Caring for Immigrant Katie Berndtson, PGY3

With much appreciated help

Children and Families from

Reiko Sakai and Emily Navar
 Case Presentation
4 year old female with potty training regression
 • Change in the child-care
routine—for example, a new
sitter, or starting a child-care or
preschool program
Causes of • The mother’s pregnancy or the
birth of a new sibling
regression • A major illness on the part of
the child or a family member
*AAP Healthychildren.org
• A recent death
• Marital conflict or parents’
divorce
• An upcoming or recent move to
a new house
 Patient’s father had recently been taken into
immigration custody, detained at a facility out of state.

Mom was undocumented and could not take them to

visit him without risking also being detained.

Mom struggling to care and provide for 5 children by

herself

Cause of regression in our patient

 Managing Regression
Identify the problem

•Let your child know that you’ve noticed her change in behavior—that she has stopped using her potty, has been having a lot of
accidents at the child-care center, or has been talking about wearing diapers again.
•Ask her why this might be—because her potty is in a new bathroom in your new house now, because the toilet at the child-care
center is scary, etc.?
•Listen to her response, and help her try to communicate the actual events that are upsetting her as well as her feelings about
them.

Sympathize

•Tell your child you know how hard it’s been for her to stay on track with so much happening.
•Let her know that lots of children in her situation have this experience. If it’s appropriate to the subject and her level of
comprehension, you may even want to tell her about a time when you yourself regressed in some way.
•Make it clear that it’s normal to feel scared in this situation, but that these feelings will soon go away.

Do what you can to fix the problem

•If there are practical steps you can take to ease your child’s distress, do so as soon as possible.

Be clear about your expectations

•Explain to your child calmly but clearly that you expect her to continue her toilet-training efforts
•Let her know that you are fully confident that she will get over this hurdle.
•Support her with positive reinforcements
 Some recent history
United States vs. Texas
• TX and 26 other states sue the US govt over DACA

• June 2016: 4-4 split decision blocked President Obama's

2014 DACA expansions and Deferred Action for Parents of
Americans and Lawful Permanent Residents (DAPA)​​
program.

• What was the DACA expansion?

– Deferred deportations for people who entered the
United States as children before January 1, 2010
(current cutoff is June 15, 2007)

• What was DAPA?

– Deferred deportation for the undocumented parents
of U.S. citizens or legal permanent residents who
have been in the U.S. for at least five years.
• As physicians, we know that
traumatic experiences like the
loss of a loving caregiver can
inflict toxic stress on a child,
hindering healthy development
and leading to changes in
physiology that promote physical
and mental illness throughout the
life course. Such trauma can even
become epigenetically encoded,
thereby passing to future
generations.
• As citizens, we have an obligation
to advocate against the
devastating harm being inflicted
in our names. If we permit such
brutal treatment of already
traumatized children to continue,
the stain will be on all our hands.
 Healthcare
• Barriers
• Challenges
• Questions

Have you worked

with immigrant families
in clinic?
 • Avoid collecting immigration status information. Avoid asking for
patients’ immigration status and, if you must collect such
information for a patient, avoid including that information in the
patient’s medical and billing records.
• Reassure your patients. Educate and reassure patients that their
health care information is protected by federal and state laws.
• Please take time to ask immigrant/non-English speaking families
about stressors, needs, and challenges
• You have no affirmative legal obligation to inquire into or report to
federal immigration authorities about your patient’s immigration
Talking about •
status.
You may refuse to provide information about patients to law
enforcement officials unless the request for information is pursuant
Immigration to a warrant or other court order for a specifically identified
individual.
Status
 21% of the SLC population age 5 years
and older speaks a language other
than English at home
18.5% of the overall SLC population is
Hispanic/Latino, which is the largest
ethnic group in the county.
24.1% of children in SLC are
Utah Statistics Hispanic/Latino (> 80,000 children)

In 2017, there were 55,516 US citizen

children in Utah living with at least
one unauthorized immigrant parent
~55% of Utah’s non-citizen population
lives in SLC  ~ 30,534 live in SLC.

*SLC Health Department and American Immigration Council

 Utah Statistics
Hispanic Children in SLC White Children in SLC
• 29.1% live below the federal • 7.9% live below the federal
poverty level. poverty level.
• 83.9% of SLC have health • 94.7% of SLC have health
insurance insurance
• Geographic segregation
highest population in:
• West Valley City
• South Salt Lake
• Kearns
• Taylorsville
 Barriers for Immigrant Families
• Immigrant populations, especially those
without immigration authorization, face:
– fear of deportation
– health insurance status
– financial resources
– transportation
– limited English skills
– Bureaucracy
Hacker K, Anies M, Folb BL, Zallman L. Barriers to health care for undocumented immigrants: a literature review.
Risk Management and Healthcare Policy. 2015;8:175-183. doi:10.2147/RMHP.S70173. PMID: 26586971
 Twenty-five states provide health
care for immigrant children
lawfully residing in the in the
United States through Medicaid
and the Children’s Health
Insurance Program.
Six other states and Washington,
D.C. provide Medicaid health
benefits to all immigrant children
regardless of immigration status

*Source: The Center for Law and Social Policy, 2017.

Health Coverage for

Child Immigrants
• 72% of families served self-identify as having Hispanic ethnicity
• 51% identify Spanish as their primary language
• 77% patients have Medicaid as their primary insurance.

SOUTH MAIN CLINIC

Resources for families
 Mental Health
Resources for Families
• The Children’s Center: community mental health
center for children.
• Aspen Ridge Counseling Center: community
mental health center for children and adults.
• Valley Behavioral Health: nonprofit network of
mental health clinics for children and adults.
• Polizzi Clinic: nonprofit organization offering
outpatient psychiatric care for low-income or
uninsured children and adults.
• Medical homes or clinics with built-in mental
health services (e.g. the South Main Clinic)
 Legal resources
Community (bilingual) legal clinics by the
University of Utah law school
• How to establish guardianship
for medically complex children
• How to legally nominate a
successor guardian in the case
of family separation - Mexican
Consulate
Safe spaces
• Juvenile Receiving Center
• YWCA Utah
• Salt Lake Area Family Justice
Center Crisis hotline
• United Way 211
• South Valley Services domestic
shelter

Resiliency resources
helping kids cope with toxic stress
• Recreation centers
Resources for Families • Boys and Girls Club
 Resources for Families

Vaccines
Utah Health Department offers
immunizations through the federal
Vaccines for Children (VFC) program at a
cost of $10-15 per vaccine for eligible
patients, which includes the uninsured.

More buttons coming soon from Reiko and Luke’s CATCH grant!
They are making an online toolkit with all of these resources
Community Health Centers, Inc.: a non-profit network of federally qualified health centers
offering discounted medical/dental care for those uninsured patients with incomes below 200
percent of the federal poverty line (CHC)

Catholic Community Services of Utah: a faith-based charity organization serving the needs of
and promoting self-sufficiency among vulnerable communities. Their immigration program
provides full legal representation as well as individual consultations to immigrants and
refugees in their immigration cases.
Medical Home Portal: a regional online resource for families of children with special health
care needs, offered in both Spanish and English, with the goal of connecting these families to
community resources

Resources for Families

Medical Home
Glendale-Mountain View Community Learning Center: a local
organization integrating early childhood education, a medical and dental
clinic, and adult education and wellness.
Head Start: early childhood education program for low-income children
and families

Alliance Community Services: a local non-profit dedicated to promoting

the well-being of culturally diverse and underserved communities

Help Me Grow: A United Way program dedicated to child wellbeing and

consisting primarily of an information and referral helpline available at no
cost

Resources for Families

Insurance Options
LETTERS OF SUPPORT

Purpose—Content—Risk—Legality
Letters of Support

What should I do if a family asks me

to write a letter of support to
prevent deportation?
Letters of Support

CLARIFY PURPOSE

– May be asked to attest that the parent(s) appear

to be providing good care for a child and/or that
the child seems to emotionally and physically well.
– May be requested to attest that the child has
medical and/or psychological conditions for which
he/she is currently being treated, and it is the
pediatrician's professional opinion that it is not in
the child's best interest to disrupt this care or
send him/her to a location where adequate care
may not be available.
Letters of Support

CONTENT & RISK

If a pediatrician chooses or is required to attest to the
state of the child's physical health, psychological health,
and/or the need for treatment, he/she should:
– reference medical notes when appropriate
– clearly identify as opinion any opinions offered,
– release or disclose HIPAA-protected information only after
obtaining proper consent or authorization
– restrict his/her comments to fact with which he or she is
personally familiar; care should be taken not to include
false statements or to mislead officials.

The pediatrician may incur significant liability risks if the

statements are knowingly false or markedly exaggerated
Letters of Support

LEGALITY
• Support letters must be individualized and
tailored to address any legitimate hardship
that a child would face if the child’s parent is
detained or deported.
• If the child’s parent(s) is working with an
immigration attorney, the pediatrician should
contact the attorney to address what to
include in the letter.
Letters of Support

SUMMARY
1. Write the letter specifically for your patient. Honestly address your
patient’s issues and situation without exaggeration or falsehood.
2. Describe physician's education, training, expertise, years in practice.
3. Provide an objective and individualized description of the child’s
medical diagnosis, treatment, and prognosis. The letter must be
factual, unbiased and authoritative.
4. Discuss the instrumental role the parent plays in seeking, supporting
treatment, e.g. taking child to treatment, administering meds, etc.
5. Discuss how the child will be harmed physically, emotionally, and
psychologically if the parent is detained or deported.
6. Provide examples of the health consequences the child would face
without their parent participating in their health care. If possible,
discuss how the child would not get the care they need elsewhere
7. Always provide facts and rationale for your medical opinion.
8. Provide supporting medical documents or reports.
IMMIGRATION ENFORCEMENT

What to do when you encounter…

Immigration Enforcement

Can immigration enforcement

request information about my
patient families?
What do I do if this happens?
Immigration Enforcement

What do I do if this happens?

• The pediatrician must forward the request to
your health care facility’s legal department.
• The request for documents may be impacted by
the following laws:
– U.S. Constitution, Fourth Amendment
– Health Insurance Portability and Accountability Act of
1996 (HIPAA)
– Uniting and Strengthening America by Providing
Appropriate Tools Required to Intercept and Obstruct
Terrorism Act of 2001 (USA PATRIOT Act)
– Individual State Privacy Laws
– Legal Process such as court-ordered or administrative
warrants, subpoenas, or summons.
Immigration Enforcement

What do I do if this happens?

• Because there may be legal obligations on the
health care provider if the request is a valid
court order, a physician should never simply
ignore a request.
• Pediatricians should document any
experiences of intimidation or involvement
with immigration enforcement officials. This
information should be shared with the health
care facility’s legal department
 Resources for Pediatricians
AAP Protecting • https://www.aap.org/en-us/advocacy-and-policy/federal-
Immigrant Children advocacy/Pages/ImmigrationReform.aspx

AAP Immigrant Child • https://www.aap.org/en-us/advocacy-and-policy/aap-health-

initiatives/Immigrant-Child-Health-Toolkit/Pages/Immigrant-
Health Toolkit Child-Health-Toolkit.aspx

• https://www.aap.org/en-us/advocacy-and-policy/aap-health-
AAP State Legal Resources initiatives/Immigrant-Child-Health-Toolkit/Pages/State-Legal-
Resources-for-Immigrant-Children-and-Families.aspx

Office of
Refugee Resettlement, • https://www.acf.hhs.gov/orr/programs/ucs/about
Unaccompanied Children
 Acknowledgements

Thank you to Reiko Sakai, Luke Dwyer, and

Emily Navar for their support and
contributions to this morning report!
Thank you
Our immigrant families need us to know them,
support them, and advocate for them!