Disclosure in Undocumented Families and School Mental Health Clinics

The following describes the case of Miguel and a missed diagnosis in an undocumented minor. Miguel Estrada (all names changed to protect identity) was a 10-year-old boy of Central American origin initially seen at age 8 years in our university outpatient child psychiatry clinic. During the initial evaluation with a native Spanish-speaking provider, his mother, Mrs. Estrada, reported behavioral problems beginning at age 5 with diagnoses of attention-deficit/hyperactivity disorder and intellectual disability; a trauma history was denied. Over the subsequent 2 years, Miguel continued treatment in our outpatient service and later transitioned to our school-based clinic. At the intake visit, Mrs. Estrada explained (with the assistance of his school paraprofessional educator and translator) that they crossed the United States/Mexico border illegally when Miguel was 5 years old. Miguel's behavioral problems began when Immigration and Customs Enforcement officials separated him from his parents, his father was deported, and he was exposed to harsh conditions. During his parents' detention, he was transitioned to five failed foster placements with escalating behavioral problems that eventually led to a 3-month psychiatric residential stay. During the initial visit to the school psychiatric clinic a trauma history was again denied by Miguel and his mother. Ten months into treatment in the school-based psychiatric clinic, Miguel reported hearing a male voice and a motorbike throughout the day, and the diagnosis of a psychotic disorder was entertained. Upon questioning, Mrs. Estrada disclosed that a shooting occurred in their country of origin and prompted their flight to the United States; she stated, "He hears the voice of the men who came on motorbikes and shot at the family home." She explained that Miguel was in the home at the time of the incident and the target was his father. Reexperiencing surfaced with the Marjorie Stoneman Douglas High School massacre on February 14, 2018; Miguel no longer felt safe at school and was fearful of being shot. Chronic posttraumatic stress disorder was diagnosed, and treatment with a selective serotonin reuptake inhibitor and trauma-focused cognitive-behavioral therapy was recommended. Mrs. Estrada preferred trauma-focused cognitive-behavioral therapy; however, the school's clinicians were not trained in this treatment modality and were unable to provide regular psychotherapy sessions. Six months later Miguel continued to report attenuated symptoms of posttraumatic stress disorder.