Eyewitness accounts by pediatricians and advocacy
groups, including two AAP delegations, documented frequent separation of children from parents and
detailed treatment of children that exposes them to
potentially traumatizing conditions. Evidence from
both within and beyond U.S. borders, described in the
policy, demonstrates that detention threatens children’s
short- and long-term health and well-being.
Children in the custody of their parents should
never be detained or separated from a parent unless
a competent family court makes that determination,
according to the policy, which is available at http://doi.
org/10.1542/peds.2017-0483 and will be published in
the May issue of Pediatrics.
Communities nationwide have become homes to
immigrant and refugee children fleeing countries across
the globe. Yet more than 95% of children crossing the
U.S. southern border are from Guatemala, Honduras
and El Salvador (Northern Triangle countries), with
smaller numbers from Mexico and other countries.
Unprecedented violence, abject poverty and lack of
state protection in the Northern Triangle countries are
driving escalated migration to the United States.
In fiscal year 2016, 59,692 unaccompanied children and 77,674 family units sought asylum or were
apprehended crossing the southern border, according
to U.S. Customs and Border Protection (http://bit.
ly/2mD6VPp). Interviews with children in detention
from Mexico and the Northern Triangle revealed that
58% had fear sufficient to merit protection under international law ( http://bit.ly/2m2Wub7).
Complex evaluation, legal process
From the point of arrival through permanent reset-
tlement in communities, immigrant children seeking
safe haven face a complicated evaluation and legal
process. Children apprehended with a parent or le-
gal guardian are either repatriated back to their home
countries under expedited removal procedures, placed
in Immigration and Customs Enforcement (ICE)-fam-
ily residential centers or released into the communi-
ty awaiting their immigration hearings (http://bit.
Intact family units often are separated from each
other at the border and placed in separate detention
facilities, since no facilities accommodate both mother-and father with children. After processing by DHS, unaccompanied immigrant children are placed in shelters
or other facilities operated by the U.S. Department of
Health and Human Service’s Office of Refugee Resettlement, and the majority are subsequently released to
the care of community sponsors (parents, other adult
family members or nonfamily individuals) throughout
the country for the duration of their immigration cases
Pediatricians have the opportunity to advocate for
systems that mitigate trauma and protect the health
and well-being of vulnerable immigrant children, including a coordinated system that facilitates consistent
access to medical care, education, child care, interpretation services and legal services at all stages of the
Key recommendations regarding treatment of children and families who arrive at the U. S. border include:
• Separation of a parent or primary caregiver from
his/her children should never occur, unless there
are concerns for the child’s safety at the hand of
• Children should not be exposed to potentially traumatizing conditions, which currently exist in DHS
• Processing of children and family units should occur in a child-friendly manner, taking place outside
current Customs and Border Protection processing
centers or conducted by child welfare professionals,
to provide conditions that emphasize the health
and well-being of children and families at this critical stage of immigration proceedings.
• DHS should discontinue the general use of family
detention and instead use community-based alternatives to detention for children apprehended
in family units.
• Community-based case management should be implemented for children and families, thus ending both
detention and the placement of electronic tracking
devices on parents. Government funding should be
provided to support case management programs.
Guideline-based care for all children
The Academy supports comprehensive health care in
a medical home for all children in the United States,
including all immigrant children and those detained or
otherwise in the care of the state. Integrated behavioral
health in the primary care setting is an optimal model for
care of immigrant and other vulnerable children, minimizing the difficulty of navigating the health care system.
Further recommendations regarding community-based management include:
• Pediatric providers serving previously detained
immigrant children should elicit specific history of abuse, neglect, abandonment, persecution,
trafficking or violence to screen children for legal
needs and subsequently refer these children for
• Integrated care strategies, such as medical-legal
partnerships, may enhance connectivity. Likewise,
immigration lawyers should have opportunities to
refer children to medical homes if children reach
the legal system prior to seeking medical care.
• Pediatric practices should facilitate children’s enrollment in public educational services, essential
to children’s development and future well-being.
School facilities should be safe settings for immigrant children to access education. School records
and facilities should not be used in any immigration enforcement action.
• No child, whether accompanied or unaccompanied, should ever represent himself or herself in
court. After release into the community, all previously detained immigrant children should have
access to legal services at no cost to the child or his
or her sponsor.
Drs. Linton, Griffin and Shapiro are lead authors of the
policy statement. Dr. Linton also is a member of the AAP
Council on Community Pediatrics Executive Committee, and with Dr. Griffin co-chairs the AAP Immigrant
Health Special Interest Group. Dr. Shapiro is co-founder
and medical director of a medical-legal partnership program for unaccompanied immigrant children.
• AAP Immigrant Child Health Toolkit, http://bit.ly/1fgRTe B
• AAP Trauma Toolbox for Primary Care, http://bit.ly/1OZ
Dr. Linton Dr. Griffin Dr. Shapiro
The following are published in the April issue of
Clinical Considerations Related to the Behavioral
Manifestations of Child Maltreatment
— An AAP clinical report from the Committee on Child
Abuse and Neglect, Council on Foster Care, Adoption
and Kinship Care; and the American Academy of Child
and Adolescent Psychiatry and National Center for Child
Traumatic Stress (See article on page 12.)
— An AAP policy statement from the Council on Foster
Care, Adoption and Kinship Care (See article on page
2017 Recommendations for Preventive Pediatric
— An AAP policy statement from the Committee on
Practice and Ambulatory Medicine and the Bright
Futures Periodicity Schedule Workgroup (See article at
Coming in May
• Detention of Immigrant Children
• Nonemergency Acute Care: When It’s Not the
• The Breastfeeding-Friendly Pediatric Office Practice
• Disaster Preparedness in Neonatal Intensive Care
• The Primary Care Pediatrician and the Care of
Children with Cleft Lip and/or Cleft Palate
This month in Pediatrics
Refugee health profiles
The Centers for Disease Control and Prevention offers
guidance for pediatricians treating patients who are refugees from Central America, http://bit.ly/2mNyEB5, and
Each Refugee Health Profile webpage includes sections
on priority health conditions, health concerns and access
to care abroad, and information about the type of medical
screening that refugees may have received prior to being
resettled in the United States. Background information
can aid pediatricians in providing culturally effective care.
Additional health profiles are available for Bhutanese,
Burmese, Congolese and Iraqi refugees. Visit http://bit.