Advertisement

Support for humanitarian aid to refugee children

        Executive Summary

        In June 2014, U.S. President Barack Obama called attention to the “urgent humanitarian situation in the Río Grande Valley areas of our Nation's Southwest border” (
        • Obama B.
        Letter from the President—Efforts to address the humanitarian situation in the Rio Grande Valley areas of our nation's southwest border.
        ). Although the surge of unaccompanied immigrant children across the border may have slowed, there remains an urgent humanitarian situation involving the current detention and housing of unaccompanied children from Central America by federal, and subsequently state, agencies while the children await their hearing in U.S. Immigration Courts. The American Academy of Nursing supports efforts to decrease the time children spend in detention and to provide opportunities to address both the physical and mental health needs of unaccompanied immigrant children.

        Background

        The American Academy of Nursing, along with multiple other organizations, has focused their attention on what U.S. President Barack Obama called the “urgent humanitarian situation in the Río Grande Valley areas of our Nation's Southwest border” (
        • Obama B.
        Letter from the President—Efforts to address the humanitarian situation in the Rio Grande Valley areas of our nation's southwest border.
        ). From October 2014 to the end of July 2015, almost 73,000 migrant children from El Salvador, Guatemala, and Honduras have crossed the southern U.S. border (
        • Zong J.
        • Batalova J.
        Central American immigrants in the United States.
        ). This humanitarian crisis raises two interrelated issues: one health care and one legal.
        The reasons cited for the surge of migrant children include escaping crime, violence, gang activity, and extreme poverty in their home countries. Some children have even fled to the United States to be reunited with a parent or other relative (
        • Kennedy E.
        No childhood here: Why Central American children are fleeing their homes.
        ). The journey to the United States for both undocumented migrants and refugees has been cited as “often stressful and dangerous” (
        • Hilfinger Messias D.K.
        • McEwen M.
        • Clark L.
        The impact and implications of undocumented immigration on individual and collective health in the United States.
        , p. 88). Once in the United States, many children are subjected to long stays in the federal, and sometimes subsequent state systems, while waiting for a hearing on their case in an U.S. Immigration Court (

        U.S. Department of Health and Human Services, Administration for Children and Families, Office of Refugee Resettlement. (2015). Unaccompanied children frequently asked questions. Retrieved from http://www.acf.hhs.gov/unaccompanied-children-frequently-asked-questions.

        ,
        Women's Refugee Commission
        Flores settlement agreement & DHS custody.
        ).
        As a result of the traumas and psychological abuses experienced in their home counties, as well as through their eventual journey and stay in temporary U.S. facilities, many of these unaccompanied immigrant children have a higher prevalence of mental health problems. Common mental health diagnoses include Adjustment Disorder, Major Depression, Generalized Anxiety, and Post-traumatic Stress Disorder, among others (

        Shapiro, A., & Stark, B. (2014). Unaccompanied immigrant children: Building resiliency. Terra Filma. Retrieved from http://www.cdfny.org/research-library/publications/2014/ashapiro-presentation_chn_11.pdf.

        ). Once in court, these children are often unrepresented by legal counsel and thus are more likely be issued removal orders or pressured to voluntarily return to their home country, thereby denying due process protections ().

        Federal Process

        Once unaccompanied children enter the United States, they are apprehended by the U.S. Department of Homeland Security (DHS), including the U.S. Customs and Border Protection (
        U.S. Department of Homeland Security
        Unaccompanied children at the southwest border.
        ). The conditions of the detention facilities and housing by the U.S. Customs and Border Protection have been described as overcrowded and unsanitary, and many of these children have been subject to sexual or other physical abuse, verbal abuse, and denied access to proper medical care (
        American Civil Liberties Union (ACLU)
        Civil and human rights groups file administrative complaint seeking immediate agency reform.
        ,

        Hennessy-Fiske, M., & Carcamo, C. (2014). Overcrowded, unsanitary conditions seen at immigrant detention centers. Los Angeles Times. Retrieved from http://www.latimes.com/nation/nationnow/la-na-nn-texas-immigrant-children-20140618-story.html#page=1.

        ). Unaccompanied children from Mexico or Canada that are detained by DHS are given the opportunity to voluntarily leave the United States “…or be sent home within 48 hours under repatriation agreements” with those two countries (

        Burchette, M., Githegi, M., & Morse, A. (2014). Child migrants to the United States. National Conference of State Legislatures. Retrieved from http://www.ncsl.org/research/immigration/child-migrants-to-the-united-states.aspx.

        ).
        Children from countries other than Mexico or Canada are required to be sent to the custody of the U.S. Department of Health and Human Services (DHHS) within 72 hours for review the child's immigration status by the Administration for Children and Families' Office of Refugee Resettlement (ORR;

        Burchette, M., Githegi, M., & Morse, A. (2014). Child migrants to the United States. National Conference of State Legislatures. Retrieved from http://www.ncsl.org/research/immigration/child-migrants-to-the-united-states.aspx.

        ). This agency helps to reunite non-Mexican/Canadian children with their family, or if not possible, facilitate placing the child into foster care at the state level (

        Burchette, M., Githegi, M., & Morse, A. (2014). Child migrants to the United States. National Conference of State Legislatures. Retrieved from http://www.ncsl.org/research/immigration/child-migrants-to-the-united-states.aspx.

        ). Court review for deportation is required for all non-Mexican/Canadian children, and the results from the proceedings include being granted the ability to stay in this country or deported (

        Burchette, M., Githegi, M., & Morse, A. (2014). Child migrants to the United States. National Conference of State Legislatures. Retrieved from http://www.ncsl.org/research/immigration/child-migrants-to-the-united-states.aspx.

        ).
        The Flores Settlement from 1997 sets the national policy on the detention, release, and treatment of minors who are in the custody of the U.S. Immigration and Naturalization Service (

        Flores v. Reno, Stipulated Settlement Agreement, No. CV 85-4544-RJK(Px) (C.D. Cal. Jan. 17, 1997). Retrieved from http://www.aclu.org/files/pdfs/immigrants/flores_v_meese_agreement.pdf).

        , ). The U.S. Immigration and Naturalization Service has since closed, and its work was transferred over to DHS (). The Flores policy now applies to both DHS and ORR for detained children who are either unaccompanied or detained with their families (). Flores requires that the child “…must be held in the least restrictive setting appropriate to age and special needs, generally, in a non-secure facility licensed by a child welfare entity and separated from unrelated adults and delinquent offenders”().

        Health Care

        The ORR has established the Unaccompanied Refugee Minor Program, the foster care program in which children who are unable to be reunited with their parents are placed (
        U.S. Department of Health and Human ServicesAdministration for Children and Families, Office of Refugee Resettlement
        Unaccompanied refugee minors.
        ). This program is administered by individual U.S. states by grants obtained through the federal government (

        U.S. Code of Federal Regulations (CFR). (2003a). 45 CFR §400.4, “Purpose of the plan.”

        ). States participating in this program must provide unaccompanied refugee children access to the same child welfare services and benefits to refugee children as it does with services, practices, standard, and procedures provided to other children in that State (

        U.S. Code of Federal Regulations (CFR). (2003b). 45 CFR §400.112(a)-(b), “Child welfare services for refugee children.”

        ). States must provide medical assistance to refugee children based on the same standards that the State's use when administering their foster care programs to other children in the State (

        U.S. Code of Federal Regulations (CFR). (2003c). 45 CFR §400.116(a), “Service for unaccompanied minors.”

        ). This care may be provided “…to an unaccompanied minor directly or through arrangements with a public or private child welfare agency approved or licensed under State law” (

        U.S. Code of Federal Regulations (CFR). (2003d). 45 CFR §400.117(a), “provision of care and services.”

        ). Public or nonprofit child welfare agencies may also provide care and services, but oversight of the program must be retained directly by the State (

        U.S. Code of Federal Regulations (CFR). (2003e). 45 CFR §400.117(b), “provision of care and services.”

        ).
        States must “…develop and implement an appropriate plan for the care and supervision of, and services provided to, each unaccompanied minor, to ensure that the child is placed in a foster home or other setting approved by the legally responsible agency and in accordance with the child's need for care and for social, health, and educational services” (

        U.S. Code of Federal Regulations (CFR). (2003f). 45 CFR §400.118(a), “Case planning.”

        ). This plan includes a health screening and treatment for the child, including medical and dental examinations and treatment (

        U.S. Code of Federal Regulations (CFR). (2003g). 45 CFR §400.118(b)(3), “Case planning.”

        ).
        States may also provide the following health-related services for refugee children: “[i]nformation; referral to appropriate resources; assistance in scheduling appointments and obtaining services; and counseling to individuals or families to help them understand and identify their physical and mental health needs and maintain or improve their physical and mental health” (

        U.S. Code of Federal Regulations (CFR). (2003h). 45 CFR §400.155(c)(2), “Health-related services.”

        ). Because the preceding health-related services are optional for states, this may result in inconsistent services provided to unaccompanied minor refugees who are located in one state versus another.

        Legal Representation

        Between July 18 and December 23, 2014, only about 27% of immigrant children had representation by an attorney during their immigration proceedings (). Of the cases that have been completed, nine of ten children who had no attorney present at the proceedings received either a removal order or voluntarily departed from the United States (). This is in contrast to seven of ten children who were allowed to stay longer in the United States as a result of having legal representation (). During 2015, the percentage of immigrant children represented by legal counsel has steadily increased. Between April and July of 2015, around 58% of unaccompanied immigrant children were represented by legal counsel, although more can be performed ().
        One major reason for the lack of legal representation for these children is that much of the work must be performed pro bono by attorneys (
        • Altman A.
        Border backlog. Immigration courts are buckling from the influx of children.
        ). Under the William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008, unaccompanied alien minors are to be provided counsel by the government “…to represent them in legal proceedings or matters and protect them from mistreatment, exploitation, and trafficking” (

        William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008, 8 USC 1232(c)(5) “Access to counsel.”

        ). This includes, “[t]o the greatest extent practicable,” having pro bono counsel represent these children without charge (

        William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008, 8 USC 1232(c)(5) “Access to counsel.”

        ). Medical/Legal Partnerships (MLPs), offering an inclusive team-based approach, have been increasingly used to address both health needs and pro bono legal representation for those without the means to pay for such services (

        Regenstein, M., Teitelbaum, J., Sharac, J., & Phyu, E. (2015). Medical-legal partnership and health centers: Addressing patients' health-harming civil legal needs as part of primary care. Retrieved from http://medical-legalpartnership.org/new-issue-brief-medical-legalpartnership-health-centers/.

        ).

        Responses and Policy Options

        In March 2015, in response to the need for legal representation for these unaccompanied minor immigrants, U.S. Representative Hakeem Jeffries (D-NY 8th) introduced H.R. 1700, the Vulnerable Immigrant Voice Act (

        114th Congress (2015-2016). H.R. 1700: Vulnerable Immigrant Voice Act. Introduced in House on March 26, 2015. Retrieved from https://www.congress.gov/bill/114th-congress/house-bill/1700.

        ). If enacted, the Act would amend the Immigration and Nationality Act to require the Attorney General within the U.S. Department of Justice to appoint legal counsel at the government's expense to “unaccompanied alien children and aliens with a serious mental disability” (

        114th Congress (2015-2016). H.R. 1700: Vulnerable Immigrant Voice Act. Introduced in House on March 26, 2015. Retrieved from https://www.congress.gov/bill/114th-congress/house-bill/1700.

        ). As of September 2015, this bill was still with the House Judiciary Subcommittee on Immigration and Border Security (

        114th Congress (2015-2016). H.R. 1700: Vulnerable Immigrant Voice Act. Introduced in House on March 26, 2015. Retrieved from https://www.congress.gov/bill/114th-congress/house-bill/1700.

        ).
        In July 2015, U.S. Senator Rob Portman (R-OH), chairman of the Senate Permanent Subcommittee on Investigations and co-chairman of the Senate Caucus to End Human Trafficking, sent a letter to U.S. DHHS Secretary Sylvia Mathews Burwell on the “…adequacy of safeguards in the Office of Refugee Resettlement's placement of unaccompanied minors with qualified sponsors” (
        • Portman R.
        Portman demands answers from Department of Health and Human Services on failure of safeguards against human trafficking.
        ). Within the letter, Senator Portman described that on at least five occasions, instead of being placed with qualified sponsors to take care of the children, the children were instead sent to human traffickers to work in labor camps in Ohio (
        • Portman R.
        Portman demands answers from Department of Health and Human Services on failure of safeguards against human trafficking.
        ). These children “…were housed in squalid trailers and subjected to psychological abuse” (
        • Portman R.
        Portman demands answers from Department of Health and Human Services on failure of safeguards against human trafficking.
        ).

        The American Academy of Nursing's Position

        The American Academy of Nursing supports access to culturally sensitive health services for vulnerable populations, including immigrant children (
        American Academy of Nursing
        Implementing culturally competent care.
        ,
        • Hilfinger Messias D.K.
        • McEwen M.
        • Clark L.
        The impact and implications of undocumented immigration on individual and collective health in the United States.
        ). The Academy also supports the participation of psychiatric/mental health nursing specialists as drivers of mental health services integrated into primary care (
        • Pearson G.S.
        • Evans L.K.
        • Hines-Martin V.P.
        • Yearwood E.L.
        • York J.A.
        • Kane C.F.
        Promoting the mental health of families.
        ). The Academy is sensitive to the impact of toxic stress on children and supports adequate physical and mental health services for children, including those that flee to the United States from poverty and violence in their home countries. In addition, MLPs should be pursued as an avenue to help unaccompanied alien minors with their health services and legal services. Nurses can play a key role in providing and advocating for appropriate, comprehensive, and culturally sensitive health services.
        The Academy will collaborate with both nursing and non-nursing organizations, including the American Academy of Pediatrics; the DHHS, Administration for Children and Families, ORR; and the National Center for Medical-Legal Partnership, to support both the health and legal needs of unaccompanied immigrant children.

        Recommendations

        • 1.
          Encourage nurses and other health professionals to engage with MLPs, such as the nurse-created model between East Tennessee State University College of Nursing and the Tennessee Justice Center, which is led by Academy fellow Patricia (Patti) Vanhook, PhD, RN, FNP-BC, FAAN. MLPs should focus on providing adequate and culturally sensitive medical care and legal representation for unaccompanied refugee children. Nurses should be integrated into the health care models of MLPs to provide more front-line medical care for unaccompanied refugee children.
        • 2.
          Develop partnerships to facilitate work with the DHHS, Administration for Children and Families, ORR, and the American Academy of Pediatrics to develop and disseminate culturally sensitive clinical screening tools for health care providers new to working with unaccompanied minor immigrants.
        • 3.
          Collaborate on the development of culturally sensitive resources on immigrant children's physical and mental health needs and the impact of toxic stress to be distributed to families, nurses, other health providers, and lawyers. These resources should include strategies to encourage holistic interactions between lawyers and vulnerable unaccompanied minor immigrant clients.
        • 4.
          Facilitate psychiatric nurses' work with immigrant refugee children on their long-term mental health needs and medication oversight. This includes the integration of mental health services into primary care services for children.
        • 5.
          Encourage child advocates to work with their state legislatures to adopt the currently optional, under federal law, health-related services. These services include “[i]nformation; referral to appropriate resources; assistance in scheduling appointments and obtaining services; and counseling to individuals or families to help them understand and identify their physical and mental health needs and maintain or improve their physical and mental health” (CFR,

          U.S. Code of Federal Regulations (CFR). (2003h). 45 CFR §400.155(c)(2), “Health-related services.”

          ).
        • 6.
          Advocate to the DHHS to amend the rules and regulations at the federal level to ensure better compliance by government agencies with the required services under the Flores Settlement. State agencies should ensure that the refugee child is placed in the least restrictive setting depending on their age and special needs.

        Acknowledgments

        The authors gratefully acknowledge the following individuals: DeAnne K. Hilfinger Messias, PhD, RN, FAAN; Marylyn Morris McEwen, PhD, RN, PHCNS-BC, FAAN; Lauren Clark, RN, PhD, FAAN; Joyceen S. Boyle, PhD, MPH, FAAN; and Barbara Smith, PhD, RN, FACSM, FAAN. In addition, the authors acknowledge Academy's Expert Panels on Global Health and Child/Adolescent/Families in developing this policy brief. Thank you to Academy staff Cheryl Sullivan, MSES, and Matthew J. Williams, JD, MA, who contributed to the research, review, and writing.

        References

        1. 114th Congress (2015-2016). H.R. 1700: Vulnerable Immigrant Voice Act. Introduced in House on March 26, 2015. Retrieved from https://www.congress.gov/bill/114th-congress/house-bill/1700.

          • Altman A.
          Border backlog. Immigration courts are buckling from the influx of children.
          (TIME)2014, September 1: 10
          • American Academy of Nursing
          Implementing culturally competent care.
          Nursing Outlook. 2015; 63: 227-229
          • American Civil Liberties Union (ACLU)
          Civil and human rights groups file administrative complaint seeking immediate agency reform.
          2014 (Retrieved from)
        2. Burchette, M., Githegi, M., & Morse, A. (2014). Child migrants to the United States. National Conference of State Legislatures. Retrieved from http://www.ncsl.org/research/immigration/child-migrants-to-the-united-states.aspx.

        3. Flores v. Reno, Stipulated Settlement Agreement, No. CV 85-4544-RJK(Px) (C.D. Cal. Jan. 17, 1997). Retrieved from http://www.aclu.org/files/pdfs/immigrants/flores_v_meese_agreement.pdf).

        4. Hennessy-Fiske, M., & Carcamo, C. (2014). Overcrowded, unsanitary conditions seen at immigrant detention centers. Los Angeles Times. Retrieved from http://www.latimes.com/nation/nationnow/la-na-nn-texas-immigrant-children-20140618-story.html#page=1.

          • Hilfinger Messias D.K.
          • McEwen M.
          • Clark L.
          The impact and implications of undocumented immigration on individual and collective health in the United States.
          Nursing Outlook. 2015; 63: 86-94
          • Kennedy E.
          No childhood here: Why Central American children are fleeing their homes.
          American Immigration Council, 2014 (Retrieved from)
          • Obama B.
          Letter from the President—Efforts to address the humanitarian situation in the Rio Grande Valley areas of our nation's southwest border.
          The White House, Office of the Press Secretary, 2014 (Retrieved from)
          • Pearson G.S.
          • Evans L.K.
          • Hines-Martin V.P.
          • Yearwood E.L.
          • York J.A.
          • Kane C.F.
          Promoting the mental health of families.
          Nursing Outlook. 2014; 62: 225-227
          • Portman R.
          Portman demands answers from Department of Health and Human Services on failure of safeguards against human trafficking.
          2015 (Retrieved from)
        5. Regenstein, M., Teitelbaum, J., Sharac, J., & Phyu, E. (2015). Medical-legal partnership and health centers: Addressing patients' health-harming civil legal needs as part of primary care. Retrieved from http://medical-legalpartnership.org/new-issue-brief-medical-legalpartnership-health-centers/.

          • Rogers D.
          Child migrants face new crisis: Uneven justice.
          2015 (Politico.com. Retrieved from)
          • Rogers D.
          Obama plan leaves child migrants adrift.
          2015 (Politico.com. Retrieved from)
        6. Shapiro, A., & Stark, B. (2014). Unaccompanied immigrant children: Building resiliency. Terra Filma. Retrieved from http://www.cdfny.org/research-library/publications/2014/ashapiro-presentation_chn_11.pdf.

        7. U.S. Code of Federal Regulations (CFR). (2003a). 45 CFR §400.4, “Purpose of the plan.”

        8. U.S. Code of Federal Regulations (CFR). (2003b). 45 CFR §400.112(a)-(b), “Child welfare services for refugee children.”

        9. U.S. Code of Federal Regulations (CFR). (2003c). 45 CFR §400.116(a), “Service for unaccompanied minors.”

        10. U.S. Code of Federal Regulations (CFR). (2003d). 45 CFR §400.117(a), “provision of care and services.”

        11. U.S. Code of Federal Regulations (CFR). (2003e). 45 CFR §400.117(b), “provision of care and services.”

        12. U.S. Code of Federal Regulations (CFR). (2003f). 45 CFR §400.118(a), “Case planning.”

        13. U.S. Code of Federal Regulations (CFR). (2003g). 45 CFR §400.118(b)(3), “Case planning.”

        14. U.S. Code of Federal Regulations (CFR). (2003h). 45 CFR §400.155(c)(2), “Health-related services.”

          • U.S. Department of Health and Human Services
          • Administration for Children and Families, Office of Refugee Resettlement
          Unaccompanied refugee minors.
          2012 (Retrieved from)
        15. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Refugee Resettlement. (2015). Unaccompanied children frequently asked questions. Retrieved from http://www.acf.hhs.gov/unaccompanied-children-frequently-asked-questions.

          • U.S. Department of Homeland Security
          Unaccompanied children at the southwest border.
          2015 (Retrieved from)
        16. William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008, 8 USC 1232(c)(5) “Access to counsel.”

          • Women's Refugee Commission
          Family detention & the Flores settlement agreement.
          2015 (Retrieved from)
          • Women's Refugee Commission
          Flores settlement agreement & DHS custody.
          2014 (Retrieved from)
          • Zong J.
          • Batalova J.
          Central American immigrants in the United States.
          Migration Policy Institute, 2015 (Retrieved from)