Addressing the 

Mental Health Problems 

of Border and 

Immigrant Youth

A Culture and Trauma Special Report from 

the National Child Traumatic Stress Network

By: Luis Flores MA, LPC, LCDC, Executive 

Vice President, SCAN, Inc. Laredo, TX and 

Arline Kaplan, Los Angeles, CA

This project was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). 

U.S. Department of Health and Human Services (HHS).
Addressing the Mental Health Problems of Border 

and Immigrant Youth

January 2009

Flores, L. & Kaplan, A. (2009). Addressing the mental health problems of border and 

immigrant youth. Los Angeles, CA & Durham, NC: National Center for Child 

Traumatic Stress.

This project was funded by the Substance Abuse and Mental Health Services 

Administration (SAMHSA), U.S. Department of Health and Human Services 

(HHS). The views, policies, and opinions expressed are those of the authors and do 

not necessarily reflect those of SAMHSA or HHS.

National Child Traumatic Stress Network

Established by Congress in 2000, the National Child Traumatic Stress Network 

(NCTSN) is a unique collaboration of academic and community-based service 

centers whose mission is to raise the standard of care and increase access to services 

for traumatized children and their families across the United States. Combining 

knowledge of child development, expertise in the full range of child traumatic 

experiences, and attention to cultural perspectives, the NCTSN serves as a national 

resource for developing and disseminating evidence-based interventions, traumainformed services, and public and professional education.

The National Child Traumatic Stress Network is coordinated by the National 

Center for Child Traumatic Stress, Los Angeles, CA, and Durham, NC.
Contents

Understanding Borderlanders’ Lives and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Cultural Collision versus Interdependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The Question of Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Socioeconomic and Environmental Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Trauma, Substance Abuse, and Mental Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Barriers to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Enhancing Mental Health Care for Borderlanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Respecting the Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Overcoming Language Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Preparing Families to Receive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Integrating Evidence-Based Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Achieving Biculturalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Case Management, Inter-Agency Coalitions, and the Importance of Outreach . . . . . . . . . . . . . . . 16

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

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Addressing the Mental Health Problems 

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Understanding Borderlanders’ Lives 

and Challenges

For health care professionals on the front lines of providing mental health and trauma care to Latino 

children and families in the United States–Mexico border region, it is crucial to understand the diverse 

cultural, socioeconomic, environmental, and political factors that daily impact the lives of their clients/

patients. Equally important, such clinicians need to implement culturally competent care while 

simultaneously addressing the families’ misconceptions and knowledge gaps about the causes of mental 

health problems and their treatment. 

Cultural Collision versus Interdependence

Along the nearly 2,000-mile long border region of the United States and Mexico, the cultures of 

Mexico and the United States frequently collide. In Distant Neighbors, author Alan Riding (1984) states, 

“Probably, nowhere in the world do two neighbors understand each other so little. More than by levels 

of development, the two countries (United States and Mexico) are separated by language, religion, race, 

philosophy, and history.” As a result, borderlanders (fronterizos) may experience “mental and emotional 

states of perplexity” (Anzaldúa, 1987, p. 78) and frequently face “physical isolation, frontier conditions, 

transnational frictions, ethnic rivalries and a sense of separation from heartland areas” (Martinez, 1994, 

p. 303).

Yet, the border region is an area where an estimated 12 million borderlanders live and grow in close 

interdependence and where a “dynamic transnational interaction” occurs (Martinez, 1994). The border 

region is characterized by 14 twin city complexes on both sides of the international boundary, such as San 

Diego, California, paired with Tijuana, Baja California, and El Paso, Texas, paired with Ciudad Juarez, 

Chihuahua. The border crossings are among the busiest in the world, with more than half a million 

people moving legally in both directions each day pursuing jobs, commerce, housing, the arts, and health 

care (United States-Mexico Border Health Commission [USMBHC], 2005). That interdependence also 

involves shared problems. San Diego’s mayor Jerry Sanders alluded to this circumstance when describing 

how crime affects both San Diego and Tijuana. He said, “What affects one side affects the other. We’re 

literally one region with a fence down the middle” (Welch, 2007, p. A3).

In the midst of the pull of interdependence and the push of colliding cultures, borderlanders face 

identity concerns, challenging socioeconomic and environmental conditions, vulnerability to trauma, 

stress, substance abuse disorders, depression, and other psychiatric disorders, and multiple barriers to 

obtaining needed treatment.
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The Question of Identity

Borderlanders are often ridiculed by mainlanders on both sides of the border. U.S. mainlanders 

frequently characterize the border region as an area plagued by poverty, banditry, racial strife, illegal 

immigration, drug smuggling, official corruption, violence, and security breaches (Martinez, 2006). 

Conversely, Latinos in Mexico’s heartland frequently view the border as a region excessively reliant on the 

U.S. economy and American goods and as a source of moral permissiveness stemming from indulgence 

of American tourists’ desires. They may disparage Mexican and Mexican American borderlanders as 

agringados, who have succumbed to Americanization and forsaken their Latino culture. 

Acculturation pressures on Latino families are many. While 

the majority status of bilingual Mexican Americans in border 

communities allows some respite from the pressures to acculturate, 

border residents also recognize that not adapting to the host 

culture may result in significant problems as they interact daily 

with people, systems, and institutions in the United States. 

Additionally, those borderlanders who do adopt mainstream U.S. 

values may feel guilty or ashamed of losing their cultural identity 

and face disapproval from their significant others and families as 

being “too American.” Sometimes the differences in acculturation 

levels within families can lead to conflicts. For example, as 

children adapt to and absorb the new culture—especially by 

going to school and learning English—mothers and fathers 

may encounter difficulty in knowing how to parent their 

“Americanized” children. 

Discriminatory experiences have been found to be related to poor mental health outcomes and negative 

life changes among marginalized communities in the United States (Araújo & Borrell, 2006). Many 

Latinos in the borderlands feel marginalized by a culture that indirectly pressures them to assimilate 

while simultaneously rejecting them. Even after achieving assimilation, most Latinos are racially 

different and, therefore, may not be accepted as easily as “Americans” as European immigrants have 

been. Discrimination is particularly intense with regard to undocumented workers in the border areas. 

Undocumented immigrants may experience guilt and shame and are often treated as “second-class” 

people or pariahs (Sullivan & Rehm, 2005). Discrimination research shows that perceived discrimination 

correlates positively with psychological distress and negatively with a sense of personal control (Moradi 

& Risco, 2006) and that experiences of discrimination may lead to symptoms of depression and anxiety 

among some immigrant populations (Hovey & Magaña, 2000). 

Stereotypes also have significant consequences in the lives of individuals who are facing the challenges 

of defining themselves and their families in a culture that views them unfavorably. Old and recent racial 
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Addressing the Mental Health Problems 

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and cultural stereotypes paint people of Mexican ancestry as lazy, oversexed, immature, aggressive, 

impulsive, dirty, and untrustworthy (e.g., bandido, greaser, beaner, welfare leech, gang member, and 

wetback). Such stereotypes, when internalized, can result in “self-hate,” especially in young people. 

Socioeconomic and Environmental Challenges

Many socioeconomic and environmental conditions negatively influence the mental health of borderlanders, including poverty and the lack of resources, drug trafficking, violence, and immigration risks. 

While significant economic changes have occurred due to international trade agreements with Mexico, 

there continue to be extensive problems associated with the widespread poverty of the border region. 

Three of the ten poorest counties in the United States are located in the border area. Twenty-one of 

the counties on the border have been designated as economically distressed areas. The unemployment 

rate along the U.S. side of the Texas-Mexico border is 250% to 300% higher than in the rest of the 

country. Approximately 432,000 individuals live in 1,200 colonias in Texas and New Mexico, which are 

unincorporated, semi-rural communities marked by substandard housing and a lack of potable water 

or proper sewage systems (USMBHC, 2005). The colonias along the United States–Mexico border are 

reflective of third-world communities, according to Davidhizar and Bechtel (1999). Even though many 

of the residents are U.S. citizens, they lack the basic educational and work opportunities found in most 

parts of the country. Because of limited infrastructure, diseases controlled in most parts of the world are 

epidemic within these communities.

The vastness of the border makes it very vulnerable to drug trafficking. There are five High Intensity 

Drug Trafficking Areas in the border region (areas within the United States that exhibit serious drug 

trafficking problems and harmfully impact other areas of the country), as designated by the White House 

Office of National Drug Control Policy (ONCDP, 2008). For instance, illicit drugs enter Texas from 

Mexico through cities such as El Paso, Laredo, McAllen, and Brownsville, as well as through smaller 

towns along the border. The drugs then move northward for distribution through Dallas/Fort Worth and 

Houston (Maxwell, 2007). Cocaine and heroin, in particular, are major problems in the border region. 

Heroin is purer at the border in El Paso and decreases in purity as it moves north, since it is “cut” with 

other products as it passes through the chain of dealers. Cocaine accounts for a high rate of admissions to 

treatment facilities. Beyond the prevalence of illicit drugs, corrupt medical practices on the Mexican side 

of the border make prescription medications, such as the benzodiazepines flunitrazepam (Rohypnol) and 

diazepam (Valium), easily available. As a result, the potential for youth in the border region to develop 

alcohol and other substance abuse disorders is high. 

Recently, the border region has been at the stage where many drug cartels have been fighting for control 

of smuggling routes and new lines of illicit businesses. The resulting violence, including killings and 

kidnappings, has created widespread insecurity among border residents. Tijuana, for example, with a 
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population of 1.2 million, saw one slaying per day in 2006 and roughly two kidnappings a week. Thirty 

victims were police officers (Welch, 2007). Many children whose relatives or neighbors were victims of 

drug-related kidnappings and murders fear that their parents may be killed when they travel across the 

border to return to Mexico. The children’s insecurity, anxiety, and fear can complicate trauma treatment.

Immigration, whether it is legal or not, 

generally increases the stress on Latino families. 

As of March 2005, the Pew Hispanic Center 

estimated that of the 11 million undocumented 

immigrants living in the United States, six 

million came from Mexico (Sullivan & 

Rehm, 2005). Many undocumented Mexican 

immigrants experience abusive treatment, 

pressures to work for below-market or 

uncertain wages, and threats of deportation. 

They may also suffer the trauma of violent 

immigration experiences (e.g., rape and seeing 

others murdered), but be afraid to seek help 

for fear of deportation. Many report feeling 

lonely, isolated, trapped, sad, and depressed. 

Recent immigration raids in different areas 

of the United States and harsher penalties for 

immigration violations also increase anxieties 

among those separated from their children and 

other family members.

Many immigrants come to the United States alone and leave their children in Mexico, usually being 

cared for by grandparents or extended family. The inability of undocumented immigrants to freely go 

back and forth between the two countries can lead to emotional distance between adults who come 

to the United States for work and any children who remain behind. Also, mothers who have left their 

children back home may experience guilt and shame, because they may feel they are not fulfilling their 

roles as mothers (Williams, 1990), since in most Latino families, women are viewed as the carriers of 

the culture and the primary nurturing figures. Another form of separation occurs along the border when 

some parents send their U.S.-born children to school in the United States. During school days they 

stay on the United States side under the care of extended family members and during the weekends 

reunite with their parents. This practice requires these children to adapt to two different sets of rules and 

structures. 

One Child’s Story

Many families in the United States–Mexico 

border region experience multiple forms of 

trauma that greatly increase anxiety levels, 

especially in children.

Such is the case of Hector, a 10-year-old boy 

whose father died in an accident. A year later, a 

favorite uncle disappeared, a victim of problems 

related to drug smuggling.

Today, every time Hector’s mother plans to go 

across the Rio Grande river to visit family in 

Mexico, Hector experiences anxiety and fear 

and clings to her. This behavior is common 

among children whose relatives or neighbors 

have been victims of drug-related kidnappings 

and murders.
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Addressing the Mental Health Problems 

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Trauma, Substance Abuse, and Mental Health Issues

Children living in the border region are often deeply affected by the violence and uncertainty that exists 

there. Because of the prevalence of illicit drugs and easy access to benzodiazepines, substance abuse in the 

border region is high, particularly among teenagers. Maxwell (2007) reported that students (grades 7 to 

12) in schools on the Texas border reported higher levels of powder or crack cocaine use (12%, lifetime 

use; 5%, past month use) as compared to students in non-border counties (7%, lifetime use; 2%, past 

month use). Cocaine use among adults on the border is also higher. Maxwell found that 26% of all 

admissions to treatment programs on the Texas side and 22% of all admissions on the Mexico side in 

2003 were for powder or crack cocaine. The average age of those admitted for cocaine use was 35 years.

Students from the border schools also report higher current (past month) use of tobacco, alcohol, 

inhalants, and multiple illicit drugs (Texas Department of State Health Services [DSHS], 2005). 

Rohypnol abuse also is prevalent: in a 2004 survey of substance 

use among 51,285 border secondary school students (93.7% 

of whom were Hispanic) and 84,377 nonborder students, 

students from the border area were almost four times more 

likely to report Rohypnol use than those living elsewhere in the 

state (9.1% versus 2.5%, lifetime use, and 3.5% versus 0.9%, 

past month use). Among adults, dramatic increases in the use 

of methamphetamines have been found among Latinos in 

and around the United States–Mexico border, in part because 

methamphetamine use enables many to work longer hours at a 

faster speed and therefore make more money. Some users report 

that dealers regularly travel to work sites, including agricultural 

fields (National Council of La Raza [NCLA], 2005).

Individuals who feel unsafe in their environments are more 

likely to use tobacco, alcohol, marijuana, and other illicit drugs 

than those who are comfortable with their surroundings. In the 

secondary school survey, researchers found there was little difference between the border and non-border 

students in their perceptions of being safe at home, but the border students were less likely than nonborder students to feel very safe in their neighborhoods (31% versus 43%) or at school (33% versus 

37%) (Texas DSHS, 2005). 

There is a paucity of studies on the mental health issues of borderlanders. To explore cultural beliefs 

and mental health among Mexican Americans, Chavez and Guerra (2006) conducted focus groups 

among Mexican Americans living along the southern border of Texas. The discussions were transcribed 

and themes identified. Among themes identified were concern about lack of resources (economical 
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and provider), knowledge deficits about the causes of and treatment for mental health problems, legal 

problems when seeking care in Mexico, the importance of kinship among Hispanics, and the presumed 

lack of providers who understand their needs.

Another recent study looked at health-related quality of life among Mexican Americans living in colonias 

at the Texas-Mexico border (Mier et al., 2008). Women were more likely than men to report worse 

mental health status. The authors suggested this difference may be related to domestic violence issues 

or perceived high levels of discrimination. In addition, increased length of time living in the colonia (10 

years or more), having three or more comorbid health conditions, and perceived problems with health 

care access, were associated with lower mental health status in both men and women. 

Indicators of mental health issues encountered by borderlanders can be extracted from some U.S. 

prevalence studies that address the mental health of Latinos. Researchers used the National Institute on 

Alcohol Abuse and Alcoholism’s Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 

to examine lifetime prevalence of DSM-IV disorders among 2,227 foreign-born and 2,331 U.S.-

born Mexican Americans (Grant et al., 2004). With few exceptions, foreign-born Mexican Americans 

were at significantly lower risk of DSM-IV disorders compared to their U.S.-born counterparts (any 

disorder: 28.5%, foreign-born, compared to 47.6%, U.S.-born). By diagnostic category, 10.2% of 

foreign-born had a mood disorder, compared to 19.3% of U.S.-born; and 9.1% of foreign-born had 

an anxiety disorder compared to 16.3% U.S.-born. These results prompted the researchers to suggest 

that traditional cultural retention may be a “protective factor of the mental health of individuals of 

Mexican descent.”

Other researchers using data from the National Health and Nutrition Examination Survey III (NHANES 

III) found that, compared to White Americans, Mexican American individuals have higher lifetime 

prevalence rates of dysthymic disorder but lower rates of major depressive disorder. Lack of education 

remained a significant risk factor for dysthymic disorder (Riolo, Nguyen, Greden, & King, 2004). More 

recently, researchers combined and examined data from the National Latino and Asian American Study 

(NLAAS) and the National Comorbidity Survey Replication (NCS-R). In the aggregate, they found 

that the risk for most psychiatric disorders was lower for Latino individuals than for non-Latino White 

individuals. Also, using the NLAAS data, the researchers found that U.S.-born Latinos reported higher 

lifetime rates for most psychiatric disorders than Latino immigrants (Alegría et al., 2008). For instance, 

U.S.-born Latino individuals were at significantly higher risk than immigrant Latinos for a major 

depressive episode (18.6% versus 13.4%), for any depressive disorder (19.8% versus 14.8%), for any 

anxiety disorder (18.9% versus 15.2%), and for any substance abuse disorder (20.4% versus 7%). 

Latino youth are at risk for psychiatric disorders as well. According to the Youth Risk Behavior 

Surveillance study, the prevalence of having felt sad or hopeless almost every day for two or more weeks 

was higher among Hispanic (36.2%) than White (25.8%) or Black (28.4%) students (Eaton et al., 
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Addressing the Mental Health Problems 

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2006). The prevalence of having actually attempted suicide in the past year was higher among Hispanic 

(11.3%) than White (7.3%) or Black (7.6%) students, and higher in Hispanic females (14.9%) than 

Hispanic males (7.9%). The prevalence of having vomited or taken laxatives to lose weight or to keep 

from gaining weight was also higher among Hispanic (5.4%) than Black (3.4%) students.

Barriers to Care 

Even when borderlanders suffer mental health problems due to acculturative stress or the loss of their 

culture, environment and language, they may not be able to access treatment due to their illegal status, 

lack of resources and fear of detection. Many immigrant mothers with U.S.-born children are reluctant 

to access public assistance for their children for fear of detection or being perceived as a public charge 

when applying for citizenship (Padilla, Radey, Hummer, & Kim, 2006).

Additionally, most border communities have many 

gaps in services that can affect if and when families 

will be able to receive services, if the family will stay in 

treatment, and where the family can receive treatment. 

Some immigrant parents may not understand the 

many service systems in the United States because 

there may not be counterparts of those agencies in 

their country of origin or those agencies may have 

limited resources and reach. Also, participants may 

feel intimidated about initiating contact because 

they think they might be reported to immigration 

authorities and deported. Due to scarcity of resources and of clinical staff, available programs may 

have long waiting lists that may discourage access to services, and participants may have problems with 

treatment adherence because of the high degree of instability in their lives. Therapy may not be a priority 

when families are facing homelessness, poverty, food, violence, and other problems.

There is also a distressing shortage of Latinos working as professional mental health providers (National 

Council of La Raza, 2005) and a general shortage of mental health professionals in the border region. In 

Texas, for instance, the border counties have lower supply ratios than Texas as a whole for psychiatrists 

and many other mental health professions. While there are 5.6 psychiatrists per 100,000 inhabitants in 

Texas generally, the ratio in border counties is 5 for every 100,000, and in rural border counties, it is 4.1 

per 100,000 (Texas Department of State Health Services Center for Health Statistics, 2006). Differences 

in supply ratios of psychologists by region also exist (e.g., 24.2 psychologists per 100,000 population for 

entire state, 19.1 per 100,000, border, 9.0 per 100,000, rural border). The same is true for social workers 

(e.g., 68.2 per 100,000 for entire state, 61.0 per 100,000, border, 34.8 per 100,000, rural border).