While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Children who came to the United States from war-torn Somalia lived through things no child should ever have to see or experience. "This group has experienced incredible trauma. Some lost family members. Some witnessed atrocities, violence, or rape," said Beverley Heidi Ellis, PhD, director of the Center for Refugee Trauma and Resilience at Children's Hospital Boston, and assistant professor of psychology at Harvard Medical School.
"In the refugee camps where many of these kids had spent their whole lives," continued Ellis, "there was a tremendous amount of violence and a scarcity of resources." Food and schools were two of the essentials of life in short supply in the camps.
Ellis directed the Boston project under Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth. The national program, funded by the Robert Wood Johnson Foundation brought school-connected mental health services and, in most cases, supportive services such as case management to immigrants and refugees at 15 sites in eight states from 2007 until 2010. Ellis and other staff on Project SHIFA (Supporting the Health of Immigrant Families and Adolescents) worked with Somali students at the Lilla G. Frederick Pilot Middle School.
The lives of immigrants in their home countries were not as traumatic as those of refugees, but immigrants, too, have experienced trauma. Many of the Mexican and Guatemalan immigrants living in Minneapolis had also faced violence and lived in poverty, according to Mark Sander, PsyD, LP, director of the Caring Across Communities project in Minneapolis. Sander is a senior clinical psychologist for Hennepin County who serves as mental health coordinator for Minneapolis Public Schools. The Minneapolis Caring Across Communities project, which focused on three elementary schools, worked with Latino immigrants and also with Somali refugees.
Children from Somalia and Latin America are often separated from their families. Some Somali refugees came to the United States with adults who were not their parents and may not even have been relatives. And many Mexican and Guatemalan children were left behind for up to seven years while their parents got settled in the United States. "There can be real parent-child issues around unification. The kids don't feel like they know mom and dad anymore," said Sander.
Trauma-Related Mental Health Problems and Solutions. The trauma that refugee and immigrant children have experienced can lead to problems such as depression and anxiety, family conflict, and poor performance in school. Behavior that indicates these problems ranges from withdrawal, to fighting, to not paying attention in class. "These are things that get put in a behavior bucket. But if you look at it through a trauma lens, it's not just a kid who's acting out and being bad," said Ellis.
The Caring Across Communities projects in Boston and Minneapolis developed special services to help traumatized refugee and immigrant children and families cope with their experiences and start new lives in the United States.
Helping Somali Students in Boston Through a Support Group and Trauma Systems Therapy. Project SHIFA offered a weekly school-based support group to Somali students, and Trauma Systems Therapy to help the subset of Somali students with significant trauma-related mental health issues. Of the 42 Somali students at the Lilla G. Frederick Pilot Middle School, 38 participated in the group, and 19 also received Trauma Systems Therapy.
The group work design serves to help Somali students learn how to become part of American culture while maintaining their sense of who they are. The group helped engage Somali students and their parents and counter the stigma around mental health. "Working first with kids in a group setting allowed us to get to know the kids and the parents and be perceived as helpful and supportive," said Ellis. Through the group, project staff also identified students who needed more intensive mental health services.
Trauma Systems Therapy, an empirically supported treatment model developed by Ellis and others, considers the child's social environment along with the trauma he or she has experienced. The approach includes home-based care, school-based therapy, and advocacy for necessary services, such as more appropriate school placement or better housing—and is customized to each child's needs. Some children received a few services for a few months, while others received intensive services for more than a year.
The home-based care and advocacy focuses on making the child's environment safer and more stable, including by addressing problems such as inadequate housing and family conflict. For example, one Somali student lived above a bar and had to walk past people hanging around and sometimes fighting outside. Project staff members arranged to move the family to a safer environment.
Three project partners—Boston University, the Refugee and Immigration Assistance Center, and the Home for Little Wanderers (a nonprofit child and family service agency)—were involved with the home care. Two Somali social work interns from Boston University, and the parent outreach coordinator at the Immigration Assistance Center, served as cultural brokers, helping agency staff engage the families so they could help them. Cultural brokers are bilingual and bicultural, know the local refugee or immigrant community, and can spend time with families, conduct home visits, and respond to emergencies. The two Somali interns, as well as other social work interns, provided the school-based therapy, designed to help children build coping skills.
Participating Students Improve. All the children who participated in the support group, or the group plus Trauma Systems Therapy, showed improvements in symptoms of post-traumatic stress disorder and depression, and felt more a part of American culture, according to Ellis. In fact, children who received Trauma Systems Therapy were "essentially indistinguishable" from children who participated only in the group.
Ellis and colleagues published an article on Project SHIFA in the Journal of Child and Adolescent Trauma in 2011. As of August 2011, they were working on a manual for the support group.
Rebuilding Connections Between Children and Their Parents in Minneapolis. Caring Across Communities in Minneapolis focused on rebuilding connections between children and their parents, using two different programs: Parenting Through Change with the Latin American immigrants and Tree of Life with the Somali refugees.
Parenting Through Change is an evidence-based group training program mixing education and support. Parents learn effective positive parenting practices related to limit-setting, monitoring, involvement, and encouragement. A group of about 12 Latin American parents met once a week for 14 weeks. "The results were really impressive." "Parents reported substantial improvements in their relationships with their children," said Sander. "And Parents stayed engaged."
Project staff had trouble engaging the Somali parents in this type of program. Then, in the last year of the grant, they started Tree of Life, a group program for students that taps into the oral culture of Somalia and uses elements of trauma-focused cognitive behavioral therapy. Such therapy helps reduce negative emotions and behaviors and provides a supportive environment that encourages children to talk about their traumatic experiences.
"It's a story-telling approach that helps the child articulate the narrative of their life so far. Through that, it helps them understand their past and present and look to the future," said Sander.
About 100 students participated in the seven-week program, in groups of 10 to 20. To engage parents, project staff sent information home about what the children were working on so they could talk about it. The program "helped students set goals and helped build bridges between parents and students," said Sander.
Prepared by: Lori De Milto
Reviewed by: Sandra Hackman and Molly McKaughan
Program Officer: Wendy L. Yallowitz
Grant ID # CAC, 61056, 61064
Program area: Vulnerable Populations
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