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Approximately 33 million children migrate from one country to another each year and an estimated 17 million of whom were displaced due to conflict and violence (UNICEF, 2020). In the United States (U.S.), media attention has focused primarily on the tens of thousands of children migrating from Central America, fleeing potential violence and poor economic conditions, who have been apprehended at the border and detained for indefinite lengths of time. Child migration across the southern border of the U.S. is not a recent phenomenon, but many recent policy changes and executive orders may have lasting impacts on our system of immigration and the children caught in the middle (M. A. Clemens, 2017; M. Clemens & Gough, 2018; Pierce & Bolter, 2020; Sherman, Mendoza, & Burke, 2019).
To assess the potential economic impact of recent immigration policy changes, we conducted a pilot study through a collaboration through the National Child Traumatic Stress Network (NCTSN) with investigators from the University of Maryland, Boston College, and Duke University. Due to the limited data availability specific to the migrant children detained, we utilized modeling techniques informed by published literature and clinical information from a real-world sample of 458 migrant children and adolescents within the NCTSN Core Data Set (CDS). We modeled the following 3 policy scenarios from the advice from migration experts:

  1. No Detention – This refers to the period prior to 2014 when border patrol agents who apprehended migrants crossing the border would open up a case for the individual or family and then release them with a scheduled court date.
  2. Family Detention – This refers to the period between 2014 and 2018 where families apprehended at the border were detained as a unit for a period of 20 days or less in a detention center.
  3. Zero Tolerance – This refers to the period from 2018 and 2019 in which 100% of the adult migrants crossing the border were prosecuted, ultimately forcing the separation of any children in their custody for detention.

In our model, we considered No Detention the reference case and estimated additional levels of trauma for Family Detention and Zero Tolerance. Since these were assumptions, we conducted sensitivity analyses to estimate the impact of changing the trauma exposure for these groups. Using previous literature, we identified direct (e.g. hospitalizations, clinic visits, medications) and indirect (e.g. time costs, caregiver absenteeism, transportation) costs associated with posttraumatic stress disorder (PTSD), anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) and applied these costs to a hypothetical cohort of migrant children entering a health-transition model representing the probabilities children or adolescents in the health-state would have one of those illnesses. We modeled the progression over 5- and 10-year scenarios to estimate the total and incremental costs for each scenario.
Our results showed spending increases for the Family Detention and Zero Tolerance policies compared with the No Detention (Reference Case) policy, suggesting any increase in trauma for children directly related to the policy change may lead to additional direct costs for the health care system and indirect costs when considering a broader societal-perspective. We used conservative estimates, multiple sensitivity analyses, and focused on 4 common comorbidities associated with trauma to arrive at these conclusions. What we illuminated through this research process is informative for the trauma research community but much more information is needed on the economic and societal costs of policies that add traumatic experiences to the lives of children and families. Very few child trauma studies incorporate health economic methods to estimate the economic burden of disease in the U.S. and very little is known about the trauma exposure and mental health for many of these children under the care of the U.S. government. We offer this analysis as reminder that while our policies have clinical and humanistic implications, there are broader financial considerations for these families, health systems, and the government. We hope that this generates more discussion and debate within the International Society for Traumatic Stress Studies and encourages clinicians and researchers to think about the economics involved in their work as well.


Clemens, M. A. (2017). Violence, Development, and Migration Waves: Evidence from Central American Child Migrant Apprehensions. Retrieved from https://www.cgdev.org/sites/default/files/violence-development-and-migration-waves-evidence-central-american-child-migrant.pdf

Clemens, M., & Gough, K. (2018). Child Migration from Central America—Just the Facts. Retrieved August 12, 2020, from Center for Global Development website: https://www.cgdev.org/blog/child-migration-central-america-just-facts

Pierce, S., & Bolter, J. (2020). Dismantling and Reconstructing the U.S. Immigration System: A Catalog of Changes under the Trump Presidency. Retrieved August 12, 2020, from Migration Policy Institute website: https://www.migrationpolicy.org/research/us-immigration-system-changes-trump-presidency

Sherman, C., Mendoza, M., & Burke, G. (2019). US held record number of migrant children in custody in 2019. UNICEF. (2020). Child Migration.

Reference Article

Mattingly, T.J., II, Kiser, L., Hill, S., Briggs, E.C., Trunzo, C.P., Zafari, Z. and Betancourt, T.S. (2020), Unseen Costs: The Direct and Indirect Impact of U.S. Immigration Policies on Child and Adolescent Health and Well‐Being. Journal of Traumatic Stress. doi:10.1002/jts.22576

Questions for Discussion

  1. What other types of costs should be considered when evaluating policies that impact immigrant children?
  2. What other co-morbidities should be included in a health-state transition model of child trauma?

About the Authors

T. Joseph (Joey) Mattingly II, PharmD, MBA, PhD (Twitter: @joeymattingly), is an Associate Professor and Director of Operations for The PATIENTS Program, in the Department of Pharmaceutical Health Services Research, at the University of Maryland School of Pharmacy in Baltimore, Maryland.
Theresa S. Betancourt, ScD, MS, is the Salem Professor in Global Practice at the Boston College School of Social Work and Director of the Research Program on Children and Adversity (RPCA) in Boston, Massachusetts.