Through evidence, Physicians for Human Rights change is possible. 256 West 38th Street 9th Floor New York, NY 10018 +1.646.564.3720 June 14, 2018 phr.org The Honorable Kirstjen Nielsen The Honorable Jeff Sessions Secretary Attorney General U.S. Department of Homeland Security U.S. Department of Justice 245 Murray Lane, S.W. 950 Pennsylvania Avenue, N.W. Washington, D.C. 20528 Washington, D.C. 20530 Dear Secretary Nielsen and Attorney General Sessions, As medical and mental health professionals and researchers working in the United States, we are gravely concerned about the Trump administration’s practice of separating migrant and asylum-seeking families at the U.S.-Mexico border. Such a practice is profoundly harmful to children and to families, in addition to violating fundamental human rights. We urge you to immediately end forced separation of families at the border, and instead keep families together in community-based settings while their immigration proceedings are pending. The Trump administration has stated that its goal in separating children from their parents is to deter people from crossing the border between ports of entry. According to statements by Attorney General Jeff Sessions, this policy is intended to be punitive, to serve as such deterrence.1 The child welfare implications appear to be secondary at best. White House Chief of Staff and former Department of Homeland Security secretary John Kelly has stated, “The children will be taken care of — put into foster care or whatever. But the big point is they elected to come illegally into the United States and this is a technique that no one hopes will be used extensively or for very long.2” Media reports indicate that government mechanisms for ensuring that parents and children are in contact and know each other’s whereabouts are non-functional.3 Using children as leverage to punish their parents is unconscionable, both with respect to the health and well-being of children and as treatment of migrants and asylum seekers. The right to family unity is enshrined in U.S. and international law, which recognize that families are the foundation of society. The relationship of children and parents is the strongest social tie most people experience, and a threat to that tie is among the most traumatic events people can experience. Forced separation of children and parents, especially in connection with the detention of a parent, can constitute an adverse childhood experience (ACE). ACEs are linked with disrupted 1 Attorney General Jeff Sessions, "Attorney General Sessions Delivers Remarks Discussing the Immigration Enforcement Actions of the Trump Administration," Speech, May 7, 2018, https://www.justice.gov/opa/speech/ attorney-general-sessions-delivers-remarks-discussing-immigration- enforcement-actions. 2 Transcript: White House Chief Of Staff John Kelly's Interview with NPR, NPR, May 11, 2018, https://www.npr.org/2018/05/11/610116389/transcript-white-house-chief-of-staff-john-kellys-interview-with-npr. 3 Michael E. Miller, "‘They just took them?' Frantic parents separated from their kids fill courts on the border," Washington Post, June 11, 2018, https://www.washingtonpost.com/local/they-just-took-them-frantic-parents- separated-from-their-kids-fill-courts-on-the-border/2018/06/09/e3f5170c-6aa9-11e8-bea7- c8eb28bc52b1_story.html. 1 neurodevelopment, resulting in social, emotional, and cognitive impairment,4 and have even been linked with negative intergenerational effects.5 Extreme and repetitive stress -- known as toxic stress -- such as that experienced when a person is suddenly separated from parents, adversely affects brain development and is correlated with increased risk of developing chronic mental health conditions, such as depression and post-traumatic stress disorder (PTSD) and even physical conditions such as cancer, stroke, diabetes, and heart disease.6 Separation from parents has been shown to be linked with higher rates of PTSD in the affected children.7 For children, separation results in a low-support environment which places them at increased risk of PTSD and depressive disorders.8 The negative impact on the cognitive and emotional functioning of the affected children can continue into adulthood, and contribute to lower academic achievement, attachment difficulties, and poor mental health.9 Among refugees, one research study shows that individuals separated from their families had worse mental health outcomes in terms of depression, PTSD, and psychological quality of life than those who remained with their families, after controlling for trauma. After testing the contribution of 26 types of trauma to these outcomes, only the experience of being beaten and tortured had a similar impact on all three mental health measures as family separation.10 According to the new U.S. policy, children arriving with their parents will be placed in the custody of the Office of Refugee Resettlement in foster families after separation. However, foster care is not an appropriate substitute to a child remaining with his or her parents, and studies of refugee children in foster care have shown that children fare worse when placed in foster families than when cared for by their parents.11 Placing these children into foster care will strain the U.S. child welfare system and set these children up for worsened health and social outcomes.12 The best interests of the child is the recognized legal standard for the treatment of children across a range of domains, including parental custody and immigration proceedings. This standard requires that children not be separated from their parents except in extreme circumstances, if required for the child’s protection. Indeed, the literature shows that parents 4 Vincent J. Felitti et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 14, no. 4 (1998); Debora L. Oh et al., “Systematic Review of Pediatric Health Outcomes Associated with Adverse Childhood Experiences.” Pediatrics 141, no. 1 (2018). 5 Felice Le-Scherban et al. “Intergenerational Associations of Parent Adverse Childhood Experiences and Child Health Outcomes,” Pediatrics 141, no. 6 (2018). 6 Vincent J. Felitti et al. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults,” American Journal of Preventive Medicine 14, no. 4 (1998). 7 Paul L. Geltman et al. “The ‘lost boys of Sudan’: functional and behavioral health of unaccompanied refugee minors re-settled in the United States,” Archives of Pediatric and Adolescent Medicine 159, no. 6 (2005). 8 Matthew Hodes, “Psychopathology in refugee and asylum seeking children,” in Michael Rutter et al. (eds.), Rutter’s Child and Adolescent Psychiatry (Wiley-Blackwell, 2009). 9 Israel Bronstein and Paul Montgomery, “Psychological distress in refugee children: a systematic review,” Clinical Child and Family Psychology Review 14, no. 1 (2010). 10 Alexander Miller at al. “Understanding the mental health consequences of family separation for refugees: Implications for policy and practice,” American Journal of Orthopsychiatry, 88, no. 1 (2018). 11 Amy Holtan et al. “A comparison of mental health problems in kinship and nonkinship foster care,” European Child & Adolescent Psychiatry 14, no. 4 (2005); Geltman et al., “The ‘Lost Boys of Sudan.’” 12 Kym R. Ahrens, Michelle M. Garrison, and Mark E. Courtney. “Health outcomes in young adults from foster care and economically diverse backgrounds,” Pediatrics 134, no. 6 (2014); Amy Dworsky, Laura Napolitano, and Mark E. Courtney. “Homelessness during the transition from foster care to adulthood,” American Journal of Public Health, 103, no. S2 (2013). are a vital buffer for children coping with severe stress.13 A strong predictor of successful adaptation for children is family support.14 Separation from their parents denies these children this vital resource, leaving them alone to face extremely stressful and likely frightening conditions. It increases the risk that these children will experience severe and long-lasting psychological problems, and may even contribute to the development of physical health issues.15 The United States should follow the “best interests of the child” standard and immediately stop the practice of forced separation. It should not be U.S. policy to traumatize children, especially not as a form of indirect punishment of their parents. The intentional infliction of pain on children and their families is not just inhumane, it also fails to meet the stated goals of deterrence. Punishing parents with family separation may cause damage to their children, and it will not change the realities that drove the parents to seek safe haven in the United States. As experts committed to promoting health and well-being, including of children, we ask you to immediately end the practice of family separation and take all measures to ensure that currently separated families are reunited without delay. Sincerely, Homer Venters, M.D., M.S., Director of Programs, Physicians for Human Rights, New York Kerry J. Sulkowicz, M.D., Chair, Board of Directors, Physicians for Human Rights, New York Eli Newberger, M.D., Pediatrics, Massachusetts Elizabeth B. Ford, M.D., Psychiatry, New York Kathleen Foley, M.D., Neurology, New York Stephen Soldz, Ph.D, Psychology, Massachusetts Edward Ameen, Ph.D, Psychology, Washington DC Annalise Keen, M.D., Psychiatry, Utah Roya Ijadi-Maghsoodi, MD, MSHPM, California