CHILDREN DON T IMMIGRATE, THEY FLEE MINAL GIRI, MD, FAAP CHAIR, REFUGEE IMMIGRANT CHILD HEALTH INITIATIVE 8 TH ANNUAL ABC CONFERENCE

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1 CHILDREN DON T IMMIGRATE, THEY FLEE MINAL GIRI, MD, FAAP CHAIR, REFUGEE IMMIGRANT CHILD HEALTH INITIATIVE 8 TH ANNUAL ABC CONFERENCE

2 DISCLOSURE I declare that neither I, or my immediate family, have a financial interest or other relationship with any manufacturer/s of a commercial product/s or service/s which may be discussed at the conference.

3 NON-PARTISAN & PRO-CHILD

4 OBJECTIVES Discuss why immigration is a pediatric issue Understand impact on mixed citizenship families and unaccompanied minors Consider detention and other experiences of the undocumented Learn about Immigration in a Public Health context Define our role in the lives of immigrant families

5 CHILDREN DO NOT IMMIGRATE, THEY FLEE Many of the children who will be most affected are the victims of unspeakable violence and have been exposed to trauma. They are coming to the U.S. seeking safe haven in our country and they need our compassion and assistance. Broad scale expansion of family detention only exacerbates their suffering. Fernando Stein, AAP President

6 IMMIGRATION: WHY IS IT A PEDIATRIC ISSUE? As the population of immigrant children continues to grow, health care providers will increasingly manage a wide range of complex issues related to immigration as a social determinant of health Whether voluntary or involuntary, migration challenges individuals and communities and has significant social, economic, and health consequences The health effects of immigration have particular impact on the long term development and well-being of children Understanding the impact of immigration on our patients will allow us to better serve them

7 A PREDICTION Children in immigrant families will represent 1/3 of US children over the next 40 years Image reproduced from: Kids Count Data Center. *Mendoza & Festa, Pediatrics, 2013

8 ILLINOIS CHILDREN IN IMMIGRANT FAMILIES 2015 Children in Immigrant Families US 25% Children in Immigrant Families Parents are Not US Citizens IL 27% US 40% IL 41% Kids Count Data Center.

9 Immigrant Families & Children CITIZENS NON-CITIZENS 1 Mixed Citizenship Families, DACA Family members all Citizens Lawfully present / lawfully residing \ immigrants (e.g. refugees, asylees, Special visa status: VAWA, SJIS) Undocumented (unauthorized) immigrants 2 Unaccompanied minors Released into community 3 Detention

10 UNDOCUMENTED IMMIGRANTS IN ILLINOIS

11 In 5 states (CA, IL, NY, MA, WA) and D.C., immigration status does not impede a child s access to public insurance

12 CHALLENGES TO MIXED CITIZENSHIP FAMILIES Threat of Deportation Detention Actual Deportation

13 WHO ARE UNACCOMPANIED MINORS? A person who is under the age of eighteen and who is separated from both parents and is not being cared for by an adult, who, by law or custom, has responsibility to do so. Guidelines on Policies and Procedures in dealing with Unaccompanied Children Seeking Asylum. United Nations High Commission for Refugees (UNHCR), February 1997

14 UNACCOMPANIED MINORS ENTERING THE US

15 WHERE ARE THE UNACCOMPANIED MINORS? In 2016, DHS detained 59,692 unaccompanied immigrant children 37,814 as of August 2017 Apprehended at borders and airports

16 WHY THEY ARE HERE Ethnic/ political persecution Abusive families Forced gang recruitment Sexual exploitation Commercial War conditions Abandonment Sold by relatives Attempting to reunite with relatives Fleeing extreme poverty

17 WHERE THEY COME FROM Central America South America Asia South Asia Eastern Europe Africa

18 INTENDED DESTINATIONS Europe North America Australia

19 WHERE THEY END UP Sent to shelters throughout the US Held for indeterminate length of time Locate appropriate family members Foster homes Legal proceedings

20 Traffickers Hired smugglers Travel on their own METHODS OF TRANSPORT

21 WAR My parents were both kidnapped by the Lord's Resistance Army in Uganda. I am afraid they will take me too. 17 year old boy

22 SEXUAL VIOLENCE My mother, sister, and I led a Women's Rights organization in Haiti. I saw my mother gang raped and killed in My 13 year old sister and I are in hiding. We are afraid of the government gangs. 27 year old woman, case is on appeal

23 FEMALE GENITAL CUTTING I was in an arranged marriage and my husband locked me in a room for a week to try to get me to submit to circumcision. 17 year old girl from Nigeria

24 CHILD ABUSE My grandmother took us in after my mother went crazy. She beat me and forced me to work in the fields since I was seven. She took the money and fed me only once a day. If I didn t work, she would whip me until I bled. 19 year old from Guatemala

25 EFFECTS AND IMPACT ADULTS Fear and psychological distress over uncertainty of deportation Refusal to legitimate health access care Forgoing services due to fear of apprehension and deportation CHILDREN Anxiety Depression Hopelessness Somatization

26 HEALTH CONCERNS Missed medical appointments Children miss school, sports, activities that require driving or travel Fear going to parks, exercise outdoors Fear going to places of worship Fear being out in their communities

27 PUBLIC HEALTH CONSEQUENCES Not accessing important services Medical Housing Legal Community supports Education

28 SENSITIVE LOCATIONS #ROSA MARIA HERNANDEZ Hospitals Schools Places of worship Civil / religious ceremonies Public demonstrations

29 CHALLENGES TO CARING FOR IMMIGRANTS

30 TRAUMA IS A REALITY

31 WHAT IS A TRAUMATIC STRESSOR? An overwhelming event resulting in helplessness in the face of intolerable danger, anxiety and instinctual arousal Eth and Pynoos (1985)

32 TRAUMATIC STRESSORS Parental loss or caregiver separation Loss of community, familiar societal structures and norms Witnessing violence Experiencing personal violence Insecurity associated with journey

33 Flashbacks Depression

34 COMMUNICATION BARRIERS Have been instructed or threatened by an adult not to reveal their true story Distrust adults or figures of authority Fear implicating existing family members who are already in the US Simply lack a narrative They do not know why they are here Linguistic Cultural ( shame ) Developmental (delayed or lack of maturity)

35 HOW TRAUMA IMPACTS COMMUNICATION Incoherent narrative Memory gaps Out of sequence Take time to reveal full extent of trauma Appear vague and lack detail

36 DEVELOPMENTAL CONCERNS Level of maturity Thought processes Concrete vs. Abstract Thought Consequences of one s actions Cognitive deficits and the ability to learn Concepts of time Passage of time Linear narratives

37 PSYCHOLOGICAL CONCERNS Socialization and isolation Trust and attachment issues Post-traumatic stress disorder Self injury/ mutilation Anxiety Depression and suicidal ideation Behavioral disorders acting out, aggression

38 MEDICAL PROBLEMS INFECTIOUS DISEASE MALNUTRITION SEXUAL ABUSE Lack immunizations Stunted growth STI, HIV / AIDS Tuberculosis Cognitive defects Pregnancy Malaria Other parasitic infestations HIV / AIDS Anatomical damage Long term reproductive health

39 IT IS THE CHILDREN WHO PAY THE PRICE FOR OUR SHORT-SIGHTED POLITICS, OUR POLITICAL MISTAKES, OUR WARS Eglantyne Jebb, Founder of Save the Children

40 CONVENTION ON THE RIGHTS OF THE CHILD Children should be accorded special protection and assistance Ratified by 194 countries Exception of the US, Somalia, South Sudan

41 WHAT HAPPENS WHEN THEY ARRIVE?

42 TREATMENT IN UNITED STATES Placed in removal proceedings before the Immigration Court No special consideration to accommodate needs of children Adults and children viewed and treated the same way in immigration court

43 BARRIERS TO SANCTUARY FOR CHILDREN IN U.S. Lack capacity to advocate for themselves Instructed by adults family or traffickers to keep their stories secret Do not understand eligibility for application for asylum or other immigration protections

44 DETENTION

45 I WISH I COULD CHANGE EVERYBODY S MIND SO THAT WE ARE ALL EQUAL AND NOBODY IS UNEQUAL Workshop with Separated Minors (Dublin 2005)

46 DETENTION CENTER CONDITIONS Undisclosed shelters throughout the country Detention varies from a month to year Treatment not uniform Secured facilities: Criminalization, Solitary confinement

47 HOW MIGHT WE RESPOND? Finding ways to be effective in our care of those immigrant families that we serve

48 WHAT THE AMERICAN ACADEMY OF PEDIATRICS RECOMMENDS That all immigrant children and families be treated with dignity and respect; That children not be exposed to conditions or settings that may re-traumatize them, such as those that currently exist in detention; That children never be separated from a parent or primary caregiver, unless there are concerns for the safety of the child at the hand of the parent. That when in custody, children be provided with child-friendly orientation and regular updates on their status, expectations and rights. That DHS should discontinue the use of family detention and instead use community-based alternatives. That children receive timely, comprehensive medical care that is culturally and linguistically sensitive by trained medical providers, throughout the immigration processing pathway.

49 WHAT DOES THIS LOOK LIKE IN REALITY? Tap in to your own compassion to understand the realities of the lives of immigrant families Connect the dots of their experience to their behavior Know your community resources and refer, refer, refer Help families to tap into the strengths and resilience that are important tools for overcoming trauma

50 RESILIENCE Protective Factors Positive personality disposition Supportive family environment Response and functioning of parent or care taker during and after stress External societal agent supporting child s coping efforts

51 We know that children can overcome stress when they feel safe and have enduring, supportive relationships with caregivers. All children deserve to be healthy and safe. Julie Linton, MD, FAAP, chair of the AAP Immigrant Child Health Special Interest Group

52 ACKNOWLEDGEMENTS AAP Immigrant Health Special Interest Group: Julie Linton, MD, Marsha Griffin, MD, Alan Shapiro, MD, Janine Young, MD, Kate Yun, MD, Andrea Green) AAP Staff: Tamar Haro, Camille Watson