This year, we’ve seen more than 2,000 children separated from their parents, who were legally seeking asylum in the US. Most were from Central American countries in which crime and unrest place many at risk for violence. These children were taken from their families by US government employees between April 19 and May 31, 2018, under an April 6 order from Attorney General Jeff Sessions.
Although many children have been returned to their parents under federal court order, many others remain separated and in prison-like conditions, and many of the adults cannot be located, having been deported or otherwise lost contact with their children. Our government’s employees may not have kept adequate records needed for reunification.
The problem of unaccompanied children being held in government-sponsored facilities is not new. Between January and May of this year, there were 21,181 children detained at the US-Mexico border, deemed “unaccompanied minors” by US Customs and Border Protection (CBP), an agency under the Department of Homeland Security (DHS). In contrast, there were 39,970 unaccompanied minors in 2015, 59,692 in 2016, and 41,435 in 2017. Many of the children who came to the US border in previous years were also from Central American countries in strife. Some may have run away, others may have been sent away by parents who wanted them safer, and others are likely to have been orphaned.
Many thousands of children are being held in a variety of facilities in multiple states, each with its own regulatory processes. Some children are held on federal land, such as the “tent city” in Tornillo, Texas. Those children are not under state child care or health department regulations. Prior to the April 6 order for taking children from their parents, multiple facilities, under contract with the US Department of Health and Human Services (HHS) Office of Refugee Resettlement, housed dozens of children. Some of these children were placed in short-term foster care while HHS attempted to find a relative living in the US. Because of these huge numbers of children coming into the US during the last few years, many children were in these facilities for long periods of time, on average around two months, and if no relatives could be found, they were placed in long-term foster care. One such facility owner, Southwest Key, owns 16 facilities in Texas and has been cited for health violations by the state’s Department of Health and Human Services, including citations for inadequate supervision and delays in medical care.
Even before April 6 the system was strained, with medical care needs for these children overwhelming the capabilities of local physicians and with too few physicians, nurses, and other health care professionals to manage the complex needs of children who rarely brought medical records and who often spoke languages indigenous to central American that have few competent translators. Then, with the abrupt increase in children moved into the facilities after April 6, and the much younger age of many of these children, some still nursing babies, the HHS-contracted facilities appear to have been unable–or unwilling–to provide humane care.
Multiple news stories of unimaginable cruelty have filled the media this summer. In June, federal employees separated a child with Down Syndrome from the mother. The mother was not charged with a crime but was held as a witness to another’s crime. We have seen photos of children in chain-link fence pens in re-purposed stores, with lights on 24 hours per day, and of tent cities in searing desert heart. And now that some children have been returned to their parents, reports have emerged of children having been beaten, kicked, refused food and water, refused basic sanitation, and even being refused basic human care while in our government’s care.
What are the next steps for these children and families, for us as Americans, and for the medical and public health professions?
Abrupt separation from parents, especially for very young children, is a severe adverse childhood experience. That these children have been denied basic care, denied comfort when crying, denied adequate sanitation and chronobiologically-appropriate light/dark cycles will exacerbate their psychological injury.
The children and their families experienced acute grief and fear. Their care now should be trauma-informed and should bring disaster behavioral health principles into play.
- They will need thorough medical evaluations, careful assessment for physical injury, including occult injury such as traumatic brain injuries.
- They will need psychological and developmental assessments, early children interventions and services, grief counseling, and ongoing support.
- They may need financial support for this care and for transportation to sites equipped to provide it, plus housing during assessment and treatment.
These federal agencies have engendered massive mistrust, and should provide funding so that the care and transport can be provided by trusted advocates.
All Americans can continue to pressure our elected representatives to end the administration’s family separation policies, to set up a task force to reunite all separated children with their families immediately, and to fund federal agencies to move children who came to the US unaccompanied, and are now held in communal facilities, into therapeutic foster families. Pressure for expanded Medicaid services for the children in foster care and training for these foster families should be brought to bear at the state and federal level. We can insist that investigations into the practices in CBP custody and these HHS-contracted facilities be thorough and prompt. Detailed inspections, review of video records from inside facilities, interviews with staff, and careful records of all who were held must be reviewed for evidence of medical need and for unlawful activity.
We have heard recent reports that a child has just died from a communicable respiratory illness after being released from DHS custody. Whether this illness was contracted in a federally-contracted or owned facility and whether there is risk for a disease outbreak must be investigated promptly.
A federal judge has had to order our government to cease the egregious practice of administering unnecessary psychiatric medications to children, as a behavior control measure, without the consent of their parents. Physicians and nurses who engaged in these practices in violation of standard of care should be identified and reported to licensing boards for investigation.
We must pay closer attention to our government’s practices with regard to these children and families — and all children in federal and state government care. We can learn where these facilities are located, what jurisdictions govern them, what laws apply, and how violations are prevented, identified, and corrected. We can call and write our elected officials and agency directors, and our religious and civic organizations can insist on being a part of inspections and other oversight.
For those clinicians who care for these children and families, appropriate training and education, as well as resources, are vital.
- The Institute for the History of Psychiatry at Weill Cornell offers a useful fact sheet on the trauma of childhood separation.
- Dr. Anita Ravi, founder and medical director of the PurpLE Clinic at the Institute for Family Health in New York City, has written an important perspective piece for the American Academy of Family Physicians that includes drawings made by children in detention.
- Physicians for Human Rights, HealthRight International, and other organizations offer training specifically for the assessment of asylum seekers.
We can seek out training, volunteer our time to provide care, and we can speak out. This crisis is ongoing, and we may be faced with other crises caused by decisions made by our government. We must be vigilant. And we must continue to care.
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