CHAPTER 41

Working With Immigrant Children and Their Families

Ismael Corral, MD, MBA, and Carol D. Berkowitz, MD, FAAP

The United States is described as a nation of immigrants. Out of a population of 326 million, current estimates are that about 43 million, or approximately 13.2% of the current US population, are foreign-born citizens or noncitizens. Half of these immigrants are Hispanic, and 65% of Hispanics are of Mexican descent. It is expected that by 2030, Hispanic children will account for most children living in the United States. During the 1990s, 70% of the overall US population growth was influenced by a wave of recent immigrants, mostly from Latin America and Asia, and by the children born to these newcomers. The vast growth in the population of children living in immigrant families, whether foreign born (first generation) or US born (second generation), poses a unique set of challenges. This is especially the case in 10 major metropolitan areas that are classified as traditional immigrant destinations, where approximately 48% of immigrant children reside. While this chapter focuses on immigrant children, children of migrant workers, and children living by the United States-Mexico border may face similar issues related to access to quality health care.

Households with immigrant children are more likely to live below the federal poverty level (FPL) and have at least 1 parent who did not graduate high school or is not fluent in English. An estimated 31% of mothers and a similar number of fathers in these families have not graduated from high school. In 2013, 26% of children in immigrant families lived below the FPL, compared with 19% of children whose parents were born in the United States. This has gradually increased since 2006, when 22% of children in immigrant families lived below the FPL. These children are also more likely to live in crowded housing (>1 person per room) and in a multigenerational household. Families of immigrant children tend to be larger, with 19% having 5 or more children, compared with families of children born in the United States, of which only 14% are of that size. While some immigrant children are citizens and eligible for safety net programs, their family’s status directly influences whether these children will even access such care. Children of immigrant parents are twice as likely to be uninsured (15%) as children in nonimmigrant families (8%). There is also growing concern that the health status of some immigrant children, whether foreign born or first generation, actually declines after settling in the United States.

Demographics of Immigrant Children

There are 5 general categories of immigrants in the United States, each benefiting from specific entitlements and services and having certain legal rights: lawful permanent residents, naturalized citizens, refugees/asylees, nonimmigrants, and undocumented immigrants (Box 41.1).

In 2007, individuals who had become naturalized citizens included immigrants (32%), lawful permanent residents (29%), undocumented immigrants (29%), refugees (7%), and nonimmigrants (3%). From 1980 to 2000, the children of immigrants increased from 5% to 20% of school-age children, representing approximately 10 million of the estimated 60 million school-age children in the United States.

By far the largest category of immigrants is nonimmigrants or temporary visitors. Approximately 3 million children arrive each year, mostly from Asia, Western Europe, and parts of North America, typically accompanying their parents, who are seeking work. A smaller percentage are students or exchange visitors. While not technically immigrants, this special group may present for care with similarly unaddressed health issues depending on their country of origin.

The next largest group, almost a quarter-million children, enter the United States as lawful permanent residents, with most eventually becoming naturalized citizens. Although most arrive with or to meet family already residing in the United States, several thousand adolescents immigrate unaccompanied each year; most are female, and many are married to a naturalized citizen at the time of immigration. Included in this group are children of refugees or asylees. More than 75,000 individuals arrive each year, most recently from the countries of the former Yugoslavia and former Soviet Union, Vietnam, Somalia, and other war-torn regions. Numbers for the third-largest group, undocumented immigrants, are based primarily on estimates. Most are from Mexico or other Latin American states. Some entered the United States legally but have overstayed their visa or lost their status by committing a crime.

While most pediatricians are not in a position to assist families in their efforts to attain citizenship or legal status, programs such as the National Center for Medical-Legal Partnership (https://medical-legalpartnership.org) may provide necessary advice and services. There is also an Immigrant Child Health Toolkit available through the American Academy of Pediatrics (AAP) that provides primary care physicians with immigration-specific resources readily available within their area.

Health Care Needs of Immigrant Children

When the child of an immigrant family presents for care, primary concerns are about the presence of an infectious disease (from exposures and possible lack of vaccination) or of a hidden genetic or ethnic condition (eg, hemoglobinopathies, glucose-6-phosphate dehydrogenase deficiency). Investigating the health status of a child, especially from undocumented immigrant families, is paramount because these children likely have not seen a doctor prior to immigrating. Similarly, nonimmigrants, such as tourists and other temporary visitors, from many Western or Pacific Rim countries are not required to have a medical examination performed as part of their application. Only visas for permanent residency require a health examination to be performed by an approved physician, and even then, the focus of the examination is to exclude certain conditions, such as active tuberculosis (TB), HIV, and other severe physical or mental disabilities. In children, laboratory testing may be limited, and proof of vaccination status may be exempted for certain groups, such as international adoptees.

Lack of education and poverty, which results in relative food insecurity and inadequate, crowded housing conditions, poses an ominous threat to the health of these same children. Immigrant parents of children born in the United States may be reluctant to apply for Medicaid or the Children’s Health Insurance Program for fear of being considered a public charge (ie, a person dependent on the government for expenses of living). The Patient Protection and Affordable Care Act of 2010 excluded undocumented immigrants from health care coverage. Noncitizen children who are lawful permanent residents must wait at least 5 years before they are able to apply for public assistance. While most refugee children may receive some form of subsidized care, such as Medicaid, many of these benefits are time-sensitive. Even US-born children of undocumented mothers, while legally eligible as US citizens for benefits such as nutritional assistance programs, may not receive these because of parental fears of detection and deportation.

Physicians should ascertain that the family has adequate housing and access to food, 2 basic human needs. The physician should take the following factors into consideration during health supervision visits (Box 41.2): Is the food available in the family’s neighborhood consistent with the traditional food that the family desires? Is the food healthy, or does the family live in a food desert where there is a plethora of fast-food restaurants and a paucity of supermarkets or grocery stores? The ability to safely attend the local park, walk around the neighborhood, or even go outside the family’s own home should be determined, as any of these factors may interfere with treatment plans. In cases in which safety or access is an issue, information about local community centers should be provided during clinic visits. Often, families may not be aware of affordable, local, easily accessible resources.

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