Wake Forest Baptist Medical Center

Children in Immigrant Families:

How to Be an Advocate

Julie M. Linton, MD, FAAP

Assistant Professor of Pediatrics, Wake Forest School of Medicine

Co-Chair, AAP Immigrant Health Special Interest Group

Disclosure

In the past 12 months, I have had no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of

commercial services discussed in this CME activity.

I do not intend to discuss an unapproved/investigative use of a commercial product/device in my

presentation.

Objectives

The names and identifying details of the children and families whose stories I will share have been changed to protect their confidentiality and safety.

Describe the changing policy landscape for children in immigrant families

Illustrate the impact of evolving policy on children and families

Offer opportunities for pediatric health professionals to support and advocate for children in immigrant families

Background: The Changing Landscape

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One in four

US children

lives in an

immigrant

family.

Nine out of

ten of these

children are

US citizens.

Almost 6 million US-citizen children under the age of 18live in mixed-citizenship status families.

Background: Common Language

Children in Immigrant Families

Citizens Non-citizens

Lawfully present/ lawfully residing

immigrants

Immigrantswithout

legal status

Mixed citizenship

families

LawfulpermanentResidents

Refugees, asylees, people with T- and U

non-immigrant status, special immigrant

juvenile status

J-1 classificationand other

lawful status

Family members

are all citizens

DACAYouth

Image by Ricky Choi, MD, MPH and Julie M. Linton, MD

Background: Key Immigration Principles

• Immigration system draws on 3 key principles:

1) reunification of families;

2) admitting immigrants with skills that are valuable to US economy

3) protecting persons fleeing persecution and other humanitarian reasons

• Lawful Permanent Residence (“green card” or LPR status)

o Certain categories of immigrants may become eligible to apply for LPR status.

• U.S. Citizenship

o To become eligible to apply for naturalization, must have LPR status for at

least 5 years (or 3 years if obtained LPR status through US citizen spouse)

• Immigrants without legal status

o Individuals who lost permission to remain in the U.S., or who entered the U.S.

without permission

But it’s much more complicated…

Slide Credit: Tamar Magarik Haro, American Academy of Pediatrics

Federal Policy Update:Building a Foundation

for Advocacy

Changing Policy Landscape

• 2017 Executive Orders

• Restrict entry from selected Muslim-majority countries, North Korea

• Cut refugee entry from 110,000 to 45,000 in FY18

• Make all immigrants in US w/o authorization immigration enforcement priorities

• Punish “sanctuary cities”

• Call for construction of a border wall

• Increase border patrol and detention along the southern border

• Family separation at the border

• Deferred Action for Childhood Arrivals (DACA)

• Public Charge

Slide Credit: Tamar Magarik Haro, American Academy of Pediatrics

Refugee Resettlement

Image from: https://www.npr.org/2016/08/20/490682349/in-the-face-of-a-bloodied-boy-a-call-to-look-more-deeply-at-syria

Photo Credit: Veronica Cardenas

Children and Families in Flight

Separation of Children and Families

“Studies overwhelmingly demonstrate the irreparable harm

caused by breaking up families.”

Dr. Colleen CraftPresident, American

Academy of Pediatrics

http://www.latimes.com/opinion/op-ed/la-oe-kraft-border-separation-suit-20180503-

story.html

Detention of Immigrant Children

When first detained,

children are sent to CBP processing

centers, where

conditions threaten children’s

health and well-being.

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Fear, Uncertainty, and Toxic Stress

Photo Credit: Veronica Cardenas

Sensitive Locations

• Current DHS policy says

immigration enforcement actions

are not to occur at:

• schools

• medical treatment and health

care facilities

• places of worship, religious or

civil ceremonies

• during public demonstrations

• Exceptions to the policy exist.

Slide Credit: Tamar Magarik Haro, American Academy of Pediatrics

Image from: https://www.washingtonpost.com/news/post-

nation/wp/2017/10/26/a-10-year-old-immigrant-was-rushed-to-the-hospital-in-an-ambulance-she-

was-detained-on-the-way/?utm_term=.d6cb85bcfd98

Deferred Action for Childhood Arrivals

• There are more

than 680,000

youth with DACA,

but there still is

NO deal

• Court ruling

forces DHS to

accept new

DACA renewals

• Permanent

solution resides

with Congress

Data on DACA: https://www.migrationpolicy.org/programs/data-hub/deferred-action-childhood-arrivals-daca-profiles

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Public Charge

• A person is a “public charge” if they are dependent on the

government for basic subsistence

• Longstanding policy and guidance provide that only two types of

benefits are considered in a public charge determination:

1. cash assistance

2. institutionalization for long-term care at government expense

• In early February, a leaked, draft proposal from DHS would

drastically expand the benefits considered to include WIC, SNAP,

Medicaid, CHIP, the ACA health insurance subsidies, Section 8

housing assistance, and Earned Income Tax Credit

• Not final, not public and not in effect

• Opportunity for public comment if/when published

Slide Credit: Tamar Magarik Haro, American Academy of Pediatrics

Wake Forest Baptist Medical Center

All Hands on Deck:

Supporting Children in Immigrant Families

Advocacy: Many Facets, Many Levels

High Quality Health Care

Medical Education

Research and Public

HealthAdvocacy

Community Engagement

Childrenand

Families

IndividualClinic

Community RegionalNational

“Public Sphere”

Cultural Humility and Cultural Safety

• Cultural humility: Openness and respect for differences1

• Cultural safety: Recognition of power differences and in[equities] in

health and the clinical encounter that result from social, historical,

economic, and political circumstances2

1. Tervalon & Murray-Garcia J, Journal of Health Care for the Poor and Underserved, 19982. Papps & Ramsden, International Journal of Quality in Health Care, 1996

Creating Safe(r) Spaces

Image from Bellevue Hospital, courtesy of Dr. Benard Dreyer

Key Resources:

• National Immigration Law Center (NILC) Toolkit: https://healthtoolkit.nilc.org/login/

• KIND (Kids in Need of Defense): https://supportkind.org/resources/know-rights-information-ice-raids-parentscommunityattorneys/

• AAP Council on Community Pediatrics Immigrant Health Toolkit: http://bit.ly/1y6HR1D

Key Resources:National Immigration Law Center (NILC) Toolkit: https://healthtoolkit.nilc.org/login/

KIND (Kids in Need of Defense): https://supportkind.org/resources/know-rights-information-ice-raids-parentscommunityattorneys/

Supporting Families

• Build resilience:

Engage children

and families in

efforts to read, talk,

sing, and play

together

• Encourage parental

self care (e.g.

physical activity,

community, faith)

Wake Forest Baptist Medical Center

Engaging in Communities

Pete Cooch & Heyman Oo

Holly Vo & John Luttrell

Slide Credit: Tamar Magarik Haro, Madeline Curtis

Protecting Immigrant Children

(January 2017)

Opposing President Trump’s Decision to End DACA

(September 2017)

Professional Organizations:

American Academy of Pediatrics Response

Opposing detention of pregnant women and

adolescents (March 2018)

Opposing Separation of Mothers and Children at

the Border (March 2017, 2018)

AAP Chapter Advocacy

Public Dissemination of Research

Full broadcast available at: https://www.kff.org/other/event/immigrant-families-in-america-today-how-fear-and-toxic-stress-is-affecting-daily-life-well-being-and-health/?utm_campaign=KFF-2017-December-Immigrant-Families-Lawfully-Undocumented&utm_source=hs_email&utm_medium=email&utm_content=2&_hsenc=p2ANqtz-8j4DvjLayipgspLg-6cbJ6Vg6enKQnHUDb7-DllDr6lQV5gwOicptXaR3kqVg0AwzFhB4VbLQIsLOHeYL8M5RQxybEzg

Wake Forest Baptist Medical Center

Earned Media

Social Media

The Public Sphere: #putkids1st

• Disseminate evidence regarding the impact of policy on health

• Speak up via earned media (e.g. Op Eds, interviews with reporters)

• Connect via social media (#tweetiatrician)

• Become a key contact via AAP Federal Advocacy:

email kids1st@aap.org

• Join the AAP Immigrant Health Special Interest Group via the

AAP Council on Community Pediatrics: email cocp@aap.org

Conclusions

• Immigration policies increasingly threaten the health of immigrant families.

• Health care providers are uniquely poised to provide credible, caring messages to support immigrant families, from the bedside to the community to the broader public sphere.

• We must empower all children – including our own – to speak up against hate.

Photo Credit: Veronica Cardenas

Acknowledgements• Wake Forest School of Medicine Department of Pediatrics

• Wake Forest Clinical and Translational Science Institute

• Program in Community Engagement

• Maya Angelou Center for Health Equity

• American Academy of Pediatrics colleagues

• AAP Immigrant Health Special Interest Group (Marsha Griffin, MD; Alan Shapiro, MD; Raul Gutierrez, MD, MPH; Ricky Choi, MD, MPH; Lanre Falusi, MD; Yasuko Fakuda, MD; Janine Young, MD; Kate Yun, MD; Andrea Green, MD, et al.),

• AAP COCP & COCM Executive Committees (Jim Duffee, MD; Nusheen Ameenuddin, MD; David Hill, MD; et al.)

• AAP leadership and staff (Benard Dreyer, MD; Fernando Stein, MD; Karen Remley, MD, MPH, MBA; Mark Del Monte; Judy Dolins; Tamar Haro; Madeline Curtis; Camille Watson; Jamie Poslosky; Susan Martin; et al.)

• Community and advocacy partners locally and nationally

• Forsyth County Department of Public Health; Imprints Cares; HealthCare Access; Winston-Salem Forsyth County Schools

• The Young Center, NILC, KIND, Frameworks Institute

• Culture of Health Leaders, a Program of the Robert Wood Johnson Foundation

• Photographer: Verónica G. Cárdenas-Vento, http://veronicagabriela.com/

References 1. AAP Council on Community Pediatrics Immigrant Health Toolkit, http://bit.ly/1y6HR1D.

2. AAP Council on Community Pediatrics. Community pediatrics: navigating the intersection of medicine, public health, and social determinants of children’s health.

Pediatrics 2013; 131(3): 623-628.

3. AAP Council on Community Pediatrics. Providing Care for Immigrant, Migrant, and Border Children Pediatrics, 2013, 131(6): e2028-34.

4. AAP. Trauma toolbox for primary care. M. D. Dowd, Editor. www.aap.org/traumaguide

5. Artiga S & Ubri P. Living in an immigrant family in America: How fear and toxic stress are affecting daily life, well-being, & health. Henry J Kaiser Family Foundation.

Available at https://www.kff.org/disparities-policy/issue-brief/living-in-an-immigrant-family-in-america-how-fear-and-toxic-stress-are-affecting-daily-life-well-being-

health/.

6. Byrne O, Miller E. The flow of unaccompanied children through the immigration system: A resource for practitioners, policy makers, and researchers. Vera Institute

New York, 2012.https://www.vera.org/publications/the-flow-of-unaccompanied-children-through-the-immigration-system-a-resource-for-practitioners-policy-makers-

and-researchers

7. Capps R, Fix M, Zong J. The Education and Work Profiles of the DACA Population. Migration Policy Institute 2017; Available at:

http://www.migrationpolicy.org/research/education-and-work-profiles-daca-population. Accessed September 8, 2017.

8. Deferred Action for Childhood Arrivals (DACA) Data Tools. Migration Policy Institute. Available at: https://www.migrationpolicy.org/programs/data-hub/deferred-

action-childhood-arrivals-daca-profiles.

9. Dreby J. The burden of deportation on children in Mexican immigrant families. Journal of Family and Marriage 2012;74(4):828-45.

10. Fazel et al. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet 2012; 379: 266–82.

11. Hainmueller J et al. Protecting unauthorized immigrant mothers improves their children’s mental health. Science 2017; doi 10.1126/science.aan5893.

12. Kids Count Data Center. http://datacenter.kidscount.org

13. KIND (Kids in Need of Defense). Know Your Rights Information on ICE Raids for Parents/Community/Attorneys. Available at:

https://supportkind.org/resources/know-rights-information-ice-raids-parentscommunityattorneys/. Accessed July 29, 2017.

14. Linton JM, Griffin M, Shapiro A. Detention of Immigrant Children. Pediatrics, Published online March 2017, DOI: 10.1542/peds.2017-0483.

15. Linton JM, Kennedy E, Shapiro A, Griffin M. Unaccompanied Children Seeking Safe Haven: Providing Care and Supporting Well-Being of a Vulnerable Population.

Children and Youth Services Review. Accepted for publication on March 22, 2018. In press.

16. Mathema S. Keeping Families Together: Why All Americans Should Care About What Happens to Unauthorized Immigrants. University of Southern California’s

Center for the Study of Immigrant Integration (CSII) and Center for American Progress, March 16, 2017. Available at:

https://www.americanprogress.org/issues/immigration/reports/2017/03/16/428335/keeping-families-together/. Accessed July 31, 2017.

17. National Immigration Law Center. www.nilc.org

18. National Child Traumatic Stress Network. Refugee Services Toolkit Core Stressors Overview. Available at: http://nctsn.org/trauma-types/refugee-trauma/learn-about-

refugee-core-stressors. Accessed July 12, 2017.

19. Papps & Ramsden, International Journal of Quality in Health Care, 1996

20. Rhodes SD, Mann L, Siman FM, Song E, Alonzo J, Downs M, Lawlor E, Martinez O, Sun CJ, O’Brien MC, Reboussin BA, & Hall MA. The impact of local

immigration enforcement policies on the health of immigrant Hispanics/Latinos in the United States. Am J Public Health, published online ahead of print Dec 18

2014, e1-e9.

21. Tervalon & Murray-Garcia J, Journal of Health Care for the Poor and Underserved, 1998

22. US Department of State. Refugee Resettlement in the United States. 10/21/15. Available at: https://2009-2017.state.gov/documents/organization/249289.pdf,

Accessed July 29, 2017.

23. UNHCR. Children on the Run. Washington, DC. May 2014.

24. Venkataramani et al., Lancet Public Health, 2017;2:e175-81.

25. Women’s Refugee Commission, Lutheran Immigration and Refugee Service, Kids in Need of Defense. Betraying Family Values: How Immigration Policy at the

United States Border is Separating Families. Available at: https://www.womensrefugeecommission.org/rights/gbv/resources/1450-betraying-family-values

Wake Forest Baptist Medical Center

Photo Credits: American Academy of Pediatrics