Featured Article
Article Title
Approaching pediatric mental health screening and care in immigration detention
Authors
Shela Sridhar - Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, 75 Frances Street, Boston, MA, 02115, USA
Leah Ratner - Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, 75 Frances Street, Boston, MA, 02115, USA
Matthew G. Gartland - Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Harvard Medical School, 125 Nashua St. Suite 725, Boston, MA, 02114, USA
Dennis Kunichoff - François-Xavier Bagnoud Center for Health and Human Rights, Harvard University, 677 Huntington Ave, Boston, MA, 02115, USA
Margaret M. Sullivan - François-Xavier Bagnoud Center for Health and Human Rights, Harvard University, 677 Huntington Ave, Boston, MA, 02115, USA
Vasileia Digidiki - François-Xavier Bagnoud Center for Health and Human Rights, Harvard University, 677 Huntington Ave, Boston, MA, 02115, USA
Abstract
Children held in US immigration detention facilities often arrive with significant mental health conditions requiring prompt attention. Despite the abundance of literature highlighting the need for adequate mental health care in migrant children, there is a chasm between the care offered to detained migrant children in the US and the minimum standards of healthcare in the US. This discrepancy is fueled by the mandate of Immigration and Customs Enforcement (ICE), which prioritizes immigration enforcement rather than the health and well-being of detained children. The tension between the existing ICE’s enforcement mandate and the internationally recognized right to health care for children results in inadequate mental health care, causing long-term harm. We highlight current pediatric mental health screening and treatment practices in immigration detention facilities, exploring the role of ICE and child protection frameworks. We conclude by providing policy recommendations to improve mental health care in US-based detention facilities.
Keywords
Immigration; Clinical practice
Summary of Research
“Global migration continues to rise as [families] are driven out of their homes by … domestic violence, persecution, and war to economic disparities and socio-political unrest. Of these migrants, 36 million are under the age of 18… evidence from the ground indicates that border control efficacy is prioritized over their child protection obligations … This focus on border security, rather than child protection, can have dramatic impacts on the overall health and well-being of those children detained on the basis of immigration… Many child migrants experience trauma in their home countries, even prior to beginning their journeys… 78% of children seeking asylum suffered direct physical violence, and 18% were subject to sexual violence… conditions that they are exposed to upon arrival to the US exacerbate the emotional and psychological trauma endured in their home countries and the often-arduous journeys experienced before arrival to the US.
…The lack of legally mandated specialized medical care and resources needed to identify and address this trauma leads to chronic physiologic and psychological stress and lasting developmental problems. Existing research has shown that children who have experienced forced migration and subsequent detention due to strict migration policies have higher rates of social, emotional, behavioral difficulties and mental health disorders, including Post-Traumatic Stress Disorder (PTSD), depression, and anxiety” (p. 1).
“… There is a chasm between what is offered to detained migrant children in the US and the minimum standards of medical care in the US… Children who arrive as unaccompanied minors are held in detention facilities operated by the Office of Refugee Resettlement…. Several news reports over the years have documented negative health impacts related to overcrowding, lack of sanitation, insufficient food, inappropriate temperature control, and lack of basic health care and health screening in ICE facilities… existing data shows that more than 30% of children detained on the basis of immigration were detained in ICE custody for longer than the 20-day mandated period…
This health policy paper presents the findings of a study delineating the mental health screening and medical management of children in ICE detention in the United States. We discuss these findings in the context of the role of DHS-run agencies, specifically ICE, and US-based frameworks in child protection…
As long as child migrant detention persists, national standards of mental health care must be transparently established, practiced, and regulated. If these needs cannot be met within DHS, we posit that the role of DHS in holding children should be minimized through the abolition of child detention or transition of care to a child-focused federal agency equipped to adequately meet the needs of these children” (p. 1- 2).
“By not implementing this rights-based approach to child health, the US is not subject to the standards of the Convention on the Rights of the Child and is able to continue… Despite the growing concern about the impact of these administrative practices on children, no efforts appear to exist to improve conditions and ensure access to quality and age-appropriate mental health care or redress harms experienced by children in immigration detention…
…Our findings reveal inadequate screening and follow-up for children who are found to have mental health concerns in migrant detention centers run by ICE… It is critical to understand our findings in the context of existing policies and adherence to policies regarding mental health care in detention facilities” (p. 3- 6).
“We ask that Congress provide adequate funding to DHS for staff to receive training in effective pediatric mental health screening, including implementation of trauma informed care and implementation of proper screening tools based on age…
As the practice remains in place and children are detained for extended periods of time, ICE must be held to a legal standard that includes protecting the health of children who remain in immigration detention custody. Existing laws must both be enhanced and enforced with the proper oversight to ensure that age-appropriate mental health care, appropriate referral systems, and immediate release where necessary are available and provided… To meet our commitment to protect children, we advocate for the end of child migrant detention and the assignment of their protection to an agency adequately equipped to meet the needs of these children. The medical, legal, and political communities must work to ensure that organizations that interact with children are focused on the medical and mental health care of all children in US custody” (p. 8).
Translating Research into Practice
“By effectively screening children for mental health conditions, children who require specialized care are more likely to be moved out of CBP custody as soon as possible and receive the appropriate standard of care they are entitled to as a human right outlined by international and US law… screening for migrant children is critical and should be designed to “determine who should be referred for mental health diagnosis and management” (p. 3- 4).
“Staff should be provided with the time and resources to provide care that reassure families that they will not face retribution and that responses to the screening questions will not be held against the children or their families… For meaningful accountability, there must be transparency and a legal standard to which ICE officials are held when it comes to humane medical and mental health practices in detention. Enhancing the legal accountability as well as providing the necessary resources to meet this aim is critical to improving care of children detained on the basis of immigration…
If the mandate of DHS run agencies such as ICE cannot expand to include these criteria, it is critical that the federal government enlists other agencies or accountable entities to step in and provide medical care… The US should invest in alternatives that can ensure the protection and safety of migrant children without compromising the safety of the country’s borders. This includes measures that would increase local medical and support staff within detention facilities to provide more comprehensive care. Other measures could enhance referral systems and case managers at the federal level to support those children who screen positive for higher-level needs, while still maintaining a system to track those individuals who may not have authorized status” (p. 6- 7).
Other Interesting Tidbits for Researchers and Clinicians
“It is critical that screening tools fit the following paradigms to be effective:
1) appropriate context and need;
2) technically reliable, accurate, and valid;
3) generates useful data to inform current mental health state;
4) feasible to implement with feasible referral pathways;
5) beneficial, without causing harm and recognizes the cultural context.
If screening does not meet these standards, it fails to identify those children who are truly at risk, resulting in missed diagnoses and delayed mental health care” (p. 3).
“There are several barriers to adequate pediatric mental health care in detention facilities that likely contributed to the inadequate mental health management of children in detention, which we have outlined here:
1) Given the number of migrants who are crossing the border, the processing system for newly arrived migrants is slow. This results in overcrowding and, therefore, inadequate staffing to meet the mandates for appropriate mental health care in detention facilities.
2) Even when staffing is sufficient, there is an inadequate emphasis on the specialized training and diagnostics needed for pediatric populations.
3) Most importantly, the agency responsible for processing migrants, including children, cannot, based on its conflicting mandate, provide comprehensive, trauma-informed care to children” (p. 6).
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