The Development of a Mental Health Program for Unaccompanied Minors in the United States

Abstract

The unique needs of unaccompanied children (UC) and unaccompanied refugee minors (URM) often make it challenging for them to engage in traditional mental health services. This paper describes the development and implementation of a mental health program for UC and URM using a collaborative approach with key stakeholders. In the Exploration phase, we conducted an assessment of youths’ mental health needs, barriers to, and recommendations for care through discussions with community partners. Next, we describe the Preparation phase in which we designed the program around three major domains: 1) training and consultation, 2) cross-sector collaboration, and 3) direct services. Discussion of the Implementation phase includes a description of youth served and program materials. Finally, the Sustainment phase focuses on recommendations for best practice informed by successes and challenges of program implementation. Findings have implications for future mental health programming for UC/URM.

Appendices

Appendix A: Group Agenda

Session 1: INTRODUCTION

• 1. Introduction: The String

  Material: Yarn

  • Participants can be sitting or standing in a circle. One person starts out holding the ball of string and a piece of the string. They say their name, a favorite thing (person, animal, food, etc.), and one good thing that happened to them last week. They then throw the ball of string (while still holding their piece of string) to a new participant. That new person says the name of the previous person, that person’s favorite thing, and the good thing that happened to that person last week, and then says their own name, favorite thing, and good thing that happened. They hold onto a piece of string and throw the ball to a new person. Eventually, there is a web of string that connects everyone. At the end, the challenge is to untangle the string in 2 minutes.

• 2. Creating the rules

  Material: Cardboard, scissors, and colors

  • Each participant gets a piece of cardboard and writes 2 rules. They can cut the piece of cardboard into any shape, use doodles, words, “graffiti style” lettering, and pictures. When done, each group member will place their two rules on a bigger piece of cardboard, creating an abstract figure.

  • Variation: Instead of using individual pieces of cardboard, participants can all work on the rules on a single big piece of cardboard.

• 3. Brainstorming topics for group

  • Distribute topic survey and/or have a group discussion to decide group agenda

• 4. Getting to know you game(s)

• 5. Optional concluding activity: Soccer outside

Session 2: COOPERATION AND TEAM-BUILDING

• 1. Check-in/Introductions for new members

  M&M Game

  Material: M&M’s

  Give each group member a handful of M&Ms. Go around the circle and have them choose a color. Each color represents a question below. Have members answer the question and then eat the M&M.

  • Green- Word to describe yourself

  • Blue- Ways you have fun

  • Orange- Things you would like to change about yourself

  • Red- Things you worry about

  • Yellow- Good things about your life

  • Debrief: How are we all similar? How are we different?

  Two Truths & A Lie

  Material: None

  Ask each participant to think about two true facts about themselves and one lie. Each person in the group takes a turn telling the group their three items. The group then has to agree on which fact they think is a lie. Once the group announces their decision, the speaker tells the group the correct answer. The group then can talk about any of the interesting things they just learned about the new person.

• 2. Team-Building Activity 1: Cup stacking

  Material: Plastic cups, a rubber band, string

  Each group member holds a separate string tied to a rubber band. When members pull their strings, the rubber band expands. Working together, the group members need to pick up and stack a set of cups into a pyramid. This activity facilitates communication and teamwork.

• 3. Questions to reflect on communication and teamwork

  Source:  https://ventureteambuilding.co.uk/de-brief-questions-master-list/#.YDxomF1KhpQ

  • How did you feel during the activity?

  • What lessons can you learn from this challenge?

  • Did you listen to others in the team?

  • Did everyone understand the plan? If not, why not?

  • Did anyone take the lead during the activity?

  • Can you have more than one team leader?

  • How important was communication when leading?

  • What key qualities does a leader need to have?

  • What is the purpose of a team leader?

  • How important was planning? Did everyone have a role during the challenge?

  • Did the group have a clear action plan and how did you come up with this?

  • If you failed, what happened next? How did you move past it?

  • Do you feel you worked well as a team?

  • How did you help your team during the activity?

  • Did the whole team agree? Did everyone have an input?

  • What did a fellow team member do that was really helpful?

  • Did anyone in your team surprise you?

  • How did you support others in the team?

  • Did anyone feel left out? Why?

  • What helped you or stopped you from achieving the outcomes?

  • Did you trust your team during the activity? Why was this important?

  • How did you overcome negativity in the team? Did this affect how you approached the activity?

  • Looking back, what do feel is the most important element of teamwork?

  • How would you rate your teamwork between 1 and 10? 10 being the best value.

  • If you had to do it again, what changes would you make to the way you approach the task?

  • Think about your own personal experience in the activity, what would you do differently next time?

  • Looking back on the activity, what two things stand out to you the most and why?

  • What did you learn through this experience and how can you use it in the future?

  • Before moving on to the next challenge, I would like you to identify one area where you feel you could have contributed more.

  • Since you were unable to solve the problem, does this mean your team failed?

  • How did you feel when you failed the activity?

  • What did you do to turn things around?

  • Is failure a bad thing? Why do you think that?

  • What is more important the completing the activity or learning about ourselves and our team?

  • How did you support others when you found the activity difficult?

  • What did you learn about yourself and your team from the failure of this task?

• 4. Team-Building Activity 2: Common ground

  Material: Paper and pen

  Source:  http://schoolofeducators.com/2019/06/26-awesome-team-building-games-and-activities-for-kids/

  This activity helps group members discover like-minded individuals. Make these four labels and put each in a different corner of the room: Strongly Agree, Agree, Disagree, Strongly Disagree. Group members start in the middle of the room or in their seats. The group leader reads a statement and group members move to the corner of the room that represents their opinion on statements, such as “cats are better than dogs.” An alternative way to play this game for group members who may have difficulty moving around the room is to have group members remain seated and raise a piece of colored construction paper to show their response. For instance, red = strongly disagree, orange = disagree, blue = agree, and purple = strongly agree.

  • ○ Optional traits/questions: I like soccer, I like pizza, I like tacos, I like video games, I like dogs, I think I’ll be famous one day, I have a brother, I have a sister, I like school, I worry about my family, I like my foster family, I like [this city], I miss my home country, I am happy I am in the United States, There are things that surprised me about the United States…

• 5. Prep/practice for university soccer team visit- English introduction and questions for players

Session 3: SOCCER TEAM VISIT

• 1. Introductions and Q&A with team

• 2. Debrief questions:

  • What did you like about playing soccer?

  • Why is soccer special to you?

  • Is soccer the same here as it is at home?

  • Who is your favorite player and why?

Session 4: ACCULTURATION AND IDENTITY

• 1. Check-in/intro: The story of my name

  Material: None

  • Where does your name come from? Share the story of where your name comes from and what your name means. This activity helps to build intercultural respect and understanding.

• 2. Sharing aspects of culture

  Material: Worksheet

  • ○ Worksheet: https://www.mylemarks.com/store/p300/My_Culture_and_Traditions!.html

• 3. Cultural HeadBanz

  Material: Paper or index cards

  • This is a variation of the original HeadBanz game. On pieces of paper or index cards, participants write things they miss or like the most about their culture. Collect these cards, mix them up, and redistribute them. Group members should not look at their cards! Each group member will hold up their card (without looking at what it says) and take turns guessing the word based on clues from the group. Whether they guess correctly or not, group members will discuss the similarities and differences between their culture and American culture.

• 4. Identity wheel

  Material: Worksheets

  • https://sites.lsa.umich.edu/inclusive-teaching/wp-content/uploads/sites/355/2018/12/Social-Identity-Wheel-3-2.pdf

• 5. Differences diagram

  Material: Paper

  • Draw a Venn diagram with one side that includes characteristics of group members’ home country and one side that includes characteristics of the U.S. Emphasize things that are unique and things that are the same. Explore how they feel about each.

• 6. Other resources:

  • https://extension.psu.edu/programs/4-h/members/projects-resources/diversity/diversityactivities.pdf/

  • https://www.uh.edu/cdi/diversity_education/resources/activities/pdf/diversity%20activities-resource-guide.pdf

Session 5: FEELINGS

• 1. Check-in

• 2. Introduction to Feelings: Functions of feelings

  Material: None

  Use this activity to teach each group member why we experience certain feelings. For each feeling, ask them why they think we evolved to feel that emotion. Then share the answer. (Linehan, M. M. (2015). DBT® Skills Training Handouts and Worksheets (2nd ed.). New York, NY: Guilford Press.)

  • Fear- response to threats, focus on escape from danger

  • Anger- response when our goals are blocked, or there is an attack on self or others, focus on self-defense, mastery, control

  • Disgust- response to things that are offensive and contaminating, creates distance

  • Sadness- response to loss and goals lost or not attained

  • Shame- response to dishonored characteristics, focuses on hiding and appeasing transgressions

  • Guilt- response to actions that violated values, focuses on actions that repair the violation

  • Jealousy- response to those who threaten to take away relationships or important things, focus on protecting those things

  • Envy- responses to others’ having things we don’t have but we want or need, focus on working to get those things

  • Love- response to reproduction and survival, focus on union and attachment with others

  • Happiness- response to optimal functioning of self and others, focus on continuing activities that enhance pleasure and personal/social value

• 2. Discussion

  Material: None

  • How are feelings expressed in your culture? (e.g., machismo)

  • Introduction to the cognitive triangle: Connections between thoughts, feelings, and behaviors

  • Introduction to feelings ratings: Understanding variations in a feeling’s intensity (annoyed, mad, furious)

  • Introduction to trauma and feelings

    • ○ Avoidance

    • ○ Numbness

    • ○ Overwhelming feelings

    • ○ Trauma triggers

• 3. Activity: Emotional awareness

  Materials: Markers and handout with outline of a person

  Instructions: Ask each group member to write down and color code 5 different feeling words. Then have them color in an outline of a person based on where they experience each emotion in their body

  Discussion:

  • 1. Which emotion(s) you’re feeling/have felt today

  • 2. How often you experience the feelings listed

  • 3. What causes you to feel these emotions (the precipitating event)

  • 4. How can you tell when you are experiencing these feelings (e.g., internal sensations/cognitive/behavioral cues, e.g., more time in bed, more tired, negative self-talk, heart beating faster, stomach tense)

  • 5. Leaders: Reflect commonalities across group members. What are common feelings or causes endorsed for these feelings across group members? Is it easy/hard to tell that other people feel the same way we do?

• 4. Activity: Feeling the Music

  Material: Speaker, music, paper

  • Group members will listen to different pieces of music at the same time.

  • With each piece, they will write the emotion they felt when they listened to it.

  • After each piece, group members will show the emotion they wrote down (at the same time) and discuss how we know what we feel in daily life and how important it is to identity the different emotions we have throughout the day.

• 5. Activity: The Dice of Feelings

  Material: Die

  • Assign each number on the die to an emotion (1- happy, 2- sad, 3- scared, 4- surprised, 5- angry, 6- embarrassed)

  • Each group member will throw the die and give an example of when they felt the emotion that matches the number and how they dealt with that emotion.

• 6. Activity: Feelings UNO

  Material: UNO Cards

  • Feelings UNO is played using a regular deck of UNO cards and standard playing rules. When a player discards on their turn, they must identify a scenario in which a person might feel the identified feeling based on the card color. Example: When a player discards a yellow card, they must identify a scenario in which a person might feel happy. The group will discuss appropriate and inappropriate ways to handle the uncomfortable feelings.

    • ○ Red: Angry

    • ○ Green: Lonely

    • ○ Yellow: Happy

    • ○ Blue: Sad

    • ○ Wild: Scared

Session 6: COPING SKILLS

• 1. Check-in

• 2. Activity: Cognitive Triangle

  Material: Large paper or white board

  • Review connection between thoughts, feelings, and behavior using examples generated by the group on the large paper.

  • Review how to change unhelpful thoughts to feel better.

• 3. Activity: Coping Toolbox

  Materials: Large paper or white board

  Instructions: Ask group members to create a list of uncomfortable feelings (e.g., sad, angry, scared). Then ask members how they typically cope with these feelings and create a group list of positive coping strategies.

  Discussion:

  • 1. How are these feelings expressed in their cultures?

  • 2. How comfortable do they feel expressing those feelings to other people (and is it okay to feel these feelings or do they have to hide them)?

• 4. Activity: Mindfulness exercise-progressive muscle relaxation or deep breathing

  • Progressive muscle relaxation

  • Grounding skills

  • Mindful eating

  • Deep breathing

• 5. Activity: Grounding- Five Senses Exercise

  Materials: None

  Source: https://livinglessstressed.com/f/5-senses-exercise?blogcategory=stress

  • This exercise is called “five senses” and provides guidelines on practicing mindfulness quickly in nearly any situation. All that is needed is to notice something you are experiencing with each of the five senses. Follow this order to practice the five senses exercise:

    • 1. Notice five things that you can see.

      • ○ Look around you and bring your attention to five things that you can see. Pick something that you don’t normally notice, like a shadow or a small crack in the concrete.

    • 2. Notice four things that you can feel.

      • ○ Bring awareness to four things that you are currently feeling, like the texture of your pants, the feeling of the breeze on your skin, or the smooth surface of a table you are resting your hands on.

    • 3. Notice three things you can hear.

      • ○ Take a moment to listen, and note three things that you hear in the background. This can be the chirp of a bird, the hum of the refrigerator, or the faint sounds of traffic from a nearby road.

    • 4. Notice two things you can smell.

      • ○ Bring your awareness to smells that you usually filter out, whether they’re pleasant or unpleasant. Perhaps the breeze is carrying a whiff of pine trees if you’re outside, or the smell of a fast food restaurant across the street.

    • 5. Notice one thing you can taste.

      • ○ Focus on one thing that you can taste right now, in this moment. You can take a sip of a drink, chew a piece of gum, eat something, or just notice the current taste in your mouth or open your mouth to search the air for a taste.

  Discussion:

  • 1. Why is mindfulness useful?

  • 2. When could you use it?

  • 3. What might make it challenging to do?

  • 4. What do you think about it as a strategy?

Session 7: COMMUNICATION AND SELF-ADVOCACY

• 1. Check-in

• 2. Activity: I statements

  Material: Paper, worksheets

  • I feel _____ (feeling word) when you _____ (what they said or did) because _____ (the reason it upset you). I would like _____ (what you want, offer a solution).

  • Worksheet transforming “you” statements into “I statements”

• 3. Activity: Assertive communication role-plays

  Material: None

  • ○ Saying no

  • ○ Ordering in a restaurant

  • ○ Dealing with a conflict

  • ○ Dealing with discrimination

  • ○ Conflicts with teachers

  • ○ Communication barriers with teachers and peers

• 4. Activity: Act Up

  Material: Cardboard, scissors, and colors

  Complete this activity after the role plays. Have participants role-play the scenario presented in a passive or aggressive way, depending on the instruction. Then, the group will suggest better ways to be assertive in those scenarios. This activity will help participants understand the difference between passive, aggressive, and assertive communication.

• 5. Communication Activities

  • Partner shape drawing

    Material: Handout with abstract shapes

    • ○ Have group members sit back-to-back in pairs. One person describes the shape, the other draws it. Then compare how close the drawing is to the original image. Debrief what it was like to communicate with one another.

  • Word guessing/sharing

    Material: Prepare words

    • ○ Objective: Figure out what word is on your back by talking to other people, then find the person who has the other half of your word. Sit with that person and learn something about them to share with the group.

  • Blind draw

    Material: Flip chart, pictures of objects

    Source: https://www.soatechnology.net/blind-draw

    • In teams, each group member will draw an object using only verbal instructions from their group. They can choose to be blindfolded or have their back to the group. The aim of the activity is to focus on teamwork and communication skills in the group setting.

    How to play:

    • 1. Get a flipchart, markers, and a bunch of print pictures of objects. This game works best with more unobvious objects (say, a trampoline vs. a coin).

    • 2. Divide all participants into teams of 4-6 people.

    • 3. Ask each team to pick one person to be the "artist." Ask the artist to take his place next to the flipchart.

    • 4. Face the team away from the flipchart (or back to the group/blindfolded) and give them an object from your pile.

    • 5. The team will then instruct its artist on how to draw the object based on verbal instructions alone. They can describe the object but not state its name. The artist can't see the object at any time, nor can the team see what the artist is drawing. Each team gets 3 minutes for a drawing.

    • 6. The team whose drawing comes closest to the actual object wins.

  • Sneak peak

    Material: Lego structure, Legos

    Source: https://www.weareteachers.com/team-building-games-and-activities/

    • ○ This problem-solving activity will help group members learn to communicate effectively. Before the game begins, the group leader builds a small sculpture with LEGOs or building blocks and keeps it covered in an area that is of equal distance from all the groups. Group members are divided into teams of four or five, and each team is given enough blocks to duplicate the structure. To begin the game, the structure is revealed, and one member from each team is allowed to come up to look at it closely for 10 seconds, trying to memorize it before returning to their team. Once they return to their team, they have 25 seconds to instruct the group on how to build a replica of the structure. After one minute of trying to recreate it, another member from each team can come up for a sneak peek before returning to their team and trying again. The game continues until one of the teams successfully recreates the original structure.

  • What’s your number

    Material: Cards with situations

    • ○ This card game encourages participants to share what they think about the world around them and get to know more about each other in a fun way. Each participant will have a turn drawing a card with a situation (napping, amusement parks, standardized testing, etc.) and will have to rank it from 10 (the most negative) to 100 (the most positive), secretly. The rest of the group, individually, will write the number they think he chooses. The person who guesses the closest number keeps the card and earns a point. The first participant with 3 cards wins.

Session 8: FAMILY, GRIEF, LOSS

• 1. Check-in

• 2. Activity: Family and Support System (friends, school, church, etc.)

  Material: Paper

  • Ask group members to write about three things that make them feel proud and list the name of four people they know they can count on. Invite the group to discuss the ways in which these people can help them achieve new goals that will make them feel proud of themselves in the future. The aim of this activity is to help group members reflect on the positive aspects of their present support system.

• 3. Activity: Grief, Loss, Family Transitions

  Material: Paper

  • Resources

    • ○ https://www.therapistaid.com/therapy-guide/genograms

    • ○ http://www.strongbonds.jss.org.au/workers/families/genograms.html

  • The picture: Take two sheets of paper. Draw a genogram of your family before you moved to the U.S. On the other paper, draw a genogram of your foster family. Reflect on:

    • ○ The similarities in the two pictures are…

    • ○ The differences in the two pictures are…

    • ○ What I miss the most is…

    • ○ The changes that bother me the most are… What I can do is…

  • Family reflection discussion questions

    • ○ What are some ways that you are similar and different from your family?

    • ○ Who are you most like?

    • ○ How has your family shaped who you are?

    • ○ What are the strengths of your family?

    • ○ How do you wish your family could be different?

    • ○ Are there people who you consider part of your family who aren’t included in the genogram?

    • ○ What are some family traditions you cherish?

    • ○ What are some of your favorite family memories?

  • Grief discussion questions

    • ○ Who do you really miss?

    • ○ When is the hardest time of day?

    • ○ Who is your support system?

    • ○ What do you need more of/what would help you?

    • ○ What is hardest?

    • ○ When is it the most difficult part of being away from loved ones?

    • ○ What things remind you of your loved ones and make you sad (i.e., triggers)?

    • ○ What are you grateful for?

    • ○ What are some of your favorite memories?

  • Differences in family expectations between biological and foster families

    • ○ If you could craft the perfect family, what would it look like?

    • ○ What do you want your future family to look like?

    • ○ What are the rules in you current home?

    • ○ What were the rules at home in your country of origin?

Session 9: GRADUATION CELEBRATION

• 1. Check-in

• 2. Soccer

• 3. Food and debrief

  Exit discussion questions (see Feedback Form)

  • 1. What did you like about the group? What did you not like about the group? (let them know you are interested in both things they liked and didn’t like)

  • 2. Can you give me an example of something you learned in the group?

  • 3. Has the group has helped you interact with classmates or teachers in school? Can you give me examples?

  • 4. Has the group helped you get along better with your friends in the program? With your American friends? Can you give me examples?

  • 5. Has the group helped you get along better with your siblings/family members? Can you give me examples?

  • 6. Has the group helped you feel better more comfortable or happier with yourself? Can you give me examples?

  • 7. Would you recommend this group to other students in the program? Why or why not?

  • 8. Feedback on specific activities/topics

Appendix B

Formulario de Retroalimentación/Feedback Form

Gracias por tomarte el tiempo para completar este formulario! Es simple y las respuestas son personales en base a tu propia experiencia en el grupo. Tus respuestas ayudarán a mejorar las actividades para el próximo grupo de jóvenes como tú/ Thank you for taking the time to complete this form. It is simple and the answers are individual based on your own experience in the group. Your answers will help to improve the activities for the next group.

Instrucciones: En una categoría de 1 a 10 (1: no interesante- 10: muy interesante), asigna un número a las siguientes actividades/ Instructions: From 1–10 (1: least interesting—10: very interesting), assign a number to the following activities.

Actividad/ Activity	Número / Number (1–10)	Sugerencias/ Suggestions
1.La lana/ The string
2. Estableciendo las reglas del grupo/ Establishing the group rules
3. M&M Juego/Game
4. Funciones de las Emociones/ Functions of feelings • Conciencia Emocional/ Emotional awareness (Coloreando las emociones/Coloring feelings)
5. Identidad y autoestima/Identity and self-esteem • La caja de habilidades de afrontamiento/Coping toolbox • Cumplidos de su mismo y des otros/Self and other compliments (stars & hearts) • Cartas de la confianza/Confidence cards
6. Respiración profunda y la relajación/ Mindfulness: Deep Breathing and Relaxation
7. Compartiendo aspectos de mi cultura/ Sharing aspects of my culture • Historia de mi nombre/History of my name • Alimentos, fiestas, tradiciones de mi cultura/Foods, holidays, and traditions of my culture • 3 esquinas (de acuerdo, en desacuerdo, inseguro)/3 corners (agree, disagree, unsure)
8. Relaciones/Relationships • Cosas que tenemos en comun/Things we have in common • Cadena de amistad/Friendship chain • Asertividad/Assertiveness
9. Escuela/School • Diferencia entre escuela americana y escuela en el país de origen/Difference between American school and school in home country • Intimidación, hostigamiento y discriminación/Bullying, harassment and discrimination • Retos academicos/Academic challenges
10. La familia y sistema de apoyo/Family and Support system • Genograms
11. Triangulo Cognitivo/Cognitive Triangle • Pensamientos malos/Cognitive distortions
15. Actividades de ultimo dia/ Final day activities

Responde a las siguientes preguntas en base a tu experia personal/ Answer the following questions based on your personal experience.

1.Que te gusto de grupo?/ What did you like about the group?

______________________________________________________________________________________________________________________________________________________________________________________.

2. Que no te gusto del grupo?/ What did you not like about the group?

______________________________________________________________________________________________________________________________________________________________________________________.

3. Enumera al menos 3 cosas que hayas aprendido en el grupo/ Name at least 3 things you have learned in the group.

______________________________________________________________________________________________________________________________________________________________________________________.

4. De qué manera el grupo te ha ayudado en tus relaciones personales con amigos, familia, compañeros y profesores en la escuela?/ In what ways the group has helped you in your relationships with friends, family, classmates and teachers at school?

______________________________________________________________________________________________________________________________________________________________________________________.

5. De qué manera el grupo te ha ayudado a sentirte más cómodo y contento contigo mismo?/ In what ways the group has helped you feel more comfortable and happier with yourself?

______________________________________________________________________________________________________________________________________________________________________________________.

6. Recomendarías este group a otros estudiantes en el programa. Da tus razones./ Would you recommend this group to other students in the program? Explain why or why not.

______________________________________________________________________________________________________________________________________________________________________________________.