Inconsolable children who could not stop crying. A chronic shortage of qualified staff. Trauma so severe that clinicians worried about their own mental health.

These are just some of the findings revealed in a damning report on the challenges of addressing the mental health needs of migrant children in U.S. government custody. The report, compiled by the Department of Health and Human Services’ Officer of the Inspector General (OIG) and released on Wednesday morning, found that Trump administration policies—most notably the disastrous “zero-tolerance” policy that resulted in the separation of thousands of migrant children from their families—exacerbated a mental health crisis among those in the care of the Office of Refugee Resettlement (ORR).

Citing interviews with approximately 100 mental health clinicians, as well as medical coordinators, facility leadership, and 28 federal field specialists assigned to 45 ORR facilities around the country, Acting Inspector General Joanne M. Chiedi found that “separated children exhibited more fear, feelings of abandonment, and post-traumatic stress” than children who were not separated from their families.

“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,” the report states, citing program directors and mental health clinicians tasked with caring for nearly 9,000 children, almost 90 percent of whom were from Guatemala, Honduras, and El Salvador. “For example, some separated children expressed acute grief that caused them to cry inconsolably.”

The trauma described in the 48-page report is brutal. One program director described a 7- or 8-year-old boy separated from his father as being “under the delusion that his father had been killed and believed that he would also be killed.” The boy required emergency psychiatric care.

According to a medical director of an ORR facility, children constantly manifested physical symptoms of the mental and emotional trauma inflicted by separation.

“You get a lot of ‘my chest hurts,’ even though everything is fine [medically],” the director said. “Children describe symptoms—‘every heartbeat hurts,’ ‘I can’t feel my heart’—of emotional pain.”

Many of the children were already suffering from “intense trauma” that occurred before they were separated from family members at the border, experiences in their countries of origin or during their journey to the United States that made treatment even more difficult. In one case, a mental health clinician reported that a child witnessed the murder of his mother, grandmother, and uncle after fleeing an abusive father. Another clinician shared the story of a child who was abducted by a gang and held for ransom while attempting to cross into Mexico from Guatemala.

“The gang held the child in a compound, where another individual was shot in the head,” the clinician said. “Later, a woman who helped the child escape from the compound was shot by the gang.”

ORR’s facilities were in no way prepared to adequately treat issues of that magnitude, the report found, in part because shifting administration policies made it difficult to know how long a child would be in their care. Clinicians reported being wary of having children revisit traumatic incidents, for fear that they would be unable to address those incidents in future therapy. Instead, treatment was focused on maintaining stability, an approach that clinicians referred to as the equivalent of a Band-Aid: “The goal is not to treat children’s underlying issues because children will not be in the facility long enough to make meaningful progress.”

Clinicians felt “unprepared” to handle the level of trauma they witnessed in ORR facilities, to the point that they began to feel traumatized themselves. Some colleagues, who had no experience in caring for kids, were “especially unprepared,” the report found.

Compounding the difficulty of the cases was the number of cases each mental health clinician was expected to handle. Although ORR regulations require a staffing ratio of 12 patients per clinician, some had caseloads of more than 25 children, which made building a rapport with patients and scheduling counseling sessions incredibly difficult.

“The most challenging thing is the lack of time due to the caseloads,” one lead mental health clinician told the OIG. “Some [children] have behavioral issues or are going through difficult times and you need to see them more during a given period. It becomes a strain on us.”

In a briefing with reporters on Wednesday, Amy Frontz, assistant inspector general for audit services, said that more than half of shelters supervised by HHS allowed new employees to begin work without completing a background check or screening by state child-protective services. More than half of the facilities employed case managers who didn’t meet requirements to serve as mental health providers.

Low compensation, demanding schedules and a scarcity of qualified candidates in remote locations exacerbated the caseload issues, the report found. Staff at ORR facilities described making appointments with psychiatrists and psychologists as far as three months in advance—all while children with severe mental health problems languished in inadequate care. Transferring children out of ORR facilities for treatment of underlying mental health problems, or for more severe mental illness, was incredibly difficult, clinicians reported, putting kids at risk of harming themselves or others.

“The facility tries to keep them safe, but there are many ways a child can harm themselves,” one clinician reported. “The children need a secure residential treatment center for children that are high-risk and need intensive therapy.”

“It is a temporary shelter, not a treatment facility,” a program director echoed. “There is also an issue where residential treatment facilities won't take minors who are aggressive, even when those minors are aggressive because they have untreated mental trauma.”

As clinicians were stretched thin, the population of the facilities grew ever larger, in part due to new regulations requiring federal background checks and fingerprinting of family members seeking to be reunited with their children, which clinicians fear discouraged family members from coming forward. The average length of stay for kids in ORR custody reached a high of 93 days in November 2018, which the report found resulted in “higher levels of defiance, hopelessness, and frustration among children, along with more instances of self-harm and suicidal ideation.”

Some separated children, clinicians said, isolated themselves from other kids, refusing to eat or participate in activities.

“Every single separated kid has been terrified,” one program director said. “We’re [seen as] the enemy.”

The “hectic” court-ordered reunification process presented its own complications in adequate treatment, the report found. Case managers weren’t always able to let children know when, where, or even if they would be reunified with their families, an uncertainty which “added to the distress and mental health needs of separated children.”

In a series of recommendations, the OIG called for increasing regional recruitment of qualified staff, limiting caseloads to an “appropriate maximum,” ensuring that external providers include mental health specialists equipped to treat severe mental illness in children, and, perhaps most importantly, “reasonable policy and practice decisions that can help to minimize the length of stay for children in ORR facilities.”

In a response to the report, Lynn Johnson, assistant secretary for children and families, wrote that she “welcomes” the report “as we work to continually improve ORR’s delivery of mental health care.”