^{Compiled by Megan J. Wolff, PhD MPH
Last updated: July 8, 2018}

The forcible and sudden separation of children from parents constitutes a form of trauma that can have both immediate and long-lasting health consequences.

Short Term                                     

Even brief separations are stressful to young children.

• Neurophysiology
  • Faced with an outstanding source of stress, a surge of adrenalin in a child’s body will activate two systems: [1]
    • the hypothalamic-pituitary-adrenal (HPA) axis
    • the sympathetic nervous system (SNS) located in the brain stem
  • This will set in motion a "stress response" or "stress cascade," mediated primarily by the hormone cortisol. Visible characteristics include:[2]
    • Increased heart rate
    • Elevated blood pressure
    • Rapid breathing
  • Less visible components include:
    • The shunting of blood from the  digestive  [3]
    • An increase in alertness. Sight, hearing, and other senses become sharper. [4]
  • The presence of cortisol will keep the body on “high alert” until the threat passes (in this case, the caregiver returns), at which point it falls, “braking” or dampening the stress response.
• Presentation
  • The child will respond to the separation with intense distress: crying out, weeping, signaling that the parent is needed and must return.
  • The younger the child, the more significant and traumatic the separation will be.

• Buffers
  • It is well understood that the key to healthy development is “attachment,” a concept originated by British Psychiatrist John Bowlby to denote a “lasting psychological connectedness between human beings.”[5]
    • Attachment is the key to many of a child’s developmental milestones.
    • The mechanism is adaptive and enhances the infant’s chance of survival.[6]
  • Attachment also serves as a well-known buffer against the effects of trauma.
    • According to Bowlby infants have a universal need to seek close proximity with their caregiver when under stress or threatened.[7]
      • The physical touch of a caregiver will soothe a child in an agitated state.[8]
        • It has been demonstrated that caregiving touch actively calms infants in pain or discomfort.[9]
        • Distressed children hugged by caregivers experience a drop in stress hormones and a corresponding reduction in breathing and heart rate.[10]
      • Verbal and nonverbal cues from a caregiver are used from babyhood as “emotional signals” that convey warnings or reassurance about the environment.
        • In the “visual cliff” experiment, psychologists observed babies make decisions based on the facial expressions of their mothers as to whether to crawl over a plexiglass surface designed to look like a cliff. When the mothers used encouraging faces, 74% of babies crossed. When mothers supplied a look of fear, no babies ventured forward.[11]
      • Studies of children evacuated from London as a result of the Blitz during World War II found that sudden separation from their parents was more traumatic than the bombings themselves.[12]
        • An investigator in 1941 found symptoms of psychiatric distress in 52% of evacuated children, but only 20% of children who had actually been through a bombing.[13]
        • Anna Freud, who worked in a nursery for child evacuees through much of the war, remarked with her coauthor that, “The child experiences shock when it is suddenly and without preparation exposed to dangers with which it cannot cope emotionally.” The authors added, “In reality it is the very quickness of the child’s break with the mother that contains all the dangers of abnormal consequences.”[14]
      • In addition to the trauma caused by the loss of attachment, separation from caregivers may thus compound pre-existing traumas by removing the child’s emotional buffering. [15]
• The immediate clinical presentations of a child who has undergone trauma may include: [16]
  • Depression and anxiety
  • Attention problems similar to ADHD
  • Disturbed sleep
  • Anger and irritability
  • Withdrawal
  • Repeated and intrusive thoughts
  • Extreme distress

 

Long Term

Although a basic level of cortisol is required for health and normal functioning, if the stress response continues over time it can lead to persistent biological changes, potentially harming many organs in the body, including the brain. This is especially true for children.

• Childhood “Toxic Stress”
  • In the absence of the emotional buffering provided by a caregiver, traumatized children may experience a type of ongoing agitation, their bodies unable to return to baseline function even after the stressor is removed.[17]
    • Researchers have termed this “toxic stress.”[18]
    • The younger the child, the more severe the impact.
  • The effects of childhood toxic stress are long-term and may result in permanent changes to the body and brain, many of which may not be manifest until adulthood.
    • Stress-related changes in developing bodies can include
      • The early onset of menarche in young girls.[19]
      • The buildup of fat tissues as the body attempts to replenish energy stores used up during the stress response.[20]
    • “Childhood toxic stress” disrupts the neuroendocrine-immune network, interfering with immune function and increasing the risk and frequency of illness.
      • This effect can continue into adulthood.
      • Adults who suffered from childhood toxic stress experience more physical illness and poor health outcomes, including alcoholism, obesity, heart disease, depression, and cancer.[21]
    • Childhood stress is associated with both the onset and persistence of adult psychiatric disorders.[22]
      • Children may exhibit symptoms of psychiatric disorder long after their stress has ended, often in the beginning of adolescence.
        • They may present with feelings of rage and shame, demonstrating the impact of disrupted attachments and unstable, sometimes chaotic relationships.[23]
• Neurological Impact
  • Chronic stress in children can directly affect brain development, altering the architecture of the brain itself.[24]
    • The presence of elevated cortisol in the brain decreases dendritic branching and gradually causes the loss of neurons.
    • This can result in dramatic and long-term damage.
      • Cell loss is measurable, for instance, in the hippocampus, the region associated with spatial navigation, memory, and the regulation of emotions.[25]
      • Developmental changes are also observable in the corpus callosum, the left neocortex, and the amygdala.[26]
    • This suggests why children subject to ongoing trauma can experience a broad spectrum of developmental issues, including difficulty with speech and language and with gross and fine motor skills, as well as with social development.[27]
    • The younger the child, the more acute the effects of separation and the more rapid the signs of deterioration.
      • Children under the age of 2 are particularly vulnerable to disruption in the system of attachment.
        • In the early 20^th century (the first time such records were kept), the mortality rate of children under 2 admitted into orphanages rarely fell below 96%.[28]
        • Babies admitted to hospital wards and isolated in their cribs also seemed to waste away, a condition physicians referred to as “hospitalism.”
          • One 1949 description presented a “well-defined picture”: “The outstanding features are listlessness, emaciation and pallor, relative immobility, quietness, unresponsiveness to stimuli ike a smile or a coo, indifferent appetite, failure to gain weight properly despite the ingestion of diets which, in the home, are entirely adequate, frequent stools, poor sleep, an appearance of unhappiness, proneness to febrile episodes, absence of sucking habits.” [29]
        • When released to private caregivers, improvement was dramatic and almost instantaneous.
          • “The baby promptly becomes more animated and responsive. Fever, if present in the hospital, disappears in 24 to 72 hours; there is a gain in weight and an improvement in the color.”[30]
        • Investigators observed a similar phenomenon in the early 2000s among children confined to Romanian orphanages.
          • Compared to children released to foster care, children institutionalized before the age of 22 months exhibited profound deficits in almost every examinable domain, including cognition, brain activity and structure, reward sensitivity and processing, and prevalence of psychiatric disorders. [31]
        • Even short-term separation can have long-term results.
          • 1,719 children separated from their parents for evacuation to foster homes during World War II demonstrated higher rates of disorder than non-separated children upon reaching adulthood.
            • Compared to the non-separated, the evacuated had higher risks of mental, substance use and personality disorder. [32]

 

United States Immigration Policy, 2018

On April 6, 2018 Attorney General Jeff Sessions announced a “zero tolerance” policy at the southwest border requiring the separation of child migrants from their parents or caregivers. White House Chief of Staff John Kelly later justified the separation as a necessary component of the administration's effort to increase border security.

• According to a statement by the Office of Homeland Security, between May 5 and June 19 2,342 children had been separated from adult caregivers.
  • Figures such as Senator Sue Collins have indicated reason to believe the number is in fact much higher.[33]
  • Many of these children were toddlers under the age of 4.[34]
  • Some were apprehended during an illegal crossing, others belonged to families that had been legally presenting themselves for asylum.
  • Authorities initiated the removals without a plan to reunite families, resulting in numerous cases of parents and children having no contact since being forcefully separated.[35]
• Detention of Children
  • Children separated from their parents have been housed in a range of facilities, including:
    • Casa Padre, a housing facility built in a former Walmart and operated under contract for the Department of Health and Human Services.
    • Tornillo Tent City, a facility erected in the desert in western Texas and operated by the Federal Government. The site was chosen for a tent camp slated to house thousands of migrant children, including both unaccompanied minors and children separated from their parents.[36]
    • “Tender Age Shelters.” Three facilities in southern Texas set up to hold children under twelve, particularly toddlers and infants, who require special care.[37]
  • Government officials have forbidden journalists who tour the child detention centers from using cameras or conducting interviews with the children.[38]
    • Nevertheless, descriptions and audiotapes that have emerged from the shelter closely mirror the behavior of children traumatized by separation in other settings, including the London Blitz.
    • Medical professionals and lawyers who visited the facilities described "play rooms" filled with preschool children crying and in crisis.[39]
    • Colleen Kraft, the president of American Academy of Pediatrics, visited one facility and said she was "shaken" by what she saw. She described a room full of toddlers, normally “loud and rambunctious and playing and moving around. And these children were eerily quiet, except for one little child, who was crying and sobbing and inconsolable in the middle of the room. Next to her was one of the shelter workers who was trying to give her a toy or trying to give her a book, and this child wasn’t responding. The staff wasn’t allowed to pick them up or touch them or console them. ” The child had been separated from her mother the night before.[40]
    • Kraft told CNN "I've never been in this situation where I've felt so needlessly helpless. This is something that was inflicted on this child by the government, and really is nothing less than government-sanctioned child abuse."[41]
• The policy of child separation has been condemned by numerous official bodies concerned with the health, welfare, and human rights of children. These include:
  • The American College of Physicians
  • The American Psychiatric Association
  • The American Academy of Pediatrics
  • The Office of the United Nations High Commissioner for Human Rights has stated that the policy violates international law and directed that it be ceased.
    • Ravina Shamdasani, a spokeswoman for the Office, told reporters that the practice, “amounts to arbitrary and unlawful interference in family life, and is a serious violation of the rights of the child.”[42]
    • On June 19^th, two weeks after the Office’s statement, the United States withdrew from the U.N. Human Rights Council.
      • It is the first nation to ever voluntarily do so.[43]
• Under international pressure, President Trump signed an executive order halting the practice in June 20^th.
  • The order directs the Office of Homeland Security to detain family members together.
  • The Department of Health and Human Services stated that the status of children already detained will not be affected by the Executive Order. The children will not be immediately reunited with their families.[44]
• On June 26th, a federal judge in California ordered U.S. immigration authorities to reunite separated families on the border within 30 days.
  • The preliminary injunction, issued by U.S. District Judge Dana Sabraw in San Diego, indicates that children younger than 5 must be reunified within 14 days. 
  • As of June 26th, 2,047 of the separated children remain in HHS-contracted facilities, according to Secretary of Health and Human Services Alex Azar.[45]

 

 

Recommended Analysis:

Danaher, F. (2018). The Suffering of Children. New England Journal of Medicine.

https://www.nejm.org/doi/full/10.1056/NEJMp1808443

 

[1] Miller, D. B., & O'Callaghan, J. P. (2002). Neuroendocrine aspects of the response to stress. Metabolism-Clinical and Experimental, 51(6), 5-10.

[2] https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response

[3] Corcoran, C., Gallitano, A., Leitman, D., & Malaspina, D. (2001). The neurobiology of the stress cascade and its potential relevance for schizophrenia. Journal of Psychiatric Practice, 7(1), 3-14.

[4] https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response

[5] Bowlby, J. (1969). Attachment and loss: Attachment. 1969. New York: Basic Books.

[6] Bowlby, J. (1958). The nature of the child's tie to his mother. The International journal of psycho-analysis, 39, 350.

[7] Prior, V., & Glaser, D. (2006). Understanding attachment and attachment disorders: Theory, evidence and practice. Jessica Kingsley Publishers.

[8] It is well known that supportive touch improves human well-being and reduces physiological responses to stress. See Gallace, A., & Spence, C. (2010). The science of interpersonal touch: an overview. Neuroscience & Biobehavioral Reviews, 34(2), 246-259.

[9] Bellieni, C. V., Cordelli, D. M., Marchi, S., Ceccarelli, S., Perrone, S., Maffei, M., & Buonocore, G. (2007). Sensorial saturation for neonatal analgesia. The Clinical journal of pain, 23(3), 219-221.

[10] Blum, Deborah. (2003). Love at Goon Park: Harry Harlow and the science of affection. Chichester: Wiley. p268. 

[11] Sorce, J. F., Emde, R. N., Campos, J. J., & Klinnert, M. D. (1985). Maternal emotional signaling: Its effect on the visual cliff behavior of 1-year-olds. Developmental psychology, 21(1), 195.

[12] Wolf, K. M. (1945). Evacuation of children in wartime: A survey of the literature, with bibliography. The Psychoanalytic study of the child, 1(1), 389-404.

[13] Burbury, WM (1941). Effects of Evacuation and of Air Raids on City Children, BMJ, 2(4218), 660.

[14] Freud, A., & Burlingham, D. T. (1943). War and children. New York: Medical War Books.

[15] Franke, H. A. (2014). Toxic stress: Effects, prevention and treatment. Children, 1(3), 390-402.

[16] Sege, R. D., Amaya-Jackson, L., & American Academy of Pediatrics Committee on Child Abuse and Neglect. (2017). Clinical considerations related to the behavioral manifestations of child maltreatment. Pediatrics, 139(4), e20170100.

[17] Franke, H. A. (2014). 

[18] Garner AS, Shonkoff JP; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012;129(1).

[19] Wierson, M., Long, P. J., & Forehand, R. L. (1993). Toward a new understanding of early menarche: the role of environmental stress in pubertal timing. Adolescence, 28(112), 913.

[20] https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response

[21] Felitti V.J., Anda R.F., Nordenberg D., Williamson D.F., Spitz A.M., Edwards V., Koss M.P., Marks J.S. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. Am. J. Prev. Med. 14:245–258; Wyman P.A., Moynihan J., Eberly S., Cox C., Cross W., Jin X., Caserta M.T. Association of family stress with natural killer cell activity and the frequency of illnesses in children. Arch. Pediatr. Adolesc. Med. 2007;161:228–234.

[22] Sege, R. D., et al. (2017). 

[23] Amaya-Jackson L, Derosa RR. Treatment considerations for clinicians in applying evidence-based practice to complex presentations in child trauma. J Trauma Stress. 2007;20(4):379–390

[24]  Shonkoff JP, Garner AS; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1). 

[25] Corcoran, C., Gallitano, A., Leitman, D., & Malaspina, D. (2001). The neurobiology of the stress cascade and its potential relevance for schizophrenia. Journal of Psychiatric Practice, 7(1), 3-14.

[26] Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., Navalta, C. P., & Kim, D. M. (2003). The neurobiological consequences of early stress and childhood maltreatment. Neuroscience & Biobehavioral Reviews, 27(1), 33-44.

[27] van der Kolk, B. A. (2003). The neurobiology of childhood trauma and abuse. Child and adolescent psychiatric clinics of North America, 12(2), 293-318.

[28] “That is,” clarified one reporting doctor, “no infant under 1 year of age lived to be 2 years old.”  Chapin, H. D.: (1915) “ A Plea for Accurate Statistics in Infants' Institutions,”  Tr. Am. Pediat. Soc. 27:180.

[29] Bakwin, H. (1949). Emotional deprivation in infants. The Journal of pediatrics, 35(4), 512-521.

[30] Bakwin, H. (1949). 

[31] Bick, J., Zhu, T., Stamoulis, C., Fox, N. A., Zeanah, C., & Nelson, C. A. (2015). Effect of early institutionalization and foster care on long-term white matter development: a randomized clinical trial. Jama Pediatr, 169(3), 211-219. See also http://www.bucharestearlyinterventionproject.org/About-Us.html

[32] Räikkönen, K., Lahti, M., Heinonen, K., Pesonen, A. K., Wahlbeck, K., Kajantie, E., ... & Eriksson, J. G. (2011). Risk of severe mental disorders in adults separated temporarily from their parents in childhood: the Helsinki birth cohort study. Journal of psychiatric research, 45(3), 332-338.

[33] Transcript: Sen. Susan Collins on 'Face the Nation.' CBS News. June 17, 2018. https://www.cbsnews.com/news/transcript-sen-susan-collins-on-face-the-nation-june-17-2018/

[34] Dickerson, Caitlin (April 20, 2018) “Hundreds of Immigrant Children Have Been Taken From Parents at the US Border,” New York Times.

[35] Goodwin, Liz (June 10, 2018). "'Children are being used as a tool' in Trump's effort to stop border crossings." The Boston Globe.

[36] Parker, Claire (June 14, 2018), "Trump administration makes site selection for tent city near El Paso to house immigrant children separated from parents." The Texas Tribune.

[37] Dickerson, Caitlin; Fernandez, Manny (June 20, 2018). “What’s Behind the ‘Tender Age’ Shelters Opening for Young Migrants.” New York Times.

[38] Fausset, Richard (June 18, 2018), “Immigrant Children Cry Out in Audio Recorded at Detention Center.” New York Times.

[39] Burke, Garance; Mendoza, Martha (June 20, 2018). “APNewsBreak: Youngest migrants held in 'tender age' shelters." Associated Press.

[40] Transcipt: Dr. Colleen Kraft on PBS News Hour, PBS (June 20, 2018). https://www.pbs.org/newshour/show/toddlers-separated-from-parents-eerily-quiet-or-inconsolable-at-one-migrant-shelter

[41] Catherine E. Shoichet, (June 15, 2018). "Doctors saw immigrant kids separated from their parents. Now they're trying to stop it." CNN. https://www.cnn.com/2018/06/14/health/immigrant-family-separation-doctors/index.html

[42] Cumming-Bruce, Nick (June 5, 2018). “Taking Migrant Children From Parents Is Illegal, U.N. Tells U.S.” New York Times.

[43] Harris, Gardiner (June 19, 2018). “Trump Administration Withdraws U.S. From U.N. Human Rights Council.” New York Times.

[44]Shear, Michael D.; Goodnough, Abby; Haberman, Maggie (June 20, 2018). "Trump Retreats on Separating Families, but Thousands May Remain Apart." New York Times.

[45] Itkowitz, Colby (June 26, 2018). "HHS Secretary says it's up to Congress to reunite migrant families." Washington Post.