Demographics indicate that pediatricians increasingly care for children in immigrant families in routine practice. Although these children may be at risk for health disparities relating to socioeconomic disadvantage and cultural or linguistic challenges, immigrant families have unique strengths and potential for resilience. Adaptive and acculturation processes concerning health and well-being can be mediated by cultural media. Pediatricians have a professional responsibility to address the medical, mental health, and social needs of immigrant families. Advocacy and research at the practice level and beyond can further explore the unique needs of this population and evidence-based strategies for health promotion.
Key points
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Pediatricians will increasingly care for children in immigrant families (CIF) as part of routine practice.
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A large proportion of CIF are at risk for health disparities relating to socioeconomic disadvantage and cultural and/or linguistic challenges.
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CIF and their families often have strengths that can offer a positive contribution to their health (immigrant paradox).
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Changes in global communication, including cultural media, can have a particular impact on immigrant children and families that may modify acculturation process.
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Pediatricians have a professional responsibility to address the medical, mental health, and social needs of immigrant children and families to optimize the potential of this growing sector of the population.
Introduction
Children in immigrant families (CIF) represent the fastest growing segment of the US population and will soon represent 1 out of every 3 US children. Although CIF are a heterogeneous group with respect to culture, language, social class, and residential status, there are common health-related issues related to provider-patient differences in language and culture. This article highlights the current demographic trends of CIF and reviews the risk for health disparities relating to socioeconomic disadvantage and cultural and/or linguistic challenges, with an emphasis on those CIF who are most at risk for adversity, primarily Latino and some Asian subgroups. Health care providers have a critical role to play to address access to care, address unique health risks and needs, and cultivate resiliency in these new Americans.
Introduction
Children in immigrant families (CIF) represent the fastest growing segment of the US population and will soon represent 1 out of every 3 US children. Although CIF are a heterogeneous group with respect to culture, language, social class, and residential status, there are common health-related issues related to provider-patient differences in language and culture. This article highlights the current demographic trends of CIF and reviews the risk for health disparities relating to socioeconomic disadvantage and cultural and/or linguistic challenges, with an emphasis on those CIF who are most at risk for adversity, primarily Latino and some Asian subgroups. Health care providers have a critical role to play to address access to care, address unique health risks and needs, and cultivate resiliency in these new Americans.
Demographics
CIF are defined as children who are either born outside the United States (immigrant children) or are US citizens and have at least 1 parent born outside the United States. First-generation immigrant children are defined as those born outside the United States, whereas second-generation immigrant children represent US-born children with at least 1 immigrant parent ( Table 1 ). Between 1994 and 2014, the percentage of first-generation or second-generation immigrant children in the United States has risen by 45% (to 18.7 million). Currently, they represent one-quarter of the 75 million children in the US. It is predicted that by 2050, CIF will comprise one-third of more than 100 million US children. It is estimated that during the next 40 years, immigrants and their US-born children will generate almost all growth in the young adult population and nearly all growth of the nation’s labor force.
| Generational Status | Definition |
|---|---|
| First-generation | Children born outside of the United States |
| Second-generation | US-born children with at least 1 immigrant parent |
| Third-generation (and higher) | Children born to US-born parents |
| Immigration Status | Definition as Defined by the United States Citizenship and Immigration Services (USCIS), an Agency of the Department of Homeland Security |
|---|---|
| US Citizen | Children born in the United States or children who are residing as green card holders in the United States and both parents are naturalized before the child’s turns 18 y old |
| Lawful permanent resident (Green Card holder) | Any person not a citizen of the United States who is residing the in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. |
| Refugee | A person outside his or her country of nationality who is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution (and is granted refugee status by USCIS) |
| Asylee | An alien in the United States or at a port of entry who is found to be unable or unwilling to return to his or her country of nationality, or to seek the protection of that country, because of persecution or a well-founded fear of persecution |
| Temporary protected status | Conditions in the country temporarily prevent the country’s nationals from returning safely or, in certain circumstances, in which the country is unable to handle the return of its nationals adequately |
| Special Immigrant Juvenile Status (SIJS) | Humanitarian form of relief available to noncitizen minors who enter the child welfare system due to abuse, neglect, or abandonment by 1 or both parents To be eligible for SIJS, a child must be under 21, unmarried, and the subject of certain dependency orders issued by a juvenile court |
| T Nonimmigrant Status (T visa) | Visa that protects victims of human trafficking and allows victims to remain in the United States to assist in an investigation or prosecution of human trafficking |
| U Nonimmigrant Status (U visa) | Visa for victims of certain crimes who have suffered mental or physical abuse and are helpful to law enforcement or government officials in the investigation or prosecution of criminal activity |
| Mixed-status families | More than 1 US-citizen child and at least 1 undocumented parent |
Although just 10 states (Arizona, California, Florida, Georgia, Illinois, Massachusetts, New Jersey, New York, Texas, and Washington) house nearly three-fourths of these children, there has been significant growth in immigrant populations in other states in recent years. Between 1990 and 2009, the number of CIF increased by more than fivefold in North Carolina, Georgia, Nevada, and Arkansas. State-level data in 2013 indicate that California (48%), Nevada (37%), and New Jersey (36%) have the highest populations of CIF among children living in these states; West Virginia (3%), Montana (4%), and Mississippi (4%) have the lowest ( Fig. 1 ). These data underscore the need for pediatricians to realize the health needs of CIF as part of routine training, practice, and continuing education.
As pediatricians prepare to care for more CIF, demographic shift and linguistic diversity of immigrant populations must be considered. Most CIF are of Latin American origin (including 40% of CIF with parents from Mexico), followed by 20% with parents from Asia (predominantly China, India, and the Philippines). Besides race and Hispanic origin, major differences have been noted among first-generation and second-generation immigrant children by generation, country of origin, poverty status, and family structure. A non-English language is spoken in the homes of 20.3% of the US population. Among CIF, 56% of parents have difficulty speaking English, and 22% of CIF live in linguistically isolated households where no person at least 14 years old speaks English “very well,” However, arrival in the United States before adolescence, living in the United States for a longer period of time, and having a higher level of education are associated with English proficiency. Time in the United States affects immigrant children and their US-born siblings, particularly with respect to language and culture.
Legal status is a complex issue for many CIF. Of CIF, 88% to 89% are US citizens. The remainder include refugees, asylees, those with temporary protected status, and unauthorized children (see Table 1 ). Unauthorized children, or those who are foreign-born without legal status, represent 4% to 6% of the CIF population. The number of US-born children of unauthorized immigrants has been growing and represents about 8% of all US births. It is estimated that 5.5 million children live with 1 unauthorized parent, and 4.5 million of these children are born in the United States Most children of unauthorized immigrants are Latino, with the largest percentage from Mexico. Although 79% of the children of undocumented immigrants are US citizens, mixed-resident status families may include undocumented children. Among undocumented children, unaccompanied minors and children who have been separated from their families are the most vulnerable. Beginning in October 2011, the US government recorded a dramatic rise in the number of unaccompanied and separated children arriving to the United States from El Salvador, Guatemala, and Honduras, as well as children continuing to arrive from Mexico.
Although the United States is a country founded by immigrants, immigration policy is a topic historically marked by confusion and conflict. Immigration policy debate often ensues following increased migration due to war, armed conflict, or political unrest that incites larger flows of immigrants. Several key historical changes ( Table 2 ) in US immigration policy have affected the current state of CIF, particularly the Immigrant Act of 1965, which focused on family reunification. The impact of immigration policy is 2-pronged: the effect on the child and on the parent. Adult deportation policy is a topic of importance for pediatricians because of the profound impact of parental deportation on children’s health. Total deportations more than doubled during the past decade. Yet, recent executive orders, including Deferred Action for Childhood Arrivals (DACA) and the Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA) program, have aimed to promote safety and well-being of children and families who reside in the United States by deferring deportation and allowing work for select undocumented immigrants.
| → | 1875 | → | 1882 | → | 1921 | → | 1965 | → | 1980 | → | 1990 | → | 2000 | → | 2008 | |
| Unrestricted Immigration | Immigration restriction for criminals, prostitutes, and Chinese contract laborers | Chinese Exclusion Act of 1882 specifically prohibits naturalization of Chinese workers | The first numerical immigration quotas provoked a shift in U.S. immigration from Europe to Latin America and Asia | Previous national origin quota systems were abolished, and a new visa system focused on family reunification and skills | Following the Vietnam War, Congress enacted refugee and asylum provisions that brought the United States into compliance with international standards of refugee protection | Temporary Protected Status offers legal status to individuals unable to return to their home countries because of a political or environmental catastrophe | Trafficking Victims Protection Act, addresses human trafficking concerns | All unaccompanied alien children must be screened as potential victims of human trafficking; children from non-contiguous states must be transferred to ORR a within 72 h and simultaneously placed in removal proceedings with EOIR b within the Department of Justice |
Risk from social determinants of health
A myriad of issues are faced by CIF at an individual, family, and societal level ( Table 3 ). Because the health and safety of children depend on the people and environment around them, social determinants of health, briefly defined as “the economic and social conditions that shape the health of individuals and communities,” deserve particular consideration in pediatric practice. US immigrant populations have a broad range of health risks from social determinants, and not all CIF share comparable risks for health disparities. For many immigrant children, however, poverty, low educational level, poor access to health care, legal status, language barriers, and discrimination can have health impacts. Although data exist for some racial and ethnic groups, many health disparities are obscured by the lack of disaggregated data for smaller ethnic populations. Yet, some themes are common across populations, particularly those at greatest risk for health disparities such as Latinos and some Asian subgroups.
| Individual | Family | Society |
|---|---|---|
| Individual health (infectious, congenital, etc) | Intergenerational conflict | Poverty |
| Nutrition and obesity | Acculturation | Health disparities |
| Oral health | Linguistic isolation | Language barriers |
| School readiness | Parental education | Educational opportunity |
| Mental health | Immigration status | Immigration policy |
| Medications (home country, alternative therapies) | Traditional parenting practices | Transportation (access, driver’s license) |
| Fear of parental deportation | Deportation | Unemployment |
| Abuse | Domestic violence | Fear and stigma |
| Health insurance status | Mobility or migration | Health policy |
| Federal benefit eligibility | Food or housing insecurity | Federal benefit eligibility |
Among CIF, 54% live at or below 200% of the poverty line and 12% of parents have less than a ninth-grade education. In the setting of poverty, exposure to violence, and family separation due to migration patterns or deportation, some immigrant children may be predisposed to the impact of toxic stress. When stressful events are long-term, overwhelming, and/or lacking the buffer of stable, responsive support from adults, toxic stress can affect children’s health and even brain architecture. Given that toxic stress can affect children’s health, toxic stress must be considered when evaluating the well-being of CIF. The early identification of CIF who are at risk for toxic stress remains a challenge. Use of validated screening tools for social determinants of health may offer an opportunity to screen CIF for risk factors associated with toxic stress.
Resilience is characterized by successful adaptation to adversity, such as “transforms potentially toxic stress into tolerable stress.” The most important way to build resilience in a child is through a stable, supportive relationship with at least 1 parent or other caring adult. Despite the potential risks for toxic stress, immigrants often demonstrate resilience as observed in several psychological, behavioral, and educational outcomes. In particular, strong social support systems may enhance resilience among CIF, such as being raised in 2-parent families, of which there are a higher proportion in immigrant families, and using extended familial and/or social networks as a way to increase social support and resiliency to toxic stress environments.
The Immigrant Paradox and Health
The immigrant paradox is a phenomenon that highlights the success of children of immigrants beyond expectation based on the key social determinants. Despite higher poverty rates, lower educational levels, and lower access to health care among Hispanic immigrants compared with non-Hispanic whites and US-born Hispanics, they demonstrate similar or better outcomes in several key indicators, including low birth weight and infant mortality. Immigrant women are more likely to initiate and sustain breastfeeding than native women, and immigrants seem to have lower risk of smoke exposure and several chronic physical and mental health conditions when compared with racially and ethnically matched peers. Furthermore, despite a higher prevalence of obesity, physical inactivity, and parental reports of fair or poor child health among immigrant children versus US-born members of the same racial or ethnic groups, ultimate life expectancy is higher among immigrants compared with matched peers. Theories to explain this paradox include the “healthy immigrant effect” (the concept that immigrants may be healthier than those staying in their native countries), lower health-risk behaviors, and higher family and social support. Specifically, CIF are markedly more likely to live in 2-parent households than are children of native-born US citizens. Thus, supporting cultural behaviors may significantly benefit CIF and their families, a role that pediatricians should play in practicing family pediatrics as recommended by the American Academy of Pediatrics (AAP).
The Immigrant Paradox and Education
Immigrant children face learning and education challenges. As early as infancy, immigrant children demonstrate smaller gains in cognitive proficiencies between 9 and 24 months compared with middle-class populations. Children of undocumented parents may face particular risk for lower levels of cognitive development.
Low parental literacy is linked to a limited cognitive home environment. As immigrant toddlers approach early childhood, they are less likely than children of US-born parents to be enrolled in school or center-based preschool programs. Limited school readiness confers academic risk, particularly among children of Latino origin. Due to language barriers and limited functional literacy, many immigrant parents have limited access to early educational opportunities or may struggle to communicate concerns with the school system. Access to early childhood education and care may be particularly exacerbated among smaller minority groups and speakers of languages other than Spanish. At home, parents in immigrant families are less likely to share books with children during early childhood, which can translate into delays in language skills and literacy.
However, older immigrant children show unanticipated educational success. Another aspect of the immigrant paradox, children of immigrant parents have better high school completion, grade point average, and standardized test scores than peers of the same racial, ethnic, or national background who have US-born parents. This phenomenon is stronger for boys than girls and for children of Asian and African immigrants than other groups. Although CIF show this paradox, early childhood development still needs to be a critical focus for these children.
Identity Formation and Health Behaviors in a Changing World
Immigration to a new country is a transformational event in the life of a child and family. It means learning to live, work, and attend school in a new culture with different rules and expectations. Acculturation is defined as “the process of cultural and psychological change in cultural groups, families, and individuals following intercultural contact.” Immigrant children and adolescents may struggle with their identities as Americans because the process of immigration no longer entails complete severance of ties to a native culture. Media (television, print, and Internet) allows immigrant families to live in the United States while maintaining a virtual connection with their home countries. Therefore, mass media and social media may help children and their families develop a hybrid identity as new Americans by offering a connection to their home country while introducing them to the norms of their new home country. This connection is a resource for cultural and identity grounding for children during acculturation.
The process of acculturation varies among CIF based on immigrant parents’ sociocultural, economic, and educational levels with differing impact on physical health, mental health, and behavior. For example, when compared with whites, first-generation Asian adolescents’ preventive health behaviors are reported to be worse but to improve over subsequent generations. Latino adolescents’ behaviors are in some areas similar to whites, and in others worse, with limited change across generations. Among Latino children and adults, acculturation has a mixed impact. It has been associated with poorer health and nutritional outcomes; however, with improved access to and satisfaction with health care come reports of better health. Social activities may reflect different approaches to acculturation, such as participation in traditional dance versus engaging in ballet, and may promote identity formation and resilience. Pediatricians should discuss issues of acculturation with parents and children to evaluate the impact it has on the child’s health and well being.
As immigrant children reach adolescence, sexual health becomes a crucial cultural issue. Nationally, teen birth rates are highest among Hispanic and Latino teens and lowest among Asians and Pacific Islanders. However, teen pregnancy rates vary markedly between and within ethnic groups and must be evaluated in the context of cultural and generational status. Among Hispanic youth, although first-generation youth and those who prefer speaking Spanish are less likely than second-generation and third-generation youth to engage in sexual intercourse before age 18, they are also less likely to consistently use contraception. As sexual behavior may be a taboo topic in some communities, pediatricians should address these issues within a confidential setting and build trust with families while remaining mindful of their cultural values in this important area of adolescent development.
Physical Health Among Immigrant Children
On entry into the health care system, immigrant children and families may be at risk for particular conditions affecting physical health related to disease prevalence in their country of origin or the process of immigration. Infectious diseases are among the most common medical risks for immigrant children. The most commonly encountered infectious diseases include tuberculosis, hepatitis B, parasitic infectious, and sexually transmitted infections; prevalence for these conditions varies significantly based on country of origin, age of child, and individual risk factors. Nutritional issues, impaired vision, and hearing are also important. Children’s health and safety is contingent on a comprehensive medical evaluation that includes screening for and management of commonly encountered medical conditions. Additionally, immigrants visiting their country of origin have disproportionate travel-related infections due to factors such as travel to high-risk destinations, belief that they are immune to disease, and last minute travel planning. The AAP Immigrant Health Toolkit ( http://bit.ly/1y6HR1D ) offers recommendations regarding particular risk factors and screening for immigrant children ( Box 1 ).
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