Persistence of Emotional Distress in Unaccompanied Migrant Children and Adolescents Primarily From the Northern Triangle of Central America

Key Points Questions How does emotional distress change longitudinally in unaccompanied migrant children and adolescents predominantly from the Northern Triangle of Central America, and what characteristics are associated with emotional distress? Findings This cohort study of 176 unaccompanied migrant children and adolescents showed that most, particularly girls, report high rates of persistent emotional distress. Girls were more likely than boys to have increased severity of emotional distress at follow-up. Meaning Results suggest that unaccompanied migrant children and adolescents, particularly girls, are at high risk for emotional distress that persists after resettlement in the US.


Introduction
Unaccompanied migrant children refers to children and adolescents younger than 18 years without legal status who migrate without a parent or guardian. Unaccompanied migrant children are often vulnerable to psychiatric sequelae because of traumatic events experienced at each stage of their migration journey. [1][2][3][4][5][6][7][8] The migration of these children and adolescents is often precipitated by economic deprivation, climate disaster, and physical or sexual violence, including gang recruitment and violence [9][10][11] ; during migration, these unaccompanied children and adolescents are vulnerable to robbery, extortion, kidnapping, and physical and sexual violence 4,[11][12][13] ; and after migration, many unaccompanied migrant children spend time in detention, which is associated with adverse mental and physical health consequences. [14][15][16][17][18] In the US, unaccompanied migrant children are released from detention to the care of sponsors, including relatives or adults with whom they had no prior relationship. 10 Afterward, many face linguistic and/or cultural barriers, discrimination, economic deprivation, community violence, and uncertainty about being granted immigration status. 4,19 The global population of unaccompanied migrant children is increasing, and the United Nations Children's Fund and High Commissioner for Refugees estimated that more than 300 000 unaccompanied migrant children migrated between 2015 and 2016 worldwide. 20 In the US context, more than 171 000 unaccompanied migrant children were apprehended at the Mexican border in 2021, 21 and more than 324 000 have been released to US-based sponsors during the last 4 fiscal years. 22 Most unaccompanied children and adolescents who migrate to the US are male adolescents from the Northern Triangle countries of Central America: Guatemala, Honduras, and El Salvador. In fiscal year 2021, 92% of unaccompanied migrant children in the custody of the Office of Refugee Resettlement were from the Northern Triangle, 72% were older than 14 years, and 66% were boys. 23 The 15-item Refugee Health Screener (RHS-15) was developed to address a lack of standardized questionnaires tailored to detect emotional distress relevant for culturally and linguistically diverse refugees and asylees. 24 It probes posttraumatic stress disorder (PTSD), depression, and anxiety symptoms; shows good psychometric properties in multiethnic adults and adolescents, including unaccompanied migrant children; and has been translated into multiple languages. 25-27 Higher scores and rates of distress on the RHS-15 are associated with older age, 28 female sex, 28 experiencing or witnessing violence, 28 being denied asylum, 29 and being an unaccompanied vs accompanied immigrant child. 29 Despite an absence of guidelines on the frequency of repeated RHS-15 administration after resettlement, data indicate that screening at least twice may facilitate the identification of initial and delayed emotional distress. 30 Studies of unaccompanied migrant children in Europe have characterized mental health symptoms and symptom chronicity, 31 but these have limited applicability for unaccompanied migrant children in the US, given differences in country of origin, migration journey, and host country's politicolegal context. No prior investigation, to our knowledge, has described the chronicity of emotional distress among unaccompanied migrant children resettled in the US. To address the gaps in the literature, this retrospective cohort study aimed to (1) identify the rate of and factors associated with positive emotional distress screening, as measured by the RHS-15, among unaccompanied migrant children primarily from the Northern Triangle; (2) describe longitudinal changes in emotional distress based on follow-up RHS-15; and (3) identify characteristics associated with increased severity.

Methods
This study received approval and a waiver of informed consent from the institutional review board of Montefiore Medical Center. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Setting
Terra Firma was founded in 2013 as a holistic model of care integrating medical, mental health, and not-for-profit legal services to meet the complex needs of unaccompanied migrant children and is located in a Bronx-based federally qualified health center. 32 Unaccompanied migrant children enter care at Terra Firma in 1 of 2 ways: (1) they are identified by a community-based organization and referred to Terra Firma or (2) they are identified by clinical staff at the health center and then internally referred to receive Terra Firma services. During the study period, a mean of 185 unique unaccompanied migrant children received services annually.

Participants
To be eligible for this retrospective cohort study, patients had to be unaccompanied migrant children

Variables and Measures Participant Characteristics
Characteristics were selected based on previously identified risk factors for psychiatric symptoms among adolescent refugees, including age, 33 biological sex, 34 length of time after resettlement, 35 preferred language, and country of origin. 27 Data were recorded at entry to care at Terra Firma; they were extracted nonblinded by one of the authors (J.Z.) with graduate-level public health training.
Data on race and ethnicity were obtained from the medical record, where it is collected at entry to care via self-report. Racism experienced at various stages of migration may contribute to emotional distress. Over 90% of the total sample either identified their race as "other" without specification or provided no race. Thus, methods of eliciting race and ethnicity among this clinical sample did not identify individuals of Indigenous heritage. Since many unaccompanied migrant children, particularly those from Guatemala, are Indigenous, this suggests that the exclusive use of US-centric racial and ethnic categories may contribute to the undercount of Indigenous migrants from Latin America. 36 Date of birth and sex were extracted from the medical record using Clinical Looking Glass software (Montefiore Information Technology). Date of entry to the US, country of origin, and preferred language were extracted from the Terra Firma program registry, which is maintained by program administrators. Age at initial RHS-15 was calculated by subtracting date of birth from initial RHS-15 date and was used as a continuous variable. Country of origin, sex, and preferred language were used as categorical variables. Time in the US at initial RHS-15 was computed from the dates of entry to the US and RHS-15 administration and was categorized into tertiles (Յ1 year, >1 to 2 years, and >2 years).
The RHS-15 results and dates of administration were manually extracted from program records. Days between RHS-15 administrations were calculated from each date of service and used as a continuous variable. Characteristics of unaccompanied migrant children and RHS-15 data were merged by matching unique identifiers.

15-Item Refugee Health Screener
The RHS-15 is completed at entry to care at Terra Firma and repeated at the discretion of medical and mental health care professionals. The RHS-15 was developed as a screening instrument of emotional distress, including symptoms of the common psychiatric conditions of major depression, anxiety, and PTSD, in refugee populations. Translation of the RHS-15 into available languages, including Spanish, 37 has been performed in iterative, participatory processes, including refugees, experts, and professional translators to optimize the cultural responsiveness and linguistic relevance of the items.
It has strong psychometric properties, 29,37,38 including high sensitivity and specificity against validated diagnostic proxies of PTSD (0.81 and 0.87, respectively), anxiety (0.94 and 0.86, respectively), and depression (0.95 and 0.89, respectively). 24 The 15-item version of the RHS-15 includes items from the Hopkins Symptoms Checklist-25, the New Mexico Refugee Symptom Checklist-121, and the Posttraumatic Symptoms Scale-Self Report, which were selected based on their association with PTSD, depression, and anxiety. Thirteen of the 15 items were taken from these instruments to measure the degree of distress associated with symptoms of PTSD, depression, and anxiety using a Likert response set ranging from not at all (0 points) to extremely bothersome (4 points); item 14 measures the degree to which individuals believe that they can cope using a Likert scale ranging from being able to cope with anything that comes your way (0 points) to unable to cope with anything (4 points); and item 15 is a distress thermometer ranging from 0 (no distress) to 10 (extreme distress). The RHS-15 total score is the sum of items 1 to 14 (score range, 0-56), 30 and a positive RHS-15 result was defined as: (1) a total score of 12 or greater (of 56) or (2) a distress thermometer of 5 or greater (of 10), which is consistent with the cutoff found to optimize sensitivity and specificity for PTSD, depression, and anxiety. 24 items were included in the analyses. To investigate differences in demographic characteristics between our study sample and excluded unaccompanied migrant children, χ 2 and 2-sample t tests were used to compare between-group sex and age at entry to care.
Logistic regression was used to evaluate the unadjusted and adjusted associations of age, biological sex, and time in the US with positive initial RHS-15 results (ie, total score Ն12 and/or thermometer Ն5). For unaccompanied migrant children who completed a follow-up RHS-15, linear regression was used to investigate the unadjusted and adjusted associations of age, sex, time in the US, time between RHS-15 administrations, and initial RHS-15 total score with follow-up RHS-15 total score. Two-tailed P < .05 was considered statistically significant. Data were analyzed using SAS software, version 9.4 (SAS Institute, Inc).

Sample Characteristics
Characteristics of the total sample of 176 unaccompanied migrant children included in our initial analysis are displayed in Table 1

Characteristics of Unaccompanied Migrant Children With Follow-up Assessment
The rates of positivity on initial RHS-15 between unaccompanied migrant children did not differ significantly between those who completed a follow-up (n = 68) and those who did not (n = 108)

Longitudinal Changes in Emotional Distress
On follow-up assessment, 44 unaccompanied migrant children (64.7%) scored above the cutoff. The

Characteristics Associated With Emotional Distress Severity at Follow-up
Multivariable linear regression was conducted to investigate the associations of the characteristics of unaccompanied migrant children and the initial RHS-15 total score with the follow-up RHS-15 total score ( Table 3)

Discussion
The present investigation examined emotional distress, its associated characteristics, and Most of the cohort screened above the cutoff for emotional distress, suggesting that they may experience PTSD, depression, and/or anxiety symptoms. RHS-15 positivity rates for unaccompanied migrant children in this sample were comparable with those of many adult refugees 40 and unaccompanied refugee youths resettled in Europe. 27 In addition to high rates of emotional distress among unaccompanied migrant children overall, the odds of reporting emotional distress were twice as high for girls compared with boys on the initial RHS-15. This is similar to findings from unaccompanied migrant children from non-Northern Triangle countries that girls report elevated psychiatric symptoms compared with boys. 1,19,20,41 Investigations have also found an association between older age and increased psychiatric symptoms in unaccompanied migrant children. 27,33 We did not detect such an association in this sample, perhaps because of relatively low statistical power.
Longitudinally, distress related to PTSD, depression, and/or anxiety appeared to persist or  Although most unaccompanied migrant children reported persistent psychiatric symptoms, more than one-fifth scored below the cutoff at initial and follow-up administration. This may reflect the strength and resilience of unaccompanied migrant children, as highlighted elsewhere. [45][46][47] Another notable result was that female sex was associated with higher odds of scoring above the cutoff on the initial RHS-15, as well as with increased follow-up RHS-15 score. Female vs male sex was associated with a more than 5-point increase in total follow-up RHS-15, notable given the positive cutoff value of 12 or higher. These results are comparable to studies of adolescent refugees and asylees from other countries of origin, which have found that girls report higher levels of psychiatric symptoms compared with boys. 20,34,41 A possible contributor for elevated risk of emotional distress for female unaccompanied children and adolescents migrating to the US is the high rates of interpersonal trauma, including sexual violence experienced by girls and women before and during migration. 11,20 Alternatively, this may be related to findings from multiethnic adolescents that coping strategies can vary by gender and sex 48-52 and that some strategies (eg, avoidance) 53

Limitations
Study limitations include the generalizability of findings to unaccompanied migrant children who do not remain connected to clinical care, since this sample consisted of youth receiving care in a wraparound service model. Thus, the findings are likely conservative; other unaccompanied migrant children may experience even higher levels of emotional distress. Although our analyses did not include all unaccompanied migrant children at Terra Firma, we observed no statistically significant differences in sex and age at entry to care among our sample compared with excluded unaccompanied migrant children. The lower proportion of girls in our sample, however, suggests that our results may have underestimated emotional distress prevalence. Analyses were unable to consider other possible protective or risk factors, including coping strategies, psychosocial support, specific mental health services received, sponsor identity, immigration status changes, and level of economic deprivation in the resettled community, because such data were not collected.
Additionally, the entire cohort of unaccompanied migrant children with an initial RHS-15 assessment did not complete a follow-up RHS-15 within the study period, which was truncated by the pandemic; the higher proportion of female unaccompanied migrant children among those with follow-up may have contributed to higher positive RHS-15 rates. Furthermore, as the RHS-15 is only validated as a screener, diagnostic prevalence rates of depression, anxiety, or PTSD could not be obtained.

Conclusions
The present findings indicate that unaccompanied migrant children, particularly girls, experience persistent psychiatric symptoms after resettlement, suggesting that they would benefit from