As the seasons change, by far one of the topics commanding our national discourse this summer was the separation of immigrant children from their parents in the setting of a “zero tolerance policy.” While this policy has since been discontinued, in favor of reunification, nearly five hundred children remain in government custody. For children who have been reunited with their parents, though, the damage may have already been done. Let’s discuss some of the key consequences associated with parental-child separation in detail, starting with the notion of toxic stress.

What is toxic stress?

When I was eight years old, my sister, my childhood best friend and I got lost in the mall. Immediately, I felt my heart pounding out of my chest, I was filled with terror — my parents had always told us to stay in eyeshot of our friends’ parents, yet this time we had wandered a little too far. Would we be doomed to roam the mall in perpetuity, with only a few dollars in change between the three of us? While the whole ordeal lasted no more than five minutes before we found my friend’s older brother, it felt like an eternity. I had already planned out how to ration our limited change to get dinner! But imagine feeling perpetually on edge, your heart pounding out of your chest, palms sweaty, feeling an overwhelming sense of fear even in situations some would call routine.

I give this example to highlight the difference between something extremely transient, like walking a little too far away from a chaperone and being alone for a few minutes, to being forcibly removed from the care of one’s care providers. While the difference in induced stress seems obvious, there are several key pathways responsible for this, largely through toxic stress.

Toxic stress refers a chronic state of activation of the body’s biologic mechanisms to adapt to and address physiologic stressors. What makes this stress toxic is the lack of support, be it of peers, of family, or of society to mitigate the physiologic stress. Over time, this leads to wear and tear that can lead to irreparable health consequences across a variety of organ systems. Further, these consequences can be imparted in childhood, and even in utero through epigenetic modification.

What are the key risk factors for toxic stress?

Toxic stress stems from any situation that can lead to chronic states of physiological stress. This includes neglect, abuse, violence, poverty, family stressors (such as separation, violence, parental health, mental health, and substance use disorders). These risk factors are potentiated by anything that reduces or eliminates supportive relationships. Supportive relationships can be mechanisms through which one learns coping skills.

How exactly does parent-child separation lead to toxic stress?

First, it helps to review parent-child separation as a source of toxic stress. How does this work? Children are forcibly removed from their parents, or the adults with whom they were traveling, and left in the care of unfamiliar adults. This is understandably upsetting and traumatic for children, particularly for those who have not been socialized with many people outside of their own family. The early years of childhood are critical for neurodevelopment. Specifically, early childhood exposures lead to the activation (or even over-activation) of the hypothalamic-pituitary-adrenal axis. The hypothalamic-pituitary-adrenal (HPA) axis is intimately associated with the limbic system, the brain’s natural responder to stressful stimuli. The HPA axis responds to stress by stimulating the release of corticosteroids, such as cortisol. As you may remember, these signals come from physical alterations, such as those in the cardiovascular and respiratory systems.

So let’s circle back to the parent-child separation. The initial moment of being separated from a familiar adult leads to physiologic stress — increased heart rate, perhaps increased respiratory rate. This triggers the cascade of the HPA axis, releasing more corticosteroids to help adapt to the new environmental stressor, being isolated from one’s family. Now, if this stress is immediately reversed, it seems to reason that minimal damage is done by the activation of the HPA axis; however, prolonged, or even chronic activation, due to repeated or continued stressful situations, can culminate in the alteration of specific genes in the HPA axis. In fact, some of the processes that result lead to oxidative stress, which, if you remember the basic science part of medical school, can culminate in cell damage. While the mechanism here is not yet clear, it is important to know that the brain’s tissue is particularly sensitive to oxidative stress, and many chronic diseases are associated with such damage.

Further, corticosteroid release is associated with immune consequences, such as cytokine signaling. Messages from cytokine are a part of many dimensions of immunity, but also with growth and development of organ systems. Coupled with individual factors including genetics, existing coping skills, and development, these yield effects on various aspects of physical and mental health, including cognition itself, the function of the immune system in general, and behavioral and executive functioning. Remembering that our case study is referring to children, particularly young children, coping skills and development may be limited, even more so by the extenuating stress of traveling to another country. Just as neuroplasticity allows the brain to adapt to and thrive in positive situations, negative stimuli, such as chronic stress, can alter the overall neuronal functioning. An example of this is through caring relationships with a parental figure. This has been seen to allow children to develop a modest HPA response to stress — that is, they will still mount a corticosteroid response, but it will not be disproportionate. In children who do not have the experience of supportive parenting at a young age, there are more drastic HPA responses in the face of even minor physiologic stress.

And on the most basic nature, it is the involuntary nature of this separation that also confers so much stress. When parents are given the agency of choice, they are better able to plan for and address stress with their children, to provide better opportunities for coping, to continue to have established care routines continue, and to assist in keeping familiar figures around to orient the child.

What, if any, are the health sequelae of this toxic stress?

The separation of parent(s) and child(ren) has been well studied and documented through the years. Studies as early as the 1950s detail “impairment of the ability to make relationships.” A study of children whose parents migrate for work in China are higher rates of anxiety and depression. This effect is even more noticeable among children whose parents migrated at earlier ages. Some psychosocial implications include increased aggression and negativity viewed in children who are separated from their mothers at a young age. In addition to anxiety and depression, children who have been separated from their parents have also been observed to have higher rates of bipolar disorder and schizophrenia. Understandably, toxic stress, such as separation, increases the risk of PTSD, a state characterized by chronic hyperactivation. There are also reported effects on academic achievement, including in math and reading. The link between education and health is well described throughout public health literature.

From a biologic perspective, emerging research suggests that cytokines, released in immune and physiologic stress, can play a role in depressive behavior exhibited by children who have endured toxic stress. Children who have endured chronic toxic stress, especially due to maltreatment, are likely to have elevated levels of CRP, which is associated with proinflammatory states, as you may remember from your Step 1 studying.

But what is most concerning from a biologic perspective is the fact that elements of neurobiologic adaptation through the HPA axis is set into motion during pregnancy, with excessive maternal cytokines potentially inhibiting appropriate fetal development. Likewise, pregnancy confers the opportunity for antibodies to be passed through the placenta. In times of stress, this process is not often completed efficiently, and the offspring subsequently is not as readily able to cope with initial brushes with infection, or to fend off dormant infections. In animal models, this manifests as decreased ability to resist infection. This a further area of concern is the impact of such traumatic separations on pregnant individuals, and of future births to individuals who have experienced this separation policy. In addition, previous studies of children in Romanian orphanages revealed that children who lived in orphanages, as opposed to in traditional family arrangements, experienced diminished development in tracts of white matter associated with emotion, attention, executive function, sensory processing and general cognitive performance. What is interesting about this particular work is that it also revealed that children who were placed into foster care or with families before the age of two were able to reverse some of the white matter damage. This suggest a role for resilience, especially among the youngest of children.

Social determinants of toxic stress also play a role. Children who are separated from their parents are much more likely to be impoverished. This would suggest a higher likelihood of encountering allergens such as roaches, dust mites, secondhand smoke, mice, and more. Some research suggests that this can lead to sensitization for lung disease, including asthma, even starting in the prenatal period. The generally accepted conclusion is that the most critical period for such changes due to these exposures is up to age eight. Chronic poverty modulates a number of contributors to toxic stress, including violence, neglect and abuse. This, in turn, results in persistently elevated cortisol levels (via HPA axis). Elevations in cortisol are associated with hypertension, insulin resistance (and subsequently Type 2 diabetes), and cardiovascular disease. Even in children who live in extreme poverty, maternal nurturance can help limit this effect; unfortunately, child separation diminishes this opportunity, especially in the setting of difficulties with reunification.

What can I, a trainee, do about this?

Whether you’re on the front lines as someone who provides healthcare to children, or you’re concerned about the implications of the legacy this policy leaves behind, here are some small ways you can make a difference:

• Read up on trauma informed care so that you can understand one approach to addressing patients who have been impacted by toxic stress.
• Contact your congresspeople to demand their continued investigation into and support for reunification of families.
• Remember that your voice is just as important as anyone else’s. Talk to your co-trainees, talk to your family members, anyone who is willing to hear your point of view.
• Seek out opportunities to involve yourself in advocacy, even as a trainee! You can testify through your local branch of government, and even take advantage of some existing resources through major organizations like American Academy of Pediatrics.
• Read pieces from opposing viewpoints — try to understand where folks are coming from to enhance your knowledge of the problem.
• Take time to care for yourself! Engaging with this material can bring up a variety of emotions and it’s important to make space to acknowledge them all.

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Policy Prescriptions

Policy Prescriptions is dedicated to exploring and challenging contemporary health policy issues, especially in the fields of behavioral health, health care access, and inclusion.

Image credit: Injustice by ep_jhu licensed under CC BY-NC 2.0.