Refugee and immigrant children have a broad range of needs, including adequate housing, healthcare, food, education, and basic security [1]. As part of their healthcare needs, refugee and immigrant children also require adequate access to mental health services and support programming that can serve as primary and/or secondary prevention of poor psychosocial health outcomes. These outcomes can consist of depression, anxiety, post-traumatic stress disorder, conduct problems, difficulties relating to adults and/or peers, attention problems, difficulty concentrating, and poor school performance [2–10].

Despite the fact that there is a critical need for mental health services and related programming for refugee and immigrant youth, there are barriers to accessing care that often include language as well as finances. For example, immigrant children in Canada have a lower likelihood of mental health/social services utilization compared to non-immigrant children (relative odds of 0.39, p = 0.02) [11]. In addition to the underutilization of mental health services, immigrant and refugee youth have also demonstrated a greater need for mental health services compared to the host population in the Netherlands [12], the United Kingdom [13], and Switzerland [14].

While the broader body of knowledge on the mental health of refugee and immigrant youth focuses on a range of psychosocial health outcomes [2–6], studies of Haitian immigrant and refugee youth have emphasized "externalizing" behaviors, such as substance use [15], high risk sexual behavior [16], delinquency [17], and "deviant behavior" [18, 19], with very little information available on "internalizing" symptoms, such as depression and anxiety, among Haitian youth. A focus on externalizing problems presents a skewed view of Haitian youth and does not address the root causes of such behaviors. Analyzing stressors and "internalizing" symptoms, such as depression and anxiety, offers a more balanced picture of the type of social and mental health services that may be needed. For example, one study indicated that the mean "internalizing" score on the Youth Self-Report was higher for Haitian youths compared with Latino and African American youths 12-18 years old attending Boston youth groups (p < 0.004) [20]. Douyon et al. [21] observed a 27.6% prevalence of PTSD among Haitian immigrant youth in Miami/Dade County, however, the researchers were primarily interested in the association of trauma exposure, PTSD, and involvement in "drug-involved social groups." A study in the greater Miami area examined the relationship between substance use and suicidal ideation; the authors found a high level of suicide attempts (11.4%) in their Haitian sub-sample of boys attending middle-school [22].

In addition, Haitian immigrant youth in the U.S. have experienced significant levels of poverty. Among a study population of Haitian immigrants in Florida, 28% reported a family income of less than $10,000 annually [23]. Family characteristics from another study with Haitian immigrants indicated that 26% earned less than $20,000 per year and 22% were unemployed; only 50% were working full-time at the time of the survey [24]. This level of poverty also has significant implications for the mental health of Haitian immigrant youth.

Given the high level of suicidality documented previously [22], the elevated rates of poverty [23, 24], and the relative lack of knowledge of "internalizing" symptoms among Haitian immigrant and refugee youth, the primary aim of this study is to estimate the prevalence of depression and post-traumatic stress disorder (PTSD) among Haitian immigrant students enrolled in public schools in an urban center in the U.S. By selecting students enrolled in school, this study offers the opportunity to inform potential interventions that can assist Haitian immigrant youth within public school systems. Through examination of factors associated with depression and PTSD in this population, a secondary aim is to identify potential areas of intervention that may enhance psychosocial health outcomes among immigrant youth from Haiti and similar settings of poverty, instability, and violence. Due to these broad systemic problems, as well as HIV/AIDS, the number of vulnerable children who have faced significant life trauma is growing. Studies that examine factors associated with poor psychosocial health outcomes among children and youth at high risk offer data that can inform programs aimed at reducing suffering, improving quality of life, and increasing chances of a promising transition to adulthood.

Factors associated with BED of depression and PTSD were initially examined through bivariate analyses. The factors that demonstrated the strongest associations with depression were history of physical or sexual abuse (OR = 9.0; 95% confidence interval (CI): 2.8, 28.7), self-report of schoolwork not going well (OR = 11.9; 95% CI: 4.2, 33.7), and low GPA (OR = 11.0; 95% CI: 2.5, 49.2). The ability to go to their mother if they needed help with a serious problem reduced the risk of depression by 74% (OR = 0.26; 95% CI: 0.10, 0.69). In terms of PTSD, the strongest factors associated were history of physical abuse (OR = 13.7; 95% CI: 4.0, 46.8), history of physical or sexual abuse (OR = 11.9; 95% CI: 3.6, 39.5), having many arguments with parents (OR = 10.9; 95% CI: 3.3, 35.8), feeling rejected by someone (OR = 9.4; 95% CI: 2.9, 29.9), and present concern for physical safety (OR = 8.6; 95% CI: 2.0, 35.8). The ability to go to their mother or father if they needed help with a serious problem reduced the risk of PTSD by 68% (OR = 0.32; 95% CI: 0.11, 0.97) in bivariate analyses.

In the present study, we observed a prevalence of depression and PTSD of 14.0% and 11.6%, respectively; 7.9% of students suffered from comorbid PTSD and depression. Existing literature from refugee, immigrant and displaced youth indicates a wide range of prevalence estimates for depression and PTSD. Prevalence estimates for depression range from 8.4% in adolescent refugees resettled in Quebec [34] to 68.7% among Cambodian youth at the Site II refugee camp in Thailand [35]. For PTSD, prevalence rates were from 9% among Cambodian adolescents living in a west coast city in the U.S. [6] to 93.8% among youth displaced by war living in collective centers in Bosnia [36]. In a review article of the literature on refugee mental health by Fazel et al. [2], a summary prevalence of 11% for PTSD among children and youth was estimated, similar to the finding from the present study. While Haitian immigrants in the U.S. are not typically considered as "refugees" to a large extent, given the context of a high degree of insecurity and political violence in Haiti and the extreme level of poverty it is not surprising that the Haitian immigrant students in this sample have a similar level of PTSD compared to other groups of refugee children and youth. For many Haitian immigrants in the U.S., the differentiation between being an economic immigrant versus a refugee fleeing political strife is often not relevant, given that in many cases those who fear political persecution often also suffer from severe economic deprivation [37, 38].

Risk factors for depression among Haitian immigrant youth in the present study for the final multivariate model included self-report of schoolwork not going well, not having opportunities to spend time with friends, having many arguments with parents, and father's death. Considering the father's death as a highly traumatic event, this finding is corroborated by existing literature in refugee and immigrant youth with respect to an association between trauma and depression. Traumatic events have been associated with depression among Cambodian adolescents in Oregon [39], refugee children in London [40], Latin American immigrant children [41] and Somalian adolescent refugees [8] in the U.S. Similar to findings in the present study, factors predicting anxiety and depression among Vietnamese Amerasian youth included a history of missing school or lack of school attendance, negative or indifferent feeling toward father, hostile relationship with step/foster father, and not always living with mother [42]. Fazel and Stein [43] also indicate that declining school performance can serve as a symptom of depression in refugee youth. Alternatively, academic difficulties due to language barriers or other problems related to adjustment may affect a young person's sense of self-efficacy, also potentially contributing to depression [44]. Finally, similar to findings from the present study, a higher level of social support was associated with a lower level of depressive symptoms among unaccompanied minors from Southeast Asia [45] as well as Namibian adolescent refugees [46].

For PTSD, factors retained in the final multivariate model for the present study included living in an unsafe neighborhood, having many arguments with parents, history of physical abuse, and current concern for physical safety. Consistent with results from the present study, many prior studies among refugee youth have demonstrated an association between traumatic events and PTSD [4, 47–49]. While these studies examined the overall association between trauma or violence exposure and PTSD, very few studies have examined the level of violence exposure in the immigrants' home countries versus the United States or other resettlement country. Among Cambodian refugee adolescents, 25% reported that they had survived violence directed at them outside of the U.S.; however, 29% also reported that they survived violence directed at them in the U.S. [6]. The magnitude of the association between the level of trauma and number of PTSD symptoms was greater for violence experienced in the U.S. (r = 0.362, p < 0.01) compared with the violence experienced overseas (r = 0.192; p > 0.05); these results persisted in the multivariate regression analysis that controlled for other variables [6]. Post-traumatic stress reactions were also associated with adolescents perceiving their mother's parenting style as "rejecting" (r = 0.30) [50], similar to results from the present study.

Findings from this study have implications for identifying much-needed services for refugee and immigrant youth. Given the fact that school performance is important and highly associated with depression, development of English language skills may help to address this issue. Language development and second language learning has been put forth as essential for immigrant youth enrolled in schools in Canada; students often feel less isolated and more connected to their new environment [51]. It is important to note however, that symptoms of PTSD may have an impact on developing second language skills [52]. A similar impact of depression on language skills may also be observed given the effect of depression on cognition [28]. A lower level of English language skills was associated with a higher level of major depression symptomatology (β = -0.234, p < 0.05) among Cambodian refugee adolescents in the U.S. [52]. However, efforts to enhance English language skills should not be promoted in exclusion of much-needed bilingual programs in the schools.

Social support or the demonstrated lack thereof (father's death, arguments with parents) was strongly associated with depression and PTSD in this population of Haitian immigrant youth. In addition, univariate analyses demonstrated a strong protective effect of parental support. A number of prior studies have documented the role of social support as a protective factor [53–56]. In particular, having a confidante that provides emotional support has been shown to have a buffering effect on depression among women [53]. For young children the primary confidante may be a parent; however, for older children and youth this may shift to support from a peer. Harding and Looney [54] observed that Vietnamese children in a refugee camp demonstrated a greater capacity to cope if they were supported by their families. Separation from families indicated a greater vulnerability to stress [57]. These findings are parallel to the earlier observations of Freud and Burlingham [58], who found that children whose parents provided greater support and consistency in their daily lives in London during World War II had lower levels of psychological distress. The findings from the present study suggest that services that enhance parental as well as peer support may serve to protect immigrant youth from depression and/or PTSD. Services that offer support for families, such as social support groups for parents on communicating with children, may strengthen families in their capacity to provide a buffer for distress among youth. Peer-support programs in the schools, involving education on mental health, may help to reduce the social isolation often experienced by those suffering from depression and/or PTSD as well as identify youth who need referral for further assistance (e.g. youth experiencing substance use problems or suicidal thinking).

Results from this study also have implications for access to mental health services. It has been documented that immigrant youth underutilize mental health services [11], and despite a significant level of symptoms reflecting depression and PTSD in this population, only 1.8% of Haitian immigrant youth were seeing a mental health professional at the time of the present study. However, there is a need to identify what kinds of mental health care are appropriate for immigrant and refugee youth. Fazel and Stein [13] indicate that more empirical data on the effectiveness of therapeutic interventions among refugee children are needed. As suggested by Summerfield [59], perhaps 'working through' trauma may not be very helpful, however, mental health care that serves to enhance coping mechanisms (potentially through cognitive-behavioral methods) and strengthen social support networks may be more useful. Fox et al. [60] demonstrated a reduction in depressive symptoms among refugee children who participated in a school-based intervention that focused on skills-building and coping. Similarly, Kataoka et al. [47] observed an improvement in post-traumatic stress disorder and depressive symptoms among immigrant children in the U.S. who participated in a school-based cognitive-behavioral group therapy program. Eisenbruch [57] argues that the school can serve as an ecosystem for "preventive intervention" for refugee children, indicating that school-based programs are useful for primary prevention but may also serve as an excellent setting for secondary prevention, i.e. identifying children with psychological distress and making referrals for appropriate mental health treatment in the healthcare system.

There are a number of limitations in this study. The stratified sampling procedure was not accounted for in the analyses and findings on prevalence rates may be biased and represent overestimates. In addition, given that all youth were enrolled in school, there may also be an underestimate of the prevalence of depression and PTSD since students with higher levels of symptoms may be at risk of dropping out of school [61, 62]. Another factor that can have an affect on the assessment of depression and PTSD includes consideration of the cross-cultural validity of the questionnaires. Although a formal validation study is beyond the scope of the present paper, bivariate and multivariate analyses support the construct validity of these assessments, since expected risk factors were associated with PTSD and depression. Another limitation is that assessments relied on self-report of youth. The BED assessments could have been augmented by clinical interviews, however, limited resources for the study prevented this. In addition, the data collection was completed for this study eight years ago. However, given the limited funding available during the past eight years for mental health programs, particularly for minority or immigrant youth, the number of agencies/programs targeting Haitian youth unfortunately has not changed significantly. Therefore, the findings from this study are still relevant for Haitian American youth, primarily among those enrolled in public schools in urban centers in the U.S. Finally, the study was cross-sectional in nature. Risk factors and symptoms were assessed at the same time; therefore, the results emphasize factors "associated" with depression and PTSD and the direction of these relationships cannot be ascertained. In this regard, the analysis was exploratory and does not allow for causal inferences.

A significant level of depression and post-traumatic stress disorder was observed in the present study reflecting a need for enhanced services in the schools and improved access to mental health services for Haitian immigrant youth. Depression and PTSD in adolescence have the potential to result in poor psychosocial outcomes and can have long-term implications. The broader context, including the safety levels of U.S. cities where many new immigrants and refugees with a history of trauma have resettled, should be considered, given that it appears that a continued lack of security in urban environments can result in a persistence of PTSD symptoms among youth [6]. While it is acknowledged that youth can serve as a tremendous resource for one another and that refugee and immigrant youth have often demonstrated a great deal of resiliency, more resources are needed at the policy and program levels to ensure that high risk youth receive much-needed prevention services and mental health treatment to prevent negative outcomes, including the risk of suicide, as they transition into adulthood.