Addressing a Fear of Family Separation Among a Hispanic Pediatric Population

The purpose of the project was to develop and disseminate a culturally relevant resource toolkit to primary care pediatric providers delivering care to immigrant populations. The aim was to equip providers to support Hispanic families facing increased stressors related to family separation in the face of current immigration policies. Problem: Approximately six million children under the age of 18 in the United States are living with one or more undocumented family member. The American Academy of Pediatrics recognizes that the threat of family separation due to detention and deportation is a stressor. Prolonged stressors can affect the architecture of the developing child's brain and reduce healthy neural connections resulting in poor emotional and physical development. In Salt Lake City, primary care pediatric providers working with immigrant families recognized the need for more training and local resources to better address the looming threat of family separation that Hispanic children and their families may face. This quality improvement project included two components. The first involved the gathering of culturally relevant materials to create a toolkit of resources for providers caring for Hispanic families. The second was the introduction of the toolkit to primary care pediatric providers through an educational thirty-minute PowerPoint presentation. Essential components of the toolkit included lists of family and community support resources, local legal and mental health resources translated into Spanish, examples of emergency care plans for families, an introduction of resiliency training and stress coping skills, and validated mental health screeners for depression and anxiety. The educational presentation included key statistics regarding immigrant populations, current information on immigration policies and family separation, and pertinent research findings on prolonged stressors and their impact on children. Forty-six participants including pediatric resident and supervising physicians, medical students, clinical office staff, and key members of the care coordination team (medical assistants, nurses and Spanish-language interpreters) attended the educational presentation. Forty-five participants completed a pre- and post-educational survey. Results showed participants had an increase in confidence after the educational presentation in offering services and resources to patients related to the fear of family separation and immigration issues. Results from a survey completed by attendees one month later showed that 70% of attendees from the first educational presentation were able to use the resources of the toolkit in their clinical practice. This project demonstrated that primary care pediatric providers who care for immigrant populations benefitted from an educational presentation focused on the issue. Participants reported that the introduction of community resources available to help immigrant families was most useful. We concluded that by educating pediatric providers to be aware of the challenges that immigrant families experience related to immigration policies and better equip them to offer patient resources, there is an opportunity to mitigate the long-term effects of continuous stressors and promote health downstream.

Running head: ADDRESSING A FEAR OF FAMILY SEPARATION Addressing a Fear of Family Separation among a Hispanic Pediatric Population Emily S. Navar The University of Utah 1 ADDRESSING A FEAR OF FAMILY SEPARATION 2 Abstract Purpose: The purpose of the project was to develop and disseminate a culturally relevant resource toolkit to primary care pediatric providers delivering care to immigrant populations. The aim was to equip providers to support Hispanic families facing increased stressors related to family separation in the face of current immigration policies. Problem: Approximately six million children under the age of 18 in the United States are living with one or more undocumented family member. The American Academy of Pediatrics recognizes that the threat of family separation due to detention and deportation is a stressor. Prolonged stressors can affect the architecture of the developing child's brain and reduce healthy neural connections resulting in poor emotional and physical development. In Salt Lake City, primary care pediatric providers working with immigrant families recognized the need for more training and local resources to better address the looming threat of family separation that Hispanic children and their families may face. Methods: This quality improvement project included two components. The first involved the gathering of culturally relevant materials to create a toolkit of resources for providers caring for Hispanic families. The second was the introduction of the toolkit to primary care pediatric providers through an educational thirty-minute PowerPoint presentation. Essential components of the toolkit included lists of family and community support resources, local legal and mental health resources translated into Spanish, examples of emergency care plans for families, an introduction of resiliency training and stress coping skills, and validated mental health screeners for depression and anxiety. The educational presentation included key statistics regarding immigrant populations, current information on immigration policies and family separation, and pertinent research findings on prolonged stressors and their impact on children. ADDRESSING A FEAR OF FAMILY SEPARATION 3 Results: Forty-six participants including pediatric resident and supervising physicians, medical students, clinical office staff, and key members of the care coordination team (medical assistants, nurses and Spanish-language interpreters) attended the educational presentation. Forty-five participants completed a pre- and post-educational survey. Results showed participants had an increase in confidence after the educational presentation in offering services and resources to patients related to the fear of family separation and immigration issues. Results from a survey completed by attendees one month later showed that 70% of attendees from the first educational presentation were able to use the resources of the toolkit in their clinical practice. Conclusions: This project demonstrated that primary care pediatric providers who care for immigrant populations benefitted from an educational presentation focused on the issue. Participants reported that the introduction of community resources available to help immigrant families was most useful. We concluded that by educating pediatric providers to be aware of the challenges that immigrant families experience related to immigration policies and better equip them to offer patient resources, there is an opportunity to mitigate the long-term effects of continuous stressors and promote health downstream. ADDRESSING A FEAR OF FAMILY SEPARATION 4 Introduction The American Academy of Pediatrics (2018) recognizes that the looming threat of family separation related to current immigration policies has had a negative impact on Hispanic children. According to the American Immigration Council (2018), approximately six million children under the age of 18 in the United States are living with one or more undocumented family member with an additional one million children who are undocumented themselves. In Salt Lake County, the largest ethnic group is Hispanic making up 18.5% of the Utah population (Claritas, 2018). In Utah, 55,000 children are living with at least one undocumented family member (American Immigration Council, 2018). Problem Description Primary care providers need to be aware of the challenges that Hispanic immigrant families experience in the face of current immigration policies. Hispanic children are the fastest growing population of children in the United States and 25% of the nation's 54 million youth in grades kindergarten through 12th grade is Hispanic (Cardoso, Detlaff, Finno-Velasquez, Scott, & Faulkner, 2014; Lopes, Krogstad, & Flores, 2018). Development during early childhood and adolescence are sensitive periods, and both positive and negative influences shape a child's biology (Bucci, Silvério Marques, Oh, & Burke Harris, 2016). Providers working with children should recognize the effects negative stressors have on the emotional development of Hispanic children (Rubio-Hernandez & Ayón, 2016). Abrupt separation from family affects a child's emotional development. Children exhibit signs of withdrawal, anxiety, depression, and oppositional defiance (Bucci et al., 2016). Living with constant anxiety is associated with poor school performance and a higher drop-out rate. Medical and mental health services are underused due to persistent anxiety related to the fear of ADDRESSING A FEAR OF FAMILY SEPARATION 5 deportation (American Academy of Pediatrics, 2018; Bucci et al., 2016; Hobson-Rohrer, 2018). Deportation also leads to an increase in United States citizen-children committed to foster care. In a national study from 2011, 5,100 children living in foster care had a parent that was either detained or deported (American Immigration Council, 2018). Research study findings indicated that resident pediatricians (physicians training to be board-certified pediatricians) providing care specifically to immigrant populations were uncomfortable with their lack of knowledge regarding immigrant health (Alpern, Davey, & Song, 2016). In Salt Lake City, pediatric residents who work with immigrant populations recognized the need for more training and resources to better address the fear of family separation among a Hispanic pediatric population in clinical practice. Pediatricians seek local and available mental health, community, and legal resources to recommend to Hispanic immigrant families (R. Sakai, personal communication, July 9, 2018; W. Hobson-Rohrer, personal communication, May 22, 2018). Teaching primary care providers how to address the issue in clinic through an educational presentation including available community resources can address the issue Hispanic children are facing on a local level. By educating providers to offer patients resources, the opportunity exists to mitigate the long-term effects of continuous stressors that immigrant children experience and promote health downstream. Available Knowledge When a child is exposed to prolonged stressors, the body's natural stress response becomes inadequate, affecting multiple biological systems and further laying the foundation for long-term poor health outcomes (Bucci et al., 2016; Hobson-Rohrer, 2018). These prolonged stressors, known as toxic stress, can affect the architecture of the developing brain and reduce healthy neural connections resulting in poor emotional and physical development. Toxic stress is ADDRESSING A FEAR OF FAMILY SEPARATION 6 defined as a constant and heightened state of anxiety that interferes with a child's stress buffer and lessens the child's ability to return to a normal physiological baseline (Artiga, & Ubri, 2017; Hobson-Rohrer, 2018). Research findings and expert level evidence indicate that the threat of family separation due to detention and deportation is a toxic stressor (American Academy of Pediatrics, 2017). In an exploratory mixed method study, the authors investigated the mental health burden that citizen-children experience tied to immigration enforcement policies that threatened separation from one or both parents and found that 50% of these citizen-children showed symptoms of depression (Gulbas et al., 2016). The American Academy of Pediatrics 2017 Council Community Pediatrics Immigrant Health Special Interest Group created a toolkit to guide strategies to address issues related to immigrant child health. The toolkit includes guidelines and protocols in addition to practical information on the consideration of the mental and physical impact on immigrant children and how best to support them. In a study by Karp, Rhee, Feldman, and Bouchkouj (2007), an educational intervention was successful in affecting and improving resident providers knowledge, attitudes, and behavior concerning the health of immigrant children. Alpern et al. (2016) found that residents welcomed more education and training on caring for an immigrant population to be better prepared to provide specific care. Rationale The knowledge to action (K2A) model is a non-linear, conceptual model that was used to guide this project (Centers for Disease Control and Prevention, 2014). The model has two components: Knowledge Creation and Action Cycle (Field, Booth, Ilott, & Gerrish, 2014). The knowledge creation process included reviewing the literature, summarizing evidence of the problem, assessing the knowledge base of providers, and reviewing the clinical practice ADDRESSING A FEAR OF FAMILY SEPARATION 7 guidelines. The action cycle included implementing the knowledge and creating change by developing and introducing a toolkit to pediatric providers to address the issue in a clinical practice. The K2A model has been used in studies to improve health equity and to look at the gaps between knowledge and action of the social determinants of health (Davison, Ndumbe-Eyoh, & Clement, 2015). Addressing the gap between knowledge and action was key to the project as local pediatric residents reported an understanding of the issue but were unsure what to do about it. Additionally, stakeholders stated that they lacked the appropriate local tools and resources (R. Sakai, personal communication, July 9, 2018; W. Hobson-Rohrer, personal communication, May 22, 2018). By responding to the needs of the residents working with a Hispanic pediatric population, assumptions were made that with better knowledge, awareness, and tools, providers would be better equipped to address the issue in a clinic. Specific Aims The purpose of the project was to develop and disseminate a culturally relevant toolkit of resources to pediatric providers at an urban pediatric clinic in South Salt Lake City, Utah and deliver it through an educational presentation (see Appendix B). The toolkit would better equip the providers to support a Hispanic pediatric population facing increased stressors related to family separation in the face of current immigration policies. The Agency of Healthcare Research and Quality (AHRQ) (2018) defines a toolkit as "a collection of related information, resources, or tools that together can guide users to develop a plan or organize efforts to follow evidence-based recommendations or meet evidence-based specific practice standards." Educating pediatric providers and presenting locally available resources to address this issue may help mitigate the downstream long-term poor health outcomes affecting a Hispanic ADDRESSING A FEAR OF FAMILY SEPARATION 8 pediatric population. The American Academy of Pediatrics (2018) provided expert level evidence that states pediatric providers are well-positioned to develop effective practice strategies and provide local community resources that support the health of immigrant children. Methods Context The setting of the educational presentation and introduction of the toolkit of resources for pediatric providers took place at two locations. The first location was an urban clinic in South Salt Lake City, Utah. The clinic serves a large Hispanic community (72%, of families or approximately 3,000 patients seen in the pediatric department self-identify as Hispanic ethnicity) and an underserved population from lower socioeconomic backgrounds (Medicaid is the primary insurance for 77% of the pediatric patients). The clinic is part of an academic setting with resident pediatricians (physicians training to specialize in pediatrics). Resident and supervising physicians attended the educational presentation as well as support staff including office staff and key members of the care coordination team (medical assistants, nurses, and Spanish language interpreters). The same educational presentation was repeated within the academic program at an urban children's hospital in Salt Lake City, Utah during a scheduled morning report. It was attended by pediatric residents, supervising physicians, and visiting medical students that were touring the University and hospital that day. Intervention The first step of the intervention was to examine current literature on pediatric provider knowledge, awareness, and needs on recognizing and addressing the stress facing Hispanic pediatric patients related to the fear of family separation. Several interviews took place between clinic and community stakeholders throughout one month. The next step was to develop a ADDRESSING A FEAR OF FAMILY SEPARATION 9 resource toolkit using components of the American Academy of Pediatrics Immigrant Child Health Toolkit, findings from the literature review, feedback from interviews with stakeholders and compiled local resources including legal, mental health, and community support. The toolkit was introduced to pediatric providers through an educational 30-minute PowerPoint presentation (see Appendix B). The educational presentation consisted of an introduction of the issue including key statistics regarding immigrant population in Utah, current information on immigration policies and family separation, and pertinent research findings on prolonged stressors and its impact on the pediatric population. Essential components of the toolkit were validated mental health screeners for depression and anxiety, lists of local legal and mental health resources, examples of emergency care plans for families, list of options for resiliency training and stress coping skills, and family and community support resources. The description of resources for families were all translated into the Spanish language. Time was spent on ensuring that all community resources of the toolkit were current and up-to-date. The educational presentation and toolkit were refined by incorporating feedback from two attending pediatricians with 15-23 years of experience working with Hispanic families and a third-year resident pediatrician at the urban clinic. Collaboration between the author and Reiko Sakai, MD, a CATCH (Community Access to Child Health) grant recipient working with this population informed the intervention. Adapting the intervention to a different local site would be dependent on available local resources within each site or geographical location. Study of the Interventions The intervention was assessed using data collected from voluntary surveys. The data collected included basic demographics (name, email, and occupation) on the participants present for the educational presentation and how many years they had been in practice. A pre- and post- ADDRESSING A FEAR OF FAMILY SEPARATION 10 education evaluation survey was administered before and after the educational presentation to evaluate changes in knowledge and readiness to address the issue related to a fear of family separation among Hispanic pediatric patients. The demographics and the pre- and posteducational surveys were distributed as paper surveys before and after the presentation and then collected by the author. One month following the presentation, participants were emailed an additional survey to evaluate the usefulness of the toolkit in their clinical practice. The onemonth post-educational presentation survey was automatically distributed 30 days posteducational presentation via email to all participants who voluntarily provided an email address. There were two automated reminder emails sent to participants to encourage completion of the one-month post-educational presentation survey. Measures Surveys were developed under expert guidance and direction of Rebecca Wilson, Ph.D., and Eli Iacob, a statistician, both from the University of Utah College of Nursing. Data was carefully entered in Research Electronic Data Capture (REDCap), an online secure web application used to develop and manage online surveys and databases (REDCap, 2018). Fortysix completed pre- and post-educational surveys were collected in total. Time spent on the educational presentation was tracked including time to complete both pre- and post-surveys. Input from stakeholders at the clinic and chief resident from the children's hospital took place. Consideration of how best to disseminate the information in the future for all pediatric residents within the academic program was discussed. Methods employed for assessing completeness and accuracy of data included double checking all data entry and assessing any missing survey data. Some key demographic data was missing on ten of the participants who were visiting medical students. They chose not to include ADDRESSING A FEAR OF FAMILY SEPARATION 11 their email address; therefore, a one-month post-educational presentation survey was not sent to those participants. Analysis Descriptive analysis was used to describe the study sample (see Appendix A). A quantitative survey was administered immediately before and after the intervention and also one month after the intervention to assess for changes in knowledge and readiness to address the issue in clinic. Non-parametric tests using the Wilcoxon signed rank test were used to measure the change between pre-intervention and post-intervention scores. Ethical Considerations The study was deemed to be a quality improvement research project and was determined to be exempt from human subjects review by the University of Utah Institutional Review Board. The author had previously worked at the clinic where the first presentation and intervention were implemented. No one was excluded from attending either presentation. The entire staff of the clinic including all pediatric resident providers and staff were invited to participate in the presentation. Also, visiting medical students were not excluded and were invited to attend the presentation at the hospital. There were no conflicts of interest and the author received no compensation for any work done on the study. Results Forty-six participants attended the educational presentation. Forty-six pre- and posteducational surveys were distributed on paper at two different locations on two different dates. All but one participant completed the post-educational survey. A one-month post-educational presentation survey was sent out by email to all participants who supplied an email address. ADDRESSING A FEAR OF FAMILY SEPARATION 12 Eleven participants in the first session (61%) completed the one-month post-educational presentation survey and eight participants (44%) from the second session completed this survey. Eighteen participants attended the first educational presentation at an urban pediatric clinic on October 24, 2018. Those that participated in the October presentation included four medical assistants (MAs), two registered nurses (RNs), eight medical doctors (MDs), and four that identified as other. Twenty-eight participants attended the second educational presentation at an urban children's hospital during a scheduled morning report on November 18, 2018. Participants in the second session included 20 MDs, six participants who identified as other, and two who did not identify their occupational status. Analysis of the mean across two Likert five-point scale survey questions resulted in a statistically significant change (see Appendix A). Using the Wilcoxon signed rank test, analysis of the question: "How would you rate your degree of confidence in offering services and resources to patients related to the fear of family separation and immigration issues?" showed a significant change one-month following the educational presentation compared to before the educational presentation (p=.010). Additionally, there was a statistical significance in comparing the five-point Likert scale question: "How would you rate your degree of confidence in discussing the effects of immigration issues with families?" Using the Wilcoxon signed rank test and comparing the data from pre-educational presentation to one-month post-educational presentation, there was a significant improvement in confidence level (p=.000). The data results suggest that the educational presentation was useful in increasing provider's confidence in addressing the issue in a clinical practice. Thirty participants across both sessions reported that the presentation was helpful and an effective way to disseminate the information. Results from the survey completed by attendees ADDRESSING A FEAR OF FAMILY SEPARATION 13 one month later showed that 70% (8/11) of the participants in the first educational presentation stated they were able to use the resources of the toolkit in their clinical practice. Only 12.5% (1/8) from the second educational presentation stated they were able to use the resources of the toolkit in their clinical practice. The difference may be explained by different work settings and exposure to Hispanic populations. Those participants that attended the first session were providers and staff from an urban clinic that served a large Hispanic community of patients. The second set of participants included attending physicians, pediatric resident physicians, and medical students in an academic setting at an urban children's hospital. The physicians that attended the second presentation worked in an inpatient hospital setting rather than an outpatient clinical setting. Although they may have had exposure to Hispanic populations, the opportunities to discuss the effects of family separation and immigration issues in an acute setting were possibly limited. Also, ten of the participants were medical students who were in school and not yet in clinical practice. As a result, we believed the second group had less chance to use the resources presented within the one-month time frame. The ten visiting medical students who attended the second educational presentation were from out-of-town and were touring the academic hospital. These students were present during the entire presentation. They completed the post-educational survey but didn't leave their email addresses. Because they didn't provide an email address, they didn't receive an email with the link for the one-month post-educational presentation survey. As a result, there was missing data. Additionally, not everyone completed the one-month post-educational presentation survey despite two attempts to remind participants to complete the survey. The data for the participants that did not complete the one-month post-educational presentation survey was incomplete and therefore, not included in the analysis. ADDRESSING A FEAR OF FAMILY SEPARATION 14 Discussion Summary In this project, we showed that a culturally relevant toolkit of resources was useful for pediatric providers who work with immigrant populations. The toolkit included necessary resources to support the providers to better address a Hispanic pediatric population facing increased stressors related to immigration policies. Interpretation Educating providers and staff who provide care specifically to immigrant populations on issues of immigrant health was shown to be useful. The results demonstrated that pediatric clinical providers showed greater confidence in addressing the threat of family separation due to current immigration policies after attending an educational presentation with the introduction of the toolkit of resources. Additionally, the presentation of locally available resources to address family separation resulted in a higher level of confidence among participants in offering services to Hispanic families presenting with problems related to a looming threat of family separation. Similarly, in a study by Karp et al. (2007) a short educational presentation was shown to be an effective way to introduce issues that affect child health. The study demonstrated that a training program that addressed the needs of immigrant families gave pediatric residents necessary knowledge and resources to provide and advocate for immigrant children and their families (Karp et al., 2007). Limitations One of the limitations of the study was the use of a small sample size in a limited geographic region. Also, surveying participants one-month post-educational presentation was a short time frame and may not have allowed sufficient time to assess the usability of the ADDRESSING A FEAR OF FAMILY SEPARATION 15 resources. Additionally, the number of Hispanic patients that were seen by the participants in a one-month time frame was not measured or analyzed. Nevertheless, many participants found the educational presentation and the toolkit of resources to be useful in their clinical practice. Two participants suggested additional resources to include in the toolkit-a video resource and a link to Sanctuary Doctoring through Loyola University. Conclusions We know that primary care pediatric providers who care for immigrant populations benefitted from an educational presentation. Participants reported that the introduction of community resources available to help immigrant children and their families were most useful. As a result, we concluded that by educating pediatric providers to be aware of the challenges that immigrant families experience related to immigration policies and better equip them to offer patient resources, there is an opportunity to mitigate the long-term effects of continuous stressors and promote health downstream. To promote the sustainability of the project and use of the toolkit, the author distributed handouts of the resources electronically and in print to all participants of the educational presentation. Clinical support staff were encouraged to maintain the materials and ensure they are updated and kept current. The issue of family separation spreads to other contexts aside from immigration. Children are affected by the separation of a parent due to divorce, military deployment, incarceration, substance abuse, and death or disease of a parent. These negative stressors can affect a child's physical and emotional development. Further intervention and research should focus on recognizing the issues that children face regarding the threat of family separation and on ADDRESSING A FEAR OF FAMILY SEPARATION 16 increasing the number of pediatric providers who feel adequately prepared to work with immigrant populations. Acknowledgments I want to thank my project faculty chair Ana Sanchez-Birkhead, Ph.D., APRN for her guidance and invaluable feedback. I want to express my gratitude to the content experts on this project, Wendy Hobson-Rohrer, MD and Joni Hemond, MD, for their support and commitment to working with children at risk and underserved populations. A special thank you to Community Access to Child Health (CATCH) Program grant recipient Reiko Sakai, MD for her collaborative support and role in the presentation. I would also like to thank my academic advisor Julie Steele, DNP, APRN for her continuous support. And finally, I would like to extend a thank you to all the pediatric residents and staff at the University of Utah South Main Clinic for their participation in the presentation and their optimal service to the patients and families at the clinic. ADDRESSING A FEAR OF FAMILY SEPARATION 17 References Agency of Healthcare Quality and Research. (2018, June). Section 6: Toolkit guidance. Retrieved from https://www.ahrq.gov/research/publications/pubcomguide/pcguide6.html Alpern, J. D., Davey, C. S., & Song, J. (2016). Perceived barriers to success for resident physicians interested in immigrant and refugee health. BMC Medical Education, 16, 178. http://doi.org/10.1186/s12909-016-0696-z American Academy of Pediatrics. (2018). Immigrant Child Health Toolkit. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Immigrant- ChildHealth-Toolkit/Pages/Immigrant-Child-Health-Toolkit.aspx American Immigration Council. (2018). U.S. citizen children impacted by immigration enforcement. Retrieved from https://americanimmigrationcouncil.org/research/uscitizen-children-impacted-immigration-enforcement Artiga, S. & Ubri, P. (2017, December). Living in an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, & Health. (Kaiser Family Foundation, Issue Brief). Retrieved from http://files.kff.org/attachment/Issue-BriefLiving-in-an-Immigrant-Family-in-America Bucci, M., Silvério Marques, S., Oh, D., & Burke Harris, N. (2016). Toxic stress in children and adolescents. Advances in Pediatrics 63; 403-428. DOI: https://doi.org/10.1016/j.yapd.2016.04.002 Cardoso, J.B., Detlaff, A.J., Finno-Velasquez, M., Scott, J., & Faulkner, M. (2014). Nativity and immigration status among Latino families involved in the child welfare system: Characteristics, risk, and maltreatment. Children and Youth Services Review 44; 189-200. Retrieved from https://doi.org/10.1016/j.childyouth.2014.06.008 ADDRESSING A FEAR OF FAMILY SEPARATION 18 Centers for Disease Control and Prevention. (2014). Applying the knowledge to action (K2A) framework: Questions to guide planning. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services. Davison, C. M., Ndumbe-Eyoh, S., & Clement, C. (2015). Critical examination of knowledge to action models and implications for promoting health equity. International Journal for Equity in Health, 14 (49). http://doi.org/10.1186/s12939-015-0178-7 Field, B., Booth, A., Ilott, I., & Gerrish, K. (2014). Using the Knowledge to Action Framework in practice: a citation analysis and systematic review. Implementation Science 9;172. http://doi.org/10.1186/s13012-014-0172-2 Gulbas, L. E., Zayas, L. H., Yoon, H., Szlyk, H., Aguilar-Gaxiola, S., & Natera, G. (2016). A mixed-method study exploring depression in U.S. citizen-children in Mexican immigrant families. Child: Care, Health and Development, 42 (2), 220-230. http://doi.org/10.1111/cch.12307 Hobson-Rohrer, W. (2018). The effects of US immigration policies on migrant children's health. [PowerPoint Slides]. Retrieved from https://uofu.app.box.com/s/3rg2gk0qqkjkvxcypassft6lggvssaxz Karp, R.J., Rhee, D., Feldman, D. & Bouchkouj, N. (2007, August). Outreach to immigrant communities: Teaching pediatric residents about access to health care. Journal of Health Care for the Poor and Underserved 18 (3), 510-515. DOI: https://doi.org/10.1353/hpu.2007.0060 Lopes, M.H, Krogstad, J.M., & Flores, A. (2018, September 13). Key facts about young Latinos, one of the nation's fastest-growing populations. Retrieved from http://www.pewresearch.org/fact-tank/2018/09/13/key-facts-about-young-latinos/ ADDRESSING A FEAR OF FAMILY SEPARATION 19 REDCap. (2018). Center for Clinical and Translational Science. Retrieved from https://redcap01.brisc.utah.edu/ccts/redcap/ Rubio-Hernandez, S.P. & Ayón, C. (2016). Pobrecitos los Niños: The emotional impact of antiimmigration policies on Latino children. Children and Youth Services Review 60, 20-26. https://doi.org/10.1016/j.childyouth.2015.11.013 ADDRESSING A FEAR OF FAMILY SEPARATION Appendix A Pre- and one-month post-educational presentation selected survey questions and data 20 ADDRESSING A FEAR OF FAMILY SEPARATION Appendix B Educational Presentation and Introduction of Toolkit 21 ADDRESSING A FEAR OF FAMILY SEPARATION 22 ADDRESSING A FEAR OF FAMILY SEPARATION 23 ADDRESSING A FEAR OF FAMILY SEPARATION 24 ADDRESSING A FEAR OF FAMILY SEPARATION 25 ADDRESSING A FEAR OF FAMILY SEPARATION 26 ADDRESSING A FEAR OF FAMILY SEPARATION 27 ADDRESSING A FEAR OF FAMILY SEPARATION 28