pediatrics

Mistreatment of Immigrant Children at the Southern Border

It was a little over a year ago when I first heard about the child separations happening at the U.S.-Mexico border. I had recently had my own son and it gave me a visceral feeling of horror imagining someone taking him away from me, not knowing where he was going, when I would see him again, or who would take care of him. I read a story of a 4-month-old taken from his mother as I held my own infant of a similar age. I imagined what kind of fear would drive me to make a dangerous journey with a newborn and beg for safety in a foreign country.  Children continue to be separated from their parents and caregivers. They are kept in conditions unfit for anyone, and especially damaging for children. We need to speak out against the treatment of migrant children that is occurring and demand more humane solutions.

Whether unaccompanied or as part of a family unit, when children present for asylum, they are brought first through a Customs and Border Protection facility where by law, they are not to be detained for more than 72 hours (Linton et al., 2017). However, some children and families are being held for much longer (Linton et al., 2017). There are small, unwashed and underfed children taking care of younger, filthy toddlers without proper sanitation available, like clean diapers (Raff, 2019). Studies have shown negative physical and emotional symptoms among detained children under any circumstance (Linton et al., 2017), then their source of resilience might be stolen away- their caregivers. Even a short time in detention can have damaging psychological effects (Linton et al., 2017). Interviewed parents have described regressive behavior in their children after detention along with increased aggression and self-injurious behavior (Linton et. al 2019). They might come with parents or they may come with extended family members hoping to join their parents already in the U.S. (Linton et al., 2017). In 2016, “Family Case Management” was terminated, a short-lived program that was 99% effective in having these families in court, even by ICE’s own statements (Singer, 2019). The former program cost taxpayers about $38 a day, while the current system costs hundreds per day (Singer, 2019).  

Children are dying. They are dying. They are kept in ‘prison-like conditions’ (Linton et al., 2017) and in the last year, at least 7 children have died in immigration custody after almost a decade of no deaths (Acevedo, 2019). Dr. Dolly Lucio Sevier, a pediatrician who visited a Customs and Border Protection facility in McAllen Texas, one of the facilities where immigrants are not to be held for longer than 72 hours. She met a baby whose uncle was forced to feed him for days from an unwashed bottle (Raff, 2019). She met a teenage mom whose baby was wrapped in diapers and plastic because they refused to give her clean clothes for her infant. This facility is known as the hielera, or ice box (Raff, 2019). This mom was trying desperately to keep her baby warm when she had nothing but concrete and mylar blankets (Raff, 2019). Dr. Sevier saw unmistakable signs of mental trauma and illness. The children had not been allowed access to soap, toothbrushes, clean clothes; and many had been in the facility weeks. They smelled, were malnourished, dehydrated, and most had at least a respiratory infection. The baby who had been drinking from a dirty bottle was fevered and ill (Raff, 2019).

Exposure to the ‘prison-like’ conditions present in the immigration facilities causes high levels of stress (Linton et al., 2017). It has been well documented that toxic stress will have lasting effects on the health of these children, even if they manage to somehow get past the mental effects of their trauma. They will be at higher risk for heart disease, cancer, diabetes, etc (Garner et al., 2015). Their present health and their future health are being destroyed in one fell swoop. The recognition and reduction of toxic stress in children should be a priority for all pediatricians (Garner et al., 2015), and should be part of a routine evaluation for the care of immigrant children (Linton et al., 2017).

The American Academy of Pediatrics  issued a policy statement about the detention of immigrant children. The policy outlines many concerns and recommendations including that separating a parent or primary caregiver from their children should never occur unless there is a concern for the safety of the child (Linton et al., 2017). Practices in the CBP processing centers are inconsistent with AAP recommendations for the care of children, and therefore children should not be subjected to them. Community-based case management should be implemented for the children and their families (Linton et al., 2017). Children should receive timely and comprehensive medical care.  “Treat all immigrant children and families seeking safe haven who are taken into US immigration custody with dignity and respect to protect their health and well-being” (Linton et al., 2017). 

It is easy to feel helpless and overwhelmed. I urge you to not become complacent. Write your own opinion. Write your congressional representatives. Donate to the Annunciation House, which helps to house some immigrants. You can also give to RACIES (Refugee and Immigrant Center for Education and legal Services) or to the Human Rights Initiative of North Texas, both of which seek to help immigrants gain asylum and legal status, among other services. I encourage my fellow physicians to look for immigrants among our patients. Recognize the trauma they have been subjected to. Practice trauma-informed care and do your best to refer to services that can help.

Marie Varnet, MD

My son and I protesting the treatment of immigrant children in Dallas, Tx

Acevedo, Nicole. “Why Are Migrant Children Dying in U.S. Custody?” NBCNews.com, NBCUniversal News Group, 30 May 2019, http://www.nbcnews.com/news/latino/why-are-migrant-children-dying-u-s-custody-n1010316.

Garner, Andrew S., et al. “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.” Pediatrics, American Academy of Pediatrics, 1 Jan. 2012, pediatrics.aappublications.org/content/129/1/e224.short.

Linton, Julie M., et al. “Detention of Immigrant Children.” Pediatrics, American Academy of Pediatrics, 1 May 2017, pediatrics.aappublications.org/content/139/5/e20170483#xref-ref-10-1.

Raff, Jeremy. “What a Pediatrician Saw Inside a Border Patrol Warehouse.” The Atlantic, Atlantic Media Company, 4 July 2019, http://www.theatlantic.com/politics/archive/2019/07/border-patrols-oversight-sick-migrant-children/593224/.

Singer, Audrey. “Immigration: Alternatives to Detention (ATD) Programs.” Congressional Research Service, 2019, fas.org/sgp/crs/homesec/R45804.pdf.

Autism is diagnosed starting at age 2. But what can we do before then?

In recent years, autism has been at the forefront of many discussions in pediatrics. Its prevalence has increased from 1 in 150 children to 1 in 59 over the last 20 years according to the CDC[i]and this is likely due in large part to our ever-growing knowledge of the condition and efforts promoting early diagnosis. Research thus far has shown that early diagnosis and intervention have been instrumental in generating positive outcomes. But how early can we start “therapy” for autism when it can’t even be diagnosed until 24 months of age? We now have research to show that pediatricians should be encouraging parents to consistently talk to their young children even if they aren’t getting any responses back.[ii]

A recent study published in the journal Autism Research delved a bit deeper into the concept of early intervention.[iii]Dr. Meghan Swanson conducted a study looking at 96 infants, 60 of whom had an older sibling with autism. Such a design was necessary given the age restriction on diagnosis and that younger siblings of children with autism have a 20% chance of having autism as well. This statistic was proven true as 14 of those 60 subjects were later diagnosed with autism at 24 months (23%). Dr. Swanson’s method was to monitor 2 full days of audio in the child’s home via LENA audio software- one day when the child was 9 months old and again at 15 months. The LENA software counts number of words as well as “conversation turns,” meaning when one person speaks and another responds. The content of what is said is not evaluated. The subjects’ language skills were then later assessed at 24 months. 

As mentioned, 14 of the subjects were ultimately diagnosed with autism and were placed in the “high-familial-risk who have ASD” group. The remaining subjects were divided into 2 groups: 1) those with older siblings affected by autism but who did not have autism themselves (high-familial-risk who did not have ASD, n=46) and 2) low-familial-risk who exhibited typical development (n=36). The conclusions of the study were two-fold. First and most important, a richer home language environment with higher numbers of adult words and conversational turns correlated to better language development for ALL study groups. Second, higher parent education levels corresponded to richer home language environment. 

As these results show, the benefit from caregiver interaction particularly in the realm of reciprocal spoken language is not restricted to typically developing children. Pediatricians should advise parents to enhance their child’s development from birth by speaking to them regardless of whether they are able to respond appropriately or at all. To be clear, autism is not a diagnosis that is caused by parenting style. The diagnosis will be present or not regardless of parental intervention. However, this study shows that frequent and early communication from birth can improve language development even in children with autism. Additionally, there are centers available that can provide more directed therapies for children struggling with language, social skills, and other developmental milestones. Life Skills Autism Academy is opening its flagship location in Plano, Texas where children 18 months to 5 years can receive personalized one-on-one therapy and assistance in developing an appropriate Individualized Education Plan (IEP) and advocating for the child in the school system.[iv]

Pediatricians can share this knowledge to help all their infant patients improve language development and kickstart their learning with the goal of success in school and beyond. 

Rachel Tonnis, MD


[i]https://www.cdc.gov/ncbddd/autism/data.html 

[ii]https://utdallas.edu/news/research/autism-language-skills-study-2019/

[iii]Swanson, Meghan R. “Early language exposure supports later language skills in infants with and without autism.” Wiley Online Library. Dallas, TX. 1 Sep. 2019. https://onlinelibrary.wiley.com/doi/abs/10.1002/aur.2163.

[iv]https://www.dallasnews.com/business/health-care/2019/08/29/life-skills-autism-academy-opening-in-plano-plans-to-provide-one-on-one-therapy/

Mental Health Screenings in Adolescent Care

The first week of October every year is designated as Mental Health Awareness Week in the United States – a pattern established by our Congress in 1990 to recognize the efforts of the National Alliance on Mental Illness (NAMI, www.nami.org) and increase awareness about mental health conditions. As we close out the end of Mental Health Awareness Week, I would like to focus on an important topic that sometimes ends up being overlooked or rushed through at a primary care visit: mental health screenings in the adolescent population.

According to results derived from a recent National Comorbidity Survey Replication, nearly 50% of all mental health conditions in the United States begin by age 14. Per data from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA), suicide is currently the second leading cause of death in adolescents; 18% of high school students nationwide reported having seriously considered attempting suicide (females > males), and at least 9% had attempted suicide one or more times. Identifying a possible mental health diagnosis early in life — such as depression, anxiety disorders, ADHD, eating disorders, or PTSD — can help save many individuals from life-altering consequences.

The American Academy of Pediatrics (AAP) recommends annual mental health screenings for adolescents starting at age 12. While state Medicaid provisions in Texas previously only allowed for one mental health screening, total, to be billed between the ages of 12 and 18 as part of an annual well-child exam, recent Texas legislation passed on September 1, 2017 (HB 1600) now allows Medicaid reimbursement for up to once-a-year mental health screenings with well-child exams from the ages of 12-18, which is an important step in the right direction.

Texas, however, is currently in the midst of a mental health workforce shortage, especially in child and adolescent psychiatry. Although legislative efforts to address this shortage within the state are in progress, it renders the pediatrician or primary care doctor’s duty to address mental health within adolescent well-child visits absolutely imperative at this moment.

Screening questions/tools that can be used in an adolescent primary care mental health screening can include, but are not limited to:

  • HEADDDSS Assessment:
    • Home – living situation, safety in the home, relationships with family
    • Education/Environment – address any learning/attention difficulties, friends and social circle, school and online bullying, social media (mis)use
    • Activities – hobbies, extracurriculars, jobs
    • Diet – include screening for disordered eating behaviors
    • Drugs:
      • Substance Use Screening Tool: CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble)
    • Depression/Suicidality:
      • Screening Tools: PHQ-2 (initial screen) + the more detailed PHQ-9
    • Sexual Activity/Sexuality/Sexual Abuse
  • Anxiety Screening Tool: SCARED (Screen for Child Anxiety-Related Emotional Disorders)
  • Trauma Screening Tool: CATS (Child-Adolescent Trauma Screen)
  • Pediatric Symptom Checklists (PSCs)

*Note: Mental health screenings for adolescents under Texas Medicaid must utilize at least 1 of the screening tools approved by Texas Health Steps, which includes the PSCs, the CRAFFT, and the PHQ-9.

For additional mental health information for patients, such as finding the closest behavioral health treatment centers, an excellent resource is the national SAMHSA website at https://www.samhsa.gov/treatment/index.aspx.

Anita Verma, MD

References:
American Academy of Child and Adolescent Psychiatry. (2013). Child and Adolescent Psychiatry Workforce Crisis: Solutions to Improve Early Intervention and Access to Care. https://www.aacap.org/App_Themes/AACAP/docs/Advocacy/policy_resources/cap_workforce_crisis_201305.pdf
American Academy of Pediatrics. (2017). Recommendations for Preventative Pediatric Health Care. Bright Futures, 4th Ed. https://www.aap.org/en‐us/documents/periodicity_schedule.pdf
Centers for Disease Control and Prevention. (2016). Children’s Mental Health Report. CDC Features: Life Stages and Populations. https://www.cdc.gov/features/childrensmentalhealth/
Centers for Disease Control and Prevention. (2016). 1991-2015 High School Youth Risk Behavior Survey data. http://nccd.cdc.gov/YouthOnline/App/Default.aspx
Department of Health and Human Services, Office of Adolescent Health: Adolescent Mental Health Fact Sheets. https://www.hhs.gov/ash/oah/facts-and-stats/national-and-state-data-sheets/adolescent-mental-health-fact-sheets/texas/index.html
HB 1600: Relating to certain mental health screenings under the Texas Health Steps program. http://www.capitol.state.tx.us/BillLookup/Text.aspx?LegSess=85R&Bill=HB1600
Kessler R.C., et al. (2005). Lifetime Prevalence and Age of Onset Distributions of DSM‐IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62(6): 593‐602. https://www.ncbi.nlm.nih.gov/pubmed/15939837
Testimony of Pritesh Gandhi, MD, MPH, to the Texas House of Representatives Public Health Committee, in support of HB 1600, March 2017. Submitted on behalf of the Texas Pediatric Society, Texas Medical Association, and Texas Academy of Family Physicians. https://txpeds.org/sites/txpeds.org/files/documents/house-ph-hb1600-3-14-17.pdf