APHA Opposes Separation of Immigrant and Refugee Children and Families at U.S. Borders

  • Date: Nov 13 2018
  • Policy Number: LB-18-01

Key Words: Immigrants, Immigration, Refugees, Childrens Health, Child Abuse, Mental Health

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. Even if these children and their families are reunited, they will need extensive therapy from by properly trained professionals to help mitigate the 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 time again through extensive research. This policy statement calls on the United States government to reunite these separated children and families immediately, 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, spiritual, and cultural consequences of separating families, including lactating mothers and babies.

Relationship to Existing APHA Policy Statements

  • APHA Policy Statement 9924: Health and Human Rights Violations at the US Mexico Border

Problem Statement
Recent U.S. immigration policy, through forced separation of minors from their parents, 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 and spiritual communities, it has cultural and spiritual 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 parent 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 separation of more than 3,000 migrant children from their parents and families at the U.S. border. 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: 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. Migrant travel from the Middle East and North Africa into Europe and from Central America into the United States has provided some recent data. Data on longer term outcomes are available from studies of earlier migrations of children from Cambodia and Bosnia in particular.

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.[5] 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.[6–8] Infectious diseases such as intestinal parasites and respiratory infections, influenza, and pneumococcal disease are therefore 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.[9] Increased levels of depression, anxiety, and posttraumatic stress disorder have been reported among refugee children.[10] 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%).[11] Rates are higher among children separated from their parents.

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.[12] 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.[13–16] Rates of inpatient psychiatric admissions and levels of self-harm and suicidal behaviors are higher among unaccompanied than accompanied refugee minors.[17] With the increase in the number of asylum seekers globally, many countries have established detention centers, which become an additional source of trauma.[18] 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.[19] Evidence points to improved coping skills among refugee and internally displaced children when they are accompanied by their parents.[20] 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.[21] In addition, 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.

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.[22] 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.[23,24] According to one study, 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.[23]

Refugee and immigrant women in general have high levels of clinical depression, posttraumatic stress disorder, and suicide.[25] Separation from a child, whether through custody loss or migration, leads to grief, depression, and social isolation.[22,23,26] 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.[27] In addition, mothers who have lost custody of a child have been shown to have higher rates of suicide attempts and completions[27] and increased rates of mortality, specifically avoidable mortality.[24]

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.[28,29] Exclusive breastfeeding for the first 6 months and continued breastfeeding for at least the first year (according to the American Academy of Pediatrics [AAP]) 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 nurse 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.[29,30] Thus, interruption of breastfeeding constitutes an added risk due to involuntary separation of lactating mothers and breastfeeding infants.

Physical health effects on mothers: Short-term or acute effects on mothers who do not express their milk when separated from their children are varied. The mother will need to express milk to remedy the discomfort that develops when breasts become engorged and to avoid plugged ducts and possible infection (mastitis).[31,32] Mastitis can cause high fever and flu-like symptoms and lead to abscess and/or hospitalization if not treated promptly and appropriately.[32,33] If the mother does not express milk regularly, her breasts can become engorged to the point where they are painful.[32] Accumulation of milk in the breast and engorgement also lead to decreased milk supply.[32,34]

Without her infant, a mother must use hand expression or pumping to relieve pressure in her breasts.[35,36] Hand expression requires clean hands and a container, which may or may not be possible or available. Pumping requires equipment of some type, whether it be a hand pump or an electric pump. It also requires that pump pieces that come in contact with milk be cleaned regularly. Appropriate sanitation could be difficult or impossible given the physical circumstances of the mother.

Long-term effects on lactating mothers who are separated from their children include premature cessation of breastfeeding and the resulting loss of birth spacing benefits, in addition to increased risks for breast and ovarian cancers, diabetes, and cardiovascular diseases (myocardial infarction, hypertension, hyperlipidemia).[28,30]

Physical health effects on infants: 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.[37] 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 the infant’s needs. In addition, breastfed infants who are prematurely separated from their mother will have higher risks of ear infections, respiratory infections, and diarrhea.[28] In the long term, infants who are not breastfed are at higher risk for malocclusion,[28] Crohn’s disease, ulcerative colitis and other gastrointestinal infections, sudden infant death syndrome, and leukemia.[30] Finally, children who are prematurely separated from their mother while nursing will lose the intelligence benefit associated with breastfeeding and later benefits related to weight control and reduced risk of diabetes.[28]

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[38] along with asthma, autoimmune diseases, poor dental health, viral hepatitis, liver cancer, and depression.[39] 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.[39]

Moreover, infants who are bottle fed are often encouraged to empty the bottle, which teaches them to ignore satiety cues.[40] Bottle-fed infants may gain more weight in their first year of life than infants fed at the breast.[41]

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. Even if a woman has support in expressing her milk while separated from her child, it is well established that women’s ability to lactate deceases during periods in which they are experiencing stress. Merely apprehension regarding not producing sufficient milk or having a negative experience can cease lactation; 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.[42] Furthermore, research in some populations suggests that discontinuation of breastfeeding is associated with a higher risk for postpartum depression among mothers.[43] Postpartum depression has serious implications for both the mother and the infant as a result of its effects on mother-infant interactions.[44]

Mental health effects on 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 [45]. As noted above, continued breastfeeding or reestablishment of breastfeeding could mitigate toxic stress among children.[38]

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. Specifically, the AAP recommends that children of all ages receive an initial medical and mental health evaluation along with ongoing health care.[46]

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 The Post-Disaster Reunification of Children: A Nationwide Approach[47] 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.[47]

Trauma and cognitive-behavioral therapy: Forcible separation of children from their parents can lead to the development of debilitating symptoms that place these children at risk for long-term problems. Extensive research, most notably the Adverse Childhood Experiences study, has linked traumatic childhood experiences to poor physical, mental, and behavioral problems later in life.[48] It is important for public health and health care officials to consider the long-term treatment options for both these children and their parents to help counteract the potential effects of the traumatic experience of being separated.

When assessing the available evidence-based treatments for childhood trauma, it is important to consider factors such as the child’s culture and age, the family environment, and the child’s memories of the traumatic event in choosing the treatment that best meets the needs and preferences of the child and family. Also, these treatments should explicitly address the traumatic experience and its impact on the lives of both children and their caregivers while being sensitive to cultural beliefs and values. Most important, any 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.[49] Other therapies in a group format may be appropriate as well.

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.[50]

When adopting trauma-focused evidence-based treatments, it is important to address any potential barriers that may affect treatment engagement while also ensuring that there is a strong support system for treatment delivery as well as guidance for clinicians administering the treatments. Implementing trauma-specific evidence-based treatments requires ongoing supervision, collaboration with clinical supervisors and intensive clinical training to ensure that both children and their families do not experience retraumatization.[49]

Opposing Arguments/Evidence
There have been two basic arguments forwarded by parties supporting the current U.S. policy on criminal prosecution and forced separation of illegal migrant families at the U.S.-Mexico border. The first relates to the perception that illegal immigration leads to increases in criminal activity in U.S. communities.[51] 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.[52,53] The second argument relates to the “zero tolerance” enforcement of existing U.S. immigration law[54] and the contention that the responsibility and consequences of family separation reside with migrant families who knowingly cross the border illegally with children.[55] 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 in 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.[56] 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 they are entitled to health care of the same standard as legal resident children.

Action Steps
Preventing the separation of immigrant and refugee children and families at U.S. borders will protect the short- and long-term health of these children and families. APHA:

  1. Calls on the federal government (e.g., the U.S. Border Patrol) and contractual partners to permanently halt the separation of immigrant children from their parents when crossing the border unless there is an imminent, ongoing threat to the children’s safety in the parents’ care.
  2. Calls on the federal government (e.g., the U.S. Department of Health and Human Services) and contractual partners to review existing practices and, where they are deficient, correct practices for the care of separated children and minors to ensure that they are at all times housed in physically and emotionally safe and developmentally appropriate environments (such as community housing) and that they receive evidence- and guideline-based health care and social services to support their health and well-being. Also, the federal government should convene a national panel of child health experts to review standards and practices and make recommendations accordingly.
  3. Calls on the federal government to maintain constitutional protections for children in U.S. custody.
  4. Calls on the federal government to collect relevant and appropriate data, including family identification numbers, to ensure that children and parents, if separated, can be located and reunited as soon as possible.
  5. Calls on the federal government (e.g., the U.S. Department of Health and Human Services) and contractual partners to offer culturally competent and appropriate resources and support to reunite separated families (including breastfeeding mothers and their infants) and to mitigate the harms caused by separation (including providing professional lactation support to women who want to relactate).
  6. Calls on the federal government to invite the Office of the United Nations High Commissioner for Refugees to monitor refugee registration, processing, and resettlement in the United States, as it does in other countries throughout the world.
  7. Calls on the federal government and international organizations to prosecute human rights violations to the fullest extent of the law.
  8. Calls on the federal government to ratify the UN Convention on the Rights of the Child.
  9. Calls on the federal government to establish a task force, which should include representation from child and family health professionals and the communities/cultures from which the separated families originate, to review and recommend revisions to existing policies and practices to ensure that they facilitate effective and caring support to promote the health and well-being of separated children and families.
  10. Urges public and private funding agencies to fund additional research designed to provide an understanding of the mental, physical, spiritual, and cultural consequences of separating families, including lactating mothers and babies. This research should emphasize delineating the harm across populations and cultures; outline the roles and history of racism, xenophobia, hierarchy, and inequality in the creation of family separation practices in the United States; and inform the development of policies and structures needed to better prevent such practices.

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