Abstract
Separation of immigrant and refugee children and their families is a public health crisis that has the potential to negatively affect these children and their families for generations to come. Aside from the fear and traumatization that these young children are experiencing, their parents are at risk of developing depression and experiencing extreme grief. Once these children are forcibly separated from their parents, the system is unable to keep track of them and houses them within unsafe detention centers, where illness is rife and deaths have occurred. Even if these children and their families are reunited, they will need extensive therapy provided by properly trained professionals to help mitigate adverse effects. Some would argue that these children and their families have brought this separation upon themselves by entering the country illegally with the intention of committing crimes. However, such claims have been refuted time and again through extensive research. This policy statement calls on the United States government to reunite these separated children and families immediately, to end the policy of separating and detaining family members, to ratify the United Nations Convention on the Rights of the Child, to prosecute human rights violations to the fullest extent of the law, and to conduct additional research on the mental, physical, and cultural consequences of separating and detaining families, including lactating mothers and babies.
Relationship to Existing APHA Policy Statements
Problem Statement
Recent U.S. immigration policy, through forced separation of minors from their parents, housing of minors in inadequate facilities, failure to notify family members of children’s whereabouts, and failure to provide means of direct contact, has failed to consider the rights of minor immigrants and is in direct violation of accepted international human rights standards. As public health professionals, it is our mandate to advance the health and well-being of all people, with particular attention to the most vulnerable. Therefore, we are compelled to speak out and document that, beyond the negative human rights implications, this policy has long-lasting negative physical and mental health implications for these separated minors.
Separation of infants and young children from their families, especially from their parents and parent figures, can have mental, emotional, physical, and behavioral consequences for families and children. When separation occurs across cultures communities, it has cultural consequences as well. Separation can be traumatizing. Trauma experienced by adults and children is further intensified when the processes of separation have been unpredictable, forced from the outside, and conducted by institutions and groups that have an extensive history of harm to the cultural communities from which the parents and children come.
Not only does family separation have significant short- and long-term adverse effects, but the impact of such traumatic experiences may also extend over subsequent generations. Specifically, adverse childhood events may program phenotypes that contribute to disease risk in subsequent generations.[1]
Human rights: According to the United Nations Convention on the Rights of the Child,[2] an internationally recognized and ratified set of principles for protection of children’s rights as yet unratified by the United States, migrant children, irrespective of their legal status, are entitled to health care of the same standard as children in the resident population. Furthermore, Article 9 of this convention specifies that parties are to ensure that a child is not separated from his or her parents except when such separation is in the best interest of the child and are to respect the right of children who are separated to maintain direct contact with their parents unless such contact is deemed contrary to their best interest. Article 37 stipulates that “[n]o child shall be deprived of his or her liberty unlawfully or arbitrarily [and that such action will] be used only as a measure of last resort and for the shortest appropriate period of time.”
The physical and mental health of migrant children is related to their health status before travel, the conditions in which they lived in transit and at their destination site, and the physical and mental health of their caregivers.[3] Traumatic events such as separation from family have been identified as having long-lasting physical and psychological effects on migrant children, including depression and posttraumatic stress disorder.[4] This is significant considering recent U.S. policies that resulted in the reported separation of more than 3,600 migrant children from their parents and families at the U.S. border, although the true number is likely to be higher.[5] At least seven children have died in immigration custody.[6] Multiple international statements and agreements acknowledge the specific vulnerability of migrant children and unaccompanied minors and the special responsibilities of destination countries toward these minors, regardless of their legal status.
Physical and mental health of children: In 2018, there were 70.8 million forcibly displaced persons worldwide, among whom 25.9 million were refugees. Children younger than 18 years constituted approximately 50% of this refugee population, of whom 110,000 were unaccompanied and separated child refugees.[7] With the increase in migration in recent years, much information has been recorded regarding negative impacts on both the physical and mental health of unaccompanied minors. There is less specific documentation on the health impact of government-forced separation of migrant children from their parents, a practice universally denounced by human rights and professional organizations.
Prompt health assessments and delivery of appropriate health care to unaccompanied minors are critical in reducing the individual burden of disease and decreasing the risk of infection to others in the population.[8] Many migrant children, whether unaccompanied or in family units, travel to flee violence and poverty and migrate from communities where the burden of endemic infectious disease is high.[9–11] Infectious diseases such as intestinal parasites and respiratory infections, influenza, and pneumococcal disease are reported most commonly. Nutritional deficiencies (e.g., iron deficiency anemia and dental caries) and mental health disorders (e.g., depression and posttraumatic stress disorder) are also common.[12] Increased levels of depression, anxiety, and posttraumatic stress disorder have been reported among refugee children.[13] Symptoms of these disorders include reexperiencing of trauma, stimulus avoidance, restlessness, agitation, sleep disorders, somatic symptoms, low mood, and poor academic performance. Rates of mental health diagnoses among refugee children are consistently reported as very high (ranging from 25% to 69%).[14] Rates are higher among children separated from their parents.[15–17]
Exposure to violence has been shown to be a key risk factor for mental illness, and rapid resolution of asylum claims, stable settlement, and family cohesion have positive long-term effects on children’s psychological functioning.[16] Longitudinal studies involving follow-ups ranging from months to several years show the persistence of mental health issues over time. In long-term follow-ups, diagnoses of depression have been shown to be more closely related to postmigration stressors than to past conflict-related experiences. In contrast, posttraumatic stress disorder has been linked to conflict-related experiences.[17,18] Rates of inpatient psychiatric admissions and levels of self-harm and suicidal behaviors are higher among unaccompanied than accompanied refugee minors.[19] With the increase in the number of asylum seekers globally, many countries have established detention centers, which become an additional source of trauma.[20] Even with improved living standards in these detention centers and cell phone and Internet access for detained children, detainees’ mental health is negatively impacted by disempowerment and lack of control.[21] Evidence points to improved coping skills among refugee and internally displaced children when they are accompanied by their parents.[22] In cultures in which the extended family unit is of primary importance, forced family separation affects not only parents and children but also aunts, uncles, cousins, grandparents, and other family members.
A 2018 review reports the negative impacts of recent punitive US immigration policies related to child separation and child detention centers. These negative impacts include damaged attachment relationships, traumatization, toxic stress, and wider detrimental effects on immigrant communities.[23] An Australian study comparing the social-emotional well-being of detained migrant children and migrant children placed in the community demonstrated that children held in detention had significantly more social, emotional, and behavioral difficulties than children living in the community.[24] In summary, the literature offers evidence on both short-term and long-term negative mental health impacts of migration on children, with these effects compounded further by detention and by separation from parents.[25]
Maternal effects of family separation: The potential maternal effects of family separation must also be considered. Literature on this topic documents the structural inequities that lead to mothers being separated from their children, including poverty, unemployment, and violence, and the negative mental and physical health effects of this separation on mothers.
Mothers who are forced to separate from their children typically experience intersecting social and economic barriers to education, health, housing, and other factors that affect their ability to financially support their children. Mothers may be driven to migrate and risk family separation in search of employment or in fleeing personal or political violence in pursuit of their children’s welfare.[26] Mothers who have lost custody of their children have been shown to have a higher baseline prevalence of social instability than mothers in the general population, and family separation only exacerbates existing problems.[27,28] The suffering experienced by these mothers after separation contributes to further instability and to adverse outcomes including homelessness, suicide attempts, intimate partner violence, and entry into sex work.[27]
Refugee and immigrant women in general have high levels of clinical depression, posttraumatic stress disorder, and suicide.[29] Separation from a child, whether through custody loss or migration, leads to grief, depression, and social isolation.[26,27] Mothers who have lost custody of a child have a higher prevalence of mental illness than even mothers who experience the death of a child.[30] In addition, mothers who have lost custody of a child have been shown to have higher rates of suicide attempts and completions[30] and increased rates of mortality, specifically avoidable mortality.[28]
Lactation and breastfeeding: Breastfeeding is one of the most cost-effective child survival interventions known, with profound health benefits for both the mother and the child.[31,32] Exclusive breastfeeding for the first 6 months and continued breastfeeding for at least the first year (according to the American Academy of Pediatrics) or for the first 2 years and beyond (according to the World Health Organization) are widely endorsed by leading public health organizations, including APHA (Policy Statement 20132 [An Update to A Call to Action to Support Breastfeeding: A Fundamental Public Health Issue] and Policy Statement 20145 [Supporting Breastfeeding Worldwide through Maternity Protection]). The United States acknowledged and supported these recommendations in the 2011 Surgeon General’s Call to Action to Support Breastfeeding. However, forced separation of women from their children threatens the ability of women to breastfeed long enough to meet these recommendations. If a mother does not regularly express her milk according to her infant’s feeding pattern during separation, her supply will gradually diminish.[32,33] The mother will need to express milk to remedy the discomfort that develops when breasts become engorged and to avoid plugged ducts and possible breast infection (mastitis).[34] Mastitis can cause high fever and flu-like symptoms and lead to abscess and/or hospitalization if not treated promptly and appropriately.[34] When the mother does not express milk regularly, her breasts can become engorged to the point where they are painful.[34] Accumulation of milk in the breasts and engorgement also lead to decreased milk supply.[34,35] Long-term effects of early breastfeeding cessation include the loss of birth spacing benefits and increased risks for breast and ovarian cancers, diabetes, and cardiovascular diseases (myocardial infarction, hypertension, and hyperlipidemia).[31,33]
Separated infants also experience both short-term and long-term physical health effects. In the short term, breastfed infants separated from their mother probably will no longer receive human milk and will need a breastmilk substitute. Human milk stimulates infant gut development; use of formula instead of human milk impairs immune system development and affects metabolism later in life.[36] Substitutes are inherently nutritionally inferior to human milk, which is perfectly calibrated to a particular infant’s nutritional needs and changes over time to meet that infant’s needs. In addition, breastfed infants who are prematurely separated from their mother have higher risks of ear infections, respiratory infections, and diarrhea.[31] In the long term, infants who are not breastfed are at higher risk for malocclusion,[31] Crohn’s disease, ulcerative colitis and other gastrointestinal infections, sudden infant death syndrome, and leukemia.[33] Finally, children who are prematurely separated from their mother while breastfeeding will lose the intelligence benefit associated with breastfeeding and later benefits related to weight control and reduced risk of diabetes.[31] Moreover, infants who are bottle fed may be taught to ignore satiety cues and gain more weight in their first year of life than infants fed at the breast.[37] Thus, interruption or premature cessation of breastfeeding constitutes an added risk due to involuntary separation of lactating mothers and breastfeeding infants. Breastfeeding is much more than feeding; it is an infant’s primary bond to another human. It is how an infant learns to love and trust. It is the primary source of comfort, solace, and security. When that is suddenly taken away, an infant feels extreme distress. Moreover, early separation of mothers from infants has been shown to lead to later child aggression, a negative outlook on life, and language, math, and skill impairments.[38]
Continued breastfeeding or reestablishment of breastfeeding could mitigate toxic stress in children, which has been linked to adult diseases such as obesity, diabetes, hypertension, and cardiovascular diseases[39] along with asthma, autoimmune diseases, poor dental health, viral hepatitis, liver cancer, and depression.[40] Toxic stress has also been shown to have a negative impact on children’s later abilities to learn new skills, overcome adversity, and make decisions related to their health.[40]
Mental health effects on mothers: Involuntary separation of a mother and her infant causes distress for the mother, and the loss can result in complicated grief reactions. Involuntary discontinuation of lactation also causes distress and guilt, and a woman’s ability to lactate may decease during periods of stress. Thus, there are serious concerns about cessation of milk production when a mother has been forcefully separated from her infant.
Specific to women crossing the border, asylum seekers and mothers who are immigrating are more likely to experience postpartum depression than native-born mothers.[29] Furthermore, research in some populations suggests that discontinuation of breastfeeding is associated with a higher risk for postpartum depression among mothers.[41] Postpartum depression has serious implications for both the mother and the infant as a result of its effects on mother-infant interactions.[42]
Evidence-Based Strategies to Address the Problem
Services for detained immigrant children: While in federal custody, it is critical that separated children and unaccompanied minors be housed in physically and emotionally safe and developmentally appropriate environments. Moreover, detained immigrant children should receive evidence- and guideline-based health care and social services to support their health and well-being.[43,44] Specifically, the American Academy of Pediatrics recommends that immigrant children of all ages receive an initial medical and mental health evaluation along with ongoing health care, including community-based case management.[43]
A disaster crisis response: When the time comes to reunite these separated children and families, it is imperative to address this situation with a disaster response plan. After the devastating Hurricanes Katrina and Rita in 2005, the National Center for Missing and Exploited Children received more than 34,000 calls concerning separated minors. Reunification of families became a national priority. A report titled Post-Disaster Reunification of Children: A Nationwide Approach[45] documents several steps that should be taken in the process of reuniting separated minors with their parents or legal guardians: (1) identify the minor; (2) arrange for secure, safe shelter and care; (3) provide personal services such as grooming, clothing, and food; (4) designate a legal guardian in place of the unavailable parent or legal guardian; (5) implement a tracking system for a child’s location; (6) conduct a local and national search for the parent or legal guardian; and (7) verify the identity of the located parent or legal guardian before releasing the child to that individual’s care. The report also lists the following resources to help identify children and their parents: school records, social service records, birth records, state registration documents, and fingerprinting and/or DNA testing. Some of these identification methods may need to be modified for children and parents arriving in the United States under complex circumstances.[45]
Trauma and cognitive-behavioral therapy: It is important for public health and health care officials to consider the long-term treatment options for forcibly separated children and their parents to help counteract the potential effects of the traumatic experience of separation. The child’s age and culture, the family environment, and the child’s memories of the traumatic event are important considerations in selecting the optimal evidence-based treatments that best meet the needs and preferences of the child and family. These treatments should explicitly address the traumatic experience and its impacts while being sensitive to cultural beliefs and values. Proposed treatments should focus on healing and building resilience. An example of an evidence-based treatment for childhood trauma is trauma-focused cognitive-behavioral therapy, which combines child and parent psychotherapy to treat traumatized children.[46]
It is critical to treat both children and their families in the most effective manner possible to help counteract potential adverse long-term effects. The National Child Traumatic Stress Network suggests the following specific strategies: (1) regularly screening children for exposure to trauma and posttraumatic stress symptoms; (2) providing evidence-based, culturally responsive assessments and treatment for posttraumatic stress and related mental health problems; (3) ensuring that resources are available on trauma, its impact, and appropriate treatments; (4) focusing on strengthening protective factors that support resilience among children and families affected by trauma; and (5) addressing the traumatic experiences of parents and caregivers and their effects on the family.[47]
When adopting trauma-focused evidence-based treatments, it is important to address potential barriers that may affect treatment engagement while also ensuring that there is a strong support system for treatment delivery and guidance for clinicians administering the treatments. Implementing trauma-specific evidence-based treatments requires clinical training and ongoing supervision and collaboration with clinical supervisors to ensure that both children and their families do not experience retraumatization.[46]
Opposing Arguments/Evidence
There are two basic arguments forwarded by parties supporting the current U.S. policy on criminal prosecution and forced separation and detention of illegal migrant families at the U.S.-Mexico border, which has been used by the current U.S. administration to deter asylum seekers. The first relates to the perception that illegal immigration leads to increases in criminal activity in U.S. communities.[48] This argument is refuted by available research showing similar or lower crime rates among immigrants and, at a macro level, among neighborhoods with large immigrant populations.[49,50] The second argument relates to the “zero tolerance” enforcement of existing U.S. immigration law[51] and the contention that the responsibility and consequences of family separation reside with migrant families who knowingly cross the border illegally with children.[52] The argument that the zero tolerance policy, including family separation, simply enforces current law is refuted by a number of facts. This argument fails to take into account the reality that some families, fleeing persecution by local governments or criminal gangs, may be eligible for legal refugee status and asylum in the United States. Under international laws, individuals across the globe have the right to cross an international border and request protection and asylum.[53] Under such laws, migrants eligible for an asylum hearing should not be prosecuted. Zero tolerance enforcement violates this human right, and forced separation of children from their parents violates the UN Convention on the Rights of the Child.[2] Under this convention, children must not be denied liberty or separated from their parents (except when such separation is in the best interest of the child), and irrespective of their legal status migrant children are entitled to health care of the same standard as legal resident children.
Alternative Strategies
One alternative strategy is to seek court injunctions to reunite children with their families[54,55] and claim monetary compensation for the trauma suffered during separation.[56]
Action Steps
Preventing the separation and detention of immigrant and refugee children and families at U.S. borders will protect the short- and long-term health of these children and families. Therefore, APHA:
References
1. Rubin LP. Maternal and pediatric health and disease: integrating biopsychosocial models and epigenetics. Available at: https://www.nature.com. Accessed November 29, 2019.
2. United Nations. Convention on the Rights of the Child. Available at: http://www.unhcr.org. Accessed November 29, 2019.
3. International Society for Social Pediatrics and Child Health Migration Working Group. ISSOP position statement on migrant child health. Child Care Health Dev. 2018;44:161–170.
4. Institute of Medicine. Migration of children to Europe. Available at: https://missingmigrants.iom.int. Accessed November 29, 2019.
5. Public Broadcasting Service. U.S. sees limitations on reuniting migrant families. Available at: https://www.pbs.org. Accessed November 29, 2019.
6. Acevedo N. Why are migrant children dying in U.S. custody? Available at: https://apple.news. Accessed November 29, 2019.
7. Office of the United Nations High Commissioner for Refugees. Global trends: forced displacement in 2018. Available at: https://www.unhcr.org. Accessed November 29, 2019.
8. Marquardt L, Kramer A, Fiscjer F, Prifer-Kramer L. Health status and disease burden of unaccompanied asylum-seeking adolescents in Blielfeld, Germany: cross sectional pilot study. Trop Med Int Health. 2015;21:210–218.
9. Theuring S, Friedrich-Jänicke B, Pörtner K, et al. Screening for infectious disease among unaccompanied minor refugees in Berlin, 2014–2015. Eur J Epidemiol. 2016;31:707–710.
10. Kobayashi M. Pneumococcal serotype 5 colonization prevalence among newly arrived unaccompanied children 1 year after an outbreak—Texas, 2015. Pediatr Infect Dis J. 2017;36:236–238.11. Tomczyk A, Arriola C, Beall B. Multistate outbreak of respiratory infections among unaccompanied children, June 2014–July 2014. Clin Infect Dis. 2016;63:48–56.
12. Williams B, Cassar C, Siggers G, Taylor S. Medical and social issues of child refugees. Arch Dis Child. 2016;101:839–842.
13. Fazel M, Stein A. The mental health of refugee children. Arch Dis Child. 2002;87:366–370.
14. Jakobsen M, Dermott MA, Heir T. Prevalence of psychiatric disorders among unaccompanied asylum-seeking adolescents in Norway. Clin Pract Epidemiol Public Health. 2014;10:53–58.
15. Jakobsen M, DeMott M, Wentzel-Larsen T, Heir T. The impact of the asylum process on public health: a longitudinal study of unaccompanied refugee minors in Norway. BMJ Open. 2017;7(6):e015157.
16. Fazel M, Reed R, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012;379:266–282.
17. Panter-Brick C, Goodman A, Tol W, Eggerman M. Mental health and childhood adversities: a longitudinal study in Kabul. J Am Acad Child Adolesc Psychiatry. 2011;50:349–363.
18. Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental health of Cambodian refugees 2 decades after resettlement in the United States. JAMA. 2005;294:571–579.
19. Ramel B, Taljemark J, Lindgren A, Axel Johansson B. Overrepresentation of unaccompanied refugee minors in inpatient psychiatric care. Springerplus. 2015;4:131.
20. Dudley M, Steel Z, Mares S, Newman L. Children and young people in immigration detention. Curr Opin Psychiatry. 2012;25:285–292.
21. Puthoopparambil SJ, Maina-Ahlberg B, Bjerneld M. Do higher standards of detention promote well-being? Forced Migration Rev. 2013;44:39.
22. Drury J, Williams R. Children and young people who are refugees, internally displaced persons or survivors or perpetrators of war, mass violence and terrorism. Curr Opin Psychiatry. 2012;25:277–284.
23. Foong A, Arthur D, West S, Kornhaber R, McClean L, Cleary M. The mental health plight of unaccompanied asylum-seeking children in detention. J Adv Nurs. 2019;75:255–257.
24. Wood LCN. Impact of punitive immigration policies, parent-child separation and child detention on mental health and development of children. BMJ Paediatrics Open. 2018;2:e000338.
25. Zwi K, Mares S, Nathanson D, Tay AK, Silove D. The impact of detention on social-emotional wellbeing of children seeking asylum: a comparison with community-based children. Eur Child Adolesc Psychiatry. 2018;27:411–422.
26. Bernhard J, Landolt P, Goldring L. Transnational, multi-local motherhood: experiences of separation and reunification among Latin American families in Canada. Early Child Educ J. 2005;6:44.
27. Kenny KS, Barrington C, Green S. “I felt for a long time like everything beautiful in me had been taken out”: women’s suffering, remembering, and survival following the loss of child custody. Int J Drug Policy. 2015;26:1158–1166.
28. Wall-Wieler E, Roos LL, Brownell M, Nickel N, Chateau D, Singal D. Suicide attempts and completions among mothers whose children were taken into care by child protection services: a cohort study using linkable administrative data. Can J Psychiatry. 2018;63:170–177.
29. Collins C, Zimmerman C, Howard L. Refugee, asylum seeker, immigrant women and postnatal depression: rates and risk factors. Arch Womens Ment Health. 2011;14:3–11.
30. Wall-Wieler E, Roos LL, Nickel N, Chateau D, Brownell M. Mortality among mothers whose children were taken into care by child protection services: a discordant sibling analysis. Am J Epidemiol. 2018;187:kwy062.
31. Victora CG, Bahol R, Barros A, et al. Breastfeeding in the 21st cent
