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Addendum B
Addendum B: Trauma Informed Care for Children Exposed to Violence; Tips for Agencies Working With Immigrant Families
by OJJDP, Office of Juvenile Justice and Delinquency Prevention

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Why focus on immigrant families?

Children born to immigrant parents are a large and rapidly growing segment of the Nation’s population of children. Most of these children (93 percent) are American citizens. Children of immigrants are more likely than children of U.S.-born citizens to face economic hardships and significant barriers to healthy social and emotional development. These barriers include exposure
to violence and can affect children’s readiness to succeed in school and beyond.

Immigration is a process that includes the initial decision to migrate, the process of migration, and acclamation to the new environment. This process impacts several generations. Despite their need for services, immigrant families face unique challenges that affect their ability and willingness to seek assistance—especially mental health services. If they are undocumented, they may not qualify for certain services. In addition, they may be unable to access services because of language barriers and poverty. Many immigrants live in rural, impoverished areas where public transportation is unavailable. Instability in the lives of immigrant families may also prevent them from seeking or following through with services.

Furthermore, many State and local agencies are voicing concerns related to the impact of Immigration and Customs Enforcement (ICE) raids on children and families. ICE raids in workplaces, neighborhoods, or homes are a method of enforcing U.S. immigration laws. Those who are suspected of being undocumented are arrested, and deportation proceedings are initiated. ICE raids have resulted in the involuntary separation of children from parents/caregivers, placing children and adolescents at risk for long-term family separation, psychological and economic distress, poor health, and developmental delays. The development of infants, toddlers, and preschoolers can be negatively impacted while parents/caregivers are in detention and cannot attend to their children’s biological needs (for example, breastfeeding). For many families, this situation represents yet another traumatic event in their lives.

A greater understanding of the impact of lifetime exposure to violence, as well as the current stressors that immigrant families may experience, plays a crucial role in improving outcomes for children in all systems.

What happens when children are exposed to violence?

Children are very resilient—but they are not unbreakable. No matter what their age, children are deeply hurt when they are physically, sexually, or emotionally abused or when they see or hear violence in their homes and communities. When children see and hear too much that is frightening, their world feels unsafe and insecure.

Each child and situation is different, but exposure to violence can overwhelm children at any age and can lead to problems in their daily lives. Some children may have an emotional or physical reaction. Others may find it harder to recover from a frightening experience. Exposure to violence—especially when it is ongoing and intense—can harm children’s natural, healthful development unless they receive support to help them cope and heal.

Violent or traumatic events can cause ongoing and overwhelming feelings of hopelessness and fear. Those feelings are compounded by other stressors that are unique to immigrants and refugees. For example, the loss of familiar surroundings, family networks, and support systems; the struggle to understand a new language; and the inevitable stressors of acculturation can increase feelings of hopelessness and fear. Even daily routines that often help families cope with stress cannot be replicated in the new country.

Early and effective interventions that are culturally competent and family centered can help immigrant and refugee children begin a healing process and ultimately thrive. Service providers can be more responsive to the needs of these families once they understand the impact of exposure to violence and become more knowledgeable about the symptoms to watch for. An effective response gives children the opportunity to regain a sense of safety and ultimately recover from the effects of exposure to violence.

What are some of the warning signs of exposure to violence?

Children’s reaction to exposure to violence can be immediate or appear much later. Many studies have documented mental health symptoms in immigrant and refugee children that are linked to exposure to violence before migration. Reactions differ in severity and cover a range of behaviors depending on the frequency, intensity, and closeness of the traumatic events. People from different cultures may have their own ways of showing their reactions. How a child responds also varies according to the child’s age.

Young Children (5 and younger)
Young children bear a disproportionate share of violence and abuse in the home. Exposure to domestic violence (abuse between adult partners in the home) affects many young children. When very young children are exposed to violence, their expectations for a predictable world are shattered and they may lose the basic trust that a caregiver will emotionally and physically protect them.

Children in this age range may respond in a variety of ways. They may:

■ Be irritable or fussy or have difficulty calming down
■ Become easily startled
■ Resort to behaviors common to being younger (for example, thumb sucking, bed wetting, or fear of the dark)
■Have frequent tantrums
■ Cling to caregivers
■ Experience changes in level of activity
■ Repeat events over and over in play or conversation
■ Become passive and lose interest in playing
■ Become over-compliant

Elementary School-Age Children (6–12 years)
Elementary and middle school children exposed to violence may show problems
at school and at home. They may:

■Have difficulty paying attention
■Become quiet, upset, and withdrawn
■Be tearful and sad and talk about scary feelings and ideas
■Fight with peers or adults
■Show changes in school performance
■Want to be left alone
■Eat more or less than usual
■Get into trouble at home or school

Teenagers (13–18 years)
During these years, the most rapidly developing brain areas are those crucial for success in forming interpersonal relationships and solving problems. Exposure to violence impedes this development and can lead to difficulties in behavior, cognition, and identity formation.
Teenagers exposed to violence may:

■Talk about the event all the time or deny that it happened
■Refuse to follow rules or talk back with greater frequency
■Complain of being tired all the time
■Engage in risky behaviors
■Sleep more or less than usual
■Increase aggressive behaviors
■Want to be alone, not even wanting to spend time with friends
■Experience frequent nightmares
■Use drugs or alcohol, run away from home, or get into trouble with the law

What can staff in agencies serving immigrants do?

Service providers including teachers, early care and education providers, child welfare staff, and public health workers can play a critical role in preventing and reducing the impact of exposure to violence on immigrant children and their families. The first step is to recognize that a lifetime of exposure to violence is pervasive in immigrant families. Rates of exposure to different types of violence—including family, school, and community violence—vary across different groups. Families from different ethnic and linguistic groups may express the impact in different ways. However, it is critical to be sensitive to the ways in which exposure affects current behavior, treatment, and outcomes for each family. Agencies may:

Screen for exposure to violence symptoms and mental health needs of children and their families on an ongoing basis

Routine screening for safety and risk in cases of exposure—especially exposure to domestic violence— and the possible impact on children is recommended for staff working in every system. In addition, it is critical for staff to screen for the ongoing mental health service needs of immigrant families throughout their involvement with agencies (especially child welfare agencies).

Refer families for comprehensive mental health assessments that include lifetime exposure to violence and acculturation stressors

An assessment of a family’s history of exposure to violence and its impacts, as well as current acculturation stressors, provides a solid basis for the development of interventions for adults and children in immigrant families. An area of critical importance to explore is the rate of acculturation between generations (children acculturate faster than adults), which may lead to additional problems and distress. The interventions and services plan should assist the family in resolving the impact of this exposure and, at the same time, support each child’s development and well-being.

Plan for individualized interventions that take into consideration traumatic experiences for both caregivers and children, which may be affecting the current family situation

Children’s responses to violence differ based on age, gender, and life history. Treatment plans must be adjusted to ensure individualization, age appropriateness, and family history. In every case, however, it is critical that treatment plans help the child and caregivers reestablish a normal routine, safety, and predictability. In addition, it is important to realize that families and other caregivers may have been exposed to violence themselves and may display signs of reaction to trauma. In such cases, it is important to develop specific plans and structures that help caregivers address their own needs so that they can become a powerful anchor to the child’s treatment.

Expand the definition of "trauma-informed care" and "evidence-based interventions"

Exposure to violence and other stressful life experiences of immigrant families may differ from those experienced by native-born American citizens. It is important for providers to consider the socio-cultural, ethnic, linguistic, and other contextual variables (for example, immigration)
that may compound the impact of exposure to violence.

Currently, several evidence-based interventions are available for children exposed to violence. These interventions include evidence-based treatment approaches that usually aim at improving child outcomes through the use of clinical practices informed by the best available research and program expertise in the context of the family’s culture and preferences. The report Evidence-Based Practices for Children Exposed to Violence: A Selection from Federal Databases describes several interventions that have shown success in decreasing negative symptoms in children who have been exposed to violence. In addition, this report provides information on several common characteristics of effective treatments for children. Some research indicates that ethnic minorities in general—including immigrant populations—respond well to evidence-based treatments when they are modified to include specific provisions for cultural groups.

Research on the efficacy of interventions with immigrant populations is scarce. Practitioners working with populations that are underrepresented in mainstream efficacy studies (such as immigrant populations) should recognize the potential value of data collected through different research designs (for example, clinical observation, qualitative research, systematic case reviews) and in practice-based approaches to treatment.

However, these evidence-based interventions are not a substitute for other needed services.

Become familiar with immigration laws, policies, and resources

Immigrant children and families whether they are documented or not may be eligible to receive various services if they have been victims of crime or violence.

Undocumented families need assurances that they will not be deported for receiving services and that staff will not report their citizenship status to immigration authorities.

During intake, service providers might ask questions about immigration and documentation status because these issues may prevent families from accessing or continuing with services. If families are undocumented, the providers are in a unique position of being able to help the families connect with available services.

Increase cultural responsiveness to families

Service providers should ensure that they have a clear understanding of all family members’ perspective about their exposure to violence. Agencies can establish protocols to assess the impact of violence on current problems and mechanisms to select the most appropriate interventions for each family. To do this, service providers should:

■Ask the family which language it prefers
■Gather information about the family’s ethnic background before meeting with family members
■Have a list of qualified interpreters—preferably with a mental health background—rather than use family members to translate
■Partner with case management services that facilitate access to culturally relevant agencies that are knowledgeable about the challenges of immigrant families
■Refer families to community- and ethnic-based
organizations that have the infrastructure and
resources to deliver and adapt evidence-based
practices within cultural contexts

Mandated Reporting

Many children experiencing crises or violence are also at risk for child abuse and neglect. All
States have child welfare systems that receive and respond to reports of child abuse and neglect,
offer services to families, provide foster homes for children who must be removed from their
parents’ care, and work to find permanent placements for children who cannot safely return

Domestic violence does not equal child abuse and neglect, and therefore not all cases of
domestic violence must be reported to child protective services. When responding to families
affected by domestic violence, it is very important to consider simultaneously the safety of the
child and the safety of the adult victim.

State by State information on reporting requirements can be found at

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