Sleep Deprivation of Detained Children: Another Reason to End Child Detention.

Introduction

The US administration’s “zero tolerance” policy has ushered in an escalation of mass detention of immigrants in the United States. In its present iteration, this system processes children without sufficient numbers of personnel with pediatric medical training or who can recognize life-threatening conditions. This same system also detains increasing numbers of children for longer periods of time without trauma-informed pediatric physical and mental health oversight. Since September 2018, at least seven children have died in US government custody or immediately after being released. This provoked nationwide concern that led to the exposure of unsanitary and dangerous conditions in border patrol facilities holding hundreds of migrant children in Texas. In Flores v. Barr, attorneys representing detained migrant children successfully argued that the government violated the “safe and sanitary” standard of the 1997 Flores settlement agreement based on recent evidence of horrific conditions in US Customs and Border Protection holding cells. Conditions cited included lack of facilities for bathing, sleep surfaces of concrete floors instead of beds, overcrowding, cold temperatures, aluminum blankets as the only source of warmth, and constant illumination.

We wish to call attention to a specific inevitable and inhumane consequence of child detention—sleep deprivation—as yet another reason to end child detention altogether. As part of the ruling in Flores v. Barr, the 9th Circuit Court of Appeals upheld a district court ruling that inadequate conditions for sleep are included in the violation of the definition of “safe and sanitary” conditions. Such violations are rampant. Border Patrol holding cells are illuminated 24 hours per day and do not have beds. They are referred to as hieleras (iceboxes) given their frigid temperatures. Sleeping mats and actual blankets are only inconsistently provided. As a result, children frequently attempt sleep in freezing rooms with constant illumination on concrete floors with aluminum blankets as the only coverage for warmth. Family detention centers are no better. There, children stay in rooms with non-related adults and are routinely woken up for head counts at night and in the early morning. In one family detention center, the Berks County Family Residential Center in Pennsylvania, an official bed check policy occurs every 15 minutes throughout the night. Findings from interviews with families and staff at the Berks facility, as detailed in an amicus brief filed in support of the Pennsylvania Department of Human Services, revealed grave concern about the effects of this practice of sleep deprivation. Families detailed how children at Berks exhibited mental health and behavioral problems associated with sleep deprivation, such as withdrawal from family members, self-injurious behaviors, and suicidal ideation.

As physicians, public health professionals, and human rights advocates who care for children, we call for all practices that cause sleep deprivation within detention facilities to stop immediately. Sleep deprivation, whether resulting from intentional practices or as the unintentional consequence of inappropriate environments, is inhumane. It is associated with long-term physical and mental health morbidity, which we argue compounds the harms and trauma of detention. While halting such practices is the appropriate first step, the Department of Homeland Security must urgently prioritize alternatives to detention to minimize or eliminate entirely the detention time of any one child. In this perspectives piece, we expand on the negative health effects of sleep deprivation, explore how such practices in other contexts are considered a form of cruel, inhumane and degrading treatment, and offer recommendations for action by child and adolescent health providers and policy makers.

Mental and physical health effects of sleep deprivation and the compounding effects of detention

Quality sleep is integral to the health and development of infants and children. Mental health markers generally known to correlate positively with appropriate sleep include improved attention, behavior, learning, memory, and emotional regulation. As would follow, insufficient or poor quality sleep has negative impacts on normal cognitive and neurobehavioral function, such that children with sleep disruption commonly experience problems with memory recall, behavioral regulation, and attention-related disorders. Furthermore, while sleep deprivation has a known reciprocal association with depression and anxiety, sleep deprivation independently predicts an increased risk of suicidal behavior. One study of 779 Palestinian adults found that sleep disturbances were associated with worsening post-traumatic stress disorder symptoms and intensified severity of anxiety-related disorders. This worsening of symptoms is especially harmful for detainees who have a high likelihood of experiencing trauma in detention, thus compounding the trauma that forced them to flee their home countries in the first place.

Chronic sleep deprivation also has significant physical health consequences. Observed associations between sleep disruptions and negative cardiometabolic health outcomes include the development of diabetes and obesity in children and adults, suggesting sleep’s important role in modulating insulin and hunger-related hormones. Sleep deprivation is additionally associated with endothothelial dysfunction, hypertension, inflammatory states, changes in autonomic tone, and hormonal dysregulation, all known risk factors for the development of cardiovascular disease.

While the potential harms caused specifically by sleep deprivation are worrying in their own right, they further compound other harms inherent in the practice of detaining children. In an American Academy of Pediatrics policy statement, cited studies noted that detained immigrant children experienced developmental regression, poor psychological adjustment, high rates of post-traumatic stress disorder, anxiety, depression, suicidal ideation, and other behavioral problems.

Inhumane treatment of children

Intentional sleep deprivation is internationally denounced as a form of torture or cruel, inhumane, and degrading treatment, including as a form of prisoner abuse practiced by the US government in Guantanamo Bay. Several US federal courts characterize sleep deprivation as torture when inflicted by other countries. The Flores settlement agreement requires children to stay in the least restrictive settings possible, but mandatory bed checks, lack of access to normal diurnal patterns of light and darkness, shared sleeping facilities, and inhospitable temperature regulation are all characteristic of highly secured facilities, rather than “least restrictive” settings.

The detention of children and its direct association with sleep deprivation conflicts with child rights standards, which state that the best interests of the child must be the primary consideration in all actions involving children. Intentionally holding children for prolonged periods in conditions where they will be unable to obtain the recommended amount of healthy sleep is unnecessary, harmful, and violates the right of children to be treated humanely.

Recommendations

As clinicians and asylum experts who conduct and organize physical and psychological evaluations for youth asylum seekers, we call for the cessation of all practices—intentional or otherwise—that lead to sleep deprivation of detained immigrant children. We ask policy makers, regulators, and detention facility managers to cease all unnecessary bed checks, provide reasonable darkness or dimmed lighting in sleep areas, and ensure full access to warm blankets, beds, or sleeping mats, and pillows. The trauma caused by detention itself, the structural limits of family detention centers whereby multiple families are forced to share rooms, and the procedures in place—such as the night-time “bed checks”—make the adequate and high-quality sleep necessary for normal child development impossible. Furthermore, beyond the lack of quality sleep, these very practices of bed checks, inhospitable temperatures, and constant lighting can be severely re-traumatizing for youth who have fled situations of abuse, neglect, and risk to their life.

The inhumane conditions of pre-detention holding facilities and detention centers and the lack of comprehensive pediatric care cause significant health risks. Unfortunately, the last year has borne witness to the most extreme form of such risk—the death of detained children from preventable causes. Thus, the most appropriate step is to stop detaining immigrant children altogether. The appropriate alternative to detention is to transfer children and families to community settings through proven case-management approaches. Such approaches ensure compliance with immigration proceedings and facilitate expanded access to health care, legal assistance, education, housing, and other essential services. With the transfer of children and families to community settings, trained pediatric medical providers can play an integral role in caring for these children and families, including coordinating care across multiple service sectors. Experts in child development, pediatricians, child mental health clinicians, and family physicians will be instrumental in calling for such alternatives to detention and creating appropriate child-centered programs and resources as part of these models.

Lastly, those interacting closely with previously detained children and families in the community—clinicians, child welfare and social service workers, attorneys, teachers, and school staff—should be aware not only of the harmful effects of detention but also of the lesser known effects of sleep deprivation. Such awareness is critical to be able to appropriately care for these families in the community. Ongoing effects of detention and sleep deprivation—such as insomnia and fear at night, worsening of post-traumatic stress disorder symptoms, poor concentration and performance in school, and irritability and depression—may continue to plague youth and affect functioning long after detention. Future studies should assess the mental and physical health consequences of the combination of sleep deprivation and detention in children.

Conclusion

During this time of mass detention, it is increasingly important for all clinicians, policy makers, and advocates who work with children to understand the trauma and health risks that children and families face through pre-detention and detention, including experiences such as sleep deprivation, to mitigate the acute and chronic effects of trauma experienced by these youth and families. Clinicians have a crucial role in bringing attention to these cruel practices and their health and mental health effects in order to stem the long-lasting damage being inflicted on this generation of children. Detention of a child inflicts profound short- and long-term harm, and its use for thousands of children as standard policy of the US government should end. In the short term, practices in detention centers that deprive children of sleep should cease immediately. Detainees must have access to warmth and to a safe sleep environment.

The content and views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs, the National Institutes of Health, or the United States Government.