BHIPP Bulletin

Volume 9, Issue 12

June 2024

This month's BHIPP Bulletin is a contribution from

Rheanna Platt, MD, Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine and BHIPP Consultant and Barbara Robles-Ramamurthy, MD, and is adapted from an American Academy of Pediatrics newsletter with permission from the authors.

Children in immigrant families (CIF) include those who are born outside of the United States or who have at least one foreign-born parent. CIF are a diverse group comprising 1/4 of the under-18 US population.¹ CIF face unique risks to mental health due in part to high rates of trauma occurring before, during, and after migration, particularly for unaccompanied immigrant minors.² In many cases, CIF may be separated from caregivers, further compounding these traumatic experiences and potentially leading to poorer mental health outcomes.³ However, stable and supportive relationships are a protective factor against the impacts of childhood adversity.⁴ Importantly, these children and families have tremendous strengths and sources of resilience, that can be protective of their mental health and should be supported in the primary care setting.⁵ 

Federal, state and local policies can significantly impact the mental health of CIF. These include policies related to immigration status and those dictating parent or child eligibility for and access to programs (e.g., Medicaid) or opportunities (e.g., work, education).^6-8 For example, fear of parental deportation may increase risks of anxiety and depressive symptoms, and suicidal ideation.⁹ Conversely, parent eligibility for Deferred Action for Childhood Arrivals (DACA) is associated with a significant reduction in child mental health diagnoses.¹⁰ Additionally, policies can have downstream impacts on family socioeconomic status, influencing access to school and neighborhood-level resources.

Apart from policies, the family context, including parent mental health, parenting, family separations, and parent-child communication, is an important factor influencing the mental health of CIF. There is some evidence that the prevalence of postpartum depression (PPD) is elevated amongst immigrant mothers,¹¹ but also that PPD symptoms are less likely to be detected and treated in this population,¹² leading to potential downstream impacts on parenting and on child health and mental health outcomes.¹³ Parent-child communication in immigrant families may be complicated or limited by periods of separation, differences in cultural values and language proficiency,⁵ and long work hours.¹⁴

Pediatric primary care providers (PCPs) have a continuum of opportunities to promote the mental health of CIF which range from prevention or mitigation of risk factors, to increasing identification of mental health needs among CIF and promoting engagement in mental health care and/or community supports for those with significant symptoms. As experts on the health and well-being of children, PCPs can advocate for policies that protect the mental health of CIF, including those influencing risk of deportation, health benefits for children and parents, adequate reimbursement for interpretation services, and access to resources such as education.¹⁵ PCPs can also advocate for systems, structures (e.g., medical-legal partnerships), policies, and practices (e.g., language access) that welcome and engage CIF and their caregivers, some of which are outlined in this toolkit.¹⁶ These actions may promote trust to engage in mental health care by supporting safe access to health care more broadly.

The identification of psychosocial concerns can be improved for CIF in the primary care setting by carefully considering the assessment processes and tools used (e.g., availability in preferred language, readability). Contextualizing screening tools with clinical assessment is important as there is evidence to suggest that using general population cutoffs might lead to under-detection of concerns in CIF.¹⁷ Likewise, standard adverse childhood experience measures may not capture adverse experiences most relevant to children in immigrant families, such as experiences of or fear of immigration raids.¹⁸ Screening is an opportunity to begin a discussion with children and families, and to signal that promoting and addressing mental health are part and parcel of general health care.¹⁹

All discussions about mental health should be approached with cultural humility. PCPs can practice cultural humility by engaging in self-reflection and acknowledging the life-long learning process to adapt clinical assessments and interventions in ways that incorporate the patient’s own words, understanding and preferences. ^20,21 These recommendations should be built in partnership with families and convey a sense that PCPs are interested in meeting families’ needs. There may also be psychosocial needs, such as food insecurity or concerns around immigration proceedings, that may require prioritization before therapeutic interventions as part of overall mental health care. Additional layers of mental health support include efforts to help families find a supportive community; this may include cultural strengthening and adaptation through peer-to-peer support offered through local non-profit organizations and English-as-a-Second-Language classes, among others. 

Barriers connecting to mental health services include language access,^22,23 lack of culturally appropriate services, cost/insurance, logistical barriers, and challenges navigating the health care system.²⁴ Integrative models that include mental health education and therapeutic services with adequate use of interpreters, along with psychosocial services, medico-legal partnerships and other opportunities for community engagement and empowerment show promise and can advance the cultural changes needed in the primary care setting.²⁵ This cultural change moves primary care staff beyond self-reflection and education into community-grounded action-based engagement that can ultimately result in the higher-level advocacy required to address the mental health disparities in immigrant families.

Related Resources for CIF in Maryland:

1. Maryland Coalition of Families – Support Group for Spanish Speaking Families: https://www.mdcoalition.org/support_group/online-support-group-for-spanish-speaking-families/ 

2. Centro Sol is an organization that aims to promote equity in health and opportunity for Latinos. Centro Sol has mental health programs for Latino adolescents and adults: https://jhcentrosol.org/community/recursos-comunitarios/

3. CASA provides services to immigrant families and advocates for their rights by offering legal, citizenship, vocational, case management, and other services: https://wearecasa.org/programs/

4. Esparanza Center is a comprehensive resource center that provides services including, but not limited to, health care, education, immigration legal matters, family reunification, and general community support to immigrant families: https://cc-md.org/programs/esperanza-center/

5. International Rescue Committee is a humanitarian aid organization that provides services to refugees, asylees, and other immigrants to help them thrive in Maryland: https://www.rescue.org/united-states/baltimore-md

6. Pediatric mental health screening tools in additional languages: https://capp.ucsf.edu/content/screening-tools

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, X, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

BHIPP Announcement

Join BHIPP and NAPNAP MD: Chesapeake for an In-Person Training Event!

Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) is pleased to partner with the National Association of Pediatric Nurse Practitioners (NAPNAP), Maryland Chesapeake Chapter to offer an in-person training event in Waldorf, MD. 

This conference will feature a presentation about BHIPP and the services we offer to primary care providers in Maryland, a presentation by Amie Bettencourt, PhD on Non-pharmacological Approaches to Managing Disruptive Behavior in Young Children, and a presentation by Antonia Girard, PsyD on Surveillance and Screening in the Primary Care Setting.

Date: Saturday, July 13th, 2024

Time: 8:00am-12:00pm

Location: Hilton Garden Inn 10385 O'Donnell Place, Waldorf, MD 20603

Free CME/CEU credits will be available for participation. *CME is pending*

For more information, visit https://community.napnap.org/newmarylandchapter/maryland-bhipp/maryland-bhipp