The Border Is Everywhere: Proactive Tips for Care of Immigrant Kids

Laurie Scudder, DNP, PNP


May 31, 2019

The Unique Stressors Facing Immigrant Children

During a well-attended plenary session at IPA 2019 moderated by Kraft and Errol Alden, MD, the incoming president of IPA, speakers explored the universal stressors and commonalities experienced by children in humanitarian settings, and the needed response from the healthcare community to help children cope with violence, displacement, and separation.

After the session, Kraft sat down with Medscape to share her experiences and her recommendations for caring for these at-risk kids.

Exposure to violence and stress poses a unique threat to the developing brains of children. Can you summarize what we know about the effects of toxic stress on young children?

Neuromodulation of stress hormones follows specific patterns. Brief, intermittent elevations in cortisol production by the hypothalamic pituitary axis in response to a stress—the "fight or flight response"—is generally a good thing, essential to developing resilience. A 15-month-old who has a temper tantrum when prevented from touching something they want to explore has a rise in cortisol. But in the presence of a loving adult, the child is redirected and learns that "somebody can say no to me and I'm going to be okay." Tolerable stress is that situation in which there are scary things happening around you, but that adult who is your connection can be supportive, help you figure out the next step, and this is a good result.

Toxic stress is very different, resulting in high levels of cortisol that are not mitigated by that caring, loving adult. That child never learns what happens when those stress hormones fall. He or she is always on red alert.

Toxic stress disrupts the developing brain architecture in these young children. Children exposed to toxic stress and adverse childhood experiences are more likely to have developmental delay that leads to poor behavior, lack of readiness for school, and school failure. It leads to the adoption of behaviors to help to combat that stress, such as fighting, overeating, and later, smoking, alcohol use, and truancy. Eventually that leads to chronic adult problems. Long-term, these kids are much more likely to develop cancer, heart disease, morbid obesity, renal disease, or arthritis. That all stems from these high levels of stress hormones that are toxic and unmitigated by that loving adult.

So the difference between tolerable and toxic stress is entirely that adult who can love and support that child.

Let's spend a couple of minutes talking about the clinician's role. Virtually all pediatric clinicians will at some point provide care for a child who is an immigrant, lives in a violence-prone community, or has been affected or displaced by a natural disaster, such as a hurricane. What are the red flags that you think everybody needs to know to indicate that this kid needs intervention and needs it soon?

The first thing that I look for are adaptive versus maladaptive behaviors. Is the child eating? Sleeping? Does the child exhibit externalizing behaviors that are troublesome, such as acting out, fighting, crying excessively? On the flip side, are there internalizing behaviors, such as being anxious and withdrawn?

But just as important to assess are strengths: Who is the strong person that the child looks up to? Does the child have an adult in their life who is their connection?

Strengths are not just the other folks who are in a child's life. What are the child's own strengths? Do they like music, art, or reading? Are they good at something athletic?

You find their strengths and their supports and you begin to build on them. This is good advice for any child, but particularly for children who have been through traumatic events. That's the first and foremost thing that a healthcare provider needs to do.

Children who have very maladaptive responses to stress, who cannot cope because they are so anxious that they're not able to eat, sleep, play with other children, or participate in school, need to receive trauma-informed care because those children have clearly been traumatized. A specialized therapist can work with both the parents or adults and the children to rekindle some of those strengths, using the things the child enjoys so that they can rebuild, or build for the first time, those social emotional bonds.

Then we get into the issue of capacity, particularly with mass disasters or large low-resource communities. When you identify a child who needs intervention but is unable to access appropriate mental health resources, what do you do? Are there evidence-based interventions that clinicians can employ themselves in situations in which they just can't get a child into trauma-informed care because it doesn't exist or is overwhelmed?

Yes. There are community-based, nonspecialized interventions that really help families to create an environment supportive for the children. Home visiting is an important intervention, if it is available, because when you have a traumatized child, you also have a traumatized parent. If you can help empower that parent to make that situation a healing situation for that child, to begin to interact with that child in a way that's positive, begin to do things that they both enjoy (eg, drawing, reading, cooking), then you begin that healing process. That's something that can be very low-resource.

A pediatric clinician can identify the strengths in the parents and the child and help promote them in a healing fashion. That's something that can work. A clinician can support a parent by reinforcing that the simple things they do with their child are important, necessary, and therapeutic. Reading for 20 minutes at bedtime. Sitting down and drawing pictures about their lives. Simple things. Simply telling a parent how therapeutic that behavior can be, especially a parent who may well be overwhelmed themselves, empowers that parent.

I tell parents to be sure to catch their child doing right. But a word from a trusted pediatrician reinforcing what the parent is doing right is just as important: "I love the way that you're singing to your infant; that's really going to build her brain." Or "I love the way that you're playing 'I spy' with your 3-year-old; that's going to encourage his development."

Simple suggestions as small as those, small tools that clinicians can share with their families, help parents promote that social-emotional bond and enjoy a positive time with their child. That behavior then becomes part of a routine that is healing.

It's not going to take the place of trauma-informed care for children with serious behavioral or mental symptoms, but it is a good start.

What about trauma-informed kits or other "off-the-shelf" resources? Are these helpful?

Yes, many of these trauma-informed kits are evidence-based. They include components to foster attachment, encourage exploration, build mastery. They can be used in an office setting, a community center, or other safe spaces that are provided by first responders during disasters.

The Substance Abuse and Mental Health Services Administration offers a number of resources for child trauma-informed care. These are not specific to any one type of event but can be helpful across a range of situations, from children who are being bullied, to children who have experienced domestic abuse, to kids who are navigating the juvenile justice system. Let me also make a pitch for AAP's Resilience Project. The site provides tools and resources to help clinicians support children who are dealing with violence and toxic stress.

Both the AAP and IPA have focused on the importance of advocacy and encouraged clinicians to step out of our comfort zones, get out of our practices, and advocate for these at-risk kids. But that can be a bit scary. Most of us do not innately have the ability to advocate. What tools do you suggest?

AAP provides the Bright Futures toolkit, which is available to members. That's a great resource. But remember that advocacy is local, too. It can be things like writing an op-ed for a local paper, testifying at town hall meetings about the importance of a playground, or getting more involved on social media to disseminate good health information. As a child advocate, if you affect the community where that child spends their day and promote health and wellness locally, that's advocacy.

That day-to-day advocacy can happen in an office, too. Encouraging families to get a library card, pointing a family to resources for identifying high-quality childcare, telling them where to find a local playground—these are one-on-one interventions that we all can do every day. And it's all advocacy.

The National Child Traumatic Stress Network is another great resource. Their trauma-informed care site, in particular, provides resources for healthcare professionals and families in a range of languages.

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