Testimony Before the  
United States House Committee on Energy & Commerce 
 
 
     
 
HHS-OIG Oversight of the Unaccompanied Alien Children Program 
 
Testimony of: 
 
Ann Maxwell 
Assistant Inspector General 
Office of Evaluation and Inspections 
Office of Inspector General 
U.S. Department of Health and Human Services 
 
 
 
 
 
September 19, 2019 
10:00 a.m. 
Location: 2123 Rayburn House Office Building   
 Testimony of: 
Ann Maxwell 
Assistant Inspector General for Evaluation and Inspections 
Office of Inspector General, U.S. Department of Health and Human Services 
Good morning, Chair DeGette, Ranking Member Guthrie, and Members of the 
Committee.  I am Ann Maxwell, Assistant Inspector General for Evaluation and Inspections for 
the Office of Inspector General (OIG), U.S. Department of Health and Human Services (HHS).  I 
appreciate the opportunity to appear before you to discuss the challenges that care provider 
facilities faced addressing the mental health needs of children in HHS custody.  Any significant 
challenges that facilities face in addressing a childs mental health needs could have serious 
immediate and long-term ramifications for childrens well-being.  
OIGs Oversight  
  OIG oversees all HHS programs and operations.  OIG combats fraud, waste, and abuse in 
those programs; promotes their economy, efficiency, and effectiveness; and protects the 
beneficiaries they serve.  To accomplish this, OIG employs an array of tools, including audits, 
evaluations, and investigations. 
OIG takes very seriously its responsibility to protect the health and welfare of vulnerable 
children.  As such, we have prioritized oversight of the Unaccompanied Alien Children (UAC) 
Program, which is administered by the Office of Refugee Resettlement (ORR) within HHSs 
Administration for Children and Families (ACF), since responsibility for caring for 
unaccompanied children was transferred to HHS by the Homeland Security Act of 2002.  
One important goal of OIGs work on the UAC Program has been to promote the 
protection of children in HHS care.  We have reviewed whether ORR grantees met safety 
standards for the care and release of children in their care, and the efforts of ORR to ensure the 
safety and well-being of children after their release to sponsors.  
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  In 2018, numerous stakeholders raised serious concerns about the health and safety of 
unaccompanied children, including the provision of appropriate mental healthcare services, at 
HHS-funded facilities.  Given the urgency of the situation, and OIGs independent oversight 
role, we launched a series of reviews examining health and safety issues in the UAC Program. 
This testimony focuses on challenges to providing mental health services.  Other reviews from 
our 2018 initiative address employee screening, including staff background checks, physical 
security of facilities, and challenges facilities faced in ensuring childrens safety.  We are also 
assessing the challenges HHS and facilities faced in reuniting separated children with their 
parents. 
ORRs Unaccompanied Alien Children Program   
 
The UAC Program serves children who have no lawful immigration status in the United 
States and no parent or legal guardian available to provide care and physical custody.  By law, 
ORR has custody of and must care for each unaccompanied child by providing housing, food, 
educational services, recreational activities, and health services, including mental health services. 
ORR funds a network of more than 100 facilities that furnish care for children until they 
are released to a sponsor or otherwise leave ORR custody.  These facilities, generally, are State-
licensed and must meet ORR requirements.  Most children are in shelter facilities, the least 
restrictive setting.  ORRs network also includes residential treatment centers that provide 
therapeutic care, as well as secure and staff secure facilities that provide a higher level of 
supervision.  One of the staff secure facilities also offers specialized therapeutic care. 
Mental Health Services in Care Provider Facilities 
According to the terms of the 1997 Flores Settlement Agreement, which sets national 
standards for the detention, release, and treatment of children without legal immigration status in 
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  Federal custody, children must receive necessary medical and mental health services.  At a 
minimum, each child in ORR custody must receive at least one individual counseling session per 
week from a trained mental health clinician.  When needed, children also may receive care from 
external mental healthcare specialists, such as psychiatrists and psychologists.  
Mental health clinicians are employed at every facility and are responsible for providing 
in-house mental healthcare for children.  These clinicians, who must meet minimum education 
and experience qualifications, are responsible for conducting mental health assessments, 
providing counseling services, providing crisis intervention services, and recommending care 
from external specialists.  ORR requires each facility to employ at least 1 mental health clinician 
for every 12 children in care.  
HHS-OIG Review of Mental Healthcare Challenges in ORR-Funded Facilities 
 
To complete this review, OIG conducted site visits at 45 of the 102 ORR-funded facilities 
that were in operation in August and September of 2018.  We visited facilities to hear directly 
from their staff about the challenges they faced caring for children and ensuring their safety.  
Facilities were purposively selected to achieve wide coverage of facilities participating in 
the UAC Program, varying by size and geographic location, among other factors.  These 
facilities cared for about 72 percent of children in ORRs custody at the time of our review. 
We conducted qualitative analysis of interview data from: (1) approximately 100 mental 
health clinicians who had regular interaction with children across the 45 facilities; (2) medical 
coordinators in each of the 45 facilities; (3) the program director and lead mental health clinician 
in each of the 45 facilities, and (4) the 28 ORR federal field specialists assigned to the 
45 selected facilities.  
3 
  We did not determine whether the challenges that were identified resulted in care that 
failed to meet ORR requirements or clinical standards, nor did we assess the quality of the 
mental healthcare provided.  Instead, we offer a broad survey of the challenges facing the 
program as reported by staff in order to provide ORR with information useful for directing 
attention toward the most significant mental health-related challenges facing facilities.  
Report Findings and Recommendations 
Facilities reported several challenges in addressing childrens mental health needs.  Some 
were systemic in nature, such as: (1) the inherent challenges associated with treating children 
who have experienced intense trauma, (2) difficulty accessing external mental health specialists, 
and (3) difficulty finding therapeutic placement options within ORRs network.  In 2018, 
existing challenges were exacerbated by Federal policy changes that resulted in facilities caring 
for an increasing and changing population, including younger children who were unexpectedly 
separated from their parents.  We recommend practical steps ORR can take to assist facilities and 
address these challenges. 
Mental Health Clinicians Stated That They Were Not Prepared To Care for Children Who 
Had Experienced Intense Trauma  
Facility staff discussed the challenges inherent in caring for a population of children who 
have experienced intense trauma.  Facility staff reported that many of the children in their care 
had experienced intense trauma from a variety of events in their home countries or on their 
journey to the United States.  Some children experienced additional trauma when they were 
unexpectedly separated from their parents upon arrival in the United States.  
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  Despite their training and experience, mental health clinicians reported feeling 
unprepared to address the level of trauma that some children had experienced.1   The UAC 
Program is designed to house and care for children during relatively short-term stays until they 
can be released to sponsors.  Because the length of childrens stays are unpredictable and, from a 
mental health treatment standpoint, relatively short, mental health clinicians reported being 
unable to adequately address their trauma.  Mental health clinicians reported that they were wary 
of opening wounds that they would not have time to address adequately through continued 
therapy and, instead, focused on making sure that children were stable and able to cope day-to-
day.  
All facilities reported that staffincluding mental health cliniciansreceived training to 
help them work with children who had experienced trauma.  Nonetheless, mental health 
clinicians discussed how challenging it was to hear about childrens traumatic experiences.  
Further, mental health clinicians said that colleagues hired without previous experience in caring 
for unaccompanied children in ORR custody may have been especially unprepared for the severe 
trauma of children in their care.  Mental health clinicians and program directors told us that 
facility staff would benefit from more training on trauma-informed care.  
OIG recommends: Additional guidance on addressing trauma in children. To 
address these issues, we recommend that ORR provide facilities with evidence-based 
guidance on addressing trauma in short-term therapy in children of all ages.  
                                                           
1 Our companion review: Unaccompanied Alien Children Care Provider Facilities Generally Conducted Required 
Background Checks but Faced Challenges in Hiring, Screening, and Retaining Employees found that almost all the 
facilities we visited hired mental health clinicians who met minimum requirements. 
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  High Counseling Caseloads Stretched In-House Mental Health Clinicians  
Care provider facilities reported high counseling caseloads due to challenges in recruiting 
and retaining mental health clinicians.  This made it more difficult for them to make sure that all 
children received the time and attention they needed.  Even facilities that met ORRs required 
facility-wide ratio of 1 clinician for every 12 children may have had individual clinicians who 
were responsible for counseling more than twice that number because of the way cases were 
distributed.    
OIG also found that, at the time of our visits in August and September 2018, 26 of the 
45 facilities reported that the mental health clinician position posed the greatest hiring challenge.  
Facilities most often attributed this to difficulties finding bilingual candidates and candidates 
who met the minimum qualifications.  
OIG recommends: Strategies for addressing high mental health clinician caseloads.  
We recommend that ORR assess whether to establish maximum caseloads for individual 
mental health clinicians.  We also recommend that ORR develop and implement 
strategies to assist care provider facilities in overcoming obstacles to hiring and retaining 
qualified mental health clinicians.  
Facilities Faced Challenges Accessing External Specialists for Children Who Needed 
Specialized Diagnosis and Treatment   
We found that facilities faced challenges accessing external specialists for children who 
needed more mental health treatment than was available from in-house staff.  ORR uses an 
insurance company that maintains a network of doctors, hospitals, and other health professionals 
to provide mental health services to children in ORR custody.  However, facility staff told us that 
this provider network does not include enough mental health specialists to meet childrens needs.  
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  These challenges were acute for facilities in medically underserved areas.  Bilingual specialists, 
in particular, were difficult to find.  
OIG recommends:  Strategies for improving access to external mental health 
specialists.  ORR should ensure that the national network of external healthcare 
providers maintained by its insurer includes the mental health specialists needed to 
address childrens mental health needs.  For facilities in areas with a scarcity of mental 
health specialists, ORR could consider entering into agreements with Federal, State, or 
local health agencies or qualified specialists to provide necessary mental health treatment.  
Facilities Were Unable To Transfer Children Who Needed a Higher Level of Mental 
Healthcare to More Appropriate Placements Within ORRs Network  
Mental health clinicians determined that some children needed a higher level of care than 
facility staff and external specialists could provide, but facilities reported difficulties transferring 
these children to facilities in the ORR network that are licensed to provide specialized care.  
Staff said that the two residential treatment facilities in ORRs network lacked bed space for 
children who needed transfers.  Combined, these two facilities have 50 beds dedicated to 
children in ORR care.  
Facility staff also described difficulty in finding appropriate placements for children who 
needed more therapeutic treatment but who also had a history of problem behaviors that put 
themselves or others at risk.  Children with significant mental health needs such as oppositional 
defiant disorder, dissociative symptoms, and suicidal ideation remained in settings not well 
equipped to address their needs. 
OIG recommends: Increased options for therapeutic placements in ORRs network. 
ORR should increase therapeutic placement options for children who require more 
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  intensive mental health treatment, including options for children with behavioral issues 
that accompany their mental health needs.    
Federal Policy Changes Exacerbated Existing Challenges in 2018 
Policy changes in 2018 exacerbated existing challenges, as they resulted in 1) a rapid 
increase in the number of children separated from their parents after entering the United States, 
many of whom were younger, and 2) longer stays in ORR custody for children.  
Separated and Younger Children.  According to program directors and mental health clinicians, 
separated children exhibited more fear, feelings of abandonment, and post-traumatic stress than 
did children who were not separated.  Separated children experienced heightened feelings of 
anxiety and loss as a result of their unexpected separation from their parents after their arrival in 
the United States.  In addition, the trauma of their separation, and resulting feelings of distrust, 
made it difficult for mental health clinicians to establish therapeutic relationships through which 
they could address childrens needs.  
In addition, the number of young children, age 12 and younger, in ORRs care increased 
sharply in May 2018 when the Department of Homeland Security (DHS) formally adopted the 
zero-tolerance policy of criminally prosecuting all adults for illegal entry into the United States.  
This policy led to many more children, some of them quite young, being separated from their 
parents.  The proportion of young children in ORR care rose from 14 percent of referrals to ORR 
in April 2018 to 24 percent of referrals in May 2018. 
Caring for young children presented different challenges than caring for the teenagers 
facilities typically served.  Young children had shorter attention spans, lacked the ability to 
comprehend the role of the facility, and more commonly exhibited defiance and other negative 
behaviors.  Facilities noted the difficulties associated with completing assessments and other 
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  screenings for pre-school-aged and younger children who could not accurately communicate 
their background information, needs, or the source of any distress. 
OIG recommends: Guidance that helps facilities care for young children.  As 
previously mentioned, we recommend that ORR disseminate guidance on addressing 
trauma in short-term therapy.  This guidance can improve facilities readiness to meet the 
mental healthcare needs of children of all ages, including very young children. 
Longer Stays in Facilities.  A more stringent sponsor screening process led to longer stays in 
facilities.  Facilities reported that children with longer stays experienced more stress, anxiety, 
and behavioral issues, which staff had to manage.  Some children who did not initially exhibit 
mental health or behavioral issues began reacting negatively as their stays grew longer.  Children 
who experienced longer facility stays exhibited higher levels of defiance, hopelessness, and 
frustration, along with more instances of self-harm and suicidal ideation.  
ORRs requirements for screening potential sponsors have varied over time, as it attempts 
to balance safety concerns with the need for the timely release of children from HHS custody.  In 
June 2018, ORR began requiring fingerprint background checks of all potential sponsors and the 
adult members of their households and sharing that information with DHS.  Following this 
policy change, the amount of time that children remained in ORR care increased dramatically.  
In March 2019, ORR changed its policy again; it eliminated fingerprint background checks for 
parents or legal guardians, in most circumstances.  By April 2019, the average length of stay had 
declined to 48 days.  Since then, length of stay was 45 days in May and June and 47 days in July 
2019.2 
                                                           
2 The average length of time spent in care provider facilities by children who have been released from ORR custody. 
HHS, Latest UAC Data- FY 2019. https://www.hhs.gov/programs/social-services/unaccompanied-alien-
children/latest-uac-data-fy2019/index.html#. 
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  OIG recommends: Take reasonable steps to minimize the time that children remain 
in ORR custody.  It is essential that ORR appropriately assesses all sponsors before 
making a release determination.  We recommend that ORR assess current policies and 
procedures to ensure that they do not present unnecessary barriers and establish 
procedures to ensure that future policy changes prioritize child welfare considerations 
and do not inadvertently increase the length of stay. 
Conclusion and Upcoming OIG Work on the UAC Program 
ACF concurred with all of our recommendations and described its plans to address them, 
some of which are underway.  We encourage ACF to support the facilities that are directly 
responsible for the care of children in its custody and minimize barriers to appropriate mental 
health treatment.  
OIG appreciates the support that we have received from Congress for our work 
overseeing the UAC program and the additional resources to augment our efforts in this area.  
We anticipate initiating reviews on new topics. Specifically, we expect to examine coordination 
between HHS and DHS, sponsor screening, emergency preparedness, and the appropriateness of 
childrens placements and transfers within ORRs network of facilities.   
Challenges to addressing the needs of children in HHS custody require our combined 
attention and very best efforts.  Thank you for the opportunity to testify today and to be part of 
this conversation on this important topic. 
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