- Climate Science and the IHP
- Detained Children: Part VI
- Detained Children: Part V
- Detained Children: Part IV
- Detained Children: Part III
- Detained Children: Part II
- Detained Children: Part I
- Precious Children Locked Up
- A Good Day at the IHP
- On Inaction and Consent
- The Constitution and Public Health
- A Health Quiz: Mass violence
- A long preamble to a simple invitation...
December 01, 2018
Note: Our great colleague, Dr. Patrice Nicholas (SON), provided much of the supportive content used in this blog post.
I am not a climate denier. I know that the climate is changing and that, without intervention, the future of our world and its health is in great jeopardy. Let me confess that, while I am convinced by the data and interpretations of the scientific community, I am a climate ignorer. In recent years, I have acknowledged the concerns, appreciate the implications, but I have not done much to change things. I have hoped that government and science would come together to tackle these huge, expensive, messy problems. Last week’s release of the government’s report on climate change, the Fourth National Climate Assessment, has provided another vital wake up call to my (and hopefully your) awareness.
On November 28, 2018, another key report was released—the 2018 Lancet Countdown on Health and Climate Change Brief for the United States of America, companion to the Lancet Countdown: Tracking Progress on Health and Climate Change 2018 global report, which identifies the education of health professionals as one of the top priorities for response by the health care sector. Of note is that MGH physician, Renee Salas, MD, MPH, and associate member of the MGH Institute’s Center for Climate Change, Climate Justice, and Health, is one of the lead co-authors of the 2018 Lancet Report. It is also important to note that if things keep going the way that they are now progressing, water levels along the coast (where we live, work, and study) will rise and impact infrastructure significantly.
As you may recall, in January and March of 2018, the Institute was closed due to salt water intrusion from Boston Harbor onto our campus and 1st Avenue – events directly related to climate change. Temperatures will continue to rise, affecting weather cycles (heat, storms, flooding) and land and sea species, and individuals who live in affected areas will see increases in death rates, disease, and economic implications of climate change. Loss of life and expenses in the billions of dollars should be expected and planned for. It’s pretty frightening.
Fortunately, a group of colleagues in our School of Nursing are working to bring intelligence and action to the discussion. Expanding on concepts described in their edited text, Global Health Nursing in the Twenty-First Century (2016), Suellen Breakey, Inge Corless, and Patrice Nicholas have moved on to launch a new Center for Climate Change, Climate Justice, and Health at the IHP. Drs. Breakey, Corless, and Nicholas have also co-authored additional publications in key journals to address the deleterious health consequences related to climate change and to champion the need to incorporate climate health in the health professions curricula. Other faculty from SON involved include Leslie Neal-Boylan, Inez Tuck, Elaine Tagliareni, Patricia Lussier-Duynstee, Elissa Ladd, and Raquel Reynolds. They anticipate developing a focus on integrating climate health issues into the various nursing curricula, expanding to include other interprofessional disciplines, developing certificate programs for providers, and positioning the IHP for participation in the inevitable discussion about delivering health care in a climate-damaged society. An April symposium, "Health Impacts of Climate Change: The Role of Health Care Professionals," is planned by the School of Nursing and the Center faculty through the Department of Continuing and Professional Development. This event is also co-sponsored by the IHP School of Nursing’s Upsilon Lambda chapter of the International Honor Society of Nursing, Sigma Theta Tau. View further information and register.
The IHP has a long history of innovation, bringing the voice of all health professionals into important discussions, and of preparing providers for the needs of patients of the future. Important voices in global health, interprofessionalism, cultural competence, and designing learning for health professionals are part of our legacy. Adding climate health to this list is timely and important.
Thanks to our colleagues in the SON for leading us into this important discussion. I am relieved that I can move from being a climate ignorer to a climate activist, and I thank these colleagues for showing me the way.
October 29, 2018
In his book, The Soul of America: The Battle for our Better Angels (New York: Random House, 2018), Jon Meacham discusses some of the darkest times in American history and provides an important historical narrative about the incidents themselves and the American response. Meacham will have the opportunity to add yet another chapter very soon. This past weekend, on Saturday – the weekly Sabbath for Jews – a well-armed attacker brutally slayed 11 people and injured several more at their synagogue in Pittsburgh. There is no debate about the motives of the attacker. This was hate and anti-Semitism brought to its most visible, terror-filled, violent conclusion. Again, the combination of guns and hatred resulted in lives lost and a beautiful community damaged. Again, our public leaders either use it for political discussion or ignore obvious solutions. Again, the average citizen asks, “How can this happen again and again?” in the land of the free. How can this happen in the United States where the First Amendment guarantees freedom of religion?
The reality is it can and does happen, right in front of us. According to the Anti-defamation League (ADL), there was a 57% increase in reports of anti-Semitic incidents between 2016 and 2017. This trend line continues. This terrible slaughter in Pittsburgh is now an amplification of this statistic. This is the largest murder of Jews in American history.
These data, alarming on their own, complement the violent, racist, misogynistic, sexist events that we have observed in recent times. Think about Charleston, Charlottesville, Orlando, and now Pittsburgh and more. There are many commonalities. Their uniqueness comes in the stories of the people killed and injured. They are young and old, parents and grandparents. Lives lost. Targeted ethnic, racial, or sexual minorities. Groups that many of us embrace for the beautiful diversity that they add to our otherwise bland culture have to experience this awfulness on a regular basis.
I hope that you are offering thoughts and, if appropriate to your tradition, prayers for those lost in Pittsburgh this past weekend. Their families and their community need us. At this same time, do the same for those who have been victims of events of the past few years. Dozens of victims and their families have been innocent victims of violence and hate. For survivors and families, the hurt from these isolated events is persistent and should also be remembered.
The reality of all of this is that any targeted violence against any group of individuals is just wrong. There is no reason to think otherwise, and there is an opportunity to speak out and bring change to this narrative. What is to be our collective response to this? As a first step, using the themes Meacham raises in his book, we can ask “Where is our soul? Where are our better angels?” We need to find them now. Thank you, Jon Meacham, for a bit of inspiration today.
A Statement from Key Leaders
In this final contribution to this blog series, Dr. Inge Corless (Professor, School of Nursing) has shared a document that was prepared late last month by an interprofessional group of leaders to express concern over the separation of children and families. Thanks to Dr. Corless for her leadership and willingness to share. My hope is that this series of contributions adds to our collective understanding of the current situation affecting those being detained and separated. As always, feedback is welcome! Alex Johnson
Statement Concerning the Incarceration of Children and Adults
June 27, 2018
As an interdisciplinary, international group of health care practitioners, scholars, and experts in the field of loss and grief (including U.S. citizens), we are adding our collective voice in opposition to the current, continuing incarceration of children and their parents. The removal of children from parents can never be justified as a means of deterring migration, regardless of the driving forces.
The family, in all of its different manifestations, is a core foundational unit of a stable society. Separating children from their parents is known to have detrimental psychological effects for both children and their parents. The effects of such traumatic stress can last for generations.
Attachment, fostered within family systems, is a key factor in the physical, emotional and psychological growth and well-being of its members. Therefore, it is essential that all societies recognize their legal, moral and social responsibilities to respect, protect and fulfill children’s rights and needs within families.
As members of the International Work Group on Death Dying and Bereavement we have extensive expertise in the areas of loss and grief. For children separated from their families, the resultant trauma has been shown to have profound, prolonged and intergenerational effects. For parents, the uncertainty of when or whether they will see their children again creates unbearable stress and grief. The loss of a child is recognized as one of the most devastating losses one can experience. Families need safe and stable environments in which to effectively care for their children. Further, separation of children from their families has an impact on all inhabitants and is traumatizing not only for the affected individuals but also for the on-lookers; the children and adults for whom the current practice can also be traumatizing. The impact on law enforcement officers and other people charged with implementing a practice in violation of the Universal Declaration of Human Rights and the UN Convention on the Rights of the Child must also be considered.
We urge all governments, including the United States, to:
- End the human rights violations of vulnerable people, including separation of children from their families.
- Rapidly reunite children with their families.
- Treat asylum seekers with the customary care and respect heretofore given to such individuals.
We call on governments everywhere – including the United States Government – to fulfill their obligations under the United Nations 1951 Convention on the Status of Refugees towards all peoples who seek shelter and support outside their own countries of origin and, in particular, towards the most vulnerable of all: children.
This statement was written by a group of concerned professionals in response to the separation of children and families entering the United States. This statement represents solely the opinions of the authors and signatories.
You have full permission to translate the document into other languages, and to distribute it via websites, blogs, the media, and other venues. It is our intention that the message be shared widely.
Inge B. Corless; firstname.lastname@example.org; (617) 726-8018
Inge B. Corless, PhD, RN, FNAP, FAAN, Professor, MGH Institute of Health Professions, Boston, MA, USA.
Susan Cadell, PhD, Professor of Social Work, University of Waterloo, Waterloo, Canada.
Debra Wiegand, RN, PhD, FAAN, Associate Professor, University of Maryland, Baltimore, MD, USA.
Stacy S. Remke, Professor, School of Social Work, University of Minnesota, Minneapolis, MN, USA.
Irene Murphy, MSocSc, CQSW, Director of Bereavement & Family Support Services, Marymount University Hospital and Hospice, Curraheen, Cork., Ireland.
Andrea Warnick, RN, MA, Andrea Warnick Consulting, Guelph, Canada.
Carrie Arnold, PhD, MED, RSW, CCC FT Thanatology, King’s College, London, Ontario, Canada.
Lauren Breen, PhD, Associate Professor, Curtin University, Perth, Western Australia.
Jane Skeen, MD, Auckland, New Zealand
Phyllis Kosminsky, PhD, LCSW, New York, New York, USA.
Donna Schuurman, EdD, Portland, Oregon, USA.
Janice Nadeau, PhD, Private Practice, University of Minnesota, Minneapolis, MN, USA.
Kathleen Gilbert, PhD, Professor Emerita, Indiana University Bloomington, Indiana, USA.
Janet McCord, PhD, FT, Chilton, Wisconsin, USA.
Ida Martinson, RN, PhD, Bemidji, Minnesota, USA.
David Roth, Funeral Director, Bergisch Gladbach, Germany.
Gerry Cox, PhD, University of Wisconsin-La Crosse, Salina, Kansas, USA.
Andy Hau Yan Ho, PhD, MFT, FT, Nanyang Technological University, Singapore.
Mary L. Vachon, RN, PhD, RP, University of Toronto, Toronto, Canada.
Catriona Macpherson, EdD, Children and Family Services, Scotland.
Daniela Reis E. Silva, MCP, FT, Associacao de Terapia Familiar de Espirito Santo, Vitoria, Brazil.
Ronit Shalev, PhD, The Center for Academic Studies, Israel.
Emmanuelle Zech, Professor, Universite Catholique de Louvain, Belgium.
Wendy Bowler, PhD, La Trobe University, Melbourne, Australia.
Tammy Bartel, MA, RCC, CT, Private Practice, Surrey, British Columbia, Canada.
Danai Papadatou, Professor of Clinical Psychology, National and Kapodistrian University of Athens, Athens, Greece.
Chris Paul, Trauerinstitut Deutschland, Bonn, Germany.
Regina Szylit, Professor, University of Sao Paulo, Sao Paulo, Brazil.
Betty Davies, RN, PhD, University of Victoria, Victoria, British Columbia, Canada.
Leslie Balmer, PhD, Psychologist, Missisauga, Canada.
Astrid Ronsen, Assistant Professor, NTNU, Fjellhammer, Norway.
- American Academy of Nursing
- American Association of Colleges of Nursing
- American Family Therapy Academy
- Canadian Nurses Association
- International Family Nursing Association
- National Council on Family Relations (NCFR)
- Physicians for Human Rights
- United Nations Health Commission on Refugees (UNHCR)
This is part 5 in a series of blog contributions from faculty members at the MGH Institute of Health Professions.
Detainment. Separation. Neglect Abuse. Confinement. Cages.
Julie Keysor, PhD, and Elise Townsend, PhD, Department of Physical Therapy,
Andrea Fairman, PhD, Department of Occupational Therapy
None of these words are okay when it comes to people, and are even more deplorable when applied to children in the context of the recent U.S. policies about immigration. To see and hear the cries of detained children removed from their parents is heartbreaking. The stress from this situation will undoubtedly have long lasting effects on children and their families. Others in this blog are writing about the socio-emotional and psychological effects of this type of activity on children – the risk for significant short and long-term effects in these areas is crystal clear. My colleagues and I in our contribution to the blog are sharing a few thoughts on the physical health effects such situations can trigger.
From the most immediate and acute perspective, heart rate, blood pressure, and one’s ‘fight or flight’ nervous system will be triggered. These physiological changes may cause anxiety and behavioral responses. Limited opportunities to engage in play may result in global developmental delays including deficits in social, cognitive, sensory processing, gross and fine motor ability abilities. More specifically, prolonged restricted activity and movement will cause developmental delays in young children and could lead to abnormal bone growth and muscle development. Children will be at increased risk of developing chronic conditions such as diabetes, arthritis, and chronic pain, and these detained children have the risk of being under diagnosed or misdiagnosed leading to lifelong chronic disability, underemployment, and deprivation. The stress from this situation will impact health – no doubt – this is a health situation and affects health of the individual and our entire public health system.
And What about the Parents?
Janice Goodman, PhD, Professor, School of Nursing
Most of the news has focused on the traumatic effects of separating parents and children at the border on children. But, imagine also the anguish that a mother or father must feel to have their child ripped, crying and screaming, from their arms. Imagine not being able to comfort your child, to not even know where they are, who they are with, what is happening to them, if they are okay, when and even if they will ever see them again. Just as with children, trauma and stress increases an adult's risk for mental illnesses such as depression, anxiety and post-traumatic stress disorder. Thus, it is heartbreaking, though not surprising, to know that Marco Antonio Muñoz, a Honduran man who crossed the border in May with his wife and 3-year old son, was so distraught that he kicked, screamed, and could not be calmed after his son was forcibly taken from him. Mr. Munoz was taken to a detention center and, less than 12 hours later was found dead in his cell, apparently having taken his own life. This is how this horrific policy affects parents! It is beyond cruel. It is shameful and unacceptable.
Instead of offering compassion and safety, by forcibly separating children and parents we are inflicting further trauma and suffering on vulnerable families who have already experienced extreme suffering – in their home countries, and during their migration to what they hoped would be a safe place. As health care providers, our purpose is to alleviate suffering – both physical and emotional.
Interruptions in Nursing and Bonding During Early Development
In this fourth contribution prepared by clinical faculty members who specialize in early development of young children, the effects of disruption and separation in infants and toddlers are discussed.
Emily Zeman, OTD MS, OTR/L, Department of Occupational Therapy
and Lesley Maxwell, MS, CCC-SLP, Department of Communication Sciences and Disorders
Regarding the news of infants being torn away from their nursing mothers, and family separation in general:
An infant's development is dependent on the information they obtain from the environment. Infants and newborns rely heavily on oral-motor, scent, taste, and touch sensory experiences in the context of the parent-infant and family bonds and daily routines in all environments. A sudden change in the social and physical context, accompanied by negative experiences, may interfere with typical developmental trajectory.
Overstimulated, neglected, and abused infants, resulting from sudden family separation, may present with negative behavioral traits later in development (Cronin & Mandich, 2016). A sudden removal of the nursing or caregiving parent may significantly endanger the rich environmental context of the parent-child bond, ideal for stimulating neuronal connections and supporting healthy socio-emotional development. Such separation becomes an adverse childhood experience (ACE). As infants are dependent, high quality and positive child-parent interactions are vital for healthy socioemotional development and a sense of security.
Infants require attentive parental attention and presence to ensure safety and adherence to a feeding schedule that promotes physical growth and typical attachment bonding patterns, all setting the stage for successful emotional development. However, the stressful and sudden removal of a parent or parents from an infant may trigger an association of new feeding routines or format (to bottle), with strangers, as traumatic, and thus, not a positive experience. Feeding and eating routines, as disrupted, may then alter not only the bonding process, but the infants typical progression in feeding milestones and expectations for nourishment.
All of this could lead to failure to thrive, a myriad of health concerns, and changed emotional affect in the child. Even with return to parents at some point in the future, the infant will be forever changed by the stress caused by the separation.
Young Develop in an Environment of Relationships
“An 'environment of relationships' is crucial for the development of a child’s brain architecture, which lays the foundation for later outcomes such as academic performance, mental health, and interpersonal skills. However, many of our nation’s policies fail to consider the importance of adult-child relationships for child well-being. This working paper from the National Scientific Council on the Developing Child explains how these relationships shape child development, and identifies ways to strengthen policies that affect those relationships in the early childhood years.”
National Scientific Council on the Developing Child: Young Children Develop in an Environment of Relationships: Working Paper No. 1.
The Science of Neglect
"Young children who experience severe deprivation or neglect can experience a range of negative consequences. Neglect can delay brain development, impair executive function skills, and disrupt the body’s stress response. This working paper from the National Scientific Council on the Developing Child explains why neglect is so harmful in the earliest years of life, and why effective interventions can improve long-term outcomes in learning, health, and the parenting of 'the next generation.'"
Harvard University Center on the Developing Child: The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain: Working Paper No. 12.
“Toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years. When toxic stress response occurs continually, or is triggered by multiple sources, it can have a cumulative toll on an individual’s physical and mental health—for a lifetime. The more adverse experiences in childhood, the greater the likelihood of developmental delays and later health problems, including heart disease, diabetes, substance abuse, and depression. Research also indicates that supportive, responsive relationships with caring adults as early in life as possible can prevent or reverse the damaging effects of toxic stress response.”
Toxic Stress. Harvard University Center on the Developing Child.
The Importance of Serve and Return Between Parent and Child
“Because responsive relationships are both expected and essential, their absence is a serious threat to a child’s development and well-being. Healthy brain architecture depends on a sturdy foundation built by appropriate input from a child’s senses and stable, responsive relationships with caring adults. If an adult’s responses to a child are unreliable, inappropriate, or simply absent, the developing architecture of the brain may be disrupted, and subsequent physical, mental, and emotional health may be impaired. The persistent absence of serve and return interaction acts as a 'double whammy' for healthy development: not only does the brain not receive the positive stimulation it needs, but the body’s stress response is activated, flooding the developing brain with potentially harmful stress hormones.”
Serve and Return. Harvard University Center on the Developing Child.
This is part 3 in the continuing discussion of childhood detainees and its effect on their development. One question that can be asked is "why are these people bringing their children to the U.S?" What motivates immigration in this way.
In today's contribution , Professor Antonia Makosky (School of Nursing) describes her experience in dealing with a woman and her children in the Congo, while serving with Doctor Without Borders. Antonia draws an important parallel to the current crisis in the US, citing the United Nations High Commission for Refugees' position on family unity. I found the statement to be an important beacon in this discussion. Thanks to Antonia for sharing this important message and for her service in the Congo.
From Antonia Makosky, DNP, MSN, MPH, ANP-BC, Assistant Professor, School of Nursing
In my last trip to the Eastern Congo with Doctors without Borders I was posted in an area where the war had just recently ended. Rebels still hid in the forests with their families. One day, as we prepared to head home from a community health center, the nurse manager asked if we could take a family back to our hospital. The family consisted of a woman and her three children; the woman was the wife of one of the rebels. They had been hiding in the forest but now her middle daughter, age 3, was severely malnourished, and would die without special care. The woman, her 8-year-old, and her infant son, were also malnourished. The woman and her 8-year-old daughter were quiet and shy.
It was against the usual policy to admit a family with multiple children unless the woman was pregnant. However, the staff felt very strongly that we must take in and provide shelter and care to this whole family. The staff said to me repeatedly, “they have nothing.” There was never a question of separating the family; of only taking the sickest child to care for. In African hospitals, the patient is always accompanied by a family member.
Initially the hospital staff was concerned for the life of the 3-year-old child. She was cared for in the pediatric ICU. Slowly she improved. Meanwhile the health of the woman and her other two children improved as well. The eldest daughter became less shy and more interactive.
This family was fleeing from violence, as so many Central American families are now. These families have suffered untold hardships and trauma as they make their way north to escape drug and gang violence in their home countries. The United Nations High Commission for Refugees (UNHCR) espouses a policy of family unity. According to the UNHCR: The right to family life and family unity is a right that applies to everyone, including asylum seekers whose status has not yet been determined. There are many benefits to maintaining the family unit, including returning a sense of normalcy, easing a sense of loss, attempting to ensure safety and protect against danger. In particular, keeping the family together helps protect against human smuggling trafficking, common in both the Eastern Congo and along the Mexico-America border.
I am relieved by the recent decision to end this cruel and dangerous policy of separating parents from children on our southern border. We must do our best to reunite those children already separated from their parents, and prevent this practice from recurring in the future.
Nicholson, F. 2018. The “Essential Right” to Family Unity of Refugees and Others in Need of International Protection in the Context of Family Reunification. United Nations High Commission for Refugees. Retrieved from http://www.unhcr.org/en-us/protection/globalconsult/5a8c413a7/36-essential-right-family-unity-refugees-others-need-international-protection.html?query=family%20policy
June 26, 2018
This is Part II of this blog, devoted to child detainees and their health issues. First, Christopher Sim, a faculty member in our Department of Physician Assistant Studies further describes some of the medical concerns for immigrant populations. The second contributor is Dr. Mary Thompson, a pediatric nurse practitioner and faculty member at the IHP. She continues with more specific information that may be useful to providers concerned with care of children who are in refugee situations.
Note: In Part III we will begin to focus on some of the specific developmental concerns and mental health issues facing these children and their families and caregivers.
From Christopher Sim, MPAS, PA-C, DFAAPA
Whether children arrive in the United States as part of a prearranged immigration with advanced notice, in a more urgent refugee crisis, or as undocumented emigres, they typically are at risk from multiple health factors. Approximately 3.7% of children living in the US were born in other countries. This includes 7.7% of Latino children and 16 % of Asian children (Yun, 2016).
Hepatitis B, tuberculosis, parasites, anemia and high lead levels are the most commonly encountered diseases in children new to the United States (McBride, 2016). This is complicated by the countries of origin from which these children travel from. Although some children from refugee populations benefit from government or non-governmental organizations in terms of nutritional support and preventive health services, most refugee children from Central American countries have not been as fortunate. These children would be susceptible on their own, but also pose the risk of transmitting disease amongst themselves in the housing environments currently operated by Immigration Control and Enforcement in the US. It is also conceivable that children who arrived without such infections may, if returned to their countries of origin, transmit preventable new infection in those settings.
Failure to address these issues when children are under the care of the United States is unethical, irresponsible, and contrary to acceptable standards of humanitarian treatment of refugees. At the very least, these children require baseline testing for the most common parasitic diseases, hepatitis, tuberculosis, and lead screening. In identifying preexisting disease, public health authorities would be able to make insights into epidemiologic patterns and document current health states amongst these populations. Vaccination among these children is also either difficult to verify, if not impossible. Such children should also receive the same immunizations required of native-born US children, in the common interest of public health.
Yun, K., Matheson, J., Payton, C., Scott, K. C., Stone, B. L., Song, L., . . . Mamo, B. (2016). Health Profiles of Newly Arrived Refugee Children in the United States, 2006–2012. American Journal of Public Health,106(1), 128-135. doi:10.2105/ajph.2015.302873
Mcbride, D. L. (2016). Large Study of Health Issues for Newly Arrived Child Refugees. Journal of Pediatric Nursing,31(2), 222-223. doi:10.1016/j.pedn.2015.11.014
From Mary Thompson, PhD, RN, CPNP-PC
The American Academy of Pediatrics (AAP) has adopted a Toolkit to inform health providers of “common matters” related to the healthcare needs of immigrant children.
According to the Toolkit, many children who are newly immigrated have not had regular medical care in their country of origin. They require specialized healthcare screening for: exposure to infectious diseases (such as tuberculosis, HIV, and parasitic infections), immunization history (if known), medical history (including birth history), nutrition history, medications and use of complementary and alternative treatments, environmental hazards (including lead exposure), exposure to (tobacco, opium/heroin, and other drug use), dental history, social history, educational history, and sexual or other abuse. Children who undergo forced separation due to immigrant enforcement may not be able to provide this information.
Many children who have newly immigrated have faced Adverse Childhood Experiences (ACEs) prior to immigrating from their country of origin, or during their immigration. Separation from parents further exacerbates the negative effects from the exposure of ACEs. These children demonstrate a number of health problems, including anxiety, depression, poor school performance, sleeping and eating disruptions. Table 1 from the Toolkit includes a list of Mental Health and Developmental Screening Instruments and Resources that can be used to assess the mental health needs of immigrant children separated from their parents.
The United Nations High Commissioner for Refugees (UNHCR) document Refugee Children: Guidelines on Protection and Care offers insight in how to be responsive and acknowledge the needs of children affected by separation from their caregivers during immigration. In the immediate, children should be provided with appropriate:
Play: “Play is vital to the healthy development of a child. It is a child's way of coping with what has happened, of relaxing and relieving tensions and of assimilating what (s)he has experienced and learned. . . Playgrounds Refugee camps, settlements or reception centers should have play areas from the outset.”
Infants: “Breast feeding should be facilitated. . . Children of about 10 months (who are just about to develop speech, crawl and walk) are particularly vulnerable. In such situations the integration of infant stimulation programmes in other emergency services, such as feeding programmes, has proven helpful.”
Developmental Screening: “. . . is needed to identify children whose development is delayed. This involves knowledge about what normal development in this specific culture means. A group of refugee mothers may be able to help you. - Intervention if there is abuse or neglect.”
Counseling and Support Groups: “Children will become anxious when they do not understand what is happening to them. . . When a child becomes depressed, anxious or upset, the right to participate may effectively be lost: a child may not be able to process the information, and may not be able to make realistic decisions. Counseling to reduce stress may be necessary before children can focus on and absorb information fully. - Support groups: Encourage the creation of support groups where children have an opportunity to talk about problems and ways of addressing them. It is important that they understand that they are not alone and that they are not responsible for what has happened.”
Restoring Normalcy: “Restoring normalcy for unaccompanied children requires that tracing for parents begin immediately. When parents or relatives are located, children need help in maintaining communication with them until they can be reunited. . . The threat to psychosocial well-being is inevitably increased when lengthy or permanent disruptions occur between child and primary care-giver, or child and family. The loss of the mother, or substitute mother figure, particularly at an early age, places a child at a higher psychological risk. Arranging for substitute family care or immediate family reunion is critical.”
Perhaps most important of all:
Helping children by helping the family: “The single best way to promote the well being of children is to support their family.” This includes preserving family unity, tracing parents who have been separated, providing family support, establishing parental support networks, and helping families prepare for reunion by offering counseling.
June 25, 2018
I have felt as concerned as many of you about what we can do to be helpful with the current situation regarding detained families and separation of children from their parents. As of yesterday, June 20, President Trump has signed a new policy that prevents separation of children from parents at the borders. However, there is no clear plan for detainees currently in custody. Over 2000 infants, toddlers, children, and adolescents are currently being held in residential arrangements of various types.
The political discussion about responsibility for this mess goes on and on. As always, the politics are debatable and inconclusive. The political debate appears to offer no immediate solution for these children or their families. What I do know is that this problem of detention, congregate living, and separation presents a host of health issues unfamiliar to many of us.
Thus, I have reached out to several colleagues from around the IHP to provide us with current thinking on a number of issues that should concern all of us, especially those who will be caring for these children. Reading through the contributions of our colleagues makes me proud of the capability and insight of those with whom we work. At the same time, reading this makes me worry for the future of these young children and their families. I will start posting these contributions daily and invite you to read, share with your students, and extend a thank you to the writers.
Finally, if you would like to contribute to this blog on a topic I may have overlooked, don't be shy. Send me your contribution and I will happily post it. This appears to be a small step that we can take today. This is a health problem and education is almost always the answer.
General Health Concerns
Prepared by Dr. Patrice Nicholas, School of Nursing
The American Public Health Association released a statement on June 15, 2018 entitled Separating Parents and Children at US Border Is Inhumane and Sets the Stage for a Public Health Crisis. The statement notes that the Trump administration’s policy of separating parents and children at the U.S. and Mexico border will negatively affect the detained children and their health, both now and into the future.
"As public health professionals we know that children living without their parents face immediate and long-term health consequences. Risks include the acute mental trauma of separation, the loss of critical health information that only parents would know about their children’s health status, and in the case of breastfeeding children, the significant loss of maternal child bonding essential for normal development. Parents’ health would also be affected by this unjust separation.”
"More alarming is the interruption of these children’s chance at achieving a stable childhood. Decades of public health research have shown that family structure, stability and environment are key social determinants of a child’s and a community’s health.”
"Furthermore, this practice places children at heightened risk of experiencing adverse childhood events and trauma, which research has definitively linked to poorer long-term health. Negative outcomes associated with adverse childhood events include some of society’s most intractable health issues: alcoholism, substance misuse, depression, suicide, poor physical health and obesity.”
Adverse childhood experiences (ACEs) are stressful or traumatic events, including abuse and neglect. ACEs are strongly related to the development and prevalence of a wide range of health problems throughout a person’s lifespan, including those associated with substance misuse. The Centers for Disease Control and Prevention (CDC) addresses the health consequences associated with ACEs.
- Physical abuse
- Sexual abuse
- Emotional abuse
- Physical neglect
- Emotional neglect
- Intimate partner violence
- Mother treated violently
- Substance misuse within household
- Household mental illness
- Parental separation or divorce
- Incarcerated household member
For the children detained in the current circumstances, they are experiencing parental separation, incarcerated household member, and their own incarcerated circumstances in “tender camps” which are tantamount to serving in jails/cages.
June 18, 2018
Children, minors under age 18, are the most precious resource available to our own culture and to all the world. They represent all the hope and all the future possibilities available to everyone, everywhere. This hopeful preciousness is agnostic to their national origin, their parents’ status in social strata, their health or physical status, their religious background, or their race or ethnicity. Dependent on the adults “in the room,” their lives are precious, and they must hold special status in every aspect of society, and everywhere in the world. In the United States we have a long history of protecting children (at least trying to), and our laws attempt to provide access to health and education and assure quality of life to the fullest extent possible. When we consider violence or other inhumane acts against children we are outraged.
Recall the media coverage, the marches and protests that occurred, in response to recent school shootings in Texas and Florida. Think of Newtown and the humanitarian and noble response of Americans to that disaster, where many precious six-year-old lives were lost. Our collective conscience must never allow us to disregard the principled value we hold for children. It is in our DNA as Americans and shared by all civilized people of the world.
Juxtapose this view against your own experience as a child, parent, or grandparent. All of us connect in some way to that innate childhood connection with adults critical to our safety, protection, and love. For me, I think of my two sons (now grown up) and my three grandsons, ages 6, 4, and (almost) 2. My connection with all of them is profound. I can’t disconnect or dishonor that relationship in any way. They are all precious. When I see the sweetness and vulnerability of my grandsons I am awed. When I see their joyousness, their robust life- changing personalities, and their need for connection with their parents I am humbled. Some say that when they see the face of a young child, they see the face of God. Regardless of one’s religious bent, isn’t it fair to say that in such faces one sees the reality of goodness?
And now, I can’t think of those faces, connections, and smiles without comparing them with the hundreds of children who have been ripped out of their parents’ arms by my government. I can’t justify this for any political, legal, or moral reason. When I hear others try to legitimize this on religious grounds, I am sickened at the hypocrisy and hatefulness of their argument. I can only see my little grandsons, being taken from their parents, moved to a fenced in “shelter”, and being held against their will. I can only feel the amazing heartbreak, outrage, and shock this would cause their parents. I am deeply aware of the wounds, the pain, and the anger that would persist over generations and lifetimes. I identify with these feelings viscerally.
I hope that many speak out and act against this. While I know that our political leaders on both sides are failing us here, I hope that churches, communities, and other organizations find ways to fight these horrific actions, against children and families, by our government. This must stop.
June 9, 2018
At the Institute, there are many great days every year. Today was one of those days for me. It was a home run kind of day. On one of the first really beautiful Saturdays of this spring, there was intense activity inside the IHP. The third floor of the Shouse Building was almost vibrating with learning. In each case the learning was voluntary (not required) and was collaborative.
Walking down the hallway I bumped into some of our students who are enrolled in a voluntary medical Spanish course. This is not part of their curriculum, but something they have taken on at their own expense so that they can reach out and serve the large group of individuals who are non-English speakers. I admire these students for their dedication and for the leadership that they model for all of us. They inspire me.
Continuing down the hallway, I strolled (by accident) into a group of DNP students and faculty. They are here for one of their periodic intensive weekends of study. The rest of their program is completed online. These are nurse leaders and executives, all with at least a master's degree, who have voluntarily taken on this intensive two year course of study to complete their doctoral study in our remarkable Doctor of Nursing Practice program. Learning together, these nurse leaders are mapping next generation practices for our ever changing and ever challenging healthcare systems. They inspire me too.
Across the hall was my final destination for the day. I had the good fortune to attend the completion celebration for the 13 graduates in our MS in Health Professions program. These individuals, from the United States, Japan, Singapore, and Saudi Arabia are all earning this voluntary post-graduate degree. They are an interprofessional group that includes physicians, nurse practitioners, physician assistants, pharmacists, physical therapists, and the first ever speech-language pathologist to complete this degree at the Institute. They attended a series of on campus activities over the past three days. Their scholarly projects and their commitment to the education of health professionals will change the course and the quality of education in their own institutions and beyond. Today’s event was made even more special because it is the last such event for Dr. Deborah Navedo, who was one of the founders of the program and served as program director since its first class was enrolled in 2011. These students, all busy professionals who have completed this rigorous program of study, inspire me too. (Special congratulations to Assistant Professor Josh Merson of our PA program, one of today’s grads).
I know I am fortunate to have my professional home in an institution deeply committed to serving such exemplary learners, to transforming healthcare and education, and building tomorrow’s leaders. I hope you all share my pride and inspiration.
March 1, 2018
As promised, here is the second invited blog post. This one is from Rachel Harshaw, an administrative staff member in the Department of Communication Sciences and Disorders. Rachel addresses the issue of consent and asks us to think about our own action vs. inaction. Thanks to Rachel for her thoughtful contribution! — Alex Johnson, Provost
“All too often, when we see injustices, both great and small, we think, ‘That’s terrible,’ but we do nothing. We say nothing. We let other people fight their own battles. We remain silent because silence is easier. Qui tacet consentire videtur is Latin for ‘Silence gives consent.’ When we say nothing, when we do nothing, we are consenting to these trespasses against us.” – Roxane Gay, Bad Feministi
I was at home in Connecticut when I heard about Sandy Hook. My mother and I sat, eyes fixed on the TV screen, where bewildered anchors repeated themselves over and over until the shock finally slid off their shoulders and reality set in: twenty-six children and educators had been massacred in broad daylight.
As I struggled to come to terms with the sheer horror and senselessness of these killings, there was one pinprick, one grain, one atom of knowledge that I knew to be true: this would be the last mass shooting in America. I was steadfast in my conviction that, if anything could bridge the divide in Washington to spur sustainable change and effective legislation, it was this. I pored over articles, debriefed and debated with family and friends, and sat by while I waited for activists and politicians to do their work. One year later, there was a mass shooting in the Washington Navy Yard. Three years, Umpqua Community College. Then San Bernardino. Pulse Nightclub. Sutherland Springs Church. Las Vegas Harvest Music Festival. And now, Marjory Stoneman Douglas High School.ii
Instead of protecting our most vulnerable, we have left them to fend for themselves. I sit idly by while the children of Parkland, Florida leave their essays unwritten and their classrooms empty to march on Washington, hold their senators accountable, and attempt to dismantle the National Rifle Association. Weren’t we supposed to protect our children after Sandy Hook? Now, the whole country is watching high school senior Emma González lead the charge, all from the safety of our Twitter timelines. She should be given the space to grieve the loss of her classmates and friends. She should be studying for her Advanced Placement exams. She should be allowed to be a teenager, carefree and invincible. Instead, she is on her way to Capitol Hill to fight for her life.
I have heard the phrase “silence equals consent” countless times. It lives on t-shirts, Facebook statuses, and research papers alike, and, unsurprisingly, rose to fame around the time of the 2017 presidential election. It seems to be no coincidence that the second most looked-up word of 2017 was “complicit.”iii Why, then, do I still feel a nagging sense of inadequacy and guilt when I voice my opposition to our nation’s lack of gun control, among other public health issues? Why, if I am anything but silent, do I still feel complicit in this flawed system?
For me, advocacy and education, both of myself and of others, have ceased to be an effective response to injustice. Silence may be consent, but so is inaction. No matter your resources or abilities, there is always something tangible you can do as an agent of change. For the financially secure, donate to the #NeverAgain movement founded by Stoneman Douglas students.iv For those with limited income, donate just $1; it may not make a difference to you, but it will to the movement. For the able-bodied, join the March for Our Lives on March 24 in Washington, DC. For the able-bodied who do not live in Washington, join one of the countless sister movements cropping up in communities across the country. For anyone with U.S. citizenship, register to vote and show up to the 2018 state primaries. The people who have lost their lives to gun violence have lost these privileges; it is your duty to exercise yours.
Some days, it is all I can do to reblog a new Washington Post article that I found informative. Other days, I feel so overwhelmed and drained that I turn people away who want to initiate these difficult conversations, even though I know they are important. But today, I am putting the date of the Massachusetts primary election in my calendar, and on September 4, I will be at my local polling center, pen in hand.
Where will you be?
i. Roxane Gay, Bad Feminist
ii. The terrible numbers that grow with each mass shooting
iii. Merriam-Webster’s 2017 Words of the Year
iv. March for Our Lives
v. 2018 State Primary Election Dates
February 27, 2018
Recently, I invited two members of our community – a faculty member and a staff member – to make a post on my blog regarding their views on the recent shootings in Parkland, Florida. The first guest post, which follows, comes from our colleague Professor Inge Corless (School of Nursing). Inge has chosen to focus on the topic of the United States Constitution and Public Health. I hope you will take a moment to read this contribution. Look for another post soon! – Alex Johnson, Provost and Vice President for Academic Affairs
"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."
– Preamble to the United States Constitution (Archives.gov)
In the Preamble to the U.S. Constitution, insuring domestic tranquility is mentioned as one of the reasons for the development of the Constitution for the United States. It may be argued as to the interpretation of the phrase “insure domestic tranquility”. For some it may refer to the relationships among the states that had been established at the time. It may also result in ensuring the enjoyment of the blessings of life and liberty. If such is the case, then tranquility and security in one’s home, workplace, or school are encompassed by this statement. Indeed, safety and happiness while referring to the 13 colonies are basic to the Declaration of Independence and to the people inhabiting the colonies.
It may be argued that these references are with regard to the relationship of communities and colonies to each other; that these statements refer to the conditions of the time. And they do, and they don’t. While inspired by the conditions obtaining at that time, changes have been made to the Constitution. Such changes include ensuring the right to vote for people of various races and ethnicities (Amendment XV) and “sex” (Amendment XIX).
The right to bear arms is enshrined in the second Amendment:
A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed. (Archives.gov)
There is an indication that the right to bear arms was meant to allow citizens to respond, as members of the militia, to a dictator, and at that time, King George III was perceived as such. The Declaration of Independence enunciated all of the infringements and transgressions that necessitated the rupture of relations between England and the 13 Colonies. The Constitution provided the basis of a new government that ensured the remedies to what was perceived as tyrannical government.
Just as the Bill of Rights modifies the Constitution and expands our understanding making it pertinent to current conditions, so too should our laws specify the right to bear arms. Notwithstanding a Supreme Court ruling (2008), which pertained to the District of Columbia and allowed the possession of a handgun in the home and reversed previous rulings, such a law must cover technology not available when the Bill of Rights was enshrined in our pantheon of founding documents. These technologies, applicable to firearms, include:
- The restriction of assault rifles, sawed-off shot guns, semi-automatic guns, and bump stocks.
Other issues that need to be addressed with regard to all weapons include:
- Increasing the age to 21 when a weapon may be purchased
- Restriction on the sale of products at gun shows
- Background checks
- Improved systems of identification of potential shooters through various technological linking systems
- Red Flag laws identifying individuals who have indicated they plan to commit violent acts
This is not a constitutional issue, although it has been framed as that. It is a public health issue! There have been 34 mass shootings in the U.S. since January 1, 2018 (Gun Violence Archive, 2018). Let us support and stand with the courageous and eloquent Marjory Stoneman Douglas High School students who are expressing their sorrow by civic action demanding a public health intervention: gun law restrictions, restrictions that will save lives. There will be a “March for our Lives” at the Boston Common on Saturday, March 24, from Noon–5:00 p.m. March, speak-up, vote. The time for change was yesterday. Failing that, it is now. – Inge B. Corless
February 15, 2018
What disease process has escalated in the past six months?
What condition will cause more loss of life than occurred in the Vietnam war?
What known cause of life and limb has prohibitions against being studied or has seen a reduction in health financing?
What is a major cause of death and disability for the youngest Americans?
What condition produces death at a rate of about 4 persons per 100,000 in this country?
You know the answers.
If you were watching the news on Wednesday February 14 (Valentine’s Day), you saw the results of this condition. The answer to the health quiz above is mass shooting and gun violence. Another 16 innocent kids and a beloved teacher are dead in Florida. The teacher was their football coach. The people who were shot all have families and friends who will struggle with this situation for years to come.
Our country has successfully fought against tobacco use. We are beginning to come to terms with the realities of opioid addiction and associated death. The country seems to realize that keeping dangerous drugs out of the hands of vulnerable people makes sense. We have laws against drunk driving. The risk of driving while using a cell phone are well established. Public education around these issues is readily available and the factors cited are treated as serious public health concerns.
Yet, we continue to have ignorance about the relationships among mental health, gun violence, and mass death. Reasonable people hopefully think that this new tragedy will pull the country together toward a solution. And yet the health system, federal and local governments, science, the mental health system all fail to come together and work toward solutions. These “systems” are designed to be our safety net against danger and threat. They are failing us and failing our children.
Unfortunately, the rabid debate about gun control serves as a distraction from the underlying issues. Whether we think gun control is good or bad, whether or not shooters have a health issue or are terrorists, and whether these discussions are threat to the 2nd amendment to the US Constitution is irrelevant. In fact, these arguments may serve as barriers to forward movement. As with every other health condition, the answer lies in finding the root cause and determining the most effective treatment approaches, and then implementing them. With this complex condition of mass violence, it is likely that no one treatment, systemic change, or policy will remediate. We can be confident at this point, that doing nothing will reinforce the continuing arc of tragedy that we are currently experiencing.
As noted, there is no evidence that the current situation will change without intervention. Three of the ten worst mass shootings in history have occurred within the past six months. The disease is progressing. If this were a virus, we would feel reassured that the systems designed to protect us were working together.
As health providers how could we respond in a meaningful way?
October 3, 2017
Almost every morning I read a few online news sources. A typical day at my desk begins with quick perusal of Statnews Morning Rounds, an online healthcare news source, the online version of Boston Globe, Academe Today (an online Chronicle of Higher Education), and finally Inside Higher Ed. Finding out what is happening in the world, in health care, and in the world of higher education helps me think about my work and the Institute. I find that I constantly need to ask myself if we are paying attention to the “right stuff.” Every day I realize my gratitude for being able to work and learn at the IHP and I hope you feel the same way.
A few of this morning’s headlines, however, hit me in the gut about education, health care, and about the larger world. I find a connectedness in the following headlines that is difficult and downright scary for me. A few of today’s headlines that are on my mind are listed below:
An Unspeakable Carnage (Boston Globe, 10/3/2017)
Las Vegas Hospitals Rush to Help Shooting Victims (Statnews, 10/3/2017)
Half of People in Puerto Rico Don’t Have Clean Water (Statnews, 10/3/17)
Don’t Expect Congress to Take Action on Mass Shootings (Boston Globe, 10/3/17)
Alzheimer’s Patient in Multimillion Dollar Pharma Ad May Soon be Homeless (Statnews, 10/3/17)
Scholars Renew Calls for US to Fund Research on Gun Violence (Inside Higher Ed, 10/3/17)
Health Providers Weigh In on Reused Syringes (Statnews, 10/3/17)
Gun violence, clean water, environmental issues, homelessness for disabled persons, and the drug epidemic weigh heavily on all of us, but I see a thread in all of these headlines – the healthcare thread – that links these messages with each other and with us as the faculty and students of the IHP.
Our students, who are being prepared as health care providers and researchers, will be called upon to address the impact of violence by caring for victims as first responders and rehabilitationists, to address the impact of environmental problems and weather related disasters, to study the effect of low resources on the health of populations, and to continue to address the needs of underserved people in our society. The root themes of poverty, racial and gender based inequity, and education cannot be ignored as underlying contributors to these vexing nightmarish problems. There is no opportunity to avoid the impact of these issues on our work together, as we face the future of our health care system. The reality of these now all too common occurrences and their systemic underpinnings are now part of our pedagogy and cannot be ignored in the classroom or clinical educational setting.
On a more hopeful side, I believe that, as an educational community, we are preparing health care leaders who will be well equipped to tackle these problems when they occur. Most important, I believe that our graduates will help accomplish the goal of addressing causal factors that mitigate these horrific events in our future. As educators, we can help accelerate these future solutions by assuring that our students leave equipped with tools and skills for leadership, problem solving, innovation, and advocacy. These systems oriented solutions are critical additions to the excellent foundational work in clinical skill development, patient decision making, and ethical and interprofessional practice that are the hallmarks of an IHP education.
In the coming weeks, I want to spend extra time reflecting on these solutions as we continue to face disturbing headlines. Let me know if you are interested in joining me for reflection and discussion around these issues and their impact on the IHP and our work. Email me at email@example.com and I will follow up with you soon!