Detained Children: General Health Issues- Part II

This is Part II  of this blog, devoted to child detainees and their health issues.  First, Christopher Sim,  a faculty member in our Department of Physician Studies further describes some of the medical concerns for immigrant populations.   The second contributor is Dr. Mary Thompson, a pediatric nurse practitioner and faculty member at the IHP.  She continues with more specific information that may be useful to providers concerned with care of children who are in refugee situations.  

Note: In Part III we will begin to focus on some of the specific developmental concerns and mental health issues facing these children and their families and caregivers.

From Christopher Sim, MPAS, PA-C, DFAAPA

Whether children arrive in the United States as part of a prearranged immigration with advanced notice, in a more urgent refugee crisis, or as undocumented emigres, they typically are at risk from multiple health factors.  Approximately 3.7% of children living in the US were born in other countries. This includes 7.7% of Latino children and 16 % of Asian children (Yun, 2016).

Hepatitis B, tuberculosis, parasites, anemia and high lead levels are the most commonly encountered diseases in children new to the United States (McBride, 2016). This is complicated by the countries of origin from which these children travel from. Although some children from refugee populations benefit from government or non-governmental organizations in terms of nutritional support and preventive health services, most refugee children from Central American countries have not been as fortunate. These children would be susceptible on their own, but also pose the risk of transmitting disease amongst themselves in the housing environments currently operated by Immigration Control and Enforcement in the US. It is also conceivable that children who arrived without such infections may, if returned to their countries of origin, transmit preventable new infection in those settings.

Failure to address these issues when children are under the care of the United States is unethical, irresponsible, and contrary to acceptable standards of humanitarian treatment of refugees. At the very least, these children require baseline testing for the most common parasitic diseases, hepatitis, tuberculosis, and lead screening. In identifying preexisting disease, public health authorities would be able to make insights into epidemiologic patterns and document current health states amongst these populations. Vaccination among these children is also either difficult to verify, if not impossible. Such children should also receive the same immunizations required of native-born US children, in the common interest of public health.

                                                                    References

Yun, K., Matheson, J., Payton, C., Scott, K. C., Stone, B. L., Song, L., . . . Mamo, B. (2016). Health Profiles of Newly Arrived Refugee Children in the United States, 2006–2012. American Journal of Public Health,106(1), 128-135. doi:10.2105/ajph.2015.302873

Mcbride, D. L. (2016). Large Study of Health Issues for Newly Arrived Child Refugees. Journal of Pediatric Nursing,31(2), 222-223. doi:10.1016/j.pedn.2015.11.014

From Mary Thompson, PhD, RN, CPNP-PC

The American Academy of Pediatrics (AAP) has adopted a Toolkit to inform health providers of “common matters” related to the healthcare needs of immigrant children, which can be accessed here: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Immigrant-Child-Health-Toolkit/Pages/Immigrant-Child-Health-Toolkit.aspx

According to the Toolkit, many children who are newly immigrated have not had regular medical care in their country of origin. They require specialized healthcare screening for: exposure to infectious diseases (such as tuberculosis, HIV, and parasitic infections), immunization history (if known), medical history (including birth history), nutrition history, medications and use of complementary and alternative treatments, environmental hazards (including lead exposure), exposure to (tobacco, opium/heroin, and other drug use), dental history, social history, educational history, and sexual or other abuse.  Children who undergo forced separation due to immigrant enforcement may not be able to provide this information.

Many children who have newly immigrated have faced ACE’s prior to immigrating from their country of origin, or during their immigration. Separation from parents further exacerbates the negative effects from the exposure of ACEs. These children demonstrate a number of health problems, including anxiety, depression, poor school performance, sleeping and eating disruptions. Table 1 from the Toolkit includes a list of Mental Health and Developmental Screening Instruments and Resources that can be used to assess the mental health needs of immigrant children separated from their parents.

The United Nations High Commissioner for Refugees (UNHCR) document titled: Refugee Children: Guidelines on Protection and Care  offers insight in how to be responsive and acknowledge the needs of children affected by separation from their caregivers during immigration. In the immediate, children should be provided with appropriate:

Play: “Play is vital to the healthy development of a child. It is a child's way of coping with what has happened, of relaxing and relieving tensions and of assimilating what (s)he has experienced and learned. . . Playgrounds Refugee camps, settlements or reception centers should have play areas from the outset.”

Infants: “Breast feeding should be facilitated. . . Children of about 10 months (who are just about to develop speech, crawl and walk) are particularly vulnerable. In such situations the integration of infant stimulation programmes in other emergency services, such as feeding programmes, has proven helpful.”

Developmental Screening: “. . . is needed to identify children whose development is delayed. This involves knowledge about what normal development in this specific culture means. A group of refugee mothers may be able to help you. - Intervention if there is abuse or neglect.”

Counseling and Support Groups: “Children will become anxious when they do not understand what is happening to them. . . When a child becomes depressed, anxious or upset, the right to participate may effectively be lost: a child may not be able to process the information, and may not be able to make realistic decisions. Counselling to reduce stress may be necessary before children can focus on and absorb information fully. - Support groups: Encourage the creation of support groups where children have an opportunity to talk about problems and ways of addressing them. It is important that they understand that they are not alone and that they are not responsible for what has happened.”

Restoring Normalcy: “Restoring normalcy for unaccompanied children requires that tracing for parents begin immediately. When parents or relatives are located, children need help in maintaining communication with them until they can be reunited. . . The threat to psychosocial well-being is inevitably increased when lengthy or permanent disruptions occur between child and primary care-giver, or child and family. The loss of the mother, or substitute mother figure, particularly at an early age, places a child at a higher psychological risk. Arranging for substitute family care or immediate family reunion is critical.”

Perhaps most important of all:

Helping children by helping the family “The single best way to promote the well being of children is to support their family.”  This includes preserving family unity, tracing parents who have been separated, providing family support, establishing parental support networks, and helping families prepare for reunion by offering counseling.

Detained Children: Understanding the Issues

 I have felt as concerned as many of you about what we can do to be helpful with the current situation regarding detained families and separation of children from their parents.  As of yesterday, June 20, President Trump has signed a new policy that prevents separation of children from parents at the borders.  However, there is no clear plan for detainees currently in custody.  Over 2000 infants, toddlers, children, and adolescents are currently being held in residential arrangements of various types.

The political discussion about responsibility for this mess goes on and on.   As always, the politics are debatable and inconclusive.  The political debate appears to offer no immediate solution for these children or their families.   What I do know is that this problem of detention, congregate living, and separation presents a host of health issues unfamiliar to many of us.

Thus, I have reached out to several colleagues from around the IHP to provide us with current thinking on a number of issues that should concern all of us, especially those who will be caring for these children.  Reading through the contributions of our colleagues makes me proud of the capability and insight of those with whom we work.  At the same time, reading this makes me worry for the future of these young children and their families.  I will start posting these contributions daily and invite you to read, share with your students, and extend a thank you to the writers.

Finally, if you would like to contribute to this blog on a topic I may have overlooked, don't be shy.  Send me your contribution and I will happily post it.  This appears to be a small step that we can take today.   This is a health problem and education is almost always the answer.

General Health Concerns:

Prepared by

Dr. Patrice Nicholas, School of Nursing

The American Public Health Association released a statement on June 15, 2018 entitled Separating Parents and Children at US Border Is Inhumane and Sets the Stage for a Public Health Crisis. The statement notes that the Trump administration’s policy of separating parents and children at the U.S. and Mexico border will negatively affect the detained children and their health, both now and into the future. 

"As public health professionals we know that children living without their parents face immediate and long-term health consequences. Risks include the acute mental trauma of separation, the loss of critical health information that only parents would know about their children’s health status, and in the case of breastfeeding children, the significant loss of maternal child bonding essential for normal development. Parents’ health would also be affected by this unjust separation.”

"More alarming is the interruption of these children’s chance at achieving a stable childhood. Decades of public health research have shown that family structure, stability and environment are key social determinants of a child’s and a community’s health.”

"Furthermore, this practice places children at heightened risk of experiencing adverse childhood events and trauma, which research has definitively linked to poorer long-term health. Negative outcomes associated with adverse childhood events include some of society’s most intractable health issues: alcoholism, substance misuse, depression, suicide, poor physical health and obesity.”

The full text of the statement can be viewed here:

https://www.apha.org/news-and-media/news-releases/apha-news-releases/2018/parent-child-separation

 Adverse childhood experiences (ACEs) are stressful or traumatic events, including abuse and neglect. ACEs are strongly related to the development and prevalence of a wide range of health problems throughout a person’s lifespan, including those associated with substance misuse. The Centers for Disease Control and Prevention (CDC) addresses the health consequences associated with ACEs.

ACEs include:

• Physical abuse
• Sexual abuse
• Emotional abuse
• Physical neglect
• Emotional neglect
• Intimate partner violence
• Mother treated violently
• Substance misuse within household
• Household mental illness
• Parental separation or divorce
• Incarcerated household member

For the children detained in the current circumstances, they are experiencing parental separation, incarcerated household member, and their own incarcerated circumstances in “tender camps” which are tantamount to serving in jails/cages.

The full text of the Centers for Disease Control and Prevention website on ACEs can be viewed here:

https://www.cdc.gov/violenceprevention/acestudy/index.html

Locked Up on Father's Day

Precious Children Locked Up

Children, minors under age 18, are the most precious resource available to our own culture and to all the world.  They represent all the hope and all the future possibilities available to everyone, everywhere.  This hopeful preciousness is agnostic to their national origin, their parents’ status in social strata, their health or physical status, their religious background, or their race or ethnicity.   Dependent on the adults “in the room,” their lives are precious, and they must hold special status in every aspect of society, and everywhere in the world.    In the United States we have a long history of protecting children (at least trying to), and our laws attempt to provide access to health and education and assure quality of life to the fullest extent possible.  When we consider violence or other inhumane acts against children we are outraged. 

 Recall the media coverage, the marches and protests that occurred, in response to recent school shootings in Texas and Florida.  Think of Newtown and the humanitarian and noble response of Americans to that disaster, where many precious six-year-old lives were lost.  Our collective conscience must never allow us to disregard the principled value we hold for children.  It is in our DNA as Americans and shared  by all civilized people of the world.

Juxtapose this view against your own experience as a child, parent, or grandparent.  All of us connect in some way to that innate childhood connection with adults critical to our safety, protection, and love.  For me, I think of my two sons (now grown up) and my three grandsons, ages 6, 4, and (almost) 2.  My connection with all of them is profound.   I can’t disconnect or dishonor that relationship in any way.   They are all precious.   When I see the sweetness and vulnerability of my grandsons I am awed.  When I see their joyousness, their robust life- changing personalities, and their need for connection with their parents I am humbled. Some say that when they see the face of a young child, they see the face of God.  Regardless of one’s religious bent, isn’t it fair to say that in such faces one sees the reality of goodness?

And now, I can’t think of those faces, connections, and smiles without comparing them with the hundreds of children who have been ripped out of their parents’ arms by my government.  I can’t justify this for any political, legal, or moral reason.  When I hear others try to legitimize this on religious grounds, I am sickened at the hypocrisy and hatefulness of their argument.  I can only see my little grandsons, being taken from their parents, moved to a fenced in “shelter”, and being held against their will.  I can only feel the amazing heartbreak, outrage, and shock this would cause their parents.   I am deeply aware of the wounds, the pain, and the anger that would persist over generations and lifetimes.     I identify with these feelings viscerally. 

I hope that many speak out and act against this.  While I know that our political leaders on both sides are failing us here, I hope that churches, communities, and other organizations find ways to fight these horrific actions, against children and families, by our government.   This must stop. 

A Good Day at the IHP: Saturday, June 9, 2018

At the Institute, there are many great days every year.  Today was one of those days for me.  It was a home run kind of day.   On one of the first really beautiful Saturdays of this spring, there was intense activity inside the IHP.  The third floor of the Shouse Building was almost vibrating with learning.  In each case the learning was voluntary (not required) and was collaborative.  

Walking down the hallway I bumped into some of our students who are enrolled in a voluntary medical Spanish course.  This is not part of their curriculum, but something they have taken on at their own expense so that they can reach out and serve the large group of individuals who are non-English speakers.  I admire these students for their dedication and for the leadership that they model for all of us.  They inspire me.

Continuing down the hallway, I strolled (by accident) into a group of DNP students and faculty.  They are here for one of their periodic intensive weekends of study.  The rest of their program is completed online.  These are nurse leaders and executives, all with at least a masters degree,  who have voluntarily taken on this intensive two year course of study to complete their doctoral study in our remarkable Doctor of Nursing Practice program.   Learning together, these nurse leaders are mapping next generation practices for our ever changing and ever challenging healthcare systems.   They inspire me too.

Across the hall was my final destination for the day.  I had the good fortune to attend the completion celebration for the 13 graduates in our MS In Health Professions program.  These individuals, from the United States, Japan, Singapore, and Saudi Arabia are all earning this voluntary post-graduate degree.   They are an interprofessional group that includes physicians, nurse practitioners, physician assistants, pharmacists, physical therapists, and the first ever speech-language pathologist to complete this degree at the Institute.   They attended a series of on campus activities over the past three days.  Their scholarly projects and their commitment to the education of health professionals will change the course and the quality of education in their own institutions and beyond.   Today’s event was made even more special because it is the last such event for Dr. Deborah Navedo, who was one of the founders of the program and served as program director since its first class was enrolled in 2011.  These students, all busy professionals who have completed this rigorous program of study, inspire me too.   (Special congratulations to Assistant Professor Josh Merson of our PA program, one of today’s grads). 

I know I am fortunate to have my professional home in an institution deeply committed to serving such exemplary learners, to transforming healthcare and education, and building tomorrow’s leaders.   I hope you all share my pride and inspiration.