Aradhana Bela Sood, MD, MSHA

We are in the healing profession. We practice a trade. We are doctors, therapists, counselors. We work with children, adults, and couples. We document the physical form of our patient after examination, setting the stage for interventions that heal and alleviate suffering. With those who we do not touch physically, we hold out our psychological arms to embrace them in a therapeutic relationship.

We are privileged to appreciate their deeper selves through voice, unsaid words, and body language. A trust evolves (or might not); deeper exploration where our intuition and technical skill discover what troubles the soul. Healing begins as a delicate dance: As trust is earned, our patients risk vulnerability by revealing their weakest selves.

As healers, we often find ourselves adrift with our own insecurities, our own histories that make us human; our styles may differ but training and the tenets and guidelines set by our professional societies keep us in safe waters. These guidelines are informed by the science of health care research and vetted through centuries of observation and experience of process. “Do no harm” is perhaps one of the major rules of engaging with patients. The scaffolding that our code of ethics provides healing professions trumps external pressures to deviate. If you violate these codes, the consequences are borne by the patient and the potential loss of your license.

Some of you may have read about Kevin Euceda, an adolescent who reportedly was waiting for his immigration interview and ordered to undergo mandatory therapy as part of the immigration protocol. Kevin revealed to his therapist the history of violence he experienced as a child growing up in Honduras. His subsequent initiation into a gang was the only option he had to escape a violent death. Those of us who work with youth from gang cultures know fully that allegiance to a gang is a means to find an identity and brotherhood with the payment by a lifestyle of violence. A therapist faced with this information does not judge but helps the person deal with PTSD, nightmares, and guilt that become part of an identity just as the memories of mines blowing up in the face of combat affect veterans.

But the therapist, who reportedly holds a master’s in rehabilitation counseling and was “a year away from passing her licensing exam,” according to an article published in the Washington Post, followed policy of the Office of Refugee Resettlement. The therapist betrayed Kevin by reporting the information he shared with her confidentially to Immigration and Customs Enforcement. The reason the therapist gave for the breach was that she was compelled do so because Kevin reported participating in gang activity in Honduras. Subsequently, Kevin was sent to a high-security detention center – and is now facing deportation.
 

Betraying a patient, profession

Therapy begins as a contract between patient and therapist. The contract stipulates that all that transpires in the process of therapy (usually a 50-minute block of time, usually weekly) is information held by the therapist and patient – and is not to be shared with anyone, including parents, guardians, legal entities, and health care agencies. This allows the gradual sharing of events, emotions, behaviors, and reactions akin to peeling an onion. Memories, reactions, and feelings assist the therapist as they start their quest of discovery of the conflict and how to resolve it. Trust is the central tenet of this journey. The patient thinks: “You will hear me; you will see me you will understand me and help me understand myself.” The doctor responds: “Even I don’t yet know fully what ails you; we will discover that together. … I will not fail your trust.”

So how does this interface with external pressures? The constitution of a free country provides some inviolable protections that prevent derailment of the codes of ethics based on science. The fine line between what are considered sacrosanct ethics of a field – be it health care, climatology, or architecture – and what could be sacrificed in the name of prevailing forces (political or otherwise) has to be under constant scrutiny by the members of the guild. In health care, when patients cannot trust the science, its implementation, or is let down by the clinician, they are unlikely to benefit from treatment. A foundation of distrust paves the way for future therapeutic relationships that are stained with distrust and noncompliance.

The ethics guidelines of the American Academy of Psychiatry and the Law specify that psychiatrists in forensic roles “should be clear about limitations on confidentiality in the treatment relationship and ensure that these limitations are communicated to the patient.” Again, the therapist in this case is not a psychiatrist, but I would argue that the same rules would apply.

It is reassuring to know that several key groups, including the American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and the American Psychological Association, have all condemned the therapist’s actions. Psychiatrists and other mental health professionals must do no harm. We must not stand idly by and allow the kind of professional breach that happened to Kevin continue. Patients who confide in mental health professionals with the promise of confidentiality must be able to do so without fear. Only with confidentiality can the therapeutic relationship thrive.

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy, at Virginia Commonwealth University, Richmond.

We are in the healing profession. We practice a trade. We are doctors, therapists, counselors. We work with children, adults, and couples. We document the physical form of our patient after examination, setting the stage for interventions that heal and alleviate suffering. With those who we do not touch physically, we hold out our psychological arms to embrace them in a therapeutic relationship.

We are privileged to appreciate their deeper selves through voice, unsaid words, and body language. A trust evolves (or might not); deeper exploration where our intuition and technical skill discover what troubles the soul. Healing begins as a delicate dance: As trust is earned, our patients risk vulnerability by revealing their weakest selves.

As healers, we often find ourselves adrift with our own insecurities, our own histories that make us human; our styles may differ but training and the tenets and guidelines set by our professional societies keep us in safe waters. These guidelines are informed by the science of health care research and vetted through centuries of observation and experience of process. “Do no harm” is perhaps one of the major rules of engaging with patients. The scaffolding that our code of ethics provides healing professions trumps external pressures to deviate. If you violate these codes, the consequences are borne by the patient and the potential loss of your license.

Some of you may have read about Kevin Euceda, an adolescent who reportedly was waiting for his immigration interview and ordered to undergo mandatory therapy as part of the immigration protocol. Kevin revealed to his therapist the history of violence he experienced as a child growing up in Honduras. His subsequent initiation into a gang was the only option he had to escape a violent death. Those of us who work with youth from gang cultures know fully that allegiance to a gang is a means to find an identity and brotherhood with the payment by a lifestyle of violence. A therapist faced with this information does not judge but helps the person deal with PTSD, nightmares, and guilt that become part of an identity just as the memories of mines blowing up in the face of combat affect veterans.

But the therapist, who reportedly holds a master’s in rehabilitation counseling and was “a year away from passing her licensing exam,” according to an article published in the Washington Post, followed policy of the Office of Refugee Resettlement. The therapist betrayed Kevin by reporting the information he shared with her confidentially to Immigration and Customs Enforcement. The reason the therapist gave for the breach was that she was compelled do so because Kevin reported participating in gang activity in Honduras. Subsequently, Kevin was sent to a high-security detention center – and is now facing deportation.
 

Betraying a patient, profession

Therapy begins as a contract between patient and therapist. The contract stipulates that all that transpires in the process of therapy (usually a 50-minute block of time, usually weekly) is information held by the therapist and patient – and is not to be shared with anyone, including parents, guardians, legal entities, and health care agencies. This allows the gradual sharing of events, emotions, behaviors, and reactions akin to peeling an onion. Memories, reactions, and feelings assist the therapist as they start their quest of discovery of the conflict and how to resolve it. Trust is the central tenet of this journey. The patient thinks: “You will hear me; you will see me you will understand me and help me understand myself.” The doctor responds: “Even I don’t yet know fully what ails you; we will discover that together. … I will not fail your trust.”

So how does this interface with external pressures? The constitution of a free country provides some inviolable protections that prevent derailment of the codes of ethics based on science. The fine line between what are considered sacrosanct ethics of a field – be it health care, climatology, or architecture – and what could be sacrificed in the name of prevailing forces (political or otherwise) has to be under constant scrutiny by the members of the guild. In health care, when patients cannot trust the science, its implementation, or is let down by the clinician, they are unlikely to benefit from treatment. A foundation of distrust paves the way for future therapeutic relationships that are stained with distrust and noncompliance.

The ethics guidelines of the American Academy of Psychiatry and the Law specify that psychiatrists in forensic roles “should be clear about limitations on confidentiality in the treatment relationship and ensure that these limitations are communicated to the patient.” Again, the therapist in this case is not a psychiatrist, but I would argue that the same rules would apply.

It is reassuring to know that several key groups, including the American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and the American Psychological Association, have all condemned the therapist’s actions. Psychiatrists and other mental health professionals must do no harm. We must not stand idly by and allow the kind of professional breach that happened to Kevin continue. Patients who confide in mental health professionals with the promise of confidentiality must be able to do so without fear. Only with confidentiality can the therapeutic relationship thrive.

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy, at Virginia Commonwealth University, Richmond.

We are in the healing profession. We practice a trade. We are doctors, therapists, counselors. We work with children, adults, and couples. We document the physical form of our patient after examination, setting the stage for interventions that heal and alleviate suffering. With those who we do not touch physically, we hold out our psychological arms to embrace them in a therapeutic relationship.

We are privileged to appreciate their deeper selves through voice, unsaid words, and body language. A trust evolves (or might not); deeper exploration where our intuition and technical skill discover what troubles the soul. Healing begins as a delicate dance: As trust is earned, our patients risk vulnerability by revealing their weakest selves.

As healers, we often find ourselves adrift with our own insecurities, our own histories that make us human; our styles may differ but training and the tenets and guidelines set by our professional societies keep us in safe waters. These guidelines are informed by the science of health care research and vetted through centuries of observation and experience of process. “Do no harm” is perhaps one of the major rules of engaging with patients. The scaffolding that our code of ethics provides healing professions trumps external pressures to deviate. If you violate these codes, the consequences are borne by the patient and the potential loss of your license.

Some of you may have read about Kevin Euceda, an adolescent who reportedly was waiting for his immigration interview and ordered to undergo mandatory therapy as part of the immigration protocol. Kevin revealed to his therapist the history of violence he experienced as a child growing up in Honduras. His subsequent initiation into a gang was the only option he had to escape a violent death. Those of us who work with youth from gang cultures know fully that allegiance to a gang is a means to find an identity and brotherhood with the payment by a lifestyle of violence. A therapist faced with this information does not judge but helps the person deal with PTSD, nightmares, and guilt that become part of an identity just as the memories of mines blowing up in the face of combat affect veterans.

But the therapist, who reportedly holds a master’s in rehabilitation counseling and was “a year away from passing her licensing exam,” according to an article published in the Washington Post, followed policy of the Office of Refugee Resettlement. The therapist betrayed Kevin by reporting the information he shared with her confidentially to Immigration and Customs Enforcement. The reason the therapist gave for the breach was that she was compelled do so because Kevin reported participating in gang activity in Honduras. Subsequently, Kevin was sent to a high-security detention center – and is now facing deportation.
 

Betraying a patient, profession

Therapy begins as a contract between patient and therapist. The contract stipulates that all that transpires in the process of therapy (usually a 50-minute block of time, usually weekly) is information held by the therapist and patient – and is not to be shared with anyone, including parents, guardians, legal entities, and health care agencies. This allows the gradual sharing of events, emotions, behaviors, and reactions akin to peeling an onion. Memories, reactions, and feelings assist the therapist as they start their quest of discovery of the conflict and how to resolve it. Trust is the central tenet of this journey. The patient thinks: “You will hear me; you will see me you will understand me and help me understand myself.” The doctor responds: “Even I don’t yet know fully what ails you; we will discover that together. … I will not fail your trust.”

So how does this interface with external pressures? The constitution of a free country provides some inviolable protections that prevent derailment of the codes of ethics based on science. The fine line between what are considered sacrosanct ethics of a field – be it health care, climatology, or architecture – and what could be sacrificed in the name of prevailing forces (political or otherwise) has to be under constant scrutiny by the members of the guild. In health care, when patients cannot trust the science, its implementation, or is let down by the clinician, they are unlikely to benefit from treatment. A foundation of distrust paves the way for future therapeutic relationships that are stained with distrust and noncompliance.

The ethics guidelines of the American Academy of Psychiatry and the Law specify that psychiatrists in forensic roles “should be clear about limitations on confidentiality in the treatment relationship and ensure that these limitations are communicated to the patient.” Again, the therapist in this case is not a psychiatrist, but I would argue that the same rules would apply.

It is reassuring to know that several key groups, including the American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and the American Psychological Association, have all condemned the therapist’s actions. Psychiatrists and other mental health professionals must do no harm. We must not stand idly by and allow the kind of professional breach that happened to Kevin continue. Patients who confide in mental health professionals with the promise of confidentiality must be able to do so without fear. Only with confidentiality can the therapeutic relationship thrive.

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy, at Virginia Commonwealth University, Richmond.

An 11-year-old was caring for his toddler brother. Both were fending for themselves in a cell with dozens of other children. The little one was quiet with matted hair, a hacking cough, muddy pants, and eyes that fluttered with fatigue.

As the two brothers were reportedly interviewed, one fell asleep on two office chairs drawn together, probably the most comfortable bed he had used in weeks. They had been separated from an 18-year-old uncle and sent to the Clint Border Patrol Station in Texas. When they were interviewed in the news report, they had been there 3 weeks and counting.

Per news reports this summer, preteen migrant children have been asked to care for toddlers not related to them with no assistance from adults, and no beds, no food, and no change of clothing. Children were sleeping on concrete floors and eating the same unpalatable and unhealthy foods for close to a month: instant oatmeal, instant soup, and previously frozen burritos. Babies were roaming around in dirty diapers, fending for themselves, foraging for food. Two- and 3-year-old toddlers were sick with no adult comforting them.

When some people visited the border patrol station, they said they saw children trapped in cages like animals. Some were keening in pain while pining for their parents from whom they had been separated.

These children were forcibly separated from parents. In addition, they face living conditions that include hunger, dehydration, and lack of hygiene, to name a few. This sounds like some fantastical nightmare from a war-torn third-world country – but no these circumstances are real, and they are here in the USA.

We witness helplessly the helplessness created by a man-made disaster striking the world’s most vulnerable creature: the human child. This specter afflicting thousands of migrant children either seeking asylum or an immigrant status has far-reaching implications. This is even more ironic, given that, as a nation, we have embraced the concept of adverse childhood experiences (ACEs) and their impact on lifelong health challenges. Most of us reel with horror as these tales make their way to national headlines. But are we as a nation complicit in watching like bystanders while a generation of children is placed at risk from experiencing the long-term effects of ACEs on their physical and emotional health?

Surely if the psychological implications of ACEs do not warrant a change in course, the mere economics of the costs arising from the suffering caused by totally preventable medical problems in adulthood should be considered in policy decisions. However, that is beyond the scope of this commentary.

The human child is so utterly dependent on parents. He does not have the fairly quick physical independence from parents that we see in the animal kingdom. As soon as a child is born, a curious process of attachment begins within the mom and baby dyad, and eventually, this bond engulfs the father as well. The baby depends on the parent to understand his needs: be it when to eat, when he wants to be touched, when he needs to be left alone, when he needs to be cleaned or fed. Optimum crying serves so many purposes, and most parents are exquisitely attuned to the baby’s cry. From this relationship emerges a stable worldview, and, among many things, a stable neuroendocrine system.

Unique cultural backgrounds of individuals create the scaffolding for human variability, which in turn, confers a richness to the human race. However, development proceeds in a fairly uniform and universal fashion for children, regardless of where they come from. The progression of brain and body development moves lockstep with each other responding to a complex interplay between genetics, environment, and neurohormonal factors. It is remarkable just how resilient the human baby is in the face of the challenges that it often faces: accidental injury, illness, and even benign neglect.

However, there comes a breaking point similar to that described in the stories above, where the stress is toxic and intolerable. It is continuous, and it is relentless in its capacity to bathe the developing brain and body of the child with noxious endogenous substances that cause cell death and subsequent atrophy that is potentially irreversible.


We see such children in our clinics downstream: at ages 8, 13, or 16, after they have lost their ability to modulate emotions and are highly aggressive, or are withdrawn and depressed – or in the juvenile justice system after having repeatedly but impulsively violated the law. In other words, repeated trauma changes the wiring of the brain and neuromodulatory capacity. There is literature suggesting that traumatized children carry within them modified genes that affect their capacity to be nurturing parents. In other words, trauma has the potential to lead to multigenerational transmission of the experiences of suffering and often a psychological incapacity to parent – putting subsequent generations at risk.

So what should we do? Be bystanders, or become involved professionals?

The need to create a supportive safety net for these children is essential. Ideally, they should be reunited with their parents. The reunification of children with their parents is an absolute must if it can be done. Their parents are alive somewhere – and the best mitigators of the emotional damage already done. A strong case needs to be made for reunification, otherwise parental separation, deprivation on multiple levels, such as what these children are experiencing, will create a generation of compromised children.

A second-best option is that an emotional and physical safety net should be created that mimics a family for each child. Children need predictability and stability of caregivers with whom they can form an affective bond. This is essential for them to negotiate the cycle of inconsolable weeping, searching for their parent/s, reconciling the loss, and either reaching a level of adaptation or being engulfed in the despair that these toddlers, children, and teens continually face. In addition, these individuals/teams first and foremost should plan on giving equal consideration to the physical and emotional needs of the children.

Trained mental health professionals, particularly those who understand child development, should be central players in the planning process. The damage is done in the form of subjecting children to all that is detrimental to development. Now, steady, regular presence of shift workers who understand the importance of the continuity of relationships and who cannot only advocate for but also provide for the nutritional, sleep, and hygiene needs of the child concurrently is necessary. The children need soft and nurturing touch, predictability of routines, adequate sleep, adequate wholesome nutrition, and familiarity of faces who should make a commitment of spending no less than 6 to 9 months at a stretch in these camps.

Although the task appears herculean, drastic problems need drastic remedies, as the entire life of every child is at stake. These workers should be trained in mental health and physical health first aid, so they can recognize the gradations of despair, detachment, and acting out in children and know how to triage the children to appropriate trained mental health and medical clinicians. It is to be expected that both medical and mental health problems will be concentrated in this population, and planning for staffing such camps should anticipate that. This safety net should be created in all facilities accepting these children.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at Virginia Commonwealth University in Richmond.

An 11-year-old was caring for his toddler brother. Both were fending for themselves in a cell with dozens of other children. The little one was quiet with matted hair, a hacking cough, muddy pants, and eyes that fluttered with fatigue.

As the two brothers were reportedly interviewed, one fell asleep on two office chairs drawn together, probably the most comfortable bed he had used in weeks. They had been separated from an 18-year-old uncle and sent to the Clint Border Patrol Station in Texas. When they were interviewed in the news report, they had been there 3 weeks and counting.

Per news reports this summer, preteen migrant children have been asked to care for toddlers not related to them with no assistance from adults, and no beds, no food, and no change of clothing. Children were sleeping on concrete floors and eating the same unpalatable and unhealthy foods for close to a month: instant oatmeal, instant soup, and previously frozen burritos. Babies were roaming around in dirty diapers, fending for themselves, foraging for food. Two- and 3-year-old toddlers were sick with no adult comforting them.

When some people visited the border patrol station, they said they saw children trapped in cages like animals. Some were keening in pain while pining for their parents from whom they had been separated.

These children were forcibly separated from parents. In addition, they face living conditions that include hunger, dehydration, and lack of hygiene, to name a few. This sounds like some fantastical nightmare from a war-torn third-world country – but no these circumstances are real, and they are here in the USA.

We witness helplessly the helplessness created by a man-made disaster striking the world’s most vulnerable creature: the human child. This specter afflicting thousands of migrant children either seeking asylum or an immigrant status has far-reaching implications. This is even more ironic, given that, as a nation, we have embraced the concept of adverse childhood experiences (ACEs) and their impact on lifelong health challenges. Most of us reel with horror as these tales make their way to national headlines. But are we as a nation complicit in watching like bystanders while a generation of children is placed at risk from experiencing the long-term effects of ACEs on their physical and emotional health?

Surely if the psychological implications of ACEs do not warrant a change in course, the mere economics of the costs arising from the suffering caused by totally preventable medical problems in adulthood should be considered in policy decisions. However, that is beyond the scope of this commentary.

The human child is so utterly dependent on parents. He does not have the fairly quick physical independence from parents that we see in the animal kingdom. As soon as a child is born, a curious process of attachment begins within the mom and baby dyad, and eventually, this bond engulfs the father as well. The baby depends on the parent to understand his needs: be it when to eat, when he wants to be touched, when he needs to be left alone, when he needs to be cleaned or fed. Optimum crying serves so many purposes, and most parents are exquisitely attuned to the baby’s cry. From this relationship emerges a stable worldview, and, among many things, a stable neuroendocrine system.

Unique cultural backgrounds of individuals create the scaffolding for human variability, which in turn, confers a richness to the human race. However, development proceeds in a fairly uniform and universal fashion for children, regardless of where they come from. The progression of brain and body development moves lockstep with each other responding to a complex interplay between genetics, environment, and neurohormonal factors. It is remarkable just how resilient the human baby is in the face of the challenges that it often faces: accidental injury, illness, and even benign neglect.

However, there comes a breaking point similar to that described in the stories above, where the stress is toxic and intolerable. It is continuous, and it is relentless in its capacity to bathe the developing brain and body of the child with noxious endogenous substances that cause cell death and subsequent atrophy that is potentially irreversible.


We see such children in our clinics downstream: at ages 8, 13, or 16, after they have lost their ability to modulate emotions and are highly aggressive, or are withdrawn and depressed – or in the juvenile justice system after having repeatedly but impulsively violated the law. In other words, repeated trauma changes the wiring of the brain and neuromodulatory capacity. There is literature suggesting that traumatized children carry within them modified genes that affect their capacity to be nurturing parents. In other words, trauma has the potential to lead to multigenerational transmission of the experiences of suffering and often a psychological incapacity to parent – putting subsequent generations at risk.

So what should we do? Be bystanders, or become involved professionals?

The need to create a supportive safety net for these children is essential. Ideally, they should be reunited with their parents. The reunification of children with their parents is an absolute must if it can be done. Their parents are alive somewhere – and the best mitigators of the emotional damage already done. A strong case needs to be made for reunification, otherwise parental separation, deprivation on multiple levels, such as what these children are experiencing, will create a generation of compromised children.

A second-best option is that an emotional and physical safety net should be created that mimics a family for each child. Children need predictability and stability of caregivers with whom they can form an affective bond. This is essential for them to negotiate the cycle of inconsolable weeping, searching for their parent/s, reconciling the loss, and either reaching a level of adaptation or being engulfed in the despair that these toddlers, children, and teens continually face. In addition, these individuals/teams first and foremost should plan on giving equal consideration to the physical and emotional needs of the children.

Trained mental health professionals, particularly those who understand child development, should be central players in the planning process. The damage is done in the form of subjecting children to all that is detrimental to development. Now, steady, regular presence of shift workers who understand the importance of the continuity of relationships and who cannot only advocate for but also provide for the nutritional, sleep, and hygiene needs of the child concurrently is necessary. The children need soft and nurturing touch, predictability of routines, adequate sleep, adequate wholesome nutrition, and familiarity of faces who should make a commitment of spending no less than 6 to 9 months at a stretch in these camps.

Although the task appears herculean, drastic problems need drastic remedies, as the entire life of every child is at stake. These workers should be trained in mental health and physical health first aid, so they can recognize the gradations of despair, detachment, and acting out in children and know how to triage the children to appropriate trained mental health and medical clinicians. It is to be expected that both medical and mental health problems will be concentrated in this population, and planning for staffing such camps should anticipate that. This safety net should be created in all facilities accepting these children.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at Virginia Commonwealth University in Richmond.

An 11-year-old was caring for his toddler brother. Both were fending for themselves in a cell with dozens of other children. The little one was quiet with matted hair, a hacking cough, muddy pants, and eyes that fluttered with fatigue.

As the two brothers were reportedly interviewed, one fell asleep on two office chairs drawn together, probably the most comfortable bed he had used in weeks. They had been separated from an 18-year-old uncle and sent to the Clint Border Patrol Station in Texas. When they were interviewed in the news report, they had been there 3 weeks and counting.

Per news reports this summer, preteen migrant children have been asked to care for toddlers not related to them with no assistance from adults, and no beds, no food, and no change of clothing. Children were sleeping on concrete floors and eating the same unpalatable and unhealthy foods for close to a month: instant oatmeal, instant soup, and previously frozen burritos. Babies were roaming around in dirty diapers, fending for themselves, foraging for food. Two- and 3-year-old toddlers were sick with no adult comforting them.

When some people visited the border patrol station, they said they saw children trapped in cages like animals. Some were keening in pain while pining for their parents from whom they had been separated.

These children were forcibly separated from parents. In addition, they face living conditions that include hunger, dehydration, and lack of hygiene, to name a few. This sounds like some fantastical nightmare from a war-torn third-world country – but no these circumstances are real, and they are here in the USA.

We witness helplessly the helplessness created by a man-made disaster striking the world’s most vulnerable creature: the human child. This specter afflicting thousands of migrant children either seeking asylum or an immigrant status has far-reaching implications. This is even more ironic, given that, as a nation, we have embraced the concept of adverse childhood experiences (ACEs) and their impact on lifelong health challenges. Most of us reel with horror as these tales make their way to national headlines. But are we as a nation complicit in watching like bystanders while a generation of children is placed at risk from experiencing the long-term effects of ACEs on their physical and emotional health?

Surely if the psychological implications of ACEs do not warrant a change in course, the mere economics of the costs arising from the suffering caused by totally preventable medical problems in adulthood should be considered in policy decisions. However, that is beyond the scope of this commentary.

The human child is so utterly dependent on parents. He does not have the fairly quick physical independence from parents that we see in the animal kingdom. As soon as a child is born, a curious process of attachment begins within the mom and baby dyad, and eventually, this bond engulfs the father as well. The baby depends on the parent to understand his needs: be it when to eat, when he wants to be touched, when he needs to be left alone, when he needs to be cleaned or fed. Optimum crying serves so many purposes, and most parents are exquisitely attuned to the baby’s cry. From this relationship emerges a stable worldview, and, among many things, a stable neuroendocrine system.

Unique cultural backgrounds of individuals create the scaffolding for human variability, which in turn, confers a richness to the human race. However, development proceeds in a fairly uniform and universal fashion for children, regardless of where they come from. The progression of brain and body development moves lockstep with each other responding to a complex interplay between genetics, environment, and neurohormonal factors. It is remarkable just how resilient the human baby is in the face of the challenges that it often faces: accidental injury, illness, and even benign neglect.

However, there comes a breaking point similar to that described in the stories above, where the stress is toxic and intolerable. It is continuous, and it is relentless in its capacity to bathe the developing brain and body of the child with noxious endogenous substances that cause cell death and subsequent atrophy that is potentially irreversible.


We see such children in our clinics downstream: at ages 8, 13, or 16, after they have lost their ability to modulate emotions and are highly aggressive, or are withdrawn and depressed – or in the juvenile justice system after having repeatedly but impulsively violated the law. In other words, repeated trauma changes the wiring of the brain and neuromodulatory capacity. There is literature suggesting that traumatized children carry within them modified genes that affect their capacity to be nurturing parents. In other words, trauma has the potential to lead to multigenerational transmission of the experiences of suffering and often a psychological incapacity to parent – putting subsequent generations at risk.

So what should we do? Be bystanders, or become involved professionals?

The need to create a supportive safety net for these children is essential. Ideally, they should be reunited with their parents. The reunification of children with their parents is an absolute must if it can be done. Their parents are alive somewhere – and the best mitigators of the emotional damage already done. A strong case needs to be made for reunification, otherwise parental separation, deprivation on multiple levels, such as what these children are experiencing, will create a generation of compromised children.

A second-best option is that an emotional and physical safety net should be created that mimics a family for each child. Children need predictability and stability of caregivers with whom they can form an affective bond. This is essential for them to negotiate the cycle of inconsolable weeping, searching for their parent/s, reconciling the loss, and either reaching a level of adaptation or being engulfed in the despair that these toddlers, children, and teens continually face. In addition, these individuals/teams first and foremost should plan on giving equal consideration to the physical and emotional needs of the children.

Trained mental health professionals, particularly those who understand child development, should be central players in the planning process. The damage is done in the form of subjecting children to all that is detrimental to development. Now, steady, regular presence of shift workers who understand the importance of the continuity of relationships and who cannot only advocate for but also provide for the nutritional, sleep, and hygiene needs of the child concurrently is necessary. The children need soft and nurturing touch, predictability of routines, adequate sleep, adequate wholesome nutrition, and familiarity of faces who should make a commitment of spending no less than 6 to 9 months at a stretch in these camps.

Although the task appears herculean, drastic problems need drastic remedies, as the entire life of every child is at stake. These workers should be trained in mental health and physical health first aid, so they can recognize the gradations of despair, detachment, and acting out in children and know how to triage the children to appropriate trained mental health and medical clinicians. It is to be expected that both medical and mental health problems will be concentrated in this population, and planning for staffing such camps should anticipate that. This safety net should be created in all facilities accepting these children.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at Virginia Commonwealth University in Richmond.

The recent crises of the separation of stressed children from their equally stressed parents at this country’s southern border raises the specter of emotional and cognitive reactions within these children – the negative ramifications of which will manifest themselves for years to come.

Stress is ubiquitous. Children experience stress in the normal everyday frustrations that come their way: going to day care for a few hours and leaving mommy, the tripping and falling as they learn to walk, a toy breaking. These stresses help a child develop the capacity for emotional regulation and are termed “tolerable stress.” There is, however, a big difference between tolerable stress and toxic stress.

When the stress reaction in response to perceived or actual danger is beyond tolerable levels by virtue of its quality, intensity, and longevity, it saps the body’s ability to rally or handle the trauma that is being faced because of depleted neurotransmitters that normally assist the body to fight or flee from danger. Unfortunately, that’s not the end of the story: As the stressor persists, it has the capacity to produce long-term alterations in the resilience of the brain and body of the young child. This change often is irreversible.

Scientists and the lay public have begun to actively discuss the impact of adverse childhood experiences and their causal link to irreversible negative adult health outcomes. We now know without a doubt the impact of toxic versus tolerable stress on the hypothalamic-pituitary-adrenal axis of the young child. We are aware that the brain of a young child is particularly vulnerable to stress during critical and sensitive periods of development and that downstream effects of early trauma show up as disorganized behavior and cognitive underperformance.

Development plays a central role in children’s behavioral response to separation from parents. Infants develop a sense of stranger anxiety and the primacy of one central figure between ages 8 and 10 months. The baby chooses the parent over strangers for comfort and care. Roughly between ages 3 and 4, a child develops an internal representation of the parent as the primary figure in their lives so that they can tolerate short periods of being away from the primary caregiver for, let’s say, half a day. They depend on the parent for all their physical and emotional needs, which includes the need for a stable, nurturing, and predictable presence.

Familiarity of the environment, family rituals, consistency of daily routines provided by the parent help neural pathways responsible for the biologic unfolding of developmental milestones. Only recently, the science of early brain development and the role of early childhood trauma on brain biology has caught up with the longitudinal observational studies of bereaved children who lost their parents under circumstances of acute stress (the blitzkrieg, the Yom Kippur War, the Hungarian orphans) followed by the chronic stress phase of no primary caregiver for months to years. These observational studies coupled by the emerging neuroscience of early brain development and trauma are powerful informants of what is tolerable stress for children and what is not.

As a psychiatrist and expert in early child development, I am concerned about these long-term effects on migrant children. Research shows that young children who are nonverbal react to the stress of separation by death or absence of parents with anxiety; frantically seeking the parent/comforting familiar caregiver. Gradually as that possibility fades, with their limited ability to verbalize needs, episodic weeping can give way to disorganized behavior, despondence, and finally apathy and regression of milestones and cognitive abilities already achieved. The separation is merely the proxy face of other disasters that are probably co-occurring for the child/family and multiplies the dose of the stress: loss of siblings, loss of familiar physical elements of the landscape, loss of adequate physical sustenance, loss of routine, loss of consistency, increased vulnerability for physical illness, and the list goes on.

By age 2 and above, children are more vocal in their desire for reunification and will weep inconsolably upon separation. At this time their bodies and the psychological lens through which they view the world is changing irrevocably. Stress hormones, noxious at high levels such as cortisol/adrenocorticotropic hormone and glutamate rise to levels that no longer respond to the traditional negative feedback loop of the body and reach levels that lead to cell death in areas of the brain responsible for modulating emotions that can permanently change brain architecture.

Psychologically, the child seeks out the parent by any means (crying, flailing, tantruming). When no positive outcome occurs, this is replaced by an unwillingness to engage with the world, or the child engages but by behavior that is aggressive, disorganized, and regressed. In their own way, young children’s mistrust of the world leads to a variety of behaviors that impede normal development: rejection of others, disengagement from social connections by quietly sitting in a corner, being unwilling to eat or sleeping fitfully.

As separation from the primary caregiver continues, there is a deepening sense of hopelessness. Generally, no amount of physical props (toys, playgrounds) without the human familiar faces can rectify the feeling of abandonment and hopelessness that children in these conditions face. Assuming they are no strangers to trauma experienced through the lives of their asylum-seeking parents, this separation refreshes all the wounds of days gone by. At least in those moments of initial trauma, they had the parent as a buffer. But with this new separation, they are left to emotionally fend for themselves with no tools to manage their emotions.

We have to deal with the aftereffects of so many natural disasters that cannot be avoided: earthquakes, tornadoes, tsunamis that displace children and families with horrific outcomes. Did we really need a man-made disaster that will irrevocably change the brains and behaviors of a generation of children who just happen to be on our southern borders because of an accident of birth? If parents abandoned their children this way it would be called child abuse. Deliberate policy decisions that have such dire effects on children also take on the label of child abuse.

Although images of my years as a young parent of three boys are turning a sepia color in faded memory, in my new role as a grandmother observing my son and his wife so in love with their 2-year-old reinforces how much mutual dependency of a child and parent on each other strengthens the very fabric of life. Children are our future and are the building blocks of a just and humane society.

As of this writing, the administration has vowed to end these separations. But how will children who have been separated be reunited with their families?

The education of decision makers about the far-reaching emotional and physical consequences on normative childhood development must be a top priority for all scientists and professionals interested in kids and families: I think that means all of us.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at the Virginia Treatment Center at Virginia Commonwealth University, Richmond. She also is affiliated with the department of psychiatry at VCU and Children’s Hospital of Richmond.

The recent crises of the separation of stressed children from their equally stressed parents at this country’s southern border raises the specter of emotional and cognitive reactions within these children – the negative ramifications of which will manifest themselves for years to come.

Stress is ubiquitous. Children experience stress in the normal everyday frustrations that come their way: going to day care for a few hours and leaving mommy, the tripping and falling as they learn to walk, a toy breaking. These stresses help a child develop the capacity for emotional regulation and are termed “tolerable stress.” There is, however, a big difference between tolerable stress and toxic stress.

When the stress reaction in response to perceived or actual danger is beyond tolerable levels by virtue of its quality, intensity, and longevity, it saps the body’s ability to rally or handle the trauma that is being faced because of depleted neurotransmitters that normally assist the body to fight or flee from danger. Unfortunately, that’s not the end of the story: As the stressor persists, it has the capacity to produce long-term alterations in the resilience of the brain and body of the young child. This change often is irreversible.

Scientists and the lay public have begun to actively discuss the impact of adverse childhood experiences and their causal link to irreversible negative adult health outcomes. We now know without a doubt the impact of toxic versus tolerable stress on the hypothalamic-pituitary-adrenal axis of the young child. We are aware that the brain of a young child is particularly vulnerable to stress during critical and sensitive periods of development and that downstream effects of early trauma show up as disorganized behavior and cognitive underperformance.

Development plays a central role in children’s behavioral response to separation from parents. Infants develop a sense of stranger anxiety and the primacy of one central figure between ages 8 and 10 months. The baby chooses the parent over strangers for comfort and care. Roughly between ages 3 and 4, a child develops an internal representation of the parent as the primary figure in their lives so that they can tolerate short periods of being away from the primary caregiver for, let’s say, half a day. They depend on the parent for all their physical and emotional needs, which includes the need for a stable, nurturing, and predictable presence.

Familiarity of the environment, family rituals, consistency of daily routines provided by the parent help neural pathways responsible for the biologic unfolding of developmental milestones. Only recently, the science of early brain development and the role of early childhood trauma on brain biology has caught up with the longitudinal observational studies of bereaved children who lost their parents under circumstances of acute stress (the blitzkrieg, the Yom Kippur War, the Hungarian orphans) followed by the chronic stress phase of no primary caregiver for months to years. These observational studies coupled by the emerging neuroscience of early brain development and trauma are powerful informants of what is tolerable stress for children and what is not.

As a psychiatrist and expert in early child development, I am concerned about these long-term effects on migrant children. Research shows that young children who are nonverbal react to the stress of separation by death or absence of parents with anxiety; frantically seeking the parent/comforting familiar caregiver. Gradually as that possibility fades, with their limited ability to verbalize needs, episodic weeping can give way to disorganized behavior, despondence, and finally apathy and regression of milestones and cognitive abilities already achieved. The separation is merely the proxy face of other disasters that are probably co-occurring for the child/family and multiplies the dose of the stress: loss of siblings, loss of familiar physical elements of the landscape, loss of adequate physical sustenance, loss of routine, loss of consistency, increased vulnerability for physical illness, and the list goes on.

By age 2 and above, children are more vocal in their desire for reunification and will weep inconsolably upon separation. At this time their bodies and the psychological lens through which they view the world is changing irrevocably. Stress hormones, noxious at high levels such as cortisol/adrenocorticotropic hormone and glutamate rise to levels that no longer respond to the traditional negative feedback loop of the body and reach levels that lead to cell death in areas of the brain responsible for modulating emotions that can permanently change brain architecture.

Psychologically, the child seeks out the parent by any means (crying, flailing, tantruming). When no positive outcome occurs, this is replaced by an unwillingness to engage with the world, or the child engages but by behavior that is aggressive, disorganized, and regressed. In their own way, young children’s mistrust of the world leads to a variety of behaviors that impede normal development: rejection of others, disengagement from social connections by quietly sitting in a corner, being unwilling to eat or sleeping fitfully.

As separation from the primary caregiver continues, there is a deepening sense of hopelessness. Generally, no amount of physical props (toys, playgrounds) without the human familiar faces can rectify the feeling of abandonment and hopelessness that children in these conditions face. Assuming they are no strangers to trauma experienced through the lives of their asylum-seeking parents, this separation refreshes all the wounds of days gone by. At least in those moments of initial trauma, they had the parent as a buffer. But with this new separation, they are left to emotionally fend for themselves with no tools to manage their emotions.

We have to deal with the aftereffects of so many natural disasters that cannot be avoided: earthquakes, tornadoes, tsunamis that displace children and families with horrific outcomes. Did we really need a man-made disaster that will irrevocably change the brains and behaviors of a generation of children who just happen to be on our southern borders because of an accident of birth? If parents abandoned their children this way it would be called child abuse. Deliberate policy decisions that have such dire effects on children also take on the label of child abuse.

Although images of my years as a young parent of three boys are turning a sepia color in faded memory, in my new role as a grandmother observing my son and his wife so in love with their 2-year-old reinforces how much mutual dependency of a child and parent on each other strengthens the very fabric of life. Children are our future and are the building blocks of a just and humane society.

As of this writing, the administration has vowed to end these separations. But how will children who have been separated be reunited with their families?

The education of decision makers about the far-reaching emotional and physical consequences on normative childhood development must be a top priority for all scientists and professionals interested in kids and families: I think that means all of us.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at the Virginia Treatment Center at Virginia Commonwealth University, Richmond. She also is affiliated with the department of psychiatry at VCU and Children’s Hospital of Richmond.

The recent crises of the separation of stressed children from their equally stressed parents at this country’s southern border raises the specter of emotional and cognitive reactions within these children – the negative ramifications of which will manifest themselves for years to come.

Stress is ubiquitous. Children experience stress in the normal everyday frustrations that come their way: going to day care for a few hours and leaving mommy, the tripping and falling as they learn to walk, a toy breaking. These stresses help a child develop the capacity for emotional regulation and are termed “tolerable stress.” There is, however, a big difference between tolerable stress and toxic stress.

When the stress reaction in response to perceived or actual danger is beyond tolerable levels by virtue of its quality, intensity, and longevity, it saps the body’s ability to rally or handle the trauma that is being faced because of depleted neurotransmitters that normally assist the body to fight or flee from danger. Unfortunately, that’s not the end of the story: As the stressor persists, it has the capacity to produce long-term alterations in the resilience of the brain and body of the young child. This change often is irreversible.

Scientists and the lay public have begun to actively discuss the impact of adverse childhood experiences and their causal link to irreversible negative adult health outcomes. We now know without a doubt the impact of toxic versus tolerable stress on the hypothalamic-pituitary-adrenal axis of the young child. We are aware that the brain of a young child is particularly vulnerable to stress during critical and sensitive periods of development and that downstream effects of early trauma show up as disorganized behavior and cognitive underperformance.

Development plays a central role in children’s behavioral response to separation from parents. Infants develop a sense of stranger anxiety and the primacy of one central figure between ages 8 and 10 months. The baby chooses the parent over strangers for comfort and care. Roughly between ages 3 and 4, a child develops an internal representation of the parent as the primary figure in their lives so that they can tolerate short periods of being away from the primary caregiver for, let’s say, half a day. They depend on the parent for all their physical and emotional needs, which includes the need for a stable, nurturing, and predictable presence.

Familiarity of the environment, family rituals, consistency of daily routines provided by the parent help neural pathways responsible for the biologic unfolding of developmental milestones. Only recently, the science of early brain development and the role of early childhood trauma on brain biology has caught up with the longitudinal observational studies of bereaved children who lost their parents under circumstances of acute stress (the blitzkrieg, the Yom Kippur War, the Hungarian orphans) followed by the chronic stress phase of no primary caregiver for months to years. These observational studies coupled by the emerging neuroscience of early brain development and trauma are powerful informants of what is tolerable stress for children and what is not.

As a psychiatrist and expert in early child development, I am concerned about these long-term effects on migrant children. Research shows that young children who are nonverbal react to the stress of separation by death or absence of parents with anxiety; frantically seeking the parent/comforting familiar caregiver. Gradually as that possibility fades, with their limited ability to verbalize needs, episodic weeping can give way to disorganized behavior, despondence, and finally apathy and regression of milestones and cognitive abilities already achieved. The separation is merely the proxy face of other disasters that are probably co-occurring for the child/family and multiplies the dose of the stress: loss of siblings, loss of familiar physical elements of the landscape, loss of adequate physical sustenance, loss of routine, loss of consistency, increased vulnerability for physical illness, and the list goes on.

By age 2 and above, children are more vocal in their desire for reunification and will weep inconsolably upon separation. At this time their bodies and the psychological lens through which they view the world is changing irrevocably. Stress hormones, noxious at high levels such as cortisol/adrenocorticotropic hormone and glutamate rise to levels that no longer respond to the traditional negative feedback loop of the body and reach levels that lead to cell death in areas of the brain responsible for modulating emotions that can permanently change brain architecture.

Psychologically, the child seeks out the parent by any means (crying, flailing, tantruming). When no positive outcome occurs, this is replaced by an unwillingness to engage with the world, or the child engages but by behavior that is aggressive, disorganized, and regressed. In their own way, young children’s mistrust of the world leads to a variety of behaviors that impede normal development: rejection of others, disengagement from social connections by quietly sitting in a corner, being unwilling to eat or sleeping fitfully.

As separation from the primary caregiver continues, there is a deepening sense of hopelessness. Generally, no amount of physical props (toys, playgrounds) without the human familiar faces can rectify the feeling of abandonment and hopelessness that children in these conditions face. Assuming they are no strangers to trauma experienced through the lives of their asylum-seeking parents, this separation refreshes all the wounds of days gone by. At least in those moments of initial trauma, they had the parent as a buffer. But with this new separation, they are left to emotionally fend for themselves with no tools to manage their emotions.

We have to deal with the aftereffects of so many natural disasters that cannot be avoided: earthquakes, tornadoes, tsunamis that displace children and families with horrific outcomes. Did we really need a man-made disaster that will irrevocably change the brains and behaviors of a generation of children who just happen to be on our southern borders because of an accident of birth? If parents abandoned their children this way it would be called child abuse. Deliberate policy decisions that have such dire effects on children also take on the label of child abuse.

Although images of my years as a young parent of three boys are turning a sepia color in faded memory, in my new role as a grandmother observing my son and his wife so in love with their 2-year-old reinforces how much mutual dependency of a child and parent on each other strengthens the very fabric of life. Children are our future and are the building blocks of a just and humane society.

As of this writing, the administration has vowed to end these separations. But how will children who have been separated be reunited with their families?

The education of decision makers about the far-reaching emotional and physical consequences on normative childhood development must be a top priority for all scientists and professionals interested in kids and families: I think that means all of us.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at the Virginia Treatment Center at Virginia Commonwealth University, Richmond. She also is affiliated with the department of psychiatry at VCU and Children’s Hospital of Richmond.