing something necessary.
Hmm. I'm wondering if you, any of the people that you met kind of stand out in your mind, and you could share a little bit about one person or one family that you encountered.
Priscilla Agyeman: 07:44
Right. There's actually several women that really stick out, and I will always remember their stories. The first woman that I spoke with was younger than me, actually, and she had a son. She was from Honduras, and she fled because of gang retaliation. Her brother did not want to join a gang—and this is a very common narrative—a lot of the women were fleeing because of gang violence or retaliation for not joining a gang. So her brother refused to join the gang. Her brother actually ran away, left the country, because the gang was trying to recruit him so much that they were threatening him, threatening members of his family. So he left the country, and she stayed. She had a husband and her child, and she stayed. But the gang members knew that that was her brother. And because they knew that they ended up actually gang raping her. And that was a very, very difficult--that was one of my first conversations with one of the woman, and she completely broke down because, you know, she felt like it was her fault and, you know, she didn't do anything to stop it. And you know, we had to let her know that that is not her fault. That was she didn't do anything to ask for that type of behavior or treatment. So she left the country with her son in order to seek asylum.
So stories like that hearing stories like that on a daily basis definitely--it drills into your mind how much these women are, they're not they're not criminals. They're not running out of fear of the police trying to arrest them or something like that. They're running for their lives, literally.
Dr. Craig Katz: 09:52
I mean it takes remarkable courage to pick up your life and, and take an often uncertain migration path, right, it wasn't like they were you know going onto Travelocity and booking a flight to the United States, right? They were hauling through often unsafe or unpredictable circumstances to get here—
With their children.
Dr. Craig Katz: 10:13
With their children, right. And so I mean, these are people you have to have a lot of respect for that now, that they made a really hard decision often, leaving family behind, sometimes leaving kids behind. Decisions about as to who to take or who not to take. You know, I think it's you know, I admire the people that I met in a very deep, in a deep way, actually, almost a spiritual way what they've been through. It's quite striking.
Let's talk a little bit about the results. What were some of your findings?
Dr. Craig Katz: 10:55
We found high rates of behavioral and emotional problems in the kids. That's how the Strengths and Difficulties Questionnaire kind of breaks out into broad clusters. And we also found high rates of posttraumatic stress disorder as well. Now, these are all according to surveys, right, so they're not definitive diagnosis, but these are very, very suggestive numbers. And our unanticipated finding is that when we were there was in the heart of the period of child separation, and Priscilla and Sarah and Josh were able to interview some mothers who had been separated from their kids and now were reunited with them to ask them, interview them, the same exact questionnaires, but now we have detained, previously separated, now reunited kids. And perhaps the most striking of our findings, again, not a surprise that kind of know it told us in science what you know in your heart, right, was that the separated, detained kids actually had higher rates of emotional problems and PTSD compared to the detained kids who, themselves, on the whole had higher rates compared to the general population in the US.
How much higher?
Dr. Craig Katz: 12:07
Actually, I confess l don't remember the exact numbers so I'd have to look up the numbers for you, if you like, I can do that, but—
Actually, I have them.
Dr. Craig Katz: 12:16
Yeah, OK. I can never—the numbers never stick in my mind.
You'll have to correct me if I'm interpreting them wrong. So I found compared to--this is the findings compared to the general U.S. population. I have five percent for the general population for emotional behavioral difficulties and 10 percent, so double. And then—this was really startling for me—PTSD for teens—
Priscilla Agyeman: 12:41
Right, was four times as much.
Four times as much. When you got those results, what was your reaction?
Dr. Craig Katz: 12:47
In some sense, my reaction was like, why did we need to do this study? Right? Didn't we all kind of know this already. Right, but now here the hard numbers, right? So, you know, someone's got to act on this.
What's been the response either from colleagues, media, government?
Dr. Craig Katz: 13:05
Well, it's complicated. Colleagues are quite interested, but colleagues-- we're preaching to the choir, right? So, you know, the psychiatric community has been quite up-in-arms about this and being, you know, putting all sorts of policy statements about how, how damaging child separation is in particular. We feel fortunate to have the data to back it up. The complicated reaction is actually been from our legal colleagues who were concerned, actually, about releasing this data. They thought the data would be misused, that, in other words, that people would say other countries are sending us their crazies.
Dr. Craig Katz: 13:49
It is startling and it speaks to the nature of the political climate right now, I guess, that we would have to kind of feel guilty about publishing our findings. But we do. And I have to say I fear that one day soon I'm gonna hear from them that there were repercussions in some way. Right. Even for if the fact of our being there or that someone is holding up our paper and using it as justification for current hard-line immigration policy.
Yeah. There was one other piece of the findings that I think is important to highlight and that's that even though you found these higher levels of mental distress and children in these facilities, you say very explicitly that you couldn't, you couldn't pinpoint the source of that. You couldn't say, for example, that because that being in detention caused this distress. And you say that for all you know, it could have preceded it. It could have come from some things that happened in their home countries, and I just think that's important to say as well. Like what we know and what we don't know based on the study.
Dr. Craig Katz: 14:51
That's correct, I think part of maybe some of the disappointment on the part of our legal colleagues is that we couldn't show that the detention caused this. And it wasn't really necessarily designed to do that. We did actually ask about the conditions of detention. We did do a survey on that, and that was going to be our one attempt to, if we could at least correlate the assessment of the quality and conditions of the detention center and the mental health system symptoms in the kid, then we could show some connection between the two. But in fact our data didn't show that. In fact to be, you know open about this, the ratings of the quality of detention were actually, were pretty good.
For this particular facility.
Dr. Craig Katz: 15:35
For this particular facility, which is, I think, unique to this facility. It's hardly, I think, representative from what I've seen and certainly from what we know from other colleagues. So we couldn't show that. But what we do know is that we're looking at a population of kids who have, you know, are carrying with them a large mental health burden and who—if there are any concerns about what they are going to contribute or if they're going to stay in the United States and what they're going to contribute to society, that we have, I think, if not a moral obligation then maybe selfish obligation. If we want them to be good contributors to our society, to correct their trajectory now and not leave these problems untended. Because you leave them unattended, unaddressed, undiagnosed, they're going to get worse. Right, as a general rule in the world of mental health, the longer you've got something, the longer you're going to have it, even when you get help, and the more problems it's going to cause. So this is a chance to actually intervene and help them on a humane basis and really help our society.
What sorts of care are they receiving?
Priscilla Agyeman: 16:50
So they have a medical facility on site. They have physicians, I believe even a dentist, if I'm not mistaken. And there is a behavioral specialist or psychiatrist on site as well. However, we don't know anything about their range of training, their specialty, if they are, you know, trauma-informed, which, I think, is really important in this population. So that was something that still has a huge level of mystery. Because there really was no way to tell.
Dr. Craig Katz: 17:33
And it's I think it's maybe you found it otherwise, but it was not clear to me that there was even a psychiatrist back there.
Priscilla Agyeman: 17:41
Dr. Craig Katz: 17:41
There might be a psychologist which would be fine. But, you know, there's this sort of whole mysterious thing like who was behind this door. So what the services are. There's something back there, but we don't know what it is. And there's I mean there's such a shortage in this country of child mental health professionals. I would be really surprised if there's any child mental health professional back there.
When we talk about mental health services for a population like this? What are the sorts of things that you know in a perfect world you would begin to introduce is it is it sending psychologists in to do one-on-one therapy? Is it—
Dr. Craig Katz: 18:19
Well, you know, child and adolescent psychiatry is a different field than adult psychiatry. I'm an adult psychiatrist. So really what you would have is a child mental health professional who is trauma-trained or as Priscilla use this term “trauma-informed.” That would be the ideal to work with this population. And whether it would come down to individual therapy or group or play or medications is kind of hard to say depending upon the nature of the problem. And I'm sorry and I should add, one of the best predictors of how a child going to do under traumatic circumstances is how their parent is going to do. As the parent goes so goes the child, unless the child has other pre-existing mental health vulnerabilities. So, ideally you don't just treat the child, but you treat the parent as well.
So the picture I'm getting in my head is of a population that is distressed, and that would require, as you just said, significant intervention. Is that correct?
Dr. Craig Katz: 19:23
That is correct. And we and we've seen the other end of this. Like I just interviewed a woman from Central America did an asylum evaluation a few weeks ago here. She's in the community. I forget what state she's in but I did this remotely. She had been separated from her kids, now reunited, and she—I was interviewing her, not the kids, but the kids are just, for lack of a better word, just an awful mess psychologically, psychiatrically. They need care and they just can't find it. I mean they're just trying to get their life together, like where they're going to live, how they're going to make ends meet. And the kids, thankfully, are able to go to their local school. But they're not getting the mental health care because they can't afford it and they don't how to find, if they even exist, pro bono or discounted mental health services for the kids. So the problem extends out across their trajectory well beyond detention, but it starts at detention.
So what does the future look like for these women and children—that's question one—and two, what's next for you and your research in this area?
Dr. Craig Katz: 20:31
What's next for them? You know, I think there's so many different paths. I think so many of them if they are—I mean if they go, if they are deported, for many of them we believe it’s a virtual death sentence because they were already being threatened in their home country. And then the fact that they tried to flee, right, is even more problematic. So they are terrified literally for their lives even more than when they fled. For those who stay in our country. You know, it just seems to me there are so many obstacles working against them in terms of the environment that they find themselves in. So, but again, I think of these as really resilient people who know how to make things work eventually, so I'm hopeful for them. I'm actually very hopeful be in another respect—even if they don't get access to specialized mental health services, one of the best ways for people to recover from trauma is social support. And in communities that we've worked in—I've been down in San Antonio—there just so many wonderful people religious groups and otherwise who are banding together and providing volunteer services just to help make sure people have clothes and a backpack and a phone to call and know how to get a bus ticket to go to meet their family. And I'd like to think that that social support—that they're hopefully also finding in their destination communities around the United States—that that that support is going to make an enormous difference in their recovery trajectory, even if they don't get the high-powered mental health services that I'm referring to.
As for our next steps—and you asked the question about what are our next steps—I'm not sure. To be honest, I think right now rather than doing research, we're just trying to keep up with the flow of requests for asylum evaluations. We can't keep up. And in terms of those are referred to us or going out to the detention centers, there are just not enough of us. And so I think we're probably at the moment less focused on the academics and more on getting, like, with some trepidation, getting information out this out there like this, letting people know, on just keeping up with the with the steady flow of this asylum-seekers.
Well, I just want to wrap by thanking you both for doing the study and for your ongoing work. It's been really, really nice speaking with you. Thank you for being here.
Priscilla Agyeman: 22:59
Dr. Craig Katz: 23:01
If you're interested, I highly recommend reading the whole study. It's compact and readable, and it includes links to related studies that will give you a more complete sense of how immigration policy impacts migrants' health. We’ll include a link to the study in the show notes. Thank you again to Dr. Katz and Priscilla for making time to talk to us. Thank you also to the other co-authors of the study: Sarah MacLean, Joshua Walther, Dr. Kim Baranowski, and Dr. Elizabeth Singer.
On the next episode, we're going to hear from a man who fled anti-gay violence in his native Ghana, and sought asylum in the U.S. But when he got here, he quickly realized that some of his greatest challenges may still lay ahead. It's a resilience story you won't forget. Road to Resilience is a production of the Icahn School of Medicine at Mount Sinai. It's produced by Katie Ullman, Nicci Hudson, and me, Jon Earle. Our executive producers are Dorie Klissas and Lucia Lee. From all of us, thanks for listening. See you next time.