September 09, 2019
Adding to previous research showing a link between toxic stress at a young age and lasting impairment, including depression and anxiety, a new study suggests a significant association between separation of families at the US border and posttraumatic stress disorder (PTSD).
In a study released by the Department of Health and Human Services (HHS) Inspector General's Office, investigators interviewed approximately 100 mental healthcare workers who had regular interactions with children in 45 Office of Refugee Resettlement's (ORR's) custody facilities from August to September 2018.
Results showed that children separated from their families exhibited more fear, feelings of abandonment, and symptoms of PTSD compared with unseparated children.
The HHS study was published online September 4.
These findings, coincidently, were released a day after the American Psychiatric Association (APA) and several other child-focused organizations put out a joint statement "strongly urging" California's federal court to resist the Trump Administration's Final Rule, which is aimed at removing the maximum length of time a migrant child can be held in federal custody.
"More than 20 organizations oppose the Trump Administration's new regulations that overturn protections guaranteed to immigrant children under the  Flores Settlement Agreement," the APA said in a press release.
David L. Dubrow, partner at Arent Fox LLP and lead attorney on an amicus brief filed in the Central District of California in the Jenny Lisette Flores, et al v. William Barr, et al case, noted in the same release that the Final Rule "deviates radically from the Flores Settlement" and directly causes harm to these children.
"These changes weaken protections for migrant children, resulting in more children being detained for greater periods of time under materially worse conditions," he said.
'We're Seen as the Enemy'
As reported by Medscape Medical News last year, the American Academy of Pediatrics (AAP) published a long list of studies assessing toxic stress and children.
In addition, a study published last year in Scientific Reports suggested that traumatic stress experienced by young children is visible on brain scans years later.
"That is a very striking study" because of the real evidence of brain changes in these children, Nathalie Bernabe Quion, MD, pediatrician at Children's National Health System in Washington DC, told Medscape Medical News at the time.
In the current report, investigators interviewed mental health clinicians who had regular interactions with detained children but who did not address the quality of their care. During August and September 2018, there were almost 9000 children (71% boys) held in the visited facilities. Of these, 85% were aged 13 to 17 years; 13% were aged 6 to 12 years; and 2% were aged 0 to 5 years.
The report notes that each of these children are supposed to receive at least one session per week of individual counseling and two group sessions per week. And the staffing ratio required by the ORR is supposed to be 1 mental health clinician for every 12 children. However, some of these staff workers reported caseloads of more than 25 children — leading to less time for therapy.
Other study results showed that children who were confused as to why they were separated from their parents experienced increased levels of mental distress, with some believing their parents had abandoned them.
Challenges faced by mental healthcare workers included the uncertainty that came from chaotic reunification processes and a child exhibiting isolating behavior, not participating in activities, and having trust issues, such as when they could not distinguish between facility staff and immigration agents.
"Every single separated kid has been terrified. We're [seen as] the enemy," one program director told the investigators.
Last November marked the highest average length of stay for children released from ORR custody (93 days). The stays began to decrease in December. However, the average was still 48 days as of April.
The report ends with six recommendations for the ORR to help facilities address mental healthcare of detained children, including identifying evidence-based approaches to addressing trauma in the short term and expanding therapeutic placements for those who need more intensive mental healthcare treatment.
APA Joint Statement
As noted earlier, the joint statement condemning the recent policy change was released by the APA and 19 other organizations. These include the AAP, the American Academy of Child and Adolescent Psychiatry, the American Professional Society on the Abuse of Children, and the American Medical Association.
"The children and families seeking asylum at our borders have already endured stress and trauma in leaving their home countries, and are faced with increased risks of mental illness," Bruce J. Schwartz, MD, president of the APA, said in the statement. "Prolonging the families' detention may lead to even more harmful mental health consequences for them."
"Children flourish under conditions where their health, safety, and protection by a caring adult are in the least restrictive environments. It is vital for the well-being of all children, including migrant children, that they receive appropriate trauma-informed care," the AACAP added.
"'Detention' is a sanitized word for the circumstances in which these children are being held," said Yasuko Fukuda, MD, chair of the AAP-California. "When the trauma, pain, and suffering of any child is within our power to prevent or to heal, it is our shared responsibility to do so."
The full HHS report is available for download on the organization's website.