Toxic Stress in Children in Deportation Centers Is Real: Strategies to Help Them

Interviewer: Laurie Scudder, DNP, NP; Interviewee: Julie M. Linton, MD


July 02, 2018

The American Academy of Pediatrics (AAP), in conjunction with other healthcare professional organizations, has released a statement opposing the separation of children and families at the border.

(c) 2017 Flynn Larsen. Photo courtesy of the Robert Wood Johnson Foundation.

Medscape spoke with Julie M. Linton, MD, FAAP, co-chairperson of the AAP Immigrant Health Special Interest Group and a pediatrician in Winston-Salem, North Carolina, about the environment that led to this statement. We asked Dr Linton to discuss what she is seeing in her own practice as well as practical strategies for pediatric clinicians who provide care for both documented and undocumented immigrant children.

Medscape: This recent statement from the AAP follows a 2017 policy from the AAP on Detention of Immigrant Children that you coauthored. So the recent statement is consistent with a number of policies and statements advocating for immigrant children. While these policy statements are clearly important, can you describe the AAP's other efforts to address this situation?

Linton: There are two critical issues here. First, although the systematic separation of children and families may be stopping based on the executive order issued by the White House on June 21, all children who have been separated from parents should be reunited immediately with the parent(s) with whom they traveled and from whom they were separated. Second, the detention of children is not a solution to the forced separation of children from their parents at the US border.

Medscape: You and others from the AAP, notably current president Colleen Kraft, have been very visible in your efforts to call attention to and reverse this policy. But aside from that very public space and bringing attention to this issue, what else has the AAP been doing behind the scenes?

Linton: Pediatricians across the country, in our communities and in the press, are speaking up on behalf of children and families. The AAP Immigrant Health Special Interest Group has been more active than ever in an effort to prioritize children's health at the local, regional, and national levels. There has been a lot of work by the AAP at the federal and state levels with lawmakers and government officials in support of policies that put the best interest of children and families at the forefront and apply a child health lens to all policy.

Medscape: You spoke with us last year about the concept of toxic stress and the effect on children. And there is certainly the very real concern that children separated from their parents will suffer from toxic stress. But what about the kids in your practice — far from the border? Is the current situation — and the resulting media coverage — affecting these "bystander" kids? Can you share with us what you are seeing on the ground, in the kids in your practice, in response to the immigration policy being enforced at the border?

Linton: That requires a two-part answer. The first part is about newly arrived immigrant children, which is not just a border issue but one that impacts Americans all across the country. Children, both those who have been separated from parents and processed as unaccompanied as well as unaccompanied immigrant children, and children in family units are living in communities across the country. When children are under the custody of the Office of Refugee Resettlement, they are sent to shelters in communities all over the country and ultimately released to sponsors in communities across the country. So a clinician anywhere is likely to encounter unaccompanied immigrant children and children who have been separated from parents at the border. Healthcare professionals, teachers, and other community members have an opportunity and really a responsibility to begin to repair the minds and the bodies of children who have been harmed by policies forcing separation and detention.

The second part of your question is about children in immigrant families in general. Children in immigrant families are foreign-born or have at least one parent who is foreign-born. I believe that harmful policies — such as Executive Orders that leave children in mixed-status families to fear separation from their parents — are associated with significant stress. Some of the negative discussion about immigration in general adds further to the climate of fear and uncertainty that already threatens the health and well-being of children and immigrant families in general.

Highly stressful experiences like family separation and detention cause irreparable harm to the developing brain of children.

Medscape: What are the red flags that alert you to toxic stress in the kids in your own practice? Are there signs you can see in real time, or is it something that will rear its head at a later date?

Linton: It's both. Severe prolonged stress without buffering support — toxic stress — can threaten the mental and physical health of these children now and later. Highly stressful experiences like family separation and detention cause irreparable harm to the developing brains of children. In the short term, there are a number of trauma-related red flags that we might see. Children may experience changes in bodily function, sleeping patterns, eating, or toileting, including bedwetting or even fecal incontinence.

You may see changes in behavior that may look like detachment or numbing, aggression, anxiety, or exaggerated responses, such as an exaggerated startle. You may see changes in learning, frequent severe tantrums, limited working memory, and organizational problems. It's really important for healthcare providers to recognize the red flags, but also to help parents and caregivers, or in some cases sponsors, to recognize the symptoms of trauma and to prepare them to support children who are experiencing these symptoms.

Medscape: If news reports are to be believed, there have been cases of children being forcibly medicated in an attempt to control behavior. Is there any situation in which you would use medication to help a child who was experiencing the short-term effects of toxic stress?

Linton: In the community setting when I, as a pediatrician, care for children who have experienced trauma, the first-line management is counseling. Trauma-informed cognitive-behavioral therapy has the greatest amount of evidence behind it. More broadly, children ideally need access to trauma-informed mental healthcare. In many communities, that may be limited by an availability of providers who are both trained in trauma as well as able to provide services in the child's preferred language. However, this should be the mainstay of treatment.

But, yes, there are times when medications can be used to support children who have significant symptoms as a result of trauma, used in conjunction with counseling.

Medscape: Assuming that the clinician is not aware of a child's citizenship status, is that a question that should ever be asked? What about documentation of care of these children? Is it safe to document a child's citizenship status within health records?

Linton: We get some guidance on medical documentation as it relates to immigration status from the National Immigration Law Center. It is recommended that we not document immigration status in a child's medical record, and that we're cautious about even asking about it. There are times when I will document. For example, if a child is an unaccompanied immigrant child or a family unit is already in immigration proceedings and we're working together with a lawyer. I think it's important to get guidance from the lawyer on providing supportive medical documentation that can facilitate access to legal relief. And so that is an important time where documentation in the medical record is supportive for the child.

If it's a case where it's documentation in the setting of fear of separation from the parent due to the parent's immigration status for instance, I do not document the legal status of a parent on the medical record.

Medscape: Recognizing that cognitive-behavioral therapy is not always available, particularly for families with limited financial resources who may or may not have third-party insurance, what are some of the other resources that you would recommend?

Linton: The AAP Immigrant Health Toolkit has a number of resources. There is a special section on mental health that offers some suggestions.

The availability and number of community-based mental health providers varies, and clinicians are encouraged to learn their local resources. In the community, many pediatric practices have co-located or integrated behavioral health services within the practice and in that setting that would be the first person to go to. Some departments of public health, federally qualified health centers, and free clinics offer mental health services. School-based interventions are a really great option for children, particularly for those having symptoms that impact their ability to function in the school setting. Finally, some of the refugee resettlement organizations offer support.

Medscape: Aside from the clinical care of these children and families, what other things do you suggest to your colleagues that can help them advocate for these children? We are all aware that we can call our legislators or write opinion pieces for local newspapers. But are there other activities that the rest of us may not be as aware of that you would suggest are potentially helpful?

Linton: Absolutely. I think the first step is getting involved in our local communities, using resources like the immigrant health toolkit or other resources that give suggestions, not just on providing healthcare, but also on engaging in the community. Every newly arrived immigrant child needs access to healthcare, free public education, and, for those in legal proceedings, legal representation. Being familiar with how newly arrived immigrant children can enroll in school in your community and being familiar with the resources that exist in your community are incredibly important.

I also encourage my pediatrician colleagues to connect with their local or state AAP chapter. For family physicians and other healthcare professionals, I'd suggest the same.

Learn about any opportunities taking place in your state or community to speak up for immigrant children and families. Family Belong Together provides information about events relating to family separation in your state or city. Another organization I would recommend is The Protecting Immigrant Families, Advancing Our Future campaign, co-chaired by the Center for Law and Social Policy and the National Immigration Law Center which provide a number of resources.

Physicians can also volunteer to write Letters of Declaration or affidavits for pro bono legal organizations for children and/or adults with medical conditions that are worsened by being in detention. The Migrant Clinician Network has now created the infrastructure for physicians to volunteer to write these letters and a place to sign up.

And then finally there are a number of resources for children on the AAP's Healthy Children website regarding supporting children and families and the health impacts of detention as well.

Medscape: What about social media? Do you think there is any role for social media use by professionals?

Linton: Certainly, and not just for following your own organization but the other organizations that you care about. Social media can be great. Use hashtags that bring people from different professions that are working towards the same thing —-#FamiliesBelongTogether and #ProtectFamilies are two examples that may provide an opportunity to reach outside of the echo chamber. But I do think we have an obligation to be sure that our sources are well founded and consistent with the principles that we are trying to uphold. I closely follow the Young Center for Immigrant Children's Rights and Kids in Need of Defense (KIND ).

Medscape: Is there anything else you would like to emphasize?

Linton: It is important to repeatedly emphasize that conditions in detention facilities are traumatizing for children and damaging to short and long-term health. Detention of families is not a solution to family separation.

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