AMA Acts on Treatment of Children at Border, Gun Violence, Pediatric Decision Making

At last month’s Interim Meeting of the AMA House of Delegates at National Harbor in Washington, D.C., delegates overwhelmingly approved a resolution objecting to policies that separate children and guardian parents seeking entry to the United States at the border.

Mark Moran

Delegates also approved a resolution stating that the AMA will support the practice of administering psychotropic drugs to immigrant children only “when there has been evaluation by appropriate medical personnel and with parental or guardian consent or court order, except in the case of imminent danger to self or others.” The House also passed a resolution urging continuity of care for all migrant children released from detention facilities.

(A further resolution objecting to policies prohibiting unaccompanied, undocumented minors access to the United States was referred to the AMA Board of Trustees for a decision.)

Debate at the House on the policies related to immigration took place in the context of reports that migrant children are being given psychotropic medication after being separated from parents and the Trump administration’s efforts to modify the Flores settlement. Flores is the 1997 legal settlement of lawsuits filed against what was then known as the Immigration and Naturalization Service (INS) for alleged maltreatment of migrant children. The settlement requires the government to release children from immigration detention without unnecessary delay to their parents, other adult relatives, or licensed programs. It also requires immigration officials to provide detained minors a certain quality of life, including food, drinking water, and medical assistance in emergencies.

(Last month APA submitted public comments to the administration regarding its proposed rule change to the Flores settlement. “The proposed rule seeks to amend the [settlement] to allow the Department of Homeland Security to keep ‘families who must or should be detained together at appropriately licensed family residential centers for the time needed to complete immigration proceedings,’ ” APA wrote. “This vague guidance about how long families may be detained is concerning and has the potential to impose long-lasting trauma on detained children and their parents.”)

Speaking for the Academy of Child and Adolescent Psychiatry, David Fassler, M.D., a delegate from the academy and a member of the AMA Section Council on Psychiatry, told the House that the academy opposes all policies that attempt to deter immigration by separating children from their parents.

“Separation places already vulnerable children at increased risk for traumatic stress reactions, psychiatric disorders, and other adverse medical outcomes,” Fassler said. “We also oppose the excessive or indiscriminate administration of psychotropic medication to these kids, in the absence of comprehensive evaluations, accurate diagnoses, individualized treatment plans, and appropriate informed consent. Children who’ve been separated from their parents as a result of our immigration policies are frightened and alone. Many have prior histories of trauma and abuse. As physicians, we have an obligation to speak out and advocate on their behalf.”

He added, “We also support the language and protections of the existing Flores agreement.”

Gun Violence

The plight of migrant children at the border was only one of the high-profile issues addressed by the House. Just weeks following the shooting at a Pittsburgh synagogue where 11 people were killed, the House also approved a report to the Board of Trustees calling for a variety of measures to prevent or reduce gun violence. The House also debated, but did not approve, a report from the Council on Ethical and Judicial Affairs on the contentious topic of physician-assisted suicide.

“The House passed excellent policy that will help protect our patients and our practices on a variety of topics at this meeting,” said Jerry Halverson, M.D., chair of the AMA Section Council on Psychiatry. “Gun control, opioids, and suicide continue to be hot topics on the minds of physicians of all specialties, and strong AMA policy, influenced by psychiatrists, on these topics will help to change laws.”

The gun violence report from the AMA’s Board of Trustees, approved by the House, advocates and supports, among other actions, the following:

• A waiting period and background check for all firearm purchasers; legislation that enforces a waiting period and background check for all firearm purchasers; and legislation to prohibit the manufacture, sale, or import of lethal and nonlethal guns made of plastic, ceramics, or other nonmetallic materials that cannot be detected by airport- and weapon-detection devices.

• Requiring the owners and purchasers of firearms to obtain a license or permit, complete a safety course, and register all firearms.

• Gun violence restraining orders for individuals arrested or convicted of domestic violence or stalking, and extreme risk protection orders, commonly known as “red-flag” laws, for individuals who have demonstrated significant signs of potential violence.

• Increasing efforts to reduce pediatric firearm morbidity and mortality by encouraging physicians to inquire about the presence of household firearms as a part of childproofing the home and encouraging state medical societies to work with other organizations to increase public education about firearm safety.

• The enactment of state laws requiring the reporting of all classes of prohibited individuals, as defined by state and federal law, to the National Instant Criminal Background Check System (NICS) and federal funding to provide grants to states to improve NICS reporting.

Pediatric Decision Making

Delegates also approved a report from the Council on Ethical and Judicial Affairs on pediatric decision making in cases of children with differences of sex development. The report provides guidance to physicians on delivering compassionate care to all pediatric patients, while negotiating with parents or guardians to develop a shared understanding of the patient’s medical and psychosocial needs and interests.

The report received support from a number of patients and parents of patients with congenital adrenal hyperplasia (CAH), who testified that surgery is a vital option that should be preserved as part of shared decision making. At reference committee hearings, they refuted claims by what they called “anti-surgery activists” who assert that surgery is medically sanctioned violence. (CAH is a group of rare inherited autosomal recessive disorders characterized by a deficiency of one of the enzymes needed to make specific hormones, which may result in abnormal genital development.)

One mother of an 11-year-old girl with CAH told the House of Delegates, “Parents and families have a right to choose what is best for their child.”

Delegates also approved the following:

• A resolution supporting the right of federally certified Opioid Treatment Programs (OTPs) to be located within residential, commercial, and other areas where there is a demonstrated medical need.

• A resolution supporting legislation and federal funding for evidence-based training programs by qualified professionals aimed at educating corrections officers in effectively interacting with people diagnosed with a mental illness in federal prisons and detention and correction facilities.

• A resolution calling for advocacy for the Accreditation Council for Graduate Medical Education (ACGME) to collect data on the suicide deaths of medical students, residents, and fellows to identify patterns that could predict suicidal behavior. ■