In January 2019 two migrant children died in detention centers in the US. More than six months after a federal judge ordered the Trump administration to reunite families separated at the US border, an unknown number of children still remain separated from their parents.
This situation was a direct consequence of a “zero-tolerance” policy promulgated by United States Attorney General Jeff Sessions. In a departure from previous practice, he argued that anyone crossing the border illegally should be prosecuted for committing an offence. As children could not be held in jails, the inevitable consequence was that they would be held separately. Eventually, the pressure was overwhelming, forcing President Trump to rescind the policy by issuing an executive order to stop further separations, although maintaining the policy of 100% prosecutions. After an executive order was issued on 20 June 2018, which reversed the family separations, it was not immediately clear who the families were. When the original order to separate children from their parents was implemented, there was clearly no forethought given to the reunification of families, and guidance from the Federal government was lacking. Accordingly, parents did not know where their children were, and children did not know where their parents were, and the US government agencies did not know either. The fortunate children were being looked after by foster carers, albeit hundreds of miles away from the border and with no knowledge of, nor means of contacting, the children’s parents. Many others were being detained, some in “cages created by metal fencing.”  Although initially shrouded in secrecy, accounts of the terror that they were experiencing slowly began leaking out.
The government is now attempting to use DNA testing to reunite children with their parents—a slow process that is not always conclusive, and is particularly problematic in the case of several parents who have already been returned to their country of origin. For now, the children are being held in what are euphemistically termed “tender-age shelters”, or what might otherwise be called baby and toddler jails. Adding a further level of stress, these children—some still in diapers—were ordered to appear in court. Separating children from their parents at the border, however, amounts to using children to manipulate parent’s decisions, which may cause irreversible, lifelong damage to both children and their parents.
The medical and public health community has united in condemnation of these developments. The president of the American Academy of Pediatrics, Colleen Kraft, said in June 2018 in a CNN interview that President Trump’s so called “Zero-tolerance” policy amounts to a form of child abuse. Indeed, the use of children to manipulate decisions of adults is a strategy of domestic abuse.
Pediatricians who have visited the migrant children at the border predict “irreparable harm” from the “toxic stress” caused by such separations, which disrupts a child’s brain development, let alone from possible experiences of sexual, physical, and verbal abuse of which a number of complaints have been brought forward.
Their concern is well supported by evidence.  A large body of research has found that traumatic events in childhood can have long-lasting adverse health effects, in particular the Adverse Childhood Experiences (ACE) study, which examined the childhood experiences of over 17,000 adults in the 1990s. [3,4] Children experiencing separation from their parents, being placed in foster homes, and witnessing the incarceration of their parents, have health consequences that may only become manifest years later.  Such experiences in early life create a maladapted stress response in the child that disrupts neural circuits in the developing brain affecting its fundamental architecture.  This increases their vulnerability to later emotional, physical, and behavioral illness. Children exposed to such abuses are at increased risk of conduct disorder, substance abuse, depression, and anxiety. For the young girls, it means increased risk of many complications when they later become pregnant, and may even increase risk of adverse outcomes passed on to their children, including possibly autism spectrum disorders and attention deficit-hyperactivity disorder (ADHD). [8,9] These are tremendously burdensome public health issues that not only have drastic personal consequences, but also larger financial costs to society. The estimated costs to US employers of major depressive disorders among employees was estimated at US$83 billion in 2000.  In the 1990s the annual direct cost of anxiety disorders was estimated to be US$42.3 billion. 
The damage that these events have caused will only become fully apparent in the years to come. Separating children from their parents was a call to action for politicians, humanitarians, religious groups and for us as health professionals. All of us must continue to highlight this issue and call for children and their families to be reunited. Those caring for children in detention centres must adhere to their ethical responsibilities, even when faced with authorities creating a hostile climate, taking what measures they can to give the children a voice. And those who care for children elsewhere must be aware of the trauma that such children have experienced in the past.
Jutta Lindert, University of Applied Sciences Emden, Germany; Brandeis University, Waltham, United States
Martin McKee, London School of Hygiene and Tropical Medicine
Ichiro Kawachi, Harvard T.H. Chan School of Public Health
Judith Lindert, University Hospital Luebeck, Luebeck, Germany
Marc G. Weisskopf, Harvard T.H. Chan School of Public Health
Competing interests: None declared
1 Washington Post. D81 children separated from parents since June. Washington Post, December 6th, 2018.
2 The Guardian. Separation at the border: children waiting in cages at South Texas warehouse. The Guardian. June 17th, 2018.
3 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:e232-4.
4 Lindert J, von Ehrenstein OS, Grashow R, Gal G, Braehler E, Weisskopf MG. Sexual and physical abuse in childhood is associated with depression and anxiety over the life course: systematic review and meta-analysis. Int J Public Health. 2014;59:359-72.
5 Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, Giles WH. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006; 256: 174-86.
6 Slopen N, Loucks EB, Appleton AA, Kawachi I, Kubzansky LD, Non AL, Buka S, Gilman SE. Early origins of inflammation: An examination of prenatal and childhood social adversity in a prospective cohort study. Psychoneuroendocrinology. 2015;51 403-1.
7 Danese A, McEwen BS. Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiol Behav. 2012;106:29-39.
8 Roberts AL, Liew Z, Lyall K, Ascherio A, Weisskopf MG. Association of maternal exposure to childhood abuse with elevated risk for attention deficit hyperactivity disorder in offspring. Am J Epidemiol, 187(9):1896-1906, 2018.
9 Roberts AL, Lyall K, Rich-Edwards JW, Ascherio A, Weisskopf MG. Maternal exposure to childhood abuse is associated with elevated risk of autism. JAMA Psychiatry 2013;70(5):508-15.
10 Wang PS, Simon G, Kessler RC. The economic burden of depression and the cost-effectiveness of treatment. Int J Methods Psychiatr Res. 2003;12:22-33.
11 Lépine J-P. The epidemiology of anxiety disorders: prevalence and societal costs. J Clin Psychiatr. 2002;63:4-8.