July 20, 2018
Albany, NY

ICYMI: Health Commissioner Zucker's Article on Potential Child Health Consequences of the Federal Policy Separating Immigrant Children from their Parents

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ICYMI: Health Commissioner Zucker's Article on Potential Child Health Consequences of the Federal Policy Separating Immigrant Children from their Parents
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Actions taken by the US federal government during the past 18 months suggest that the health and welfare of children, particularly children from marginalized groups, may no longer be a priority

New York State Department of Health Commissioner Dr. Howard Zucker and Department of Health Chief of Staff Danielle Greene published an article in the Journal of the American Medical Association outlining the potential health consequences of the federal policy separating immigrant children from their parents. The article is available here and below.

Actions taken by the US federal government during the past 18 months suggest that the health and welfare of children, particularly children from marginalized groups, may no longer be a priority. The most recent example is the policy of separating children from their parents when the family enters the United States illegally or seeks asylum at the border.

In the face of mounting public and political pressure the Trump administration reversed its policy, but more than 2300 children have been removed from their parents at the border in Texas, New Mexico, and Arizona and sent to 17 different states as far away as Illinois, New York, and Washington State. A federal judge ruled that family separation must stop, reunification must occur within 30 days, and children younger than 5 years must be reunited with their parents within 14 days, but reunification plans remain vague. As of July 10, some children have been reunited with their families, but more than 2000 remain separated from their parents.

The immediate consequences of separating children from their parents may be easy to comprehend—anxiety, loss of appetite, poor sleeping, withdrawal, or aggressive behavior. Reports of children who are depressed, suicidal, or otherwise in danger of harming themselves have already surfaced. But even if children are reunited with their families, the long-term effects may be more insidious, permanent, and devastating. After the nation's attention has moved to the next crisis, these children and their families will still be confronting the potentially long-lasting physical and emotional effects of forced separation.

Research shows that the experience of multiple stressful and unpredictable events during childhood, known as adverse childhood experiences (ACEs), is cumulative and results in stress that can have adverse effects on health and well-being throughout life and into subsequent generations. The 10 categories of ACEs include emotional neglect, physical neglect, emotional abuse, physical abuse, sexual abuse, parental separation/divorce, witnessing violence between adults in the household, and having a household member with substance use disorder, mental illness, or who is or has been incarcerated. The policy of family separation subjects children to at least 4 of the categories of ACEs: emotional neglect, parental separation, witnessing violence, and parental incarceration. Incarceration of children is not an official ACE, and technically the separated children are not incarcerated, but many are living in temporary government-run group facilities against their will. Simply being held in these facilities may become an ACE for some of them. In addition, as mentioned previously, some separated children are exhibiting symptoms of depression and other mental illness. Because they are living in group settings, these children are the temporary "household members" of other separated children.

Many immigrant families come to the US border seeking asylum from violence related to gangs, drugs, or domestic situations in their countries of origin. Thus, children may be arriving with numerous adverse exposures already. A 1998 survey and physical examination of 17337 Kaiser Permanente HMO members showed that the risk of poor health outcomes increased in association with the number of ACEs experienced. For example, compared with people with no ACEs, those with 4 or more had a higher risk for being depressed for 2 or more weeks in the past year (50.7% vs 14.2%, adjusted odds ratio [aOR], 4.6 [95% CI, 3.8-5.6]), ever attempted suicide (18.3% vs 1.2%; aOR, 12.2 [95% CI, 8.5-17.5]), ever had a sexually transmitted disease (16.7% vs 5.6%; aOR, 2.5 [95% CI, 1.9-3.2]), ever injected drugs (3.4% vs 0.3%; aOR, 10.3 [95% CI, 4.9-21.4]), had cardiovascular disease (5.6% vs 3.7%; aOR, 2.2 [95% CI, 1.3-3.7]), and were a current smoker (16.5% vs 6.8%; aOR, 2.2 [95% CI, 1.7-2.9]).

The structure and function of the developing brain is impeded by ACEs through 7 different mechanisms. Subjecting the developing brain to chronic stress can result in impairments in the sympathetic-adrenomedullary system and the hypothalamic-pituitary-adrenocortical axis, causing increased release of epinephrine and cortisol. The increased release of hormones results in decreased hippocampal volume and can affect the brain's emotion and memory processing, as well as stress modulation. Diminished gray matter in other key areas causes overreaction to even minor stressors. These overreactions are reinforced by epigenetic shifts in regulator genes, permanently locking them into a high response setting, which heightens the inflammatory response and onset of disease. The experience of toxic stress damages neurocircuitry, reducing children's capacity to respond to changing situations. Inflammatory chemicals flood the lymphatic system, affecting physical health. Exposure to chronic ACEs weakens neural connections in the limbic system and amplifies the risk for the development of anxiety and depression, along with other mood disorders. Unregulated neural pruning and neuroinflammation contributes to suboptimal decision-making and executive functioning skills. ACEs-related stress shortens telomeres, increasing the risk of disease in children and accelerating the aging process.

It is unknown whether short-term separations of immigrant children from their parents will affect these children's developing brains or lead to lasting physical or emotional effects. However, the line of demarcation between short-term and long-term is not known, and separations have currently lasted from weeks to more than 7 months. Although children may be resilient and the effect of a single traumatic event might be temporary, the emotional and physiological effects of cumulative ACEs may be permanent.

The younger ages of the children who were separated from their parents is also a concern. Although the social, physical, and emotional consequences affect all children, the biological processes affected by ACES are most active before 6 years of age. For the youngest children, resiliency potential may be undermined. Early nurturing promotes the development of epigenetic regulation. This process monitors stress levels and is determined during early childhood through cellular and synaptic plasticity. With the greatest growth in connections occurring by 6 years, these networks direct an individual's ability to respond and adjust to adversity. Resilience is born from the interplay between internal disposition and external experience.

Additionally, there have been reports that caretakers in receiving shelters have been instructed to avoid touching and hugging among the children or between staff and children. Multiple research studies have concluded that touch is critical to child development, and deprivation of tactile stimulation in early life causes developmental delays, as well as impaired growth and cognitive development.

Family reunification in a safe environment is necessary to heal displaced children. It is likely that children affected by separation will need services in the future that are culturally sensitive, trauma-specific, and evidence-based, including health, mental health, and social services. However, most of these children will be deported to countries without such supports. Even those that remain may not qualify for support, or the families may be afraid to obtain them.

The task is made even more difficult by federal prohibitions that prevent states from providing services to the children placed within their borders. In addition, foster and resettlement agencies have been told not to disclose any information about the children they are sheltering to state regulators.

The adverse consequences of these policies will last far into the future. It is in the best interests of these children, and society, to reconnect them with their parents and provide access to the services they may require as a consequence of their separation. Forcibly separating parents from their children in the United States should never happen again.

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