Over the past decade, applications for asylum in the United States have increased significantly. In 2017, more than 250,000 people applied for asylum, a more than 4-fold rise since 2009.1 Children represent a significant proportion of immigrants seeking asylum. Although many children involved in asylum applications are linked to a parent or legal guardian's application, an increasing number of unaccompanied minors and children are filing independent claims. In 2017, more than 17,000 unaccompanied minors from Guatemala, El Salvador, and Honduras applied for asylum, representing the majority of affirmative asylum applications from the region.1
Pediatricians may serve as a resource for children seeking asylum by performing a forensic medical evaluation (FME) to address the consistency of signs and symptoms of prior trauma with reported abuse for use in the legal process.2 Forensic medical evaluations can be performed by many types of pediatric medical providers, but in this article we focus on the role of pediatricians who have received training in this area. Evaluations are typically, but not always, performed in a volunteer capacity by an independent provider rather than a child's pediatrician, because the role of the evaluator is to present an objective assessment rather than to advocate for a specific outcome.
A study by Physicians for Human Rights (PHR), an international nongovernmental organization, showed that asylum applicants who underwent FME by a trained volunteer provider were granted asylum 89% of the time compared to a national average of 37.5% during the study period.3 An FME consists of an interview to record an applicant's history of abuse, a physical examination of scars or injuries, and/or an assessment of psychological symptoms of trauma-related mental health disorders. Evaluators summarize findings in a report submitted through the applicant's attorney to the asylum office at the US Citizenship and Immigration Services or immigration court.
The circumstances surrounding FME for pediatric applicants seeking asylum differ from that of adults, including the vulnerability of children to different types of trauma, varying manifestations of traumatic stress, and a greater risk for re-traumatization in the evaluation.4 Children are particularly vulnerable to forms of persecution such as human trafficking, sexual violence, sexual and gender identity discrimination, female genital cutting, recruitment into gang-related activities, and deprivation of food and medical treatment.5 The objective of this article is to provide guidance to general pediatricians on FME of children applying for asylum in the US. We present legal and medical considerations with an emphasis on age- and development-specific approaches to FME.
Children and Asylum Law
Children are eligible for several types of humanitarian immigration relief. Although this article focuses on asylum, Table 1 highlights other types of status, including Special Immigrant Juvenile (SIJ), for which FME may be useful. Asylum may be granted to a person who is unable or unwilling to return to their country of origin because of a well-founded fear of persecution on account of race, religion, nationality, political opinion, or membership in a particular social group. An asylum applicant can submit an affirmative application within 1 year of entry and present their case in an asylum office, or a defensive application if the applicant is in deportation proceedings and present their case in immigration court. An applicant granted asylum is eligible for a pathway to legal permanent residence and citizenship, family reunification, work authorization, and social assistance.
Asylum and Related Types of Humanitarian Immigration Relief
A portion of applicants for asylum or SIJ status may be unaccompanied minors or children younger than age 18 years at the time of entry who do not arrive in the US with a parent or legal guardian. These children are in the legal custody and care of the Department of Health and Human Services Office of Refugee Resettlement until a parent, legal guardian, or other sponsor is identified.
The FME includes an interview to elicit past medical and social history and a narrative of the reported abuse, a psychological assessment, and/or a medical assessment including a physical examination.6 The purpose of the evaluation is to assess the consistency of medical and psychological findings with the reported abuse. The attorney and the evaluator determine the need for a psychological, medical, or other specialized assessment such as a gynecological examination based on the type of trauma and resulting symptoms.
In preparation for evaluating children exposed to a diverse spectrum of trauma, the evaluator must become an expert in taking history on mechanisms of injury, scar formation and healing, and physical and psychological sequelae of trauma. Half- or full-day trainings conducted by organizations like PHR and at many academic medical centers provide evaluators with additional skills and legal background. Attendance of a training is recommended, although it not required in immigration court if expertise can be demonstrated otherwise.
The evaluator prepares for an evaluation by corresponding with the applicant's attorney to discuss suspected injuries and symptoms, important legal aspects of the case, and logistical considerations. A written statement by the asylum applicant or a caregiver describing the abuse experienced is generally provided ahead of time. Evaluators should use a certified medical interpreter where available rather than family or community members. It is important to repeat or verify aspects of the child's history and symptoms before they are documented in the written affidavit because inconsistencies due to misunderstanding or misinterpretation can be detrimental to the child's asylum case.
Guidelines for conducting FME for adults include the PHR's Examining Asylum Seekers and United Nations High Commissioner for Refugees Istanbul Protocol.6,7 These documents provide step-by-step instructions for the investigation of torture and other forms of persecution and serve as a reference for specific types of injuries and mental health disorders.
Approach to the Interview
The objective of the interview is to establish a narrative of the abuse related to a child's legal claim of persecution. The interview is common to both psychological and medical assessments, although the focus of the questions may differ. The interview comprises a progression of open- and closed-ended questions to elicit and clarify details of the abuse. Although the primary purpose of the FME is to document symptoms related to the reported persecution, it may also be important to understand and document trauma that occurs during migration, periods of detention, and thereafter as it affects the child's current mental and physical health.
Research has shown that children will provide more accurate information when details are elicited from free-recall memory with open-ended questions.8 Questioning should be informed by a child's age, developmental stage, and cognitive level as these can affect their ability to provide an accurate history. Evidence-based forensic interview guides may be helpful to structure the interview.8
A child's capacity to form, recall, and narrate memories may be diminished by traumatic stress and the presence of a trauma-related mental disorder.9 Additionally, trauma survivors may not reveal details due to embarrassment or guilt. Traumatic brain injury or medical illness such as chronic malnutrition can affect cognitive function. Because the ability to recall events evolves throughout childhood, written or visual sequencing tools can be utilized to establish a clear timeline.
The approach to the evaluation should reflect the principles of trauma-informed care (TIC). Resources from the American Academy of Pediatrics (AAP) and National Child Traumatic Stress Network emphasize providing a child-friendly environment, promoting collaboration, and responding to distress with empathy.10,11 Transparency and expectation-setting are essential to initiating trust and rapport. The evaluation begins with introductions and an explanation of the purpose of the visit. The evaluator should explain this is a forensic evaluation rather than a medical consultation.
Another fundamental principle of TIC is to minimize re-traumatization of the child. The evaluator must determine what elements of the story are most important to hear directly for the effectiveness of the report and balance this with the distress experienced during the evaluation. The well-being of the child is paramount. The evaluator may draw on the applicant's written statement to complement information from the interview.
An evaluator will determine whether to invite a parent or caregiver to join for part or all of the evaluation, as they may provide additional security and support. For younger patients, caregivers may be a primary source of history and observations; however, the evaluator should note the source of information in the evaluation report. Caregivers often have suffered their own traumatic events and may experience distress or guilt related to their child's trauma. The evaluation of adolescents should include an opportunity to share history without a guardian present.
Children of all ages may experience shame, self-blame, and avoidance or repression of negative thoughts or memories to avoid distress.12 Gently introduce questions about trauma with an approach to meet the child where he or she is, giving the child control and respecting their choices about how much information they share. Explain why particular information is being sought out and how it will aid the evaluation. Provide affirmation and validate difficult or embarrassing feelings that may arise.
Given the high rates of trauma among children seeking asylum, a psychological assessment can be a critical component of the asylum evaluation. The assessment builds on the trauma narrative established in the first part of the interview and proceeds to document psychological symptoms and observations of the child's behavior after the trauma. The core components of the psychological assessment are summarized in Table 2.
Components of Psychological and Medical Assessment
Children may not readily volunteer trauma symptoms. Trauma checklists and screening tools for depression and trauma-related symptoms may be helpful in assessing psychological function, but they are not required and may not be culturally validated.13 As when eliciting a trauma narrative, discussion of psychological symptoms can bring up distressing emotions. The evaluator should be mindful of the risk of re-traumatization and pay attention to signs that the child may be experiencing heightened emotions or need a break.
When documenting the psychological assessment, the evaluator describes the child's symptoms and functional impairment. The evaluator should delineate any formal psychiatric diagnoses identified in the evaluation while recognizing that the child may have significant distress from symptoms that do not meet full diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).4,14
When concluding the psychological assessment with the child, it is helpful to provide psychoeducation about common responses to trauma. Allow time for the child to recover and offer simple coping tools such as deep breathing exercises. Make a plan for safety and offer recommendations or referrals for mental health follow-up.
Manifestations of Traumatic Stress in Children
Traumatic stress can present differently in children compared to adults. The DSM has evolved to incorporate developmental considerations, including the addition of a preschool subtype of posttraumatic stress disorder in the DSM-5.14 However, symptoms and behaviors related to traumatic stress in children may not be captured in formal diagnostic criteria or may go unrecognized in an evaluation leading to under-diagnosis and misdiagnosis of trauma-related psychiatric disorders.4
Children may avoid people, situations, or physical reminders of their trauma. This can be pronounced in the psychological evaluation, when a child avoids talking about the traumatic events or distressing feelings.12 Young children often display behavioral changes related to trauma, including aggression, irritability, under-reacting to situations or appearing “numb,” having trouble sitting still, problems concentrating, or nonspecific fears.4 Adolescents may engage in self-harming or reckless behaviors, or isolate themselves from peers. Young children and adolescents may grapple with sleep problems including insomnia and bedwetting. Re-experiencing symptoms for children include re-enacting the event or themes of the event, or repetitive play.9 Some children have trouble with separation and fear threats to their caregiver such as deportation. Children exposed to trauma may report somatic complaints such as headaches, abdominal pain, dizziness, or fatigue. These symptoms vary with age and often correlate with trauma-related psychiatric disorders.15
It is important to take a culturally informed approach to the psychological assessment. Various cultures or linguistic groups have different names for psychological symptoms or concepts such as anxiety or depression. Furthermore, disclosure of mental health symptoms may be affected by stigma. The evaluator must recognize their own biases, culture, trauma history, privilege, and underlying motivation for completing the evaluation.
Protective Factors and Resilience
Despite high rates of exposure to trauma, children seeking asylum are often resilient. Elements that promote resilience include internal factors like adaptive coping and self-efficacy, and external factors such as caregiver and social supports.16 For many children seeking asylum, these factors help children to recover and even thrive in school upon arrival to the US, develop new peer relationships, and maintain strong life goals despite enduring trauma. An evaluator may choose to document protective factors to emphasize the positive impact of a safe environment and the potential consequences of a child returning to their country of origin. To foster resilience, close the evaluation on a respectful and affirmative note. Acknowledge the strength it takes to endure traumatic experiences and the courage it requires to undergo this type of evaluation.
The objective of the medical assessment is to correlate the history of trauma with observed scars, musculoskeletal complaints, disability, or persistent symptoms. The components of the medical assessment are reviewed in Table 2. The evaluator draws on expertise to formulate and document an impression of the consistency of evaluation findings with the reported abuse (Table 3, Figure 1).7 Many examination findings in asylum evaluations will be nonspecific due to the remote nature of the reported trauma; however, the location, pattern, and burden of scars can suggest repeated or intentional abuse.
Classification of Degree of Consistency in Forensic Medical Assessment Using the Istanbul Protocol
Examples of an evaluator's impressions of the degree of consistency of physical examination findings with reported mechanism of injury using standard classification provided by the Istanbul Protocol.7 (A) Asylum applicant reported being tied up with a plastic zip tie (classification: “diagnostic of”). (b) Asylum applicant reported a laceration of the face and ear from a large knife repaired with sutures. (classification: “highly consistent”). (C) Asylum applicant reported a laceration from being beaten with a stick (classification: “consistent”. (D) Asylum applicant reported these were stretch marks unrelated to abuse (classification: “not consistent”).
A focused history of the events that led to an injury must be elucidated in detail. This includes the mechanisms of any injuries. It is important to ask about acute and chronic symptoms for each injury. A complete review of systems may help the evaluator elicit further related symptoms.
The evaluator should document medical care the child received as this may provide further corroboration of the injuries suffered. A history of medical treatment can also provide the evaluator with important context for the expected healing of remote injuries. Conversely, poor wound healing, infection, or a mal-aligned healed fracture may reflect an absence of prior medical care. Medical records summarizing care can strengthen an account, but few families have access to this documentation.
The physical examination portion of the medical evaluation consists of a general head-to-toe examination followed by a more focused inspection of areas that have sustained injury. A child exposed to significant trauma may be sensitive to aspects of the physical examination. The evaluator should offer control and choice to the child whenever possible and minimize exposure of sensitive body parts. Most cases will not require a genital examination, and this should not be performed unless it is relevant to the reported abuse and can be done in a safe and non-traumatizing manner.
Special consideration should be given to children with a history of sexual abuse or genital trauma requiring genital examination. This includes female genital cutting, a potential legal ground for an asylum claim.17 The attorney and the evaluator should determine the need for involvement of a child abuse expert, gynecologist, or other provider with expertise in this area.
The most common findings of the physical examination are dermatologic, musculoskeletal, and neurologic. The evaluator documents findings in detailed, easy-to-understand language including appearance, dimensions, distribution, range of motion, and strength.
Written Affidavit and Testimony
The evaluator summarizes findings of the FME in a legal affidavit submitted through the child's attorney. There are times when the evaluator will be called to provide oral testimony in court. The attorney will review the affidavit and prepare the evaluator for anticipated questions. Although there is no standardized format, the affidavit should contain the following information: (1) the evaluator's academic and clinical background to demonstrate expertise; (2) the purpose of the evaluation and sources of information; (3) a concise relevant history of trauma; (4) the assessment(s) performed; (5) photographs or anatomical diagrams of the documented scars; and (6) the evaluator's assessment of the level of consistency between physical and psychological examination findings and the reported history of abuse. An evaluator may also provide education for the adjudicator on a child's specific responses to trauma. For example, a child's flat or incongruent affect or inability to recall details of a trauma are within the normal spectrum of response to trauma but may be misperceived as signs of lack of credibility.