WASHINGTON -- Despite President Trump's to stop immigrant children from being separated from their parents at the border, the physician community has kept up its attacks on the former policy and questioned whether the new version adequately addresses the concerns.
For starters, Trump's order didn't indicate how, if, or when the approximately 2,300 children who have already been removed from their parents under the earlier policy will be reunited with them.
"The fact that the president is now saying we are not going to separate parents and children ... that's a good first step. But there's a lot of 'now whats,'" said Colleen Kraft, MD, MBA, president of the American Academy of Pediatrics.
"Once they're reunited, we cannot put these kids in a situation where they're re-traumatized," she stressed, panning the idea of families being held together in detention centers.
Families should be housed in a community setting "which is much more healthy for the developing child brain and for the health of these children," Kraft said.
Calls for Immediate Reunification
Ana María López, MD, MPH, president of the American College of Physicians, said she viewed the order as a "stop-gap" measure.
It does not correct the administration's , under which they are all to be detained for prosecution, nor does it provide a "permanent end" to the policy of parental separations, she wrote in a on Wednesday,
"While the order intends to end family separation, it calls for children and parents to be detained together 'throughout the pendency of criminal proceedings for improper entry or any removal or other immigration proceedings," wrote López. This directly contradicts the (now known as Flores v. Sessions due to continued litigation) that aims to prevent children from "prolonged detention" in situations where their parents face immigration violations. She expects the order to be challenged in the courts.
López also said the children needed to be reunited with their families immediately.
"Any delay in reunification will exacerbate the negative health consequences inflicted on the children and their families," she said.
With regard to their health, immigrant children have "a baseline of significant trauma" before even reaching the U.S., said Judith Cohen, MD, chair of the American Academy of Child and Adolescent Psychiatry's Child Maltreatment & Violence Committee.
Many have been exposed to domestic violence and gang violence in their home countries, and many have endured sexual violence and deprivation, including hunger and hot weather, on their journey to the U.S., she told 鶹ý.
Médecins Sans Frontières, which has provided medical treatment to immigrants along Mexico's migratory routes for the past 6 years, echoed Cohen in a detailing the hardships their patients endured: "death of family members, assault, kidnappings, extortion." The violence and "mental trauma" are akin to what MSF has observed in war zones, the group wrote.
In April 2018, Kraft visited what's known as a "tender care" shelter, where the youngest immigrant children are kept and observed the care in a room of about 15 children.
"Normally with toddlers, you see kids running around and playing and exploring and getting into trouble," Kraft told 鶹ý, but most of these children were not interacting at all.
"One little girl was in the center of the playmat ... wailing," Kraft said.
"The staff really tried to be very caring to these children, but they couldn't hold or comfort them, or soothe them at all and it was just so sad to see," she added. A 鶹ý report published in April, about a pediatrician group's visit to a Texas border detention center in 2016, included virtually identical observations.
Cohen stressed the potential harm to children following separation from a parent.
"We know that parental support is a critical protective factor for preventing the development of mental health problems ... and it can mitigate the negative impact of trauma," she said.
"When you separate children from their parents you're depriving them of this protective factor ... then you're adding a potentially third level of trauma," on top of the harsh home environments and the journey to the border, she noted.
Beyond proper medical care, what children in detention need, if they can't be physically reunited with their parents, is to speak to their parents by phone or by video chat.
"Just giving them food and a place to lie down, and something to watch on TV is not reassuring the way a parent's voice can be," Cohen said.
Impacts on Child Health
Psychiatrist Gabrielle Shapiro, MD, of Icahn School of Medicine at Mount Sinai in New York, recalled studies of Romanian infants and toddlers separated from their parents. Those children generally had less white matter in their brain and lower IQs.
"Our concern about the refugee children ... being put into facilities where staff are not allowed to touch them is that the lack of a primary attachment figure during early stages of development can lead to long term psychiatric, biological, and social sequelae," she said.
"The youngest children are the biggest concern," because older children already have the experience of developing an attachment to a parent or parent figure.
Studies by René Spitz in the 1930s and 1940s showed infants who were given food and clothes, but weren't touched, developed "" (a term no longer in use).
The infants were put in incubators and weren't touched a lot, and some became depressed and showed a failure to thrive, she said.
"Some of these kids actually died of heartbreak," Shapiro said.
Neural endocrine responses are affected by early loss or separation from parents, she noted.
"Oxytocin is thought to mediate social bonding and protect against stress, anxiety and depression symptoms," and a situation where there is no personal contact can impact infants later sensitivity to oxytocin.
Moreover, having an attachment figure, typically a parent, helps children develop a sense of safety and security in the world, and children's own sense of self is dependent on that relationship, explained Shapiro.
"With these kids, their own sense of self will be disturbed because they don't have anything to model," Shapiro said.
"The government must immediately assess each child in its custody and reunite them with their parents as soon as possible," she said.
For those parents that have already been deported, the government should attempt to connect the children with a family member or friend or place them in a culturally appropriate environment, she said.
"The longer they're in custody and the longer they're in ... an attachment-deprived situation the greater the ramifications on their later development," said Shapiro, including their immune system development, cognitive development, and social and psychological development.
In addition to concern about depression, anxiety and post-traumatic stress disorder cited by the , the ACP's López wrote that children removed from their families are more likely to engage in "risky behavior" including smoking, alcohol abuse and drug use and have an "increased likelihood to develop preventable illnesses like heart disease, cancer, or stroke."
Allegations surfaced this week that , including before the separations policy went into effect, but .