Introduction

Over the last decade, especially after the family separations of immigrant youth at the U.S.- Mexico border in the summer of 2018 and the corresponding public outrage (Kandel, 2021; Zayas, 2023), there has been a surge of interest and a call for scholarly publications on unaccompanied immigrant children (UCs) and their unique circumstances and needs (Berger Cardoso et al., 2019). The numbers of UCs seeking asylum annually in the United States (U.S.) has increased from 13,625 children in 2012 to over 100,000 children in years 2021, 2022, and 2023 (Administration for Children and Families, 2023). These are children under the age of 18 years old who arrive at the U.S. border without a parent or legal guardian who are reunified with sponsors across the U.S. These youth are among the most vulnerable yet resilient immigrants living in the U.S. (Becker Herbst et al., 2018; Berger Cardoso, 2018; Canizales, 2018; Galli, 2023; Silva et al., 2022). UCs have fled their home countries, often due to fear of persecution, and work to establish their lives with new families, cultures, and systems (Jani, 2018).

Former American Academy of Pediatrics president Dr. Fernando Stein stated that “Children do not immigrate; they flee” (Stein, 2019, p.1). For many UCs, the decision to leave their home country is difficult and may be driven by exposure to violence, poverty, or both due to reasons such as war, gang activity, persecution, natural disasters, or being separated from family members (Kennedy, 2014; Levinson, 2011). UCs experience arduous migration journeys, and may encounter threats of violence (Estefan et al., 2017; Terrio, 2015). Because of these difficult conditions, UCs and their families often make the decision to migrate in hope of finding better economic opportunities (Jani, 2018).

UCs apprehended by U.S. Border Patrol and identified as under 18 years of age, are transferred within 72 h to the custody of the Office of Refugee Resettlement (ORR) under the Department of Health and Human Services (HHS) and are placed in ORR shelters (296 facilities in 27 states) across the U.S. (Congressional Research Service, 2021; ORR, 2023). Upon arrival in a shelter, UCs receive an initial medical exam, mental health screening, clothing, food, and education services (Jani, 2018; ORR, 2023b).

After screening, ORR/shelter case managers coordinate placement for UCs either through reunification with a U.S. sponsor, voluntary deportation, or foster care placement (Hasson et al., 2023a). Many UCs are reunified with sponsors who are relatives, including parents, already living in the U.S. (ORR, 2023). For example, in fiscal year 2022, 35% of UCs went to sponsors who were a parent or legal guardian; 50% went to a sibling, grandparent or other immediate relative (aunt, uncle, or first cousin); and 15% went to a distant relative or unrelated adult relative (U.S. Department of Health and Human Services, 2022). Prior to placement, ORR evaluates the sponsor and potentially the home to ensure safety for the UC. UCs who do not have a viable sponsor or are deemed unsuitable for placement, approximately 5–35% annually, are placed in long-term foster care while awaiting legal status hearings (Crea et al., 2017). As of 2023, the average length of stay for a UC in the shelter was 28 days, down from 37 days in 2021 (ORR, 2023).

After reunification, UCs live in communities across the U.S. post-migration, and mental health for these youth and caregivers continues to be impacted by factors in the community such as deportation fears, discrimination, racial profiling, lack of healthcare, and language access (Ciaccia & John, 2016; Song, 2021). Research has found that UC mental health needs are great with emotional distress being persistent, along with symptoms of depression, anxiety, and posttraumatic stress that are often not being met in the community and were exacerbated by Covid-19 pandemic (Potler et al., 2023; Venta et al., 2024). A pivotal study by Jani (2018) documented that for many UCs and caregivers, finding resources from legal support to healthcare is challenging. A systematic review of UC’s access to healthcare, including mental health, showed that while health screening services are available, significant limitations exist due to cost and cultural barriers (Misra et al., 2021).

However, limited research has been conducted with these children and families to understand their experiences and mental health needs from the perspective of UCs themselves, their caregivers, and clinical providers in the community (Beier & Fredricks, 2023; Evans et al., 2022; Hasson et al., 2023a, b; Greenberg et al., 2021). In addition, there is limited published research on the lived experiences and mental health needs of caregivers who support UCs throughout their processes integrating into the U.S. (Berger Cardoso et al., 2019; Hasson et al., 2023a; Rafieifar et al., 2023).

Despite the continued call for supportive policies for UCs during arrival and in the community (Ataiants et al., 2018), there has been limited research with UCs and their caregivers examining the lived experiences of resettlement and reunification. In fact, Hasson et al. (2023a) stated that “qualitative research with unaccompanied children and their sponsors is an important area for future research to unearth themes that explain the lived experiences of resettlement and reunification after family separation” (p. 11). This study directly addresses a gap in the literature by investigating the lived experience and mental health needs of UCs and caregivers with the goal of guiding best practices for community providers.

Study Aim and Research Questions

To better understand the needs and factors that impact the well-being of UCs and their caregivers, a qualitative study was conducted with focus groups and interviews of UCs, their caregivers, and local community providers. We implemented an action research design in three phases that prioritized learning through action and acting informed by learning and reflection (Stringer & Aragón, 2021). Each phase of our research included actions that were rooted in participant insight, such as working with a community organizing group in phase one to better understand the needs of UCs in the community. The phases incorporated corresponding research questions that took a critical approach to inquiry from multiple perspectives, including our participants asking and exploring difficult questions in their discussions (Brydon-Miller et al., 2015; see Fig. 1 for the implementation matrix with the following three phases):

Fig. 1
figure 1

Implementation matrix: action research design of phases in the bridging borders project, Houston, 2018–2022

Participants Intent Data Sources Research Questions

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Phase 1

Community Needs Assessment and Collaborations to Support UCs.

Research Question

What are perspectives of UCs, their caregivers, clinical providers, and community leaders on access, provision, and use of mental health services within the wider context of UC needs?

Phase 2

Development of Best Practices to Support UCs in the Community.

Research Question

What are the key factors influencing mental health outcomes of UCs?

Phase 3

Training for Providers Working with UCs.

Research Question

Do qualitative findings suggest cultural and/or trauma-relevant training needs for clinical providers and community leaders for UCs?

Methods

Design

Given the limited information available in the literature about the needs of UCs while living with families or sponsors in the community, we created an action research design with cycles of development and implementation with the goal of supporting community providers working with UCs (Stringer & Aragón, 2021). The three phases included the following focus areas: (1) community needs assessment and collaboration, (2) development of best practices, and (3) training for providers working with UCs. Through action research, our goal was to identify potential solutions to issues that require immediate attention and to determine ways to improve practice that empowers community members to make social changes (Ivankova & Johnson, 2022). We conducted our study in Texas where more UCs have been reunified with sponsors than any other state. During fiscal year 2023, 16,394 UCs settled in Texas. Texas, as a study location, was chosen to address the immediate need of supporting a large number of these youths settling in the Houston community with caregivers (ORR, 2023a).

To support participation and collaboration as part of the core principles in action research (Kemmis et al., 2014), we included multiple perspectives throughout the research process, with UCs and community leaders collaborating on developing the interview questions, participating in the data collection, and reviewing final products for accuracy. Furthermore, close partnership with a community group that supports UCs in Houston, Texas (of which several of the researchers were already a part before the project began) facilitated engagement of community members and refining researchers’ understanding of the findings.

Data were collected through focus groups and interviews with UCs, their caregivers, clinical providers (i.e., healthcare and mental healthcare providers such as social workers and counselors), and community leaders. We used a cyclical process in our research design that included reflection on the needs of UCs and their caregivers with our research team, community leaders, and UCs themselves (Kemmis & McTaggart, 2000). Approval for the research was obtained from the University human subjects review committee. Researchers met weekly to develop the iterative phases of the study with mindful reflection and planning for the four-year project. Overall, our epistemology is one of critical theory, which presumes that social, political, and cultural events shape reality (Creswell & Báez, 2021).

Participants

From April to November 2019, six adolescent UCs (ages 12–17), eight caregivers (five biological parents), and 22 community providers/leaders who care for UCs participated in six focus groups (two focus groups with UCs, two focus group with caregivers, and two focus groups with providers/leaders) at three different local community centers and one health clinic. At one local community church where the numbers were insufficient to constitute a focus group, two additional interviews were conducted, one with a UC and one with their caregiver. Each participant received a $20 Visa gift card. Demographics of the 36 participants are listed in Table 1.

Table 1 Demographic characteristics of participants
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Houston area community providers and leaders including many from the Latinx community distributed flyers in English and Spanish to recruit participants for the focus groups, with snowball sampling used to identify participants (Miles et al., 2019). Recruiting UCs and their caregivers was challenging due to concerns about their legal status and confidentiality in sharing information. Our sample represented only those willing to express their views. It is possible that we may not have captured the full diversity of this population. Overall, the number of participants was determined upon the saturation of meaning, in which similar ideas continued to be mentioned regarding the needs of UCs and caregivers in the community (Hennink et al., 2017).

Data were collected by the primary authors, an interdisciplinary research team of pediatricians, mental health clinicians, and social workers who had worked directly with UCs for more than a decade in school settings and in a large shelter providing medical and mental health care to UCs. The team continuously leveraged our interdisciplinary insights and direct practice experience with UCs to shape and enhance our action research as part of our reflexivity process. Further, the research team members invited community leaders to review consent forms and interview questions to ensure they were culturally relevant and easily understood, and all forms were provided in English and Spanish.

Measures

Semi-structured interview questions were developed with input from community members who worked with UCs. Questions focused on: (1) UCs’ feelings about living in the U.S., (2) how UCs manage stress, and (3) which community services UCs were accessing. Questions were modified for each type of participant (i.e., UC, caregiver, and community provider). For example, UCs were asked “How have you felt about living in the US?”; caregivers were asked, “How has your life been living with the UC?”; and providers/community leaders were asked, “How do you think UCs feel about living in the U.S.?” Two interviewers (at least one of whom was a native Spanish speaker) conducted each focus group that began by reading an interview script to clarify the purpose of the study. Focus groups and interviews were all conducted in Spanish for UCs and caregivers, and provider focus groups were conducted in English. Focus groups and individual interviews lasted between 75 and 90 min with additional time for casual conversation before and afterwards with snacks. A school social worker or church leader was also present to support UCs and caregivers before and after each of the sessions.

Data Analysis

All interviews were recorded via a handheld recorder, and each interviewer provided field notes after each interview. All interviews were transcribed and/or translated by Rev.com, a reputable transcription service. Data were analyzed by the following thematic analysis process: (1) preparing, organizing, and reading through the data, (2) coding text segments and assigning code labels based on the main idea conveyed (usually the exact words of the participant), (3) grouping codes to eliminate redundancy, (4) developing overall themes based on codes, (5) creating a conceptual thematic map with 5–7 overarching themes, and (6) developing a narrative description of each main theme intended for providers working with UCs (Braun & Clarke, 2022; Creswell & Báez, 2021).

Qualitative data analysis software MAXQDA 2020 (VERBI Software, 2019) was used to organize and code all data. Coding was completed by three of the authors (JCB, PS, and AO-M). To ensure reliability, coders were required to achieve 85% agreement before proceeding with coding, and coders met regularly during data analysis to compare codes and develop a code book. Strategies to ensure validity included (a) triangulation of multiple data sources (i.e., UCs, caregivers, and providers), (b) examination of interviewer field notes, (c) inclusion of a code for disconfirming evidence (e.g., that UCs are merely exhibiting normal teen behavior), (d) research team sharing of experiences and potential biases in working with UCs, and (e) verifying coded findings with interview participants (n = 4). The coded preliminary findings were reviewed by two participant providers, one caregiver, and one UC who provided feedback and areas for refinement.

Results and Findings

Seven themes were developed from the data describing the lived experience and mental health needs of UCs and their caregivers: (a) safety and basic needs are number one; (b) legal support comes before health; (c) UCs face mental health challenges as part of adapting; (d) UC’s “growing phase” is part of normal teen behavior; (e) UCs experience discrimination and are labeled the “bad one;” (f)caregivers carry guilt: “We want to give them a better life;” and (g) financial worries and sacrifices for a better future. A summary and description of the seven themes with direct quote examples are summarized in Table 2.

Table 2 Seven primary themes describing the lived experience and needs of former unaccompanied immigrant children
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Safety and Basic Needs are Number One

Providers emphasized that safety was the number-one priority for UCs, the “umbrella” under which all other needs fell:

Safety is number one, so I find–most UCs don’t need help with shelter until safety becomes an issue, until they’re no longer welcome in the home, something has happened in the home, and then it’s a really urgent basic need…they’re released with a plan in place, but then it breaks down. (Provider)

Providers stressed that alongside safety, basic needs were also a priority. One provider discussed the challenge of just finding a bed for a UC, let alone address their trauma:

It’s really challenging just to access basic needs. It’s really hard to address these bigger traumas or feelings when we can’t get you a bed. We can’t get you food. We can’t get you seen by a doctor. How are we gonna even begin to address these hierarchy of needs? (Provider)

The majority of UCs and caregivers were also focused on meeting their basic needs (e.g., food, clothing, shelter) and noted mental health, education, social, and legal needs. Concerns emerged regarding the adequacy of education, health, and social services provided to UCs during and after the resettlement process. Providers, caregivers, and youth noted that often the most basic needs are unmet:

I worry about certain things sometimes, about my health, food. All of that, the rent. The money I earn isn’t enough, so I worry. (Youth)

Barriers to basic needs included the lack of transportation to earn money, the high cost of living, and language limitations. UCs and caregivers noted that these barriers prevented them from accessing essential services, ranging from purchasing food to obtaining legal and health services. As one caregiver reported:

My niece needs medical attention, and also dental work. In that regard, yes, I need help with her because I don’t have a job. The only one who has a job is my husband. We always need help because it’s not easy here. Here it’s really expensive. Dental work is very expensive. Medical attention is really expensive, everything…so we always need help. (Caregiver)

Overall, the consensus among providers, caregivers, and UCs is clear: safety and meeting basic needs are top priorities.

Legal Support Comes Before Health

UCs, caregivers, and providers noted the priority of legal support over other UC needs in light of considerable stress around the uncertainty of their legal proceedings and their ability to remain in the U.S. UCs and their caregivers experienced significant worry in accessing pro bono legal services and understanding the complex legal system. For both the caregiver and the youth, this legal concern can result in high levels of stress and anxiety. For example, the following youth expressed a great worry over her current legal proceedings and how her mom can’t get ahold of the lawyer, let along legal support:

The lawyer that we have…when my mom calls her, she almost never answers so my mom is worried because I am going to turn 18, and she doesn’t answer. (Youth)

UCs with legal representation had greater success in obtaining legal status and asylum, and prioritizing legal representation was considered important in reducing stress and anxiety. The majority of providers discussed the importance of legal representation and the importance of having adequate legal support, such as the following provider that emphasized the legal uncertainty these families face daily:

The one that stands out to me the most is legal aid, because for many of these children, they come out of the shelters and there is uncertainty…and this affects how they function day-to-day because they are living with that uncertainty of not knowing if they are going to stay here legally. (Provider)

Overall, it was noted that legal support was more important than health or mental health care in terms of priorities. The youth, caregivers, and providers all noted the importance and immediacy of legal services in the UCs lives.

UCs Face Mental Health Challenges as Part of Adapting

The process of navigating and adapting to their new cultures within the U.S. presents mental health challenges to UCs. UCs expressed the importance of learning English and becoming socialized to the norms of their peers as a necessary part of their adjustments to life in the U.S., but individual youths noted that they were adjusting differently based on their history of trauma and unique personal and cultural factors. One youth noted that she was missing her grandmother who cared for her back in Honduras and one of her closest friends, her cousin, that caused her to feel sad and cry the first week in the U.S.:

I used to fight with my mom…I wanted to go back to Honduras. I missed my grandmother and my cousin…I cried for the first week here. But it was better than being alone…the journey was lonely and scary. (Youth)

UCs and their caregivers also expressed the difficulty in adjusting to their physical environments within the U.S. UCs who came from rural areas and were accustomed to spending significant time outdoors noted, alongside their caregivers, that they struggled with feelings of boredom and confinement in their urban homes:

There is more freedom over there. For example, say, on the weekend, they go out, they play outdoors, or they hang out on the street. (Caregiver)

However, providers noted that in the face of these mental health challenges, UCs demonstrate resilience and adaptability that is influenced by the family support they have in the U.S. A provider noted the importance of family support and relationships in terms of buffering the mental challenges:

I think their success here has a lot to do with that family support and developing that relationship, and the time that the parent that’s already here—the family that’s already here—puts into developing that relationship with the kids. (Provider)

One provider even questioned if adjusting to a new culture can really qualify as a mental health condition and landed on the idea of needing to support caregivers as part of supporting UC mental health and resilience:

The idea of adjustment and so, if you’re learning to adjust to a new place, does that really qualify as a mental health disorder? Do you need to go see a mental health provider for that? Or is there somebody else that can provide those services? That’s still mental health related, and so, I don’t even know where they would potentially go. I love the idea of supporting the parents or the sponsors, I think is super important as well, to get that normal mental health and resilience that needs to get done. (Providers)

UCs’ “Growing Phase” is Part of Normal Teen Behavior

Unlike many immigrant youth, UCs often live with new caregivers with whom they may not have had a relationship back in their home countries. UCs balance new experiences and stresses while going through the normal developmental changes that occur with adolescence. UCs, caregivers, and providers focused on the importance of understanding that these youth are adapting to life in a new culture and developing new relationships with caregivers while also navigating their own identity development. One caregiver noted that her child was not used to living with her and on top of that the developmental parenting of a teenager was challenging:

In my case, he was not used to being with me. I have been living with him for only a year. It is hard for me because he has to adapt to me, and I have to adapt to him. He used to live with my mother, so, for me, this teenage phase is challenging, but little by little, he is adapting to my rules. (Caregiver)

Further, UCs showed typical adolescent development, talking about friendships and adjusting to living with new caregivers in a way that seemed to only include surface details and lack depth. In speaking about her home life, one UC talked about how she was annoyed with her sister, whom she had never lived with before:

My sister is always annoying me. That’s why I lock myself in the closet. (Youth)

Providers also discussed how UCs were often “just teenagers” who were struggling with typical developmental concerns such as friendships and school, while older teenagers were concerned about “making money.” Two different providers talked about how UCs struggle to talk with anyone about their problems, showing typical teenage reluctance to open up and communicate about personal issues:

When she has a problem, I asked her whom she talked to. Nobody. Not even with her sisters. With nobody…. They keep those emotions or concerns that I know they have, to themselves. (Provider)

UCs Experience Discrimination and are Labeled the “Bad One”

UCs and caregivers described discrimination as common in their communities and in their schools. Providers noted the discrimination with one talking about the xenophobia in the U.S. culture and how it causes anxiety for UCs and caregivers:

It’s just the sense that immigrants aren’t welcome…It’s just a pervasive anxiety. It just feels like you’re being slowly smothered by the uncertainty of the future. Then, yeah, a lot of living in the moment ‘cause you don’t know what the next moment will be. (Provider)

This discrimination became a significant source of adversity for UCs and caregivers who noted a lack of access to resources compared to other children in the schools. Caregivers stated that they routinely encourage UCs to advocate for themselves while also writing letters and directly advocating for UCs with school administrators. One caregiver talked about discussing her concerns with the school principal and how she had to stand up against discrimination:

I tell her [the principal], ‘The truth is you only notice what you want,’ that is what I told the principal, and since then, they have not called me again. (Caregiver)

Further, caregivers noted that their UC was labeled a “bad one” at school. Caregivers described confrontations with school staff where they pointed out how UCs were targets of blame:

‘Why do you always blame her and only her about things?’ I said. ‘Other kids do it as well, and you only blame her.’ Only her…just because she is not from here. (Caregiver)

Conversely, some UCs expressed views of anti-Black racism reflecting their own discrimination against others from a historical legacy of colonialism, colorism, and White supremacy. A UC discussed her concern over being around Black people, which showed the discrimination she held when she first arrived:

When I first arrived, I was scared because there were a lot of Black people…I was scared because they like to fight…they fight over nothing at school. (Youth)

Overall, the UCs, caregivers, and providers all noted discrimination and that it was negatively impacting the UCs and their families.

Caregivers Carry Guilt: “We Want to Give Them a Better Life”

Caregivers highlighted their need for support while balancing worry and guilt, striving simultaneously to keep the UC safe and provide a better future. Caregivers reported guilt about previous separation from their children and worry about being able to provide for the UC. Several caregivers agreed that leaving their children was a very difficult decision with one noting that she was worried to put her child at risk:

I was worried that I would be putting my children at risk…leaving them behind. Leaving them alone is a fear I will always hold. It is somewhat complicated, or very hard being without them. (Caregiver)

Caregivers and UCs also noted that the adjustment period was challenging as they worked toward rebuilding relationships. Some children experienced a sense of abandonment that caregivers found hurtful. One parent recounted a hurtful conversation and feeling hurt:

Yes, they do suffer a lot, and I agree with the part he mentioned about them confronting us because that happened to me with him. In the beginning, I felt hurt. I cried all night for a month or a month and a half because he would say to me, ‘You are not my mother. My mother is the one who is back in Honduras because she raised me.’ (Parent).

Providers noted this hurt that caregivers were feeling and the trauma the caregivers held:

Then these kids come with their trauma histories, and they want the parents to own that the trauma is their fault, and the parents can’t do that ‘cause they’re survivors. The dynamics are fairly complicated…these are very innate, complex problems that have generations of trauma attached. (Provider)

Caregivers also struggled with the separation and difficult reunions with their youth, and they worried about the UC’s safety in the U.S. Caregivers described living in low-income neighborhoods where safety was an ongoing concern. Caregivers wanted safe neighborhoods similar to those in their home countries with one mom saying that she is an overprotective parent:

I don’t let my children cross the street by themselves, or anything. I am an overprotective parent. They say— ‘Mommy, but we can go by ourselves.’ And, I say, ‘No, you can’t go.’ There are a lot of crazy people out in the street. I get scared. I don’t let them. (Caregiver)

The caregiver guilt was palpable in listening to the caregivers’ stories from struggling with the past trauma UCs experienced to managing their current relationship with the UCs. Further, the caregivers noted that it was “helpful” to talk with other caregivers about their struggles.

Financial Worries and Sacrifices for a Better Future

Caregivers noted the financial stress they were under to care for the UCs. Caregivers discussed the difficult struggles to obtain and keep employment, but stated that “here, at least, I have my job as compared to back home.” Caregivers noted the small salaries they were earning and all the expenses that needed to be paid. Two different caregivers talked about their financial worries and the need to work:

It is not easy here. You may be making 400 a week, but you have to pay your bus fare, and this, and that, and when you realize you don’t have enough to buy a hamburger or something for them…That is what you have to chew and swallow. (Caregiver)

Caregivers discussed the sacrifices they make to give their UCs a chance at a better life. One caregiver talked about how he shows his girls the value of hard work by bringing them into his job and reinforcing the importance of school:

On Saturday and Sunday, when the bosses don’t go in, I take my girls so they can see what kind of work I do. I tell them, ‘Do you want to do what Mom does? Go to school and pay attention and don’t listen to what others say. Go to school, because I don’t want you to end up like me, working out in the sun.’ (Caregiver).

Financial worries and sacrifices were a key piece of the caregivers’ concerns with the UCs. They discussed their struggle with earning money to support their UC and how they wanted desperately to give them a better future.

Discussion

The lived experiences shared from UCs, caregivers, and providers in the U.S. underscores the importance of not only supporting the mental health needs of UCs, but supporting the wellbeing of caregivers and sponsors who are caring for these youth. Existing literature has clearly documented the trauma that UCs experience prior, during, and after immigration (Berger Cardoso, 2018; Garcia & Birman, 2022; Song, 2021; Zayas, 2023; Zuniga, 2022), along with UCs mental health needs in the United States (Hasson et al., 2023a, b; Silva et al., 2022). Unfortunately, the current body of literature on UCs and caregivers has only begun to investigate caregiver needs (Barros-Lane et al., 2022; Rafieifar et al., 2023).

Caregivers expressed in this study that they are balancing a multitude of factors in caring for their UC:

  1. 1.

    Dealing with UCs’ past trauma while also dealing with the typical developmental changes that occur in adolescence.

  2. 2.

    Managing discrimination toward their UC in the community and schools.

  3. 3.

    Carrying guilt about not being able to provide everything to their UCs, such as a safe neighborhood.

  4. 4.

    Worrying about financial needs to keep their family afloat while trying to give their UCs a better future.

Research on UC caregivers has focused on the trauma of family disruptions and separations (Canizales, 2023; Suárez-Orozco et al., 2011), parents reuniting with UCs (Barros-Lane et al., 2022; Rafieifar et al., 2023), family stabilization services such as required case management services for a select group of UCs and their caregivers (Hasson et al., 2023a), and foster parents supporting UCs (Crea et al., 2018). This study further elaborates on caregiver needs and concerns around wanting to make a better future possible for their UCs and how caregiver wellbeing is directly connected with concerns for their UCs. These findings highlight the need to take an ecological approach in supporting UCs that actively includes mental healthcare for caregivers.

The first research question explored the access to, provision, and use of mental health services, with findings noting that UCs need safety and basic needs (e.g., housing, food, clothing, healthcare) and that legal issues take precedence over mental and physical health needs. This finding builds upon previous research that has emphasized the importance of legal relief alongside physical and mental healthcare (Linton et al., 2018; NeMoyer et al., 2019). Community-based models such as Terra Firma in Harlem and Casa Libre in Los Angeles have designed cross-sector partnerships with co-located legal, health, and mental healthcare to support UCs (Linton et al., 2018).

UCs, caregivers, and providers all stressed that legal support was more important than attending to health or mental health concerns because of the difficulty in obtaining legal support, the UCs’ ongoing asylum cases, and the fear of deportation. UCs remain in the U.S. during evaluation of their asylum cases, which can now take up to five years due to the large backlog of cases (Transactional Records Access Clearinghouse Immigration, 2021a; U.S. Department of Justice, 2023a). Furthermore, this legal stress is compounded by the low numbers of youth who are being granted asylum, with only 655 youth being granted asylum relief out of 23,293 total decisions in the third quarter of 2023 (i.e., 3% of UCs are being granted relief). Further, there is a total pending caseload of 62,183 UCs in 2023 (U.S. Department of Justice, 2023b).

In addition to these numbers, many UCs go through the legal immigration proceedings to access asylum without a lawyer, even with a clear case of credible fear (Goldberg, 2020). Only one third of UCs are represented by an attorney. Legal representation is the single most important factor influencing case outcome, with children being five times more likely to get asylum with an attorney (American Civil Liberties Union, 2018; Roubein, 2014; & TRAC Immigration, 2014). For many UCs, federal, state, and local governments, as well as nonprofit and legal organizations such as Kids in Need of Defense (KIND), provide pro bono legal services to UCs who are facing removal (KIND, 2022). However, this takes coordination of care and often diligent caregivers who can help UCs secure these services. As noted in the Migration Policy Institute (MPI) report on strengthening services for UCs (Greenberg et al., 2021), the first recommendation notes that “Health and Human Services (HHS) should ensure the availability of legal representation” (p. 41). It is important to support caregivers and UCs as they go through a legal process that is often adversarial and potentially retraumatizing (NeMoyer et al., 2019).

The second research question examined the key factors influencing mental health outcomes for UCs. Providers and youth emphasized that each UC’s needs are a complex intersection of factors, including the UC’s trauma and level of acculturation. Caregiver and sponsor support were factors influencing the mental health needs for UCs and there is considerable literature that indicates family separation is an adversity that children and families experience before, during, and after migration that impacts health, well-being, and parent-child relationships (Berger Cardoso et al., 2022; Patel et al., 2021; Rafieifar et al., 2023; Suárez -Orozco et al., 2002).

Recent research on supporting caregivers and UCs has astutely applied attachment and family systems theories to focus on repairing parent-child relationships that have been described by a UC as “it’s just like there’s tension there” due to the separation and adjustment to living together in a new culture (Barros-Lane et al., 2022, p. 13). Building off these insights, these new findings point to ideas and topics that providers can explore in supporting the repair of relationships, such as discussing the UC’s normal teen development, their experience of discrimination in the U.S., and providers could explore discussions with caregivers around carrying guilt and worrying about providing a better financial future for their UCs. This study’s new insight was that caregivers were struggling with worry over their UC’s safety and adjustment in a new country while also worrying about not having enough money to provide for their needs. Caregivers have their own independent worries that are important to address in the overall parent-child relationship to fully support the well-being of UCs. Further, research has concluded from the perspective of community providers that separation from parents is the most salient factor affecting UC and caregiver health that can be supported by community organizations (Canizales, 2023a).

The final research question, in line with action research, reflected on the qualitative research findings to develop relevant training for clinical providers and community leaders working with UCs. The findings pointed to the importance of not only understanding the lived experience of UCs, but understanding the concerns and needs of their caregivers as a vital piece of their support system. From a trauma-informed perspective, the findings reflected the need for interventions that build trust, focus on safety, and improve collaboration and empowerment not only between UCs and their caregivers, but between UCs, caregivers, and community providers. Trauma-informed care intervention models that support safety, trust, transparency, collaboration, empowerment, and have cultural and gender relevance (Levenson, 2020) are imperative in caring for UCs in the community (Linton et al., 2018). Youth and providers discussed the unique needs of UCs and the importance of exploring the complex intersection of factors impacting their well-being to build trust. Safety was a main focus for youth, providers, and caregivers, who said that safety was the “umbrella” under which all needs fall and is an important focus in working with these youth and families. New contributions included the need to focus on empowering caregivers and supporting the collaboration and communication between caregivers and UC, who are dealing with normal developmental changes that occur in adolescence, such as wanting autonomy and focusing on their friends.

Culturally diverse organizations that are trusted by immigrant communities have been recommended in the prior literature, along with culturally affirming and linguistically appropriate health and mental health services (Rafieifar et al., 2023; Silva et al., 2022). Similarly, the findings reinforced the need to focus on culture in supporting caregivers and UCs, as all three groups (i.e., UCs, caregivers, and providers) noted the difficulties in adjusting to a new culture with resettlement stressors (e.g., basic needs, new systems, poverty) alongside their unique traumas from prior, during, and after immigration. Further, an integration of culture and cultural awareness is critical as a protective factor that promotes recovery from past trauma (Isakson et al., 2015).

As part of the cyclical process of this action research, we first created a toolkit with our findings to provide free information to community providers via a website (Báez et al., 2021). We aimed to have our research findings affect changes and action in practice by providing the information to those working with UCs and their caregivers on the frontlines. Building upon the toolkit and thinking about reaching a diverse audience, including UCs, the authors also created a short documentary, Escúchame: Voices of Unaccompanied Immigrant Children, that chronicled three UCs and their caregivers navigating life in the U.S. (URL to documentary removed to anonymize the manuscript here). After the toolkit and documentary, a half-day conference was provided where key stakeholders, alongside UCs and providers, presented on culturally relevant and trauma responsive care for UCs and their caregivers (URL to conference website removed to anonymize the manuscript here). Throughout the toolkit, documentary, and conference, the authors continued to reflect on the research findings through the action research, which led to the importance of supporting not only UCs, but also their caregivers. In developing the themes beyond the toolkit, the need to create themes that were focused on supporting the caregivers became clearer, as shown in Table 2.

Limitations

Our study has several limitations. UC and caregiver participants were predominantly from the Northern Triangle, excluding El Salvador, and therefore findings may not be generalizable to UCs from other areas of Central and South America. Further, the data on the caregivers were based on a small sample size of eight caregivers (five biological parents, predominately female) that should be expanded on in future studies. The data were also collected before the COVID-19 pandemic and therefore does not encompass post-pandemic effects on UCs, caregivers, and providers. Lastly, there is possible selection bias in terms of the youth and caregivers being recruited through cultural leaders. Future access to these youth should be expanded through collaboration efforts with ORR.

Recommendations for Providers Working with UCs

Providers and community leaders are uniquely positioned to support UCs and their families. They can build trust with UCs and their families by understanding the safety and basic needs take priority, along with taking the time to understand the UC and the caregivers mental health needs. Community providers and leaders can also focus on understanding each UC’s situation by assessing basic needs such as finances, food, housing, medical care, and transportation, while also providing support to address racism and xenophobia they may be experiencing.

It is clear from the findings that caregivers need help and support that would also directly benefit the UC’s well-being, though unfortunately, caregivers are often left out of practice guidelines designed to support UCs (UNICEF, 2021). Providers and caregivers emphasized that caregivers struggled to address the needs of UCs, such as finances and navigating discrimination in the school system. A resilience framework emphasizing the importance of relationships with family, friends, school, and neighborhoods as mediating factors over adversity may be helpful for providers (Rew & Horner, 2003). Although resilient themselves, UCs need active and ongoing assistance in many areas of their lives that often include their caregiver’s help. For many UCs, their primary caregiver in the U.S. is a key relationship in need of nurture and support (Barros-Lane et al., 2022). Providers working with UCs can use a family systems perspective in connecting caregivers to community resources and organizations to help address unique needs of their UC. By building on personal and community strengths, providers can center resilience and the strengths of the families.

Expanding culturally relevant and trauma responsive case management services outside of ORR is also imperative. In a positive direction, ORR expanded post-release services to reach about 50% of UCs in FY 2022 and 2023, up from 20% in FY2021. This means that 55,960 out of 127,447 children received post-release services that included case management in 2022 (Office of Refugee Resettlement, 2024). Of note, a state-funded post-release services pilot project in California, the Opportunities for Youth (OFY) Project, has been running from 2020 to 2023 with evaluation results pending that provides “culturally and linguistically responsive, trauma-informed, and wellness-centered post-release supportive services” to UCs and family support workshops for caregivers (California Department of Social Services, 2024; Canizales, 2023b). Although ORR and California have expanded post-release services alongside community-based organizations, only half of UCs and their caregivers are being reached and the quality of these programs needs more development. Further, these post-release services are needed not only in densely populated areas with UCs such as Texas and California, but in rural areas, and other areas of the U.S. with disproportionate numbers of UCs (The New York Times, 2023).

Overall, it is concerning how many UCs go without necessary post-release services that are essential to their overall well-being and safety (Bartholomew et al., 2022) with ORR currently proposing an extension of post-release services in their proposed 2023 foundational rule (National Archives and Records Administration, 2023). This proposal adds to the Flores Settlement Agreement (Flores v. Reno, 1997) that established important guidelines for the treatment of unaccompanied minors in immigration custody and is currently under consideration. The foundational rule calls for an expansion of post-release services saying, “ORR believes that providing necessary services after an unaccompanied child’s release from ORR care is essential to promote the child’s safety and well-being” while also stating, “the comprehensiveness of post-release services shall depend on the extent appropriations are available” (National Archives and Records Administration, 2023, p. 68933). It will be important for providers to continue advocating for the funding to establish these comprehensive post-release services on a federal level with MPI recommending that post-release services be provided for all UCs and families for a minimum of 90 days, be made more accessible through teleservices, and be addressed for any barriers (Greenberg et al., 2021).

Alongside calls for an extension of post-release services and also mentoring services with UCs and their families (Evans et al., 2022; Crea et al., 2018; Silva et al., 2022), a possible strategy to increase post-release services is to expand community-driven support and mutual aid opportunities similar to what has been done for Afghan refugees with community welcoming programs (Rai et al., 2023). In 2021, the White House proposed six different ways community members can welcome and support Afghan refugees such as donating temporary housing, offering employment opportunities, hosting Afghan families within one’s own community (Markell & Ash, 2021). This inclusive model could be adapted by community-based organizations or universities with student internships, such as social work programs with practicum internships, to aid community members in supporting UCs and their families. This model could ultimately expand support options, extending support past 90 days, offering telehealth options, and providing more than 50% of UMs post-release services.

Further research and the implementation of evidence-based interventions is needed to promote UC and caregiver well-being and mitigate post-migration obstacles in our communities. Although there has been extensive research on policies regarding UCs, there is a knowledge gap in understanding practice approaches to best support UCs and caregivers in the community. This research is difficult, as it is often hard to find and connect with UCs. Systems need to be considered for connecting UCs to support, and this can be done more easily by having more transparency with overall UC data with community-based organizations to ensure a continuity of care that balances safety and privacy. Currently, access to UC data are limited to those within ORR through the shelter systems, and UC post-release data are not tracked beyond the brief services provided in the community. Community-based service providers need access to UC data to support continuity of care.

Conclusion

Considering their unique experience and needs, UCs and their caregivers need more support from providers, lawyers, and community members. We must not wait until the next news cycle that raises consciousness to the plight of UCs and cannot forget that over 100,000 of these youth are crossing annually to seek asylum. We must all think proactively and put systems into place for training, practicing, and creating supportive services for UCs and their caregivers. Supporting these marginalized and resilient youth in our communities is a humanitarian issue; providers and community members can provide UCs and caregivers with individualized, culturally relevant, and trauma responsive support as they adjust to life in the U.S.