The Journal of School Nursing2021, Vol. 37(6) 523–531© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211045688journals.sagepub.com/home/jsn
school nurse, child health, immigrant health, acculturation, trauma, stress(ors), behavioral health
School nurses are often one of the first healthcare providers to interface with newly arrived immigrant and refugee children, i.e., “newly arrived children” (Johnson et al., 2017; McGuire, 2014; McNeely et al., 2017). School-based services are readily accessible to most families, offering a hub for assessment, brief intervention, and referral to community-based services (Johnson et al., 2017).
Most school nurses are familiar with Bronfenbrenner’s ecological systems theory for understanding children’s development at the individual/family, community and societal level (Bronfenbrenner, 1979; Neal & Neal, 2013). Similarly, grounded in ecological systems theory, the Four Core Stressors Framework (Figure 1) proposes that four stressors impact newly arrived children post-migration to the United States: trauma, acculturative stress, resettlement stress, and social isolation (Boston Children; Hospital Trauma & Community Resilience Center BCH TCRC, 2021; Davis et al., 2021; Ellis et al., 2020).
The Four Core Stressors Framework is the foundation of the Refugee and Immigrant Core Stressors Toolkit (RICST), an evidence-informed web-based screening tool for assessing the strengths and needs of newly arrived children and families. The Boston Children’s Hospital Trauma and Community Resilience Center BCH TCRC is staffed by a multidisciplinary team of researchers, clinicians (i.e., psychologists and social workers) and educators, most of whom have appointments at Harvard Medical School. The BCH TCRC currently concentrates on three core areas of programming: (1) immigrant and refugee trauma and resilience; (2) multidisciplinary models of violence prevention, and (3) culturally-responsive and trauma-informed training. The BCH TCRC developed the Four Core Stressors Framework and RICST to assist service providers in parsing out the various issues involved in their clinical cases and to help prioritize interventions in response to patients’ identified needs (BCH TCRC, 2021). The development of the RICST was originally supported by the National Child Traumatic Stress Network and was informed by a community based research process that included a comprehensive literature review of common stressors experienced by immigrant and refugee youth and families as well as feedback from providers, stakeholders, and community members (Abdi, 2018; Betancourt et al., 2017; Cardeli et al., 2020; Davis et al., 2021; Ellis et al., 2011; Ellis et al., 2012; Ellis et al., 2020; Kaplin et al., 2019; Saxe et al., 2016). The RICST helps providers understand the unique experiences of newly arrived children and prompts best practices for resources and interventions to promote academic, physical, social and emotional well-being (BCH TCRC, 2021; Davis et al., 2021).
The purpose of this paper is to (1) introduce the Four Core Stressors Framework to guide school nurses who work with newly arrived children; and (2) describe the application of the RICST to school-based nurses. Throughout this article, we demonstrate the utility of the RICST for service planning and treatment using the case study of “Jasiel.” The story of Jasiel, a newly arrived child from Honduras, is told by his elementary school nurse in Florida, Roseline. Roseline uses the RICST to assess Jasiel’s needs and to promote his healthy adjustment to school and his new community.
The year 2020 marked the end of an administration that severely limited immigration, walled off the U.S.-Mexico border asylum system, and resettled the smallest number of refugees since the Refugee Act of 1980 (Batalova et al., 2021; Chishti & Bolter, 2020). The COVID-19 pandemic spurred a drastic drop in immigration due to closures of U.S. consulates and changes in global migration (Chishti & Bolter, 2020). Recent data estimates nearly 86 million immigrants and their U.S.-born children account for approximately 26% of the total U.S. population (Batalova et al., 2021).
Although the terms “immigrant” and “refugee” may sometimes be used interchangeably, their definitions vary. Immigrants are defined broadly as those living in the United States who were not U.S. citizens at birth (foreign-born), and comprise those allowed under refugee standing, some temporary legal non-immigrants (e.g., persons student or work visas), lawful permanent residents, and individuals living in the U.S. without documentation (Batalova et al., 2021). A refugee is someone who has been forced to flee their home country due to a well-founded fear of persecution related to reasons of race, nationality, religion, political opinion, violence, or war (United Nations High Commissioner for Refugees UNHCR, 2020). Included under the term refugee is a subcategory of “unaccompanied children” who entered the U.S without a parent or legal guardian available to offer care and custody at the time of apprehension (Zayas et al., 2017). According to the Administration for Children and Families (2021) more than 409,585 unaccompanied children entered the U.S. in the past nine years; mostly from the Northern Triangle Central American countries of El Salvador, Guatemala, and Honduras.
Amid the challenges responding to COVID-19 and hybrid learning, the 132,300 school nurses in the U.S. remain central to assessing newly arrived children and initiating referrals to providers and community resources (American Academy of Pediatrics Council on School Health, 2016; United States Census Bureau, 2019; Willgerodt et al., 2018). Although school nurses in the U.S. spend about one-third of their time attending to mental health issues, they receive little training to detect and coordinate care for general mental and behavioral health issues, let alone issues related to immigration (Bohnenkamp et al., 2015). Further, a 2012 National Association of School Nurses (NASN) needs assessment showed that 95% of United States school nurse respondents (n = 2645) reported barriers to providing culturally competent care (Matza et al., 2015).
Although there is a wealth of general information online about immigrant and refugee children (e.g., Bridging Refugee Youth and Children’s Services, Switchboard, JM REY’S IACAPAP), the majority of web-based tools (e.g., FindHello, Settle In, AsylumDK, RefAid, Step by Step, Refugee Buddy) focus on adult immigrants and refugees and tend not to provide suggestions for service providers (Davis et al., 2021). Boston Children’s Hospital Trauma and Community Resilience Center recognizes the important role school nurses, many of whom interface daily with immigrants and refugees and therefore have been committed to development and dissemination of youth-specific and interactive tools to assist in the direct care for this unique population (Davis et al., 2021).
The RICST is a web-based tool that offers a framework for conceptualizing risk and resilience factors in resettlement and their impact on client health and well-being. It considers the resources and strengths of newly arrived children, their families, and their communities to be integral to service planning and advocacy (Davis et al., 2021; Ellis et al., 2020). Based on observations, clinical impressions, and suggested factors for consideration, the school nurse rates levels of risk across four core stressors: (1) low green, (2) moderate yellow, or (3) high red. For example, Jasiel exhibits moderate yellow levels of emotional distress (i.e., in the trauma category) as exhibited by flashbacks and trouble concentrating. Jasiel does not currently exhibit high red symptoms such as self-injury but his symptoms seem more advanced than in the low green category (i.e., occasional distress).
RICST interventions span the social ecology of individual level interventions based on the principles of trauma informed care. These risk ratings populate suggested interventions across levels of risk. For example, after a school nurse meets a newly arrived child, he/she can assess the child using the RICST and explore strategies depending on the risk level. After submitting an individual RICST assessment, school nurses can download a helpful “summary and feedback” PDF with ratings and recommendations for each core stressor. School nurses can use this summary as a guide for developing a “Student Success Plan” (Massachusetts Department of Elementary & Secondary Education, 2019). Assessments such as the RICST can help build a holistic view, maintaining a whole child perspective by articulating the ecological context of struggles and strengths to foster healthy development. We return to our example, below.
Identifying factors that affect health and behavior of newly arrived children is often complex, difficult, and sometimes confusing to even the most seasoned service provider (Ellis et al., 2020). Here we present the four core assessment domains of the RICST—resettlement, acculturative stress, isolation, and trauma—while examining Jasiel’s needs and strengths. Some newly arrived children experience human rights violations and/or intense long-lasting trauma and may show symptoms of depression, anxiety, and posttraumatic stress disorder (BCH TCRC, 2021). Ellis et al. (2020) note we need to be sensitive to distress associated with the disclosure of traumatic experiences. Therefore, keeping in mind Jasiel’s trauma history (i.e., violence in Honduras, separation, dangerous travel, smuggling, border detention), we begin by applying the RICST to Jasiel’s case starting with resettlement, proceeding to acculturative stress and isolation, and lastly, trauma.
Resettlement stressors involve lack of basic needs, financial stress, barriers to healthcare and need for legal resources. Financial stressors include poverty, food insecurity, inadequate or unstable housing, and parents with difficulties finding employment (Alegria et al., 2010; BCH TCRC, 2021; Tienda & Haskins, 2011). Logistical stressors involve obtaining legal status, finding affordable or efficient modes of transportation, and accessing available community resources (Davis et al., 2021; Tienda & Haskins, 2011). Unaccompanied and undocumented children face added resettlement stressors because they are not integrated into governmental and social service infrastructures that may require special assessment, especially if held in detention centers during their migration and resettlement journey (Ataiants et al., 2018; Ellis et al., 2020; UNHCR, 2011).
RICST Assessment. Jasiel and his mother experience high red resettlement stress due to one or more financial and healthcare stressors. Fortunately, Jasiel and his mother moved to a Honduran community where they receive several bags of groceries each week from the local community center. His undocumented status makes him ineligible for State health insurance so Jasiel has unmet mental health/behavioral needs.
RICST Interventions. The following are suggested interventions for navigating resettlement stress:
Acculturative stressors involve challenges associated with family relationships, language learning, and cultural learning. Acculturation itself is the normative developmental process of adjustment and adaptation from one cultural context to another. Acculturative stress may vary depending on the age of the youth, length of time in resettlement, and cultural distance , (Barowsky & McIntyre, 2010; Ellis et al., 2020; Tienda & Haskins, 2011).
RICST Assessment. Jasiel presents at a moderate yellow level of acculturative stress as demonstrated by multiple stressors that interfere with his functioning at school and in his social relationships. For example, Jasiel has problems trying to fit in at school and engages in physical fights out of frustration. Jasiel’s teacher observes conflicts with peers related to cultural misunderstandings over personal space. Jasiel is not familiar with U.S. culture, the English language, and new school norms (e.g., greeting others, raise your hand to speak, take turns, keep your hands to yourself, stay in your seat and “Walk, don’t run!” in the hallways) (Kampen, 2019). Acculturative stress is further compounded by Jasiel being three years academically behind same-age U.S. peers due to limited English proficiency, inconsistent attendance record, starting primary school in Honduras at age seven, and poor quality instruction. Fortunately, Jasiel has strengths in his secure attachments to his mother and with his Students with Limited or Interrupted Formal Education (SLIFE) teacher and Nurse Roseline.
RCIST Interventions. The following are suggested interventions for acculturative stress:
School nurses working to build a culturally sensitive school can foster welcoming relationships by engaging with newly arrived children and families at such events as Open House Night. They can also demonstrate cultural sensitivity by being proactive in learning about children’s religious practices and establishing quiet spaces for children observing religious traditions (e.g., Ramadan fasting) (Brady et al., 2021).
Isolation stressors involve challenges related to alienation, loneliness and discrimination. Experiences of isolation, explicit and implicit bias, and discrimination are tragically common for newly arrived children (Alegria et al., 2010; Davis et al., 2021; Ellis et al., 2018). Newly arrived children may experience feelings of loneliness due to loss or lack of social support, which may be compounded by discrimination or harassment from peers, adults, or law enforcement (Ellis et al., 2014; Tienda & Haskins, 2011). Experiences as cultural and ethnic minorities in a new country can generate feelings of mistrust with the new host population, of not “fitting in” with peers, and loss of social status.
RICST Assessment. Jasiel and his mother could be assessed at a moderate yellow level of isolation stress. Although Jasiel misses his grandmother and extended family back in Honduras, Jasiel admits to feeling grateful about his reunification with his mother. Isolation stressors include Jasiel’s mother works long hours as a nanny “under the table” in a distant location. Further, Jasiel and his mother’s undocumented status exacerbate their feelings of isolation due to an uncertain future that may involve deportation (Dreby, 2012). Additionally, Jasiel feels left out when classmates exclude him from recess activities/games.
RICST Interventions. The following are suggested interventions for isolation:
School nurses can organize weekly cultural peer groups for parents/guardians where coffee is served and holidays celebrated (Brady et al., 2021). Mendonca et al. (2009) recommend school nurses seize opportunities to join welcoming orientations; facilitate after-school activities, dance and walk clubs; and plan culturally inclusive activities such as health fairs.
Trauma stressors may comprise challenges with emotional regulation, need for further social support and continued environmental stressors. Traumatic stress may occur when a powerful event causes or threatens to cause harm to psychological and physical well-being (Davis et al., 2021; Droždek, 2015). In certain moments, the child may experience their present environment as threatening, even if relatively safe (Droždek, 2015; Saxe et al., 2016).
Traumatic exposure can occur at multiple points along the migration journey (i.e., before, during, and after migration). This experience of sequential trauma may occur as a result of sudden separation from parents, displacement, assault, witnessing violence, food scarcity, trafficking, and/or other traumatic exposures along the migration journey (Böttche et al., 2016; Droždek, 2015; Kielson, 1992). Further, some newly arrived children can experience discrimination, stigma, rejection and re-traumatization post U.S. migration. (BCH TCRC, 2021; Fernandez et al., 2015).
RICST Assessment. Overall, Jasiel rates at a moderate yellow level of trauma. Although Jasiel has a history of trauma and emotional distress, he does not exhibit risky behaviors associated with the high red level of trauma. Jasiel’s exposure to trauma pre-migration includes separation from Jasiel’s mother at age five and having lived in a neighborhood with active gang violence in Honduras. During migration, Jasiel traveled with a smuggler and strangers, nearly drowning crossing the U.S. border river and being abandoned in the desert. As a result of these compounding traumatic exposures, Jasiel struggles with symptoms of posttraumatic stress disorder (PTSD) including (1) poor sleep, (2) anxiety, (3) flashbacks and nightmares, (4) inability to control his hands and feet, and (5) withdrawal, (6) inattention and (7) frequent crying for no apparent reason.
RICST Interventions. The following are suggested interventions for trauma:
An evaluation of traumatic exposures can also help the school nurse develop a shared understanding of the child’s needs, thereby improving communication and care quality. A recent qualitative study of Swedish school nurses who work with unaccompanied refugee youth described the need for training school nurses on trauma informed care and intercultural nursing (Musliu et al., 2019).
This example depicts the need for comprehensive assessment for newly arrived children who have faced multiple adversities before, during, and after migration. Ongoing assessment using the RICST can be completed at regular intervals throughout a child’s treatment and/or during the school year.
The U.S. education system must find creative and effective ways to foster the healthy development of newly arrived children as they are the fastest-growing segment of the U.S. population (McNeely et al., 2017; Tienda & Haskins, 2011). Schools are among the first and most influential service structures encountered by newly arrived children (Ellis et al., 2014; Johnson et al., 2017). Upstream population approaches such as applying the Four Core Stressors Framework and RICST align with NASN’s 2020–2023 goals to utilize strategic community partnerships, improve school nurse knowledge and build a culture of health in communities where students live, learn, work and play (NASN, n.d.).
Working “in the trenches”, school nurses need easy-to-use frameworks that help them to connect to tangible resources and strategies to help support and guide their practice.
Grounded in the social-ecological model, RICST can help school nurses assess the mental/health impact of trauma, acculturative stress, resettlement stress and isolation on newly arrived children and suggest interventions tailored to risk levels.
To our knowledge, this is the first paper to describe the use of the RICST in a school based setting and one of the first to propose a framework for refugee and immigrant youth assessment and service delivery that can be used by nurses to leverage their distinct roles as schoolembedded health navigators for newly arrived children. Nurses on the front lines of healthcare, yet embedded in an everyday setting like the schools, are uniquely positioned to be able to develop trust more quickly, conduct brief assessments, and refer for behavioral health services while remaining outside the mental health service system. This positioning helps to reduce mental health stigma thus encouraging people to seek help and to enlist formal and informal supports across an entire school and community ecosystem.
Another advantage of the RICST is that it has a strengthsbased orientation that also acknowledges the resiliency of individuals. Thus, RICST factors in both risk and protective factors, emphasizing a child’s capacity for resilience. It offers school nurses practical strategies to draw on assets such as a strong drive to achieve in school, learn a new language, and family cohesion (Ellis et al., 2020; McNeely et al., 2017; Tienda & Haskins, 2011). As part of the process, the school nurse gets creative and taps into school, community and national resources that match up to and complement the RICST suggestions (i.e., based on the child’s experiences and needs).
It is important to note that newly arrived children have the capacity not only to survive but to become strengthened by unique adversity experience(s), the immigration process and their ability to build on prior school and life experiences (Barowsky & McIntyre, 2010; Droždek, 2015; United States Department of Education, 2017). Factors that help foster youth resilience include: (1) family support, (2) living in a safe environment, (3) joining a religious organization, (4) finding supportive social networks, (5) accessing cultural/community support resources, and (5) establishing a positive integrated cultural identity (Barowsky & McIntyre, 2010; BCH TCRC, 2021; Droždek, 2015; Toppelberg & Collins, 2010).
The resilience of newly arrived children is indicated by the “immigrant paradox” wherein newly arrived children exhibit a higher than expected rate of school success that is attributed to their resilience, risk-avoidance and greater parental educational expectations (Hofferth & Moon, 2016; McNeely et al., 2017; Mendonca et al., 2009; Tienda & Haskins, 2011). Moreover, close knit communities with strong ethnic pride can increase community resilience and buffer the individual against discrimination, racism and bias (American Psychological Association, 2021). Understanding protective factors and recognizing resilience of newly arrived children can bolster the school nurse’s capacity to help plan culturally responsive interventions that address their health and well-being.
To date, there have been 3,209 RICST unique users (Davis et al., 2021). Among the n = 159 users who completed the RICST survey, 35.8% selected the response “I used this to assess the individual needs of a client” and 64.2% checked “To learn more about refugee and immigrant populations in general.” As the RISCT becomes more widely known and used, we will learn more about what resources and supports work successfully and this will help us expand our RICST intervention base to enhance the use of the tool by school nurses caring for newly arrived children.
Implications for school health policy include incorporation of the RICST, or components of the framework, as part of a screening and referral process to improve the emotional and physical well-being of newly arrived children. This would require coordinated, interdisciplinary teamwork between school systems and community providers. As school nurses and other school-based providers incorporate the use of the RICST in their work with newly arrived children, studies will need to explore their impact on such outcome variables as school attendance, educational achievement, levels of mental health symptoms and access to concrete resources and behavioral health services. Knowledge gained in these areas will continue to inform advocacy and will help to ensure that services for newly arrived children are maximally effective and sustainable.
Jacqueline A. Brady https://orcid.org/0000-0002-2748-1874
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Dr. Jackie Brady is currently a school nurse for the Boston Public Schools. For over 20 years she has worked in urban communities caring for elementary school students, many of whom were from immigrant and refugee families. Jackie earned her Ph.D. in Nursing at Northeastern University in May 2020. Her dissertation study, entitled “Experiences of School Nurses Caring for Newly Arrived Immigrant and Refugee Children”, was recently published in the International Journal of Education Reform. Jackie’s review of the Demands of Immigration Scale is forthcoming in the Journal of Nursing Measurement.
Dr. Lee is an Associate Professor at the Boston University School of Social Work and the Research Core Director at Boston University’s Center for Innovation in Social Work and Health. Her area of research focuses on structural determinants of mental health among immigrants, stigma and mental health outcomes, understanding the mechanisms of change in behavioral treatments for substance use, and optimizing addiction treatments to minimize health inequities related to the use of substances among immigrant and diverse populations.
Dr. Cardeli is a licensed psychologist with over a decade of experience working with children, adolescents, and families who’ve been exposed to trauma, including refugee and immigrant populations. She provides clinical consultation in Trauma Systems Therapy for Refugees in addition to studying the effectiveness of behavioral health interventions for vulnerable populations and examining cross-cultural aspects of trauma exposure, PTSD, and identity development.
Jeffrey P. Winer, PhD, is an Attending Psychologist and researcher at the Boston Children’s Hospital Trauma and Community Resilience Center and is an Instructor in Psychology in the Department of Psychiatry at Harvard Medical School. Dr. Winer’s work is primarily focused on developing, disseminating, and implementing culturally-responsive & trauma-informed psychological interventions for youth and families of refugee, immigrant, and diverse backgrounds. He provides clinical consultation on Trauma Systems Therapy for Refugees (TST-R) to providers and programs throughout the United States. He is coauthor of the book, “Mental Health Practice with Immigrant and Refugee Youth” published by the American Psychological Association. He also continues to work at the McLean Hospital 3 East Adolescent DBT Partial Hospital Program and maintains a private practice.
Dr. Pam Burke is faculty for the Boston Children’s Hospital LEAH Fellowship Program (Leadership Education in Adolescent Health) in the Division of Adolescent & Young Adult Medicine and Co-Investigator on two federally funded studies. She was previously PhD Program Director and Clinical Professor in the School of Nursing at Northeastern University. Pam is currently an Affiliate Professor in Nursing at Northeastern University and a Lecturer in Pediatrics, Part Time at Harvard Medical School. She is also a member of the Motivational Interviewing Network of Trainers.
1 School Nurse, Bradley Elementary School, East Boston
2 Associate Professor, Boston University School of Social Work.leecs@bu.edu
3 Research Associate, Boston Children’s Hospital Trauma and Community Resilience Center, Instructor in Psychology, Harvard Medical School, Department of Psychiatry, Boston Children’s Hospital, Boston, MA emma.cardeli@childrens.harvard.edu
4 Attending Psychologist, Boston Children’s Hospital Trauma and Community Resilience Center, Instructor in Psychology, Harvard Medical School
5 Clinical Professor (Retired), Northeastern University, School of Nursing. pj.burke@neu.edu
6 Faculty, LEAH Program (Leadership Education in Adolescent Health), Boston Children’s Hospital, Division of Adolescent & Young Adult Medicine, Lecturer in Pediatrics, Part Time, Harvard Medical School, pamela.burke@childrens.harvard.edu
Corresponding Author:Jacqueline Brady, 85 East India Row, 15H, Boston, MA, 02110.Email: jbrady3@bostonpublicschools.org
