The following essay, by Dr Nadia Nikroo, is the winner of this year's annual Section on Pediatric Trainees (SOPT) essay competition. The competition focused on the 2024-2025 SOPT advocacy campaign "HEADSS Up!" by inviting essays on adolescent mental health. The runner-up essay will appear in a future issue of Pediatrics.Every week in our community-based pediatric clinic, I encounter teenagers whose stories never make the news. They've crossed borders, not just of countries, but of unimaginable trauma. Some arrive alone, fleeing poverty and violence, seeking safety and opportunity in the United States. Their journey through the Darien Gap—a treacherous jungle spanning the border of Colombia and Panama—is one of desperation and survival. As pediatricians, we meet them—not at the border, but after; after the rain has soaked their clothes for days, after they've seen bodies that didn't make it, after assault, illness, and fear.1 We meet them in the office as they try to pretend it's all behind them.But it never is.Now living in temporary shelters, often with strangers, they're adjusting to a new culture, language, and system—while grappling with trauma that hasn't been named, processed, or healed. It's within this context that I've learned the true weight and worth of the Home, Education/Employment, Eating/Exercise, Activities/Peer Relationships, Drugs/Alcohol, Sexuality, Suicide/Depression, and Safety (HEADSS) assessment, and how, when used with care and intention, it can be more than a screening tool—it can be a lifeline.I often begin with "home," aware that it's rarely straightforward: who they live with, is it safe? "Home" is a complicated concept. Many migrant youths are placed in shelters, stripped of the comforts that once made home feel safe—familiar smells, sounds, and the warmth of a favorite meal. When I ask where they're staying, some give me an address; others pause, eyes distant. "Nuestra habitación está llena, pero estoy agradecida de estar aquí" ("Our room is crowded, but I'm grateful I am here"), one teen shared, her voice soft but steady, her expression both weary and thankful, as if trying to reconcile the chaos of her surroundings with the comfort of being with those she loves.Home was a place they fled. For months, it was a perilous crossing marked by dense rainforest, flash floods, and lawless zones—a place where many have disappeared or perished trying to find safety. Now, it is an overcrowded shelter, often with missing loved ones.For these resilient adolescents, "home" has been destabilized. The trauma of separation from parents, siblings, and friends and the loss of a stable environment compounds their risk for anxiety, depression, and posttraumatic stress disorder (PTSD).2 A superficial HEADSS evaluation risks missing the deep cracks beneath the surface. But when we enquire with patience, and listen without judgment, we open the door. Sometimes, just asking "Who do you trust here?" is enough to begin building a sense of safety.Many migrant teens express a sense of both fear and excitement about school—an unfamiliar but promising structure in their new world. However, they face countless barriers: limited English proficiency, undocumented status, lack of previous education, and the stigma of being "the immigrant kid."One 15-year-old I saw had completed sixth-grade education before fleeing Peru. Now enrolled in a US high school, he is expected to keep up with peers of his same age. He is obviously bright, but he is overwhelmed. "I want to learn," he said in Spanish, "but I don't even know how to speak English." School opens doors, but also poses challenges, both academic and social.We as clinicians must recognize that school is not just a place of learning—it is a site of identity negotiation, stress, and, eventually, potential healing.When I ask about activities—what they do for fun—many look confused. Some laugh uncomfortably. "No tengo tiempo para diversión" ("I don't have time for fun"), one girl said. "Fun" now feels foreign and distant.The pressure to earn money also looms large. Some seek clandestine or unofficial work in hopes of sending money back home. Others are consumed by guilt for the sacrifices their family made to send them here. Work is now an essential part of life, even for young teens. And yet, building personal connections and a sense of accomplishment is a critical part of healing.Reconnecting with activities—sports, music, youth groups—is not frivolous entertainment, but rather therapeutic. These essential pastimes are part of what makes adolescence developmentally rich, rather than prematurely aged by trauma.3Among the teens I see, substance use is often an undisclosed and hidden issue. Some have used substances during their migration journey—to cope, stay awake, or numb pain. Others are introduced to substances in shelters or schools where peer pressure and stress intersect.Without judgment, I ask and open the door gently: "Have you seen other teens using drugs? How do you feel about that?" Our role is to create a safe space. One without fear of judgement, punishment, or deportation. One where we can identify root causes to connect patients to resources that may address deeper issues, and not just ease symptoms.For many youths, sexuality is a landmine. Some have been sexually assaulted during their migration journey. Others struggle with gender or sexual identity in a culture that may not be accepting. Culturally sensitive conversations and trauma-informed care are essential.One young girl disclosed an assault in the Darien Gap only after multiple visits. She shared, "I didn't think I could tell anyone—because I didn't scream loud enough."We must affirm that what happened to them matters, that their voice matters. We must talk about consent, safety, and identity with language they understand, and with sensitivity and respect. This isn't just about sexual health—it's about reclaiming agency over their own body.Suicide is the second leading cause of death among adolescents in the United States,4 and for migrant teens who've faced trauma, loss, and cultural isolation, the risk is even greater. The silence around mental health in many cultures only deepens the shame.5A 12-year-old boy from Colombia, after surviving the journey and finally reuniting with his father at the US border, broke down during our HEADSS conversation. "Estoy aqui" ("I'm here"), he said, "pero sigo ahi. En la jungla. En ese momento" ("but I'm still there. In the jungle. In that moment").His nightmares kept him up. He didn't tell his family because he didn't want to seem weak. But in that exam room, with one simple question—"How has sleep been lately?"—he finally spoke.Mental health screenings must be more than a perfunctory checkbox.6 We must offer time, trust, continuity, and partnerships with mental health providers and trauma-informed therapists who understand the cultural and migration context. Only then can our patients begin the long journey toward healing.As a pediatrician, it is a privilege to be trusted with the stories of these courageous teens. I've learned that our role extends beyond prescriptions and diagnoses—we are witnesses, advocates, and often the first safe adult migrant teens encounter in this country.But we cannot do this alone. Pediatric residency programs must include sensitivity training on trauma-informed care, cross-cultural communication, and immigrant health. Policies must ensure funding for integrated mental health services in community clinics. Programs such as the Refugee Trauma and Resilience Center and School-Based Health Centers have demonstrated success in providing culturally responsive mental health care to immigrant youth by embedding services already in place for children and adolescents, thereby reducing stigma and increasing access.7,8 Additionally, evidence-based therapies such as trauma-focused cognitive behavioral therapy and narrative exposure therapy have shown promise in addressing PTSD and depression among refugee and migrant teens.9 In-person language services, legal support, and long-term mental health partnerships are essential components of health care. Most of all, providers must offer time—time to listen, time to build trust, time to ask questions beyond the stethoscope.The adolescent migrants I care for are resilient. But resilience is not a replacement for support and advocacy. It is our responsibility to treat the wounds we can see and those we cannot—listening for pain that remains hidden. If we reframe the HEADSS assessment to build connections, then we can provide our patients with a service many have not experienced: someone who listens, and someone who stays.To the brave teenagers who crossed a harrowing path to reach the United States in search of a better life—thank you for your trust, your honesty, and your unshakable courage. Sharing your truths took immense strength. Your voices are powerful, and your stories matter. It is a deep honor to carry them. I carry them not just in my heart, but into every space where change is needed. This work exists because of you—and it fights for you. Muchísimas gracias.
Nadia Nikroo (Tue,) studied this question.