University of Alabama



Behavioral Health Intervention for Unaccompanied Children Trafficking Victims during the Asylum ProceedingsCho Rong Claudia Won, LMSWAbstractCentral Americans and Mexicans account for most of the unaccompanied children (UC) refugees at the U.S. southern border, and many are found to fall victims to trafficking (VT). However, the lack of behavioral health expertise and provision of legal representation by stakeholders and poor behavioral health conditions among UCVT throughout the asylum proceedings impact their claims to well-founded fear of prosecution at the home country. Without this, they face deportation where violence is still prevalent and re-victimization is at risk. The proposed research aims to answer, “what is the behavioral health impact of a trauma-informed forensic interviewing (FI)-protocol and FI team (FIT) designed and implemented for UCVT from Central America and Mexico?” Using the human rights framework and mixed-methods evaluation design, the study will assess the attitude, challenges, and needs of all stakeholders (i.e., law enforcement officers, attorney, social workers, UCVT) on the behavioral health impact of the asylum process; and develop, implement, and evaluate a trauma-informed and age- and culturally-appropriate behavioral health interventions (e.g., FI-protocol, FIT) for UCVT. Qualitative data will be analyzed using structural coding and thematic content analysis. Descriptive and inferential statistics will be conducted to understand the context and examine any significant and insignificant relationships. Data will be integrated to inform comprehensive understanding of the development, implementation, and assessment of the FI-protocol and FIT tailored to UCVT. This study is expected to provide a positive impact to the asylum proceedings through provision of a wraparound service that serves as both behavioral health and legal remedial. Problem StatementIn 2020, about 26 million refugees were seeking resettlement in one of the 37 host countries, and about half of the refugees were children aged 18 years or under (United Nations High Commissioner for Refugees [UNHCR], 2020). Since 2014, United States (U.S.) has experienced an upsurged rate of unaccompanied children (UC) refugees from Central America and Mexico at the southern border. The rate of Central American and Mexican UC accounted for 97% of the total 68,541 UC in FY 2014, and the rate have been steady with 92% in 2020 (Department of Homeland Security [DHS], 2019; Office of Refugee Resettlement [ORR], 2021). Of those in 2020, about 72% were youth aged between 15 and 17 (ORR, 2021). Also, about 75% to 80% of UC were reported to arrive with smugglers who experts have identified as human traffickers (David et al., 2019; Kandel et al., 2014).Despite the passage of the Trafficking Victims Protection Reauthorization Act of 2008 (TVPRA), many UC are not identified as victims of trafficking (VT) during the initial interview by the Custom and Border Protection (CBP) officers (American Immigration Council, 2015). As a result, they may face deportation if they cannot provide credible claim to a well-founded fear of persecution (American Immigration Council, 2015). One contributing factor to the presentation of credible claim is their negative behavioral health conditions (i.e., post-traumatic stress disorder [PTSD]), which research has found to impact inconsistency and avoidance in revealing their trauma narratives during the interviews conducted in the immigration proceedings (McQuaid, 2020; Rouben & National Journal, 2014). However, lack of therapeutic environment during the immigration proceedings could intensify the existing behavioral health conditions (Schouler-Ocak, 2015), suggesting the need for behavioral health care throughout the immigration proceedings. Following the human rights framework, this mixed methods (MM) evaluation study aims to develop an age- and culturally-appropriate behavioral health intervention for unaccompanied child victims of trafficking (UCVT) from Central America and Mexico. Refugees and Human Trafficking Refugee is an umbrella term for those who fled their home country and cannot return due to a well-founded fear of persecution based on religion, race, nationality, political opinion, or membership in a particular social group (UNHCR, 2020). Asylee is a refugee who has already arrived at the port of the host country to seek protection (UNHCR, 2020). Due to the need for a safe haven, refugees are vulnerable to human trafficking, which a gross form of human rights violation that uses violence, fraud, or coercion to exploit individuals of sexual or labor activities (Spyropoulou, 2017). Refugees are not only at risk to become VT at their home country but also during their journey to the host country, and UC are at increased risk due to lack of adult presence who can rationally judge a form of exploitation (David et al., 2019; Spyropoulou, 2017). Additionally, based on the finding from UNHCR (2014), UC from Central American and Mexico may be at increased risk as the most common reason of fleeing the country (48%) was the rise in gang activities in which involve trafficking of children.Despite the relevance of trafficking and refugee status, studies report that UCVT are underrecognized in the U.S. during the initial screening process by CBP officers due to the expedited process and lack of training of CBP officers in identifying signs of trafficking, abuse, or trauma (U.S. Government Accountability Office, 2015). As an alternative, UCVT are given an opportunity to apply as asylee seeking protection from a well-founded fear of persecution (Ataiants et al., 2018). Then, they are placed into the custody of the ORR who searches for a sponsor, residential facility, foster home, or secure detention center where UCVT can stay until the end of the immigration proceedings (Ataiants et al., 2018). However, UCVT must bear the challenges in navigating the complex asylum proceedings alone because they are not given legal assistance to present their claim to a well-founded fear of persecution at the court (Ataiants et al., 2018). The lack of legal representation is concerning because one study found that 73% of UC cases with attorneys were given protection in the U.S. (TRAC Immigration, 2014), indicating the need for legal assistance. Other challenging factors are the intertwined behavioral health conditions and trafficking experiences among UCVT that impact avoidance and fear in sharing their trauma narratives (Brunovskis & Surtees, 2019). The trauma narratives include exposure to conflict, disaster, torture, family loss or separation, life-threatening journey, and long waiting periods that induce anxiety and fear (Blackmore et al., 2020; Horyniak et al., 2016; Steel et al., 2009; Tello et al., 2017). Also, literature report association between trauma and adverse behavioral health conditions, such as PTSD, depression, anxiety disorder, and substance use disorders among refugees, including Central Americans and Mexicans (Blackmore et al., 2020; Horyniak et al., 2016; Steel et al., 2009; Tello et al., 2017). Literature also reports common behavioral health conditions among child refugees and VT (International Organization for Migration, 2020; Suwetty et al., 2019). Hence, while being a refugee and a minor already aggravate the development of behavioral health issue, human trafficking adds on to the trauma narratives. This is concerning because those narratives can serve as evidence to their credible claim at the court (Brunovskis & Surtees, 2019), but UCVT may distrust the CBP officer or attorney in revealing their narratives due to their experience in exploitation from authoritative figures (Beadle, 2014; McQuaid, 2020; Rouben & National Journal, 2014). Also, somatic symptoms relevant in some behavioral health conditions impact the inconsistency in narratives told multiple times (Herlihy et al., 2012; Herlihy et al., 2002; Herlihy & Turner, 2006; Ibrahim et al., 2019; Vuk?evi? Markovi? et al., 2021). All of these can result to failure of credible claim to a well-founded fear of persecution. Then, they must be repatriated to the home country where violence is still prevalent and re-victimization is at risk (Herlihy & Turner, 2006; Ibrahim et al., 2019; Zak, 2020). Hence, these challenges call for a behavioral health intervention that can provide timely protection to UCVT.Forensic Interviewing (FI)One alternative is forensic interviewing (FI). It has been employed in similar demographics as UCVT, including asylees and child victims of abuse. As an evidence-based practice used for child victims of abuse, interviews are conducted by a forensic caseworker who is trained to provide age- and culturally-appropriate assessment in a therapeutic environment (APSAC Taskforce, 2012). The interviews conducted by a caseworker are either shared to the multidisciplinary team (e.g., law enforcement officers, attorneys, child protection workers, school personnel) or observed live by the team so each personnel could gather information relevant to their role (APSAC Taskforce, 2012). This mechanism is unique compared to the traditional investigation in which the child is interrogated by each personnel separately (APSAC Taskforce, 2012). Hence, the mechanism of FI allows maximization of accurate and reliable depiction of the child’s narratives while minimizing re-traumatization by reducing the number of interviews conducted (APSAC Taskforce, 2012). Studies have shown FI and multidisciplinary forensic interview team (FIT) to be effective by increasing perpetrator convictions in child abuse cases (Block et al., 2013; Carnes et al., 2001).Similarly, FI and FIT has been implemented in the asylum court processing as a forensic assessment (Evans & Hass, 2018). Forensic assessment for asylum seeker is a written evaluation by clinicians (e.g., physicians, psychiatrists) on the physical, functional, and psychological conditions related to the well-founded fear of persecution. This assessment, then, is used by the attorney to serve as a medical-legal affidavit in the court (Society of Refugee Healthcare Providers, 2020). A longitudinal study assessing the asylum granted rate among those who received forensic assessment found 89% of granted asylum cases compared to a national rate of 37.5% among those who did not receive forensic assessment (Lustig et al., 2008). Hence, the mechanism of FI and FIT may be a feasible strategy to address the behavioral conditions of UCVT while improving their legal representation. Human Rights FrameworkThis proposed study will employ the human rights framework. Based on the UN Convention on the Rights of the Child and the Guidelines on Human Rights and Human Trafficking, human rights framework defines the rights of UCVT as the following: (1) best interests of the child as a primary consideration in all decisions; (2) protection of all children regardless of nations and from armed conflict, trafficking, and exploitation; (3) right to life, security, and freedom from all forms of violence (i.e., physical or mental violence, abuse, neglect) through provision of legislative, administrative, social and educational measures; (4) right to health through provision of necessary medical care; (5) right to due process through age-appropriate care and legal representation; and (6) principle of non-refoulement which prohibits repatriation of individuals at risk of persecution, torture, ill-treatment or other serious human rights violations (UN General Assembly, 1989; UN Office of the High Commissioner for Human Rights, 2002). By employing the human rights framework, this study will explore the behavioral health impact of the asylum process on UCVT from Central America and Mexico and develop a trauma-informed FI protocol and FIT that serve as both behavioral health and legal remedial during the asylum process. Needs for a MM DesignThis study will employ the MM evaluation design. According to Creswell and Plano-Clark (2017), such design can be a multiphase study in which the intent is to evaluate a program through triangulation of evidence. The primary need for a MM design is the lack of understanding regarding the behavioral health impact of the asylum process. Second, the need to assess the cultural context of the asylum process, whether age-, culture- or behavioral health-appropriate, warrant the use of a MM design. By employing the quantitative outcome data and qualitive process data, this study will provide an in-depth understanding of the current asylum proceedings from the perspective of each stakeholder (i.e., CBP, ORR, and law enforcement officers, attorney, social workers, and UCVT). Lastly, the need to develop, implement, and evaluate a program (i.e., FIT) that incorporates the abovementioned gaps calls for the use of a MM evaluation design (Creswell & Plano-Clark, 2017). The design will allow gathering of comprehensive understanding on the positive, neutral, and negative outcomes achieved along with feasibility of FI and FIT. Ultimately, it is expected to provide indicators of and strategy for fair and efficient asylum proceedings. SignificanceThe proposed study is expected to benefit several audiences. First, since FI and FIT employ an ecological and culturally competent assessment (APSAC Taskforce, 2012; Evans & Hass, 2018), the adverse behavioral health conditions among UCVT will be accurately identified. This will be beneficial to UCVT because many UCVT lose their credibility of a well-founded fear of prosecution due to exhibition of adverse behavioral health conditions (e.g., lack of trust in authorities, somatic symptoms) that hinder consistent testimony throughout the multiple interviews (Herlihy et al., 2012; Herlihy et al., 2002; Herlihy & Turner, 2006; Ibrahim et al., 2019; Vuk?evi? Markovi? et al., 2021). Second, it can alleviate the challenges that CBP officers, the interviewers of refugee, face. One MM study in Canada reported barriers in refugee-admittance determination, including difficulties in evaluating evidence due to poor knowledge on the refugee context, cultural misunderstandings or insensitivity, assessing credibility of refugees, and personal experience of vicarious trauma (Rousseau et al., 2002). Third, social workers strive to achieve racial justice among underserved population, such as refugees, and provide competent services that are age- and culturally-appropriate (National Association of Social Workers, 2017). Hence, the social workers will be recruited to be caseworkers who conduct the FI. The theory-driven FI and FIT will enhance the competency to practice, research, and educate the social workers serving UCVT. Furthermore, the proposed behavioral health intervention is expected to provide several positive impacts. First, employment of the FI protocol and FIT will provide a secure data sharing among relevant personnel while alleviating the prolonged asylum process. Second, the therapeutic process can assist early detection of behavioral health conditions and prevention of further adverse behavioral health impact among UCVT and other underserved refugee population. Lastly, it will improve legal representation of refugees regarding their credible claim to a well-founded fear of persecution. Purpose StatementUsing the human rights framework, the purpose of this MM evaluation study is to assess the attitude, challenges, and needs of all stakeholders (i.e., CBP, ORR, and law enforcement officers, attorney, social workers, UCVT) regarding the behavioral health impact of the asylum process; describe strategies to identifying UCVT; and produce a trauma-informed and age- and culturally-appropriate behavioral health intervention tailored to UCVT. The specific aims are: (1) to understand the perspective of UCVT regarding their experience in navigating the asylum process and its impact on their behavioral health; (2) to explore the attitude, beliefs, and challenges of CBP, ORR, and law enforcement officers in identifying UCVT and conducting the initial interviews; (3) to understand the challenges and strategies of attorney in assisting the legal representation of UCVT who presents behavioral health symptoms; and (4) by incorporating the findings of aims 1-3, to design, train, pilot, and evaluate the FI protocol and multidisciplinary FIT that will be utilized during the asylum process. Research QuestionWhat is the behavioral health impact of a trauma-informed FI protocol and FIT designed and implemented for UCVT from Central America and Mexico?MethodData Collection MethodFigure 1 represents the flowchart of the five phases and data sources associated with each aim. Detailed sampling procedures are discussed in the Sampling Strategy subsection.Phase 1, in accordance with Aim 4, will involve establishment of a task force. With the task force, survey, focus group, and individual interview questionnaires will be developed. Phase 1 is projected to take three months and will occur concurrently with Phase 2. Phase 2, in accordance with Aim 1, will involve an exploratory sequential MM design. In order to develop relevant questionnaires and answer choices, qualitative individual interviews will be conducted prior to administration of the quantitative survey. Phase 2 is projected to take three months for the focus groups, another three months for analysis, two months for the surveys, one month for analysis, and one month for integration.Phase 3 will employ a convergent MM design for both Aims 2 and 3. Also, although Aims 2 and 3 are expected to occur concurrently, it may occur sequentially depending on the timely establishment of the task force along with human resources and time availability. The primary intent is to separate each data collection process and prevent any influence to each other. Each aim is projected to take three months for the focus groups, another three months for analysis, two months for the surveys, one month for analysis, and one month for integration of both data.Phase 4 is projected to take one months to integrate all of the findings from Aims 1 to 3.Phase 5 will involve multiple subphases. During the development subphase, the task force will design the FI protocol which is projected to take about six months. Then, the training subphase will follow in which FIT will be recruited to be trained by the task force members. It is projected to take three months. Pilot test subphase will involve implementation of the FI protocol to UCVT by a caseworker and collection of FIT’s feedbacks on the feasibility and acceptability of the FI protocol via survey format. After revisions are made as needed, evaluation subphase will be a full implementation of the FIT and protocol. It will employ an explanatory sequential MM design. A survey will be provided to FIT members followed by a qualitative interview to gather in-depth understanding of the survey findings. Concurrently, a pre-, post-, and 6-month follow up tests via survey format will be collected from UCVT to assess their perspective of the FI protocol and FIT along with the difference in their behavioral health symptoms. Also, a documentation of the asylum granted record will be collected for all UCVT who participated in the study. The timeline for pilot and evaluation phase cannot be speculated due to the diversity in cases, impacting the duration of each case in the asylum process.Ethical IssuesPrior to conducting the study, approvals from the institutional review board (IRB) will be obtained for each aim. While waiting for the approvals, relevant gatekeeper from the agencies indicated in the Sampling Strategy subsection will be contacted to obtain permission and gather support letters for the relevant aims of the study. After IRB approval, paper and electronic version of flyers will be distributed to relevant agencies. Then, upon gaining permission from each agency, an explanation of the purpose and process of the study will be provided by visiting each agency. After answering any questions or discussing any concerns potential participants may have, relevant data sources will be collected (i.e., survey, interview, documents) from those who agreed to participate in the study. Informed consent for survey, interviews, and training will be collected. Audio recording of the individual interviews and focus groups will be obtained either verbally or in writing. Qualtrics, an online survey tool, will be used for surveys. Participant information will be deidentified from all types of data. A brief description and purpose of the study, voluntary participation, protected confidentiality, risk of the study, contact information for research-related question, and the university’s contact for research complaints will be provided. The audio files of interviews and focus groups will be securely stored in the university’s encrypted online data storage until they are transcribed and will be deleted upon transcription. Both qualitative and quantitative data will be stored in the same online storage. Although risks of data collection are deemed to be at no greater than minimal, UCVT participants may feel emotional as a result of speaking about events that may be traumatic. Whenever possible, researchers who are licensed social workers will speak with these participants following the session about their emotional state to ensure there are no lingering effects. If participants remain distressed, the researchers will provide them with information about a national human trafficking hotline and referral information, if available, for any providers in that area.Also, another likely risk may occur during the focus group in which another participant may disclose information shared in the group. Although, this would not be reversible, efforts will be made by informing participants (a) to not disclose information shared in the groups; (b) to share information that they are not concerned about potential harm; and (c) all data will be deidentified prior to any kind of use. Sampling StrategyA purposive sampling strategy will be used depending on the aims. For Aim 1, a homogeneous sample of (a) Central America- or Mexico- born natives; (b) youth between 15 to 17 years old; (c) granted asylum; and (d) experience in trafficking or exploitation prior to arrival to the U.S. will be recruited from the two lead resettlement agencies, the Lutheran Immigration and Refugee Service and the United States Conference of Catholic Bishops. A sample of 100 participants will be surveyed, and 20 individual interviews will be conducted or until saturation is reached.For Aim 2, a maximal variation sample of (a) CBP, ORR, and law enforcement officers; (b) experience of six months, one to two years, and more than two years; and (c) employment location in the southwest border (e.g., Big Bend, El Paso, Del Rio, Rio Grande, Yuma sectors) that experienced a greater than 100% change of UC apprehension rate from FY 2020 to FY 2021 (DHS, 2021). A sample of 100 participants will be surveyed, and three focus groups of eight participants (a total of 24 participants) recruited from the survey participants will be conducted. For Aim 3, a maximal variation sample of (a) attorney and (b) experience in assisting UCVT from Central America or Mexico will be recruited. Participants will be recruited from the Refugee and Immigrant Center for Education and Legal Services (RAICES), a legal agency that provides pro-bono services to immigrants and asylees. A sample of 100 participants will be surveyed, and three focus groups of eight participants (a total of 24 participants) recruited from the survey participants will be conducted. For Aim 4, multiple sampling strategies will be employed depending on the phase. First, the design phase will involve two subphases: task force and development. A maximal variation sample of at least one CBP, ORR, and law enforcement officers and attorneys and social workers who specialize in refugee population will be recruited as members of the task force. The task force will be created at the beginning of this study to assist in all study activities relevant to the four aims. Then, the task force will develop the FI protocol. Second, for the training phase, a maximal variation sample of 10 FIT comprised of a behavioral health social worker to serve as FI caseworkers, CBP or ORR officer, and attorney will be recruited. The members will be recruited from the abovementioned agencies. Third, the pilot phase will involve a stratified random sample of (a) UCVT; (b) Central America- or Mexico- born natives; (c) child between 15 to 17 years old; and (d) entered through one of the abovementioned five southwestern sectors. A sample of 20 participants will be recruited, and 10 will receive the comprehensive care by the trained FIT while the other 10 will receive the regular care. A survey to assess the feasibility and acceptability by FIT members will be conducted along with an asylum granted record to compare the results among those who received care by FIT and those who did not. Lastly, the evaluation phase will collect a stratified random sample of (a) UCVT; (b) Central America- or Mexico- born natives; (c) child between 15 to 17 years old; and (d) entered through one of the abovementioned five southwestern sectors. A sample of 50 cases of UCVT will be provided the care by FIT. Pre-, post-, and follow up assessments examining the change in behavioral health symptoms and acceptability of the FIT in the post- and follow up assessments via survey format will be collected from UCVT along with an asylum granted record. Both surveys and interviews will be collected from FIT members.Data Analysis Qualitative Data. Qualitative data, such as focus groups and individual interviews, will be analyzed using NVivo Version 12. Since data analysis depends on the research question and interpretive framework (Trede & Higgs, 2009), the human rights framework will be used to interpret the themes that relate to the best interest of the child. A three-member analysis team who has experience and expertise in qualitative methodology will be formed, and each will independently analyze the data and analytic memos. Prior and during the whole data analysis process, the reflexivity of each investigator will be reviewed by reflecting on any personal biases, values, and experiences and how they can influence data interpretation (Creswell & Poth, 2018). Moreover, field notes which will be written after each qualitative data collection will be reviewed along with analytic memos which reflect researchers’ rationale and intuition during the coding process (Salda?a, 2016). This process will assist in minimizing researchers’ bias while providing rich description and interpretation that maximize participants’ view (Creswell & Poth, 2018; Salda?a, 2016). After reading the transcripts of the qualitative data several time, data analysis plan will be guided by the coding methods suggested by Salda?a (2016), such as attribute, structural, or in vivo coding in the first cycle and pattern coding in the second cycle. To strengthen reliability, each investigator will separately conduct data analysis one-third of the data and gather consensus to on the coding schemes which will be used for the remaining data. Then, another consensus meeting to dissolve any discrepancies will be performed to increase reliability. Trustworthiness, including credibility, transferability, dependability, and confirmability, will be achieved with rigor (Creswell & Poth, 2018). Credibility will be obtained via triangulation of design, which is the core rationale for using a mixed method design, and triangulation of analysis, which is the core rationale for using a three-member analysis team. Transferability will be obtained by providing a thick description of the study setting. Dependability will be obtained via audit trail or detailed description of the data collection and analysis procedure along with performing peer briefing with the members of the task force. Lastly, confirmability will be obtained via audit trail and examining reflexivity for potential bias (Creswell & Poth, 2018).Quantitative Data. Quantitative data, including surveys and asylum granted record, will be performed using R. Data analysis plan will be guided by the research question and survey questionnaires. For Aim 1 and surveys of UCVT from Aim 4, both descriptive statistics and inferential statistics (i.e., logistic regression, structural equation modeling) will be reported to examine any relationship between behavioral health conditions and experience of the asylum process. For Aims 2, 3, and remaining surveys from Aim 4, descriptive statistic about the stakeholders’ experience of the training’s acceptability, feasibility, and satisfaction will be conducted. For all quantitative data analysis, missing data will be checked and managed with the appropriate method (e.g., listwise deletion, mean imputation) based on the type of missing data (i.e., missing completely at random, missing at random, missing not at random) (Saunders et al., 2006). Assumptions of normality, homoscedasticity, linearity and multivariate outliers, multicollinearity, and independence of errors will be checked prior to performing any inferential statistics.Reliability will be obtained by assessing the internal consistency reliability of the scales (Miller & Lovler, 2016). Validity will be obtained via large sample sizes and using probability sampling (Miller & Lovler, 2016).Mixed Methods Data. For MM data analysis, quantitative and qualitative data will be compared to find common, disconfirming, and expansion of concepts. Joint displays will be used to show all three concepts in both quantitative and qualitative findings (Creswell & Plano-Clark, 2017).For exploratory sequential MM design, validity will be obtained by explaining how qualitative findings were employed to design the survey elements and by using different sample of quantitative and qualitative data (Creswell & Plano-Clark, 2017). For convergent MM design, validity will be obtained by using parallel questions for both qualitative and quantitative phases and by employing strategies to examine disconfirming results (Creswell & Plano-Clark, 2017). For explanatory sequential MM design, validity will be obtained by recruiting qualitative phase participants from the survey participants and by probing surprising quantitative findings in the qualitative phase (Creswell & Plano-Clark, 2017). For the MM evaluation design, validity will be obtained by clearly defining and connecting the objectives to the purpose (Creswell & Plano-Clark, 2017).ReferencesAmerican Immigration Council. (2015). A guide to children arriving at the border: Laws, policies and responses. American Immigration Council. Taskforce. (2012). Forensic interviewing in cases of suspected child abuse. APSAC Taskforce. , J., Cohen, C., Riley, A. H., Tellez Lieberman, J., Reidy, M. C., & Chilton, M. (2018). 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