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Abstract

Latinos constitute the largest minority in the United States. While the term could refer to all individuals born or whose families come from countries in which languages derived from Latin are predominant, the term has come to primarily refer to those who were born or come from families born in countries in the Western Hemisphere where Spanish is the predominant language. Latinos face discrimination in the health-care system of the United States, even if born in this country, which is negatively affecting the mental health of both adults and children. There is an ever-increasing influx of families and children in the United States coming from countries in Latin America where they have experienced various forms of violence as well as violations of human rights and have arrived an undocumented status. As a result, many Latino families fear the potential detainment and deportation of family members, including the parents of children born in the United States, creating a source of anxiety and stress for the children. In addition to this, the process of forcibly having to abandon their country of origin within the context of what has been referred to as force migration is, in and of itself, a potentially traumatic event. Providers of psychotherapy for Latino children need to become more aware of these circumstances and take them into account during the treatment of these children in order to be more effective in their interventions.

Keywords

Latino children psychotherapy violence forced migration mental health

Introduction

Words and terms have at least 2 levels of meaning. The denotative meaning refers to what the word or term means in the strictest sense. On the other hand, the connotative level of meaning refers to what the word or term has come to mean through its use. Thus, in its denotative level of meaning, the term Latino population to primarily refer to persons born in or who come from families born in all the countries in which a Romance language, derived from Latin, is the predominant language.

There are an ample number of countries throughout the world in which the predominant language is a derivative from Latin. In Europe, these countries include Italy, Spain, France, Portugal, Switzerland (where Italian and French are spoken), Romania, Andorra (where Catalan is spoken), and San Marino (where Italian is spoken). There are also many former colonies of European countries in Africa and Asia in which a Romance language is predominant.

In the Western Hemisphere, the predominant Latino population have either born or came from families of origin from countries in which the predominant language is Spanish. However, in its denotative meaning, the term should also include individuals whose countries of origin are Haiti, for example, where French Creole is the predominant language, as well as Brazil, where Portuguese is spoken. In certain regions of Canada, French is the predominant language. These also include former French colonies and territories in the Caribbean and South America.

However, the term Latino population has been used more in its connotative level of meaning in the United States, where it is used primarily to refer to individuals that have migrated themselves, or their families of origin, from Spanish-speaking countries in Latin America and the Caribbean,¹ with Mexico being the most abundantly represented country.² The term Hispanic has also been frequently used to describe this segment of the population. However, it is interesting to note that, in spite of the various groups that make up this conglomerate, there are differences among the many subgroups that are encompassed in it.³

The concept of pan-ethnicity has been used to encompass different groups of Latinos in a single political, economic, racial, and sociocultural category. According to some authors (cf. Mallet and Pinto-Coelho³), this has occluded the differences that exist among the various communities that are included in the Latino population of the United States.

For example, among the less economically affluent groups within the Latino population of the United States are Mexicans, adversely affecting their integration into the American way of life and creating specific mental health issues.^4,5 On the other hand, though Colombians are among the more affluent economically,³ their exposure to armed conflict and violence creates different but perhaps equally impacting detrimental effects on the mental health of children who migrate to the United States.

Some Issues and Concerns

Latinos make up the largest minority in the United States.^6,7 However, irrespective of their level of education or having been born in the United States, they are not protected from discrimination in the health-care system.⁸ This creates an adverse impact on the mental health of Latino adults⁹ as well as children.¹⁰ Specifically, it relates to psychotherapy. For instance, Popescu et al¹¹ found that among patients provided with this service, Latino children received it with less frequency than White children.

Relative to this, Lu et al¹² conducted a meta-analysis of barriers and facilitators of access to mental health services in the United States for 3 minority groups, African-Americans. Latinos, and Asian. According to their results, Latino children and adolescents were much less likely to access mental health services, primarily, on an outpatient basis. They identified different types of factors affecting accessibility to mental health services, including adolescent-related factors, parent-related factors, contextual and structural factors, and social and cultural factors. Among adolescent-related factors were biological factors such as age and gender, clinical factors such as symptom severity, behavioral factors such as drug or alcohol use, and psychological factors. Parent-related factors included parental perceptions and beliefs, family and parenting issues, and demographic characteristics. Contextual and structural factors included household income, insurance status, and family structure, whereas the main social and cultural factor was the level of acculturation.

No matter what their theoretical orientation is while providing psychotherapeutic intervention with Latino children, professionals providing these services need to be aware of the many circumstances that adversely affect the mental health of Latino children and create the need for psychotherapeutic intervention. Some specific issues and concerns that professionals providing psychotherapeutic services to Latino children need to be aware of are discussed in the sections that follow. These include fear of deportation of themselves or of significant family members and going through forced migration. Professionals who provide psychotherapy to Latino children also need to develop awareness and sensitivity toward specific circumstances that affect and characteristics that define the different groups that make up the Latino population.

Another very important area that needs to be explored in the process of providing psychotherapy to Latino children has to do with the experience of different types of violence that they may have been subjected to in their countries prior to migrating to the United States. This may include violence related to armed conflict, gang-related violence, gender related violence, or domestic violence.

Fear of Deportation of Significant Family Members

Although the majority of Latino children living in the United States are born in this country, and are automatically United States’ citizens as per the “jus soli doctrine,”¹³ the fear of deportation of significant family members, especially the parents, also weighs heavily on their mental health.¹⁴ Depression, anxiety, and stress are the primary symptoms experienced by adults as a result of fear of deportation.¹⁵

Latino children born in the United States, and thus citizens of this country, experience a significant amount of trauma if their parents are detained by immigration authorities or deported. Symptoms of posttraumatic stress disorder or distress are the most prevalent in these children.^16,17

In spite of the many differences that exist among the various subgroups that make up the Latino or Hispanic population of the United States, a common thread that has been identified among them is the orientation toward an extended family approach to child-rearing.¹⁸ In this regard, the extended family provides support in different spheres, such as emotional, instrumental, and informational.¹⁹ Detainment and deportation threats adversely affect existing extended family structures and deprive children of their benefits.¹⁸

Fear of deportation of significant family members is an issue that should be explored in the course of providing psychotherapy to Latino children as a factor related to the experience of symptoms of anxiety and depression.

The Experience of Forced Migration

The experience of forced migration is another set of circumstances that potentially adversely affect the mental health of Latino children. To this effect, Clauss-Ehlers²⁰ has proposed a 3-stage process to address the traumatic effect of forced migration. Phase 1 of the trilateral migration trauma described by this author centers around the circumstances that prompt the departure, which frequently include violence or human rights violations. The suddenness of the departure and the fear and apprehension related to the upcoming journey are also important sources of stress. Phase 2, according to Clauss-Ehlers,²⁰ is the actual experience of migration itself, which, in many cases, is fraught with dangers and physical perils. The risk of exploitation, violence, sexual abuse, and human trafficking weighs heavily on potentially vulnerable children. Phase 3 of the trilateral migration trauma model proposed by Clauss-Ehlers²⁰ has to do with the children’s adaptation to the new environment of the host country. Differences in language, systems of education, and customs and mores may well constitute sources of added stress.

As mentioned earlier, there are many differences among the various groups that make up the Latino community of the United States. Forced migration may have very different reasons, depending on the country in Latin America the children or their families have migrated from. Following is a discussion of the circumstances surrounding forced migration among the most frequent national groups that make up the main Latino population of the United States.

Families and children from Puerto Rico, for instance, do not face the fear of deportation of close family members, as they are citizens of the United States. Puerto Ricans, have been found to often access managerial positions, whereas Mexicans have been found to occupy lower level jobs.³ Migration of Puerto Ricans to the mainland United States usually responds to seeking better employment^21,22 and escaping the ever-increasing violence that affects the island.²³

As noted earlier, immigrants from Mexico or children born into families that have migrated from Mexico make up the biggest segment of the Latino community of the United States. In addition to seeking an improved living status and escaping poverty and unemployment,²⁴ many Mexicans seek to come to the United States to escape gang and drug violence that has traditionally adversely impacted their living conditions there.^25,26 Perils associated with forced migration are very frequently encountered by Mexican families trying to illegally cross the Southern border of the United States.²⁷

People from the Dominican Republic also constitute a sizable portion of Latinos living in the United States with approximately 2.4 million Hispanics of Dominican origin.²⁸ Countries that allied themselves with the United States in World War II were given open visa status for their citizens to migrate to the United States for 20 years after 1945. However, while Rafael Trujillo was the absolute dictator of the Dominican Republic, travel outside the country was severely restricted. With the death of the dictator in 1961, the influx of Dominicans to the United States became increasingly abundant, particularly to New York. The motive for migration for most Dominicans was seeking better economic opportunities. After the expiration of the 20-year period of open visas, there has been an increase in Dominicans seeking to migrate to the United States illegally, particularly in the decades of 1970 and 1980. Some try to reach Puerto Rico by sea and others remain illegally in the United States after their tourist visa permits expire. Fear of deportation of parents or other significant family members adversely affects the mental health of children born in the United States of Dominican parents. In addition to this, the experience of deportation back to the Dominican Republic has been found to cause significant mental health problems for those subjected to it.²⁹

Another sizable group of Latinos in the United States is that of Cubans. Since 1959, Cuba has been under the rule of the same regime, initially headed by Fidel Castro, subsequently by his brother, Raul Castro, and now by Miguel Díaz-Canel, who was appointed as the president by Raul Castro. This dictatorship has been one of the longest durations in modern history. Throughout these years, there have been different waves of Cuban migrants coming to the United States.

The initial influx of Cubans into the United States, starting in 1959 and subsequently in the decade of 1960, saw themselves as exiles that left Cuba for political reasons, that is, dissention from the regime. These were primarily well-educated individuals who either practiced their professions in Cuba or were entrepreneurs, whose businesses were confiscated by the government. Upon their arrival to the United States, this group formed what has been described as an enclave in South Florida.^30,31 An enclave has been defined as a community that produces its own services and goods, and there is no incentive for their members to be assimilated into the host culture. Thus, Spanish continues to be a predominant language among this group, and the customs and mores of Cuban culture continue to be adhered to.^31,32 As living conditions have deteriorated in Cuba, owing to the scarcity of goods and services, there have been other migrations from the island to the United States. Many have been able to come by flying from Cuba in commercial airlines either directly or having been in another country before making into the United States.

However, there are 2 types of Cuban migrants that may have been subjected to traumatic events in their quest to reach the United States. A significant number of Cubans have risked the perilous conditions of traveling by sea in makeshift rafts and not very seaworthy crafts. These are the balseros, many of whom have perished in the treacherous waters of the Gulf of Mexico or who have lost relatives in the trip. These circumstances undoubtedly foster traumatic mental health problems that practitioners of psychotherapy with children that have experienced these conditions themselves, or their families, need to take into account. However, in recent years, there has been a significant increase of Cubans entering the United States through the Southern border. Families with children that risk this potentially dangerous endeavor often need to put themselves in the hands of professional smugglers or coyotes that are famous for their shady dealings.

It should be noted that fear of deportation of self or of significant family members is not necessarily an issue with Cuban migrants to the United States. Only very relatively few Cubans have been deported to the island, at least once they have entered the United States. The Cuban Adjustment Act is a federal law that grants automatic permanent resident status to Cubans that have lived in the United States for a year and 1 day, assuming they have initially touched US soil before being apprehended by immigration authorities.

Venezuela enjoyed more than 20 years of democratic government prior to Hugo Chavez coming into power, followed by the dictatorship of Nicolas Maduro after Chavez died of natural causes. Since then, thousands of Venezuelans have left the country coming to the United States or going to neighboring countries like Colombia. Several reasons have caused this migration. The current Maduro regime is extremely harsh on dissidents or individuals who are not in agreement with the government policies.³³ In addition to this, goods and services have become increasingly scarce,³⁴ and deteriorated personal safety has become a significant issue.³⁵ These circumstances have created a fertile ground for forced migration for many Venezuelan families. Whereas many have been able to make it into the United States by means of commercial airline flights, many have attempted to come into the country through the Southern border, facing the perils and vicissitudes inherent in the course of this way of travel.

Experiencing Violence Prior to Migrating to the United States

According to King,³⁶ conditions in Central and South America have led to an influx of refugee families and unaccompanied minors to the United States in recent years that are pushed into migrating. These children have been exposed to a series of stressors and adverse circumstances, including different types of violence. Having been exposed to armed conflict and political violence is certainly one of the antecedents of traumatic stress disorders in children who have lived through them, such as in Colombia, for instance.³⁷ The same can be said of the increasing urban violence, including that related to gang, which affects countries in Central America.³⁸

In addition, children raised in Latin America and the Caribbean can be expected to have experienced a high degree of other types of violence, such as domestic violence, criminal violence, and youth violence.^39,40 According to Devries et al,⁴¹ violence is perpetrated on children in Latin America and the Caribbean by caregivers, with an estimated prevalence of 40% to 55%; by other students, with an estimated prevalence of 50% in girls and 60% in boys; and by intimate partners, with 8% to 13% of partnered girls of 15 years of age reporting physical and emotional violence, as well as 15% to 20% of girls aged between 16 and 20 years.

Epidemiology of Mental Health Disorders in Children in Latin America

Providers of psychotherapy for Latino children also need to be aware that the epidemiology of mental disorders in children and adolescents in Latin America has not been extensively studied. However, there have been some studies that may help orient providers of psychotherapy to Latino children as to what conditions to expect.

To this effect, Caqueo-Urízar et al⁴² conducted a study in Chile to assess the incidence of psychiatric disorders in children and adolescents. Among the disorders included in the evaluation conducted by these authors were: internalized problems, externalized problems, contextual problems, specific problems, problems of emotional regulation, and search for sensations. The results obtained by these authors revealed the highest incidence in disorders of anxiety, depression, and behavior, with a progressive increase in magnitude. On the bases of these results, Caqueo-Urízar and colleagues⁴² strongly suggested psychopharmacological and psychotherapeutic intervention, along with educational programs and early detection strategies to be implemented.

In a study conducted in Paragüay, Fariña et al⁴³ identified the psychiatric disorders presented by a sample of 265 children and adolescents seen at the Department of Child and Adolescent Psychiatry of the University Hospital. The preponderance of diagnoses was neurodevelopmental disorders with 83 cases, followed by depressive disorders with 79 cases and personality disorders with 47 cases. Disruptive disorders of impulse and behavioral control were also identified with 43 cases, as well as anxiety disorders with 35 cases. Schizophrenic spectrum and other psychotic disorders were also identified with 26 cases, together with diagnoses of trauma or other stress related disorders with 21 cases. Other disorders were identified in much lesser frequencies.

Among the Latino population in the United States, Mexicans and Mexican Americans make up the largest group. Thus, understanding the incidence of mental health disorders in Mexican children is very relevant to the awareness of mental health professionals who provide psychotherapeutic services to children belonging to this group. To this effect, Díaz-Castro et al⁴⁴ explored the mental health needs and accessibility to specialized services in a sample of 397 children in different regions of Mexico. Hyperkinetic disorders (51%) and depressive disorders (34%) showed the highest incidence. Access to specialized services was primarily through specialized hospitals (44.8%), thus pointing to significant challenges to access community-based mental health care for children in Mexico.

There is no question that Brazil is the largest and most populous country in Latin America. Although, as noted above, while the term Latino, in its denotative meaning, should include Portuguese-speaking Brazilians, in its connotative meaning, it is generally used to refer to individuals either born or whose families come from Spanish-speaking countries. However, according to the estimates of the Brazilian government, there are approximately 2 million Brazilians living in the United States, not including those born in the United States of Brazilian parents.⁴⁵ Understanding the incidence of children’s mental health problems in Brazil would facilitate better psychotherapeutic intervention provided by professionals in the United States. In this regard, Lopes et al⁴⁶ conducted a study of the incidence of what they termed common mental disorders (primarily anxiety and depression) in a sample of 74,589 adolescents between the ages of 12 and 17 years living in major Brazilian cities with populations of over 100,000. The results obtained by Lopes et al⁴⁶ revealed that 38.4% of the female sample and 21.6% of the male ample suffered from these conditions, indicating high rates of prevalence and need for services.

Conclusions and Recommendations

Although the adverse circumstances that affect Latino children in the United States are not necessarily unique to them, providers of psychotherapeutic services need to be aware of the situations that negatively affect their mental health and lead to the need for psychotherapy. Among these is the realization that even if born in the United States, Latinos have traditionally been discriminated by the health-care system.

In addition to this, professionals who provide psychotherapeutic services to Latino children need to develop a keen awareness of the previous potentially traumatic experiences, such as violence from armed conflict, domestic violence, or peer violence that these children may have undergone in their countries of origin, prior to migrating to the United States, and which may continue to adversely affect their current mental health. It is also fair to presume that it is unlikely that Latino immigrant children received adequate services for any mental health conditions existing prior to migration owing to the limited services generally available in Latin America, with any such preexisting conditions aggravated by premigration or postmigration stress or trauma.

Forced migration may well have also been a potential source of distress for Latino children who are provided psychotherapy. Professionals who implement these services with them need to explore the vicissitudes inherent in this process, beginning with the preparation phase of the migration, including the circumstances that create the need to flee or escape from their countries, the perils of the migration process itself, as well as the difficulties of adaptation the children may be experiencing in their insertion into the American way of living. Even if born themselves in the United States, many families of Latino children live with the constant fear that some of their significant members may face detention and deportation. Providers of psychotherapy for these children need to explore in depth the impact that these fears and concerns may have on the Latino children they are treating.

Psychotherapy with Latino children in the United States needs to address the issues that confront them and that adversely impact their mental health. There is also a definite need to increase the level of resiliency of Latino children, given their growing numbers among American children, particularly when confronted with discrimination in the health-care system.⁹ Universities that train mental health professionals should include in their curriculum additional course work addressing the specific situations that negatively affect the mental health of not only Latino children but also of different ethnic and racial minority groups. In addition to this, national and state licensing examinations should include questions assessing the candidate’s knowledge and awareness of these issues, as well as mandating specific continuing education courses in these areas, at the same level that many states require specific continuing education courses in medical errors, domestic violence, and ethics. Mental health provider organizations should promote and implement in-service training on these issues for their mental health providers.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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