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From the American Academy of PediatricsPolicy Statement

Providing Care for Children in Immigrant Families

Julie M. Linton, Andrea Green and COUNCIL ON COMMUNITY PEDIATRICS
Pediatrics September 2019, 144 (3) e20192077; DOI: https://doi.org/10.1542/peds.2019-2077
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Abstract

Children in immigrant families (CIF), who represent 1 in 4 children in the United States, represent a growing and ever more diverse US demographic that pediatric medical providers nationwide will increasingly encounter in clinical care. Immigrant children are those born outside the United States to non–US citizen parents, and CIF are defined as those who are either foreign born or have at least 1 parent who is foreign born. Some families immigrate for economic or educational reasons, and others come fleeing persecution and seeking safe haven. Some US-born children with a foreign-born parent may share vulnerabilities with children who themselves are foreign born, particularly regarding access to care and other social determinants of health. Therefore, the larger umbrella term of CIF is used in this statement. CIF, like all children, have diverse experiences that interact with their biopsychosocial development. CIF may face inequities that can threaten their health and well-being, and CIF also offer strengths and embody resilience that can surpass challenges experienced before and during integration. This policy statement describes the evolving population of CIF in the United States, briefly introduces core competencies to enhance care within a framework of cultural humility and safety, and discusses barriers and opportunities at the practice and systems levels. Practice-level recommendations describe how pediatricians can promote health equity for CIF through careful attention to core competencies in clinical care, thoughtful community engagement, and system-level support. Advocacy and policy recommendations offer ways pediatricians can advocate for policies that promote health equity for CIF.

  • Abbreviations:
    AAP —
    American Academy of Pediatrics
    CIF —
    children in immigrant families
    DACA —
    Deferred Action for Childhood Arrivals
    FGC/M —
    female genital cutting or mutilation
    LEP —
    limited English proficiency
    LPR —
    lawful permanent resident
    PTSD —
    posttraumatic stress disorder
    TPS —
    temporary protected status

    • Demographics

    Health care of children in immigrant families (CIF) in the United States has received increasing attention over the past decade, in part because of increasing migration of children caused by conflicts globally, greater diversity among migrant populations, and divisive sociopolitical discussion regarding immigration policy. Definitions regarding immigrant children vary, but for the purposes of this policy statement, immigrant children are those born outside the United States to non–US citizen parents. The term CIF includes both those who are foreign born and those who are born in the United States and have at least 1 parent who was foreign born. In 2015, 43 million people, representing 13% of the US population, were immigrants, approaching the historic high of 14.8% in 1890.1,2 Currently, 3% of US children are foreign born, and 25% of US children live in immigrant families.3,4 It is projected that by 2065, 18% of the US population will be foreign born and an additional 18% will be US-born children of immigrants.2 Immigrant children and CIF reside in all 50 states (Figs 1 and 2).

    FIGURE 1
    FIGURE 1

    Population of immigrant children in the United States, 2017. Reprinted with permission from The Annie E. Casey Foundation, KIDS COUNT Data Center, https://datacenter.kidscount.org.

    FIGURE 2
    FIGURE 2

    CIF, 2016. Reprinted with permission from The Annie E. Casey Foundation, KIDS COUNT Data Center, https://datacenter.kidscount.org.

    Children immigrate to the United States with or without their parents for diverse and complex reasons, including, but not limited to, economic needs, educational pursuits, international adoption, human trafficking, or escape from threatening conditions in pursuit of safe haven. Immigrants may arrive with temporary visas (eg, work visa, student visa, tourist visa, J-1 classification), have or obtain permanent permission to remain in the United States (eg, lawful permanent residents [LPRs] or “green card” holders), come with refugee status, seek legal protection on arrival to the United States, or remain without legal status (Table 1). Refugees, who obtain legal status before arrival, and asylees, who can obtain legal status after arrival in the United States, must have a well-founded fear of persecution based on race, religion, nationality, sexual/gender orientation, political opinion, or membership in a particular social group.5 LPRs and refugees can apply for citizenship after 5 years of living in the United States.6 In addition to asylum, other forms of protection (eg, special immigrant juvenile status, T nonimmigrant status, and U nonimmigrant status) may also be available to particular children and families seeking safe haven in the United States.7 If parents or children do not qualify for a legal form of protection, they may choose to remain in the United States without legal status. Specifically, approximately 11.1 million individuals in the United States lack current legal status,8 and 5.1 million US children live with at least 1 immigrant parent without legal status.9

    View this table:
    TABLE 1

    Definitions

    In 2016, half of the 22.5 million refugees worldwide were 18 years or younger, and less than 1% are resettled annually.10 Ongoing humanitarian needs are acutely exacerbated by global migration crises, exemplified by the displacement of nearly 12 million Syrians by the end of 2015.10 The number of refugees entering the United States is set annually by Congress and the president and historically has fluctuated on the basis of sociopolitical events. All 50 states, with the exception of Wyoming, have refugee resettlement programs.11

    Migration to the United States varies on the basis of global poverty, armed conflict, and exceedingly complex sociopolitical circumstances. Despite these complexities, the United Nations Convention on the Rights of the Child, endorsed by the American Academy of Pediatrics (AAP) but not ratified by the US government, is an internationally recognized legal framework for the protection of children’s basic rights, regardless of the reasons children migrate.12,13 The AAP policy statement “The Effects of Armed Conflict on Children” delineates the impact of armed conflict on children and the role of child health professionals in a global response.14

    Responses to migration, and especially migration of children, are equally varied and complicated.15 For instance, increasing arrivals of unaccompanied children and family units from Guatemala, Honduras, El Salvador, and Mexico at the southern US border beginning in 2014 triggered a series of governmental responses, including escalating detention of immigrant children, described in detail in the AAP policy statement “Detention of Immigrant Children.”7,16 Additionally, the Deferred Action for Childhood Arrivals (DACA) program was developed to allow young adults who had arrived in the United States as children without legal status but had grown up in the United States to apply for deportation relief and work permits.15 A related program, Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA), would have offered similar protections for parents without legal status who have US-born children, but it was halted in federal courts and was subsequently rescinded by presidential executive order before it could be implemented.15,17 In 2017, the president signed new executive orders focused on heightened immigration enforcement, increased border security, and limits to the US refugee program. Furthermore, changes to temporary protected status (TPS), granted to individuals physically present in the United States who are from countries designated by the secretary of the US Department of Homeland Security as unsafe to accept their return, have created uncertainty for the nearly 320 000 TPS beneficiaries and their families.18

    In addition to changes in the numbers and demographics of immigrants and the legal protections afforded them, family immigration status represents an important and often-neglected social determinant of health. The immigration status of children and their parents relates directly to their subsequent access to and use of health care, perceived health status, and health outcomes.7,19–26 Family immigration status is intertwined with other social determinants of health, including poverty,27 food insecurity,28,29 housing instability,30,31 discrimination,32,33 and health literacy.34–37

    Resilience and Integration

    Despite the challenges that immigrant children and families often face, many offer tremendous assets and demonstrate remarkable resilience. On first arrival in the United States, immigrant children may be healthier than native-born peers, a phenomenon often described as “the immigrant paradox” or “the healthy immigrant effect.”27,33 A strengths-based approach to immigrant child health celebrates assets of immigrant families and populations, buffers marginalization, and supports integration. Understanding cultural assets, such as ethnic-racial identity and cultural values, may offer opportunities to build resilience among immigrant children.38–40 Furthermore, recognizing assets facilitates productive dialogue that supports immigrant families not as threats but as valuable resources to our society.40

    Cultural Humility and Safety

    When caring for CIF, health care providers must recognize the role culture plays in understanding illness without reflexively assuming that challenges are always attributable to cultural differences.41–45 Because culture is dynamic, cultural competency is never fully realized,46 but rather serves as a developmental process.47 Providers bring personal cultural biases, as well as biases of biomedicine, that can implicitly or explicitly affect the provision of care.48,49 Cultural humility is the concept of openness and respect for differences.50–52 Cultural safety reflects the recognition of the power differences and inequities in health and the clinical encounter that result from social, historical, economic, and political circumstances.53–55 By recognizing ourselves and others as cultural beings, by building trust through respect and awareness of power differentials and cultural beliefs, and by developing and implementing communication skills that facilitate mutual understanding, health care providers work to minimize disparities and promote equity in a health encounter.

    Culturally sensitive systems of health care, ones that value cultural humility and safety, emerge when patients and families are engaged with 3 core values: curiosity, empathy, and respect.56 Some immigrants bring with them a system of healing that, like biomedicine practiced in the United States, claims to be curative, includes interventions that can be applied by an expert practitioner, and offers a body of theory regarding disease causation, classification, and treatment.57 With acculturation, these individuals may or may not modify their healing system to incorporate biomedical concepts. Culturally sensitive care systems have the flexibility to support health literacy, to recognize values of community and family that may supersede individual rights, to engage spirituality and respect traditions, and to include diverse perspectives in implementation and evaluation. The reciprocity of culturally sensitive health care offers us a wider lens that reduces health inequities and strengthens the practice of healing through multicultural medicine and medical practice that acknowledges nonallopathic traditions.58,59

    Care of CIF: Core Competencies

    Immigrant children benefit from increased access and communication offered in a patient- and family-centered medical home with an identified primary care provider in which care “is respectful of and responsive to individual patient preferences, needs, and values.”60–64 The medical home, infused with cultural humility and safety, supports continuous, comprehensive, and compassionate care and increases collaboration with community supports, including schools, places of worship, legal agencies, and extracurricular activities. Interpreters are an essential part of the medical team to support health literacy, improve access, and ensure quality medical care.65,66 However, disparities in access to care for CIF, and especially for those with special health care needs, have persisted.24,25,67–72 Immigrant families, particularly those with children with special health care needs, often benefit from intensive supports in negotiating a complex medical system, special education system, and network of community resources. Pediatric providers can play a lead role for the medical home team in implementing and educating on core competencies that are meant to build health equity for CIF. Core resources for the provision of care for CIF include, but are not limited to, the AAP Immigrant Child Health Toolkit44 and the Centers for Disease Control and Prevention Refugee Health Guidelines.73

    Cross-cultural Approach

    Rather than learning generalities of a given culture, a practical framework can guide the clinical approach.74,75 A classic patient-based model recommends assessing for core cross-cultural issues, exploring the meaning of the illness, determining the social context, and engaging in negotiation around treatment plans.76 Core cross-cultural issues include styles of communication, trust, family dynamics, traditions and spirituality, and sexual and gender considerations.75 Kleinman and Benson’s45 7 questions for cultural assessment are helpful to explore patient’s perspectives; most crucially, this includes what matters most to the patient and family within the context of illness and treatment (Table 2). The efficacy of treatment may need to be understood “within the scope of cultural beliefs and not that of the scientific evidence.”77,78 Therefore, there may be need for cross-cultural negotiation facilitated through tools like “LEARN” (listen, explain, acknowledge, recommend, negotiate).57,79

    View this table:
    TABLE 2

    Questions to Elicit the Patient Explanatory Model

    Knowledge and skills can be developed regarding cross-cultural patient care, migration health issues, and unique vulnerabilities and strengths of immigrant families. Although all children and families are unique, origin-country profiles may be helpful to provide generalized information about immigrant groups.80–82

    Migration Health Issues

    Care of immigrant children requires knowledge of unique health issues in the child’s country of origin and country or countries of refuge before arrival as well as an understanding of the challenges of resettlement and acculturation once within the United States. When taking a medical history, it is therefore necessary to elicit details of migration73 as well as the child’s birth; medical, immunization, developmental, social, and family history; and exposure to trauma and violence.73,83 Past medical and immunization records may require translation as well as awareness and management of different global immunization schedules.84,85 CIF often return to their families’ countries of origin to visit relatives, and providers need to be familiar with travel risks, prophylactic medications, and unique vaccine needs.86

    Communicable Disease

    When screening for and treating infectious diseases, a public health approach is advantageous.44,87 For refugees, some screenings may have been performed in another country, and presumptive treatments may have been provided through the International Organization for Migration.88 Depending on the migration history, immigrant children may need screening on arrival in the United States for infectious diseases (eg, tuberculosis; malaria; Chagas disease; intestinal parasites such as helminths, schistosomiasis, and strongyloides; chronic hepatitis B; HIV; syphilis; and other vertically and horizontally transmitted sexual infections).44,87–94 Comprehensive reproductive and mental health services are warranted for immigrant children with a history of sexual activity, trafficking, exploitation, or victimization.

    Oral Health

    The global burden of oral diseases is high.95 Caries risk varies depending on previous country of residence.96,97 Differences in oral health may reflect cultural practices and norms related to weaning and brushing, dietary changes, and limited oral health literacy.98–101 Access to dental services and education on oral health is essential for immigrant children.102

    Noncommunicable Disease

    The incidence of noncommunicable diseases globally has grown.103–105 Rates of asthma, obesity, autism,106–110 depression, anxiety, and posttraumatic stress disorder (PTSD) may be similar or disproportionately increased in immigrant children.71,111–114 In addition, newly arrived immigrant children may present with diseases not yet diagnosed or further progressed. Examples include genetic conditions related to consanguinity. Furthermore, newborn screening for hearing loss, hypothyroidism, metabolic diseases, or hemoglobinopathies may not have been performed.94,115 Vision problems and elevated blood lead concentrations are also common and must be considered.94,116–120

    Nutrition and Growth

    During assessment of nutrition and growth on entry into medical care, immigrant children may be recognized as wasted, having underweight, having overweight, or stunted.97,121–124 Health care providers will need to be familiar with global diets, dietary restrictions, and vitamin and nutrient sources.124–126 Anemia, thalassemia, glucose-6-phosphate dehydrogenase deficiency, and micronutrient deficiencies (including iron, vitamin D, and vitamin B12) may exist.97,127–129 Families can be screened for food insecurity and connected to relevant resources.126,130,131

    Developmental and Educational Considerations

    Age-appropriate developmental and behavioral screening is possible with the use of validated multilingual screening tools, such as the Ages and Stages Questionnaire132 and the Survey of Well-being of Young Children,133 and with historical assessment of milestones.134,135 Care must be taken to recognize cultural bias and experiential differences in skill development.136–139 Screening needs to be sensitive to cultural differences in parenting140,141 and disparities in reading or sharing books with children,142 but referral should not be delayed if screening results are concerning.143 Age-appropriate vision and hearing screening is essential.144 Providers’ encouragement of a language-rich environment in the parent’s primary language recognizes the strengths of bilingualism.145–150

    One in 10 students from kindergarten to 12th grade in the United States is an English-language learner.151 Dual-language learners, defined as children younger than 8 years with at least 1 parent who speaks another language in the home other than English, make up one-third of young children in the United States currently. Dual-language learners are less likely to be enrolled in high-quality early child care and preschools compared with peers, potentially limiting kindergarten readiness.152,153

    All children are entitled to free public education and specialized educational services regardless of immigration status.154 Immigrant children may face particular academic challenges.155,156 Before arrival to the United States, some children may have had no opportunity for formal schooling or may have faced protracted educational interruptions. Students with interrupted or no schooling may lack strong literacy skills, age-appropriate content knowledge, and socioemotional skills; in addition, they may need to learn the English language.157 Learning may also be affected by traumatic brain injury, cerebral malaria, malnutrition, personal trauma, in utero exposures (eg, alcohol),94 and toxic exposures (eg, lead).116–120 Testing for developmental and learning challenges in the school setting may result in overrepresentation of students with limited English proficiency (LEP) in special education.158–161 Through collaboration with parents and schools, pediatricians can facilitate thoughtful consideration of learning difficulties in the setting of LEP. Supplemental anticipatory guidance may include recognition of family strengths and differences in parent-child relationships, child-rearing practices and discipline, dietary preferences, safety risks and use of car restraints and safe sleep practices, and acculturation.162–168

    Mental Health

    Many immigrant children and youth may have had disruptions to the basic experiences that allow for healthy development.169 Immigrant children and their families may experience trauma before migration, during their journey, on arrival at our borders, and while integrating into American communities170–176 and, as a result of their increased risk, require “health and related services of a type or amount beyond that required by children generally.”177 Trauma may include personal history of physical or sexual abuse, witnessing interpersonal violence, human trafficking, actual or threatened separation from parents, or exposure to armed conflict.173,174,176,178 Traumatized children with traumatized parents (or, in some cases, without their parents) may be at risk for toxic stress or prolonged serious stress in the absence of buffering relationships.179 In addition to intergenerational transfer of mental health problems, core stressors include trauma, acculturation, isolation, and resettlement.172 In particular, acculturation includes stressors that families experience as they navigate between the culture of their country of origin and the culture in their new country.172

    On arrival, many refugee and unaccompanied children have high levels of anxiety, depression, and PTSD.174,180–186 Compared with US- origin youth, refugee youth have higher rates of community violence exposure, dissociative symptoms, traumatic grief, somatization, and phobic disorder.187 Unaccompanied minors have even higher levels of PTSD compared with accompanied immigrants,188 which may be further heightened if they are seeking asylum.189 Immigration-related trauma history may be shared over time as a trusting relationship develops with the physician.190 Some CIF who were born in the United States may face difficulty with emotional and behavioral problems relating to identity formation.191 Initial and ongoing screening for mental and behavioral health problems with multiple cross-culturally validated tools (eg, the Ages and Stages Questionnaire-Social Emotional, the Survey of Well-being of Young Children, the Strengths and Difficulty Questionnaire, the Refugee Health Screener 15, and the Child Behavior Checklist) facilitates recognition of distress and concerns.44,132,133,192–195

    By understanding the interplay of biological, social, environmental, and psychological risk and protective factors, emotional disorders can be modulated on population, community, and individual levels.196 Protective factors and sources of resilience observed in immigrants include having a positive outlook, having strong coping skills, having positive parental coping strategies, connection to prosocial organizations such as places of worship and athletics, and cultural pride reinforcement.32,197–200 Resilience is fostered through strong family relationships and community support.201 Bicultural identity, a strong attachment to one’s culture of origin in addition to a sense of belonging within the culture of residence, promotes resilience.140,202

    Because of the shame and stigma associated with mental health problems, families may be reluctant to seek treatment.203 Providers can increase access and minimize stigma by integrating culturally tailored mental health services into the medical home, in the school setting, and through engagement with community mental health resources,78,175,204 including home visitation.205 Community-wide strategies that foster belonging, reduce discrimination, and provide social supports can facilitate healing and reduce stigma.

    Traditional Health Care and Cultural Practices

    Traditional healing and cultural practices, common among some immigrant populations, warrant awareness by health care providers.206 Patients may not disclose use of herbal and traditional treatments unless directly asked.42,207 Some immigrant families use traditional forms of protection for vulnerable infants, such as prayer, amulets, kohl, or myrrh. Other immigrant families use traditional practices to treat illness (eg, cupping, coining, and uvulectomy), and stigmata of these traditional treatments may be observed on examination and may be misinterpreted as abuse.208,209

    Female genital cutting or mutilation (FGC/M) is still practiced in some communities in Africa, in the Middle East, and in parts of Asia despite increased efforts to educate on risks.210,211 Performing FGC/M is against the law in the United States and has been defined as torture by the United Nations, but foreign-born girls may have experienced this before entry into the United States.210,212 Resources exist regarding the types of FGC/M, complications that can result, recommended documentation in the medical record, and strategies to sensitively discuss this with families.213,214 In 2013, the United States passed the Transport for Female Genital Mutilation Act, which prohibits knowingly transporting a girl out of the United States for the purpose of “vacation cutting.”215 The need to screen for FGC/M further underscores the importance of examining the external genitalia of children at all preventive visits in addition to sensitively counseling families regarding the laws and other concerns regarding FGM/C.

    Practice-Level Barriers and Potential Opportunities

    Communication challenges between families with LEP and health care providers must be addressed to provide high-quality care. Fifty-four percent of CIF have resident parents who have difficulty speaking English.3 Parental LEP is associated with worse health care access and quality for children.216–220 National Standards for Culturally and Linguistically Appropriate Services in Health Care were issued by the US Department of Health and Human Services, in accordance with Title VI of the Civil Rights Act. Culturally and Linguistically Appropriate Services in Health Care Standards describe the federal expectation that health care organizations receiving federal funding must provide meaningful access to verbal and written-language services for patients with LEP.221,222 Interpreters are an integral part of the medical home team for CIF and hold the same confidentiality standards as the physician.67,68 Most state insurance programs and private insurers do not offer reimbursement for language services. Although teaching health care providers when and how to work with interpreters can improve care, few providers receive such training.223,224 For these and other reasons, some providers inappropriately use family members as ad hoc interpreters.225 However, family members, friends, and especially children are not acceptable substitutes for trained interpreters.226,227 Trained medical interpreters, via phone or tablet or in-person, facilitate mutual understanding and a high quality of communication.228,229 Use of trained interpreters maintains confidentiality, reduces errors and cost, and increases the quality of health care delivery.227,228,230–232 Interpretation requires that extra time be allotted to health care encounters. Qualified bicultural and bilingual staff can receive medical interpreter training if expected to perform as interpreters, and bilingual providers can ideally demonstrate dual-language proficiency before engaging with families in their preferred language without an interpreter.233–235 Access can be further improved by the use of multilingual signage, screening tools, handouts, and other key documents (eg, consent forms and hospital discharge summaries) that are prepared by qualified translators.

    Although some immigrant families integrate without hardship, many CIF face inequities resulting from complex determinants, including poverty, immigration status, insurance status, education, and discrimination on the basis of race and/or ethnicity.32,33 For some, fear regarding family immigration status threatens children’s health, development, and access to care.22,32,236–238 For others, growing up in 2-parent families and having environmental stimulation at home, particularly for those with low socioeconomic status, may be protective.33,239 Screening for social determinants of health can trigger referrals to community-based supports.240 The hallmarks of the medical home, comprehensive care and enhanced care coordination, are important supports for immigrant families. Integrated mental health, nutrition, social work, and patient navigation services allow for ease of access and for reduction in stigma and barriers. Community health workers who are members of immigrant communities have been effective in reducing disparity and improving health outcomes.241–246 Interagency partnerships with the local health department, home-visiting programs, community mental health providers, schools, and immigrant service organizations facilitate access to medical homes and cross-sector communication. “Warm hand-offs,” or in-person transfer of care between health care team members with patients and families present, can help to ensure linkage between providers and relevant resources.247

    Systems-Level Barriers and Potential Opportunities

    Health literacy challenges experienced by CIF include not only language comprehension but also the myriad of system barriers in the health care network. Limited health literacy can complicate enrollment in public benefits for CIF. Immigrant children are specifically less likely to have a medical home67,68 and health insurance, resulting in delayed or foregone care.248 Most immigrant children with legal status are eligible for health coverage. A majority of states have opted to allow lawfully residing immigrant children to receive Medicaid and/or Children’s Health Insurance Program coverage using federal Medicaid and Children’s Health Insurance Program funds without a 5-year waiting period, an option given to states by the Children’s Health Insurance Program Reauthorization Act of 2009; however, 17 states have not taken the Children’s Health Insurance Program Reauthorization Act of 2009 option.249–253 Only a minority of states offer health coverage to children regardless of immigration status.252,253 Additionally, immigrant children without legal status, including DACA youth, are excluded from eligibility for most federal programs, including health insurance, although some states have included and/or are considering inclusion of DACA youth (or, more broadly, other noncitizen children) as eligible for programs such as in-state tuition or professional licensing.254,255 Opportunities to mitigate these literacy, access, and health insurance enrollment challenges include system-wide use and funding of interpreters and multilingual tools and use of community health workers and patient navigators to reduce barriers through facilitation, education, and advocacy.43,58,59,256,257 For CIF without health coverage, federally qualified health centers, public health departments, free clinics, and charity care systems may offer access to consistent care. Home-visiting programs can support immigrant parents and parents with LEP who may be isolated and unable to access public services152,258; attention to cultural safety is particularly critical when engaging in home-based services. Quality after-school programming, with support of school social work, can also facilitate integration and build resilience for CIF.259,260

    Immigration and Related Legal Issues

    Federal immigration policies can adversely affect immigrant health coverage, access, and outcomes. Immigration status of children and/or their parents continues to affect access to services and public benefits, despite some improvement.33,261,262 Increased fears about the use of public programs and immigration status has deterred immigrants from accessing programs regardless of eligibility.263–265 In addition, immigration enforcement activities that occur at or near sensitive locations, such as hospitals, may prevent families from accessing needed medical care.264 Sensitive locations include medical treatment and health care facilities, places of worship, and schools, and US Immigration and Customs Enforcement actions, including apprehension, interviews, searches, or surveillance, should not occur at these locations.266,267 Fear of immigration enforcement or discrimination may exacerbate transportation barriers and worsen perceived access to care.23,237,268–271 Discrimination relating to immigration may intersect with religion (eg, Muslim immigrants) and race in complex ways.264,272–274 Discrimination and immigration enforcement policies may also create fear and uncertainty, which threaten the mental health of immigrant children275 and their families.19,236,264,276 Families living on the US-Mexico border face particular risk of mistreatment and victimization.277 Policies that offer protection from deportation, such as DACA, may confer large mental health benefits for youth and for the children of parenting youth.278,279

    Immigrant children who have been detained and are in immigration proceedings face almost universal traumatic histories and ongoing stress, including actual or threatened separation from their parents at the border.7 Immigrant children, including unaccompanied children, are not guaranteed a right to legal counsel, and as such, roughly 50% of children arriving in the United States have no one to represent them in immigration court.280 Lack of guaranteed legal representation for immigrant children and families at risk for deportation is further complicated by funding restrictions; specifically, medical-legal partnerships receiving federal funding that operate under Legal Services Corporation guidelines cannot accept most cases related to immigration.281 Many nongovernmental efforts have sought to address lack of legal representation for children, but opportunities remain to better provide immigration-specific legal support for immigrant families,282,283 including novel medical-legal partnerships with different funding streams that do not exclude people without legal status and offer representation in immigration court. In addition, traumatized immigrant children can benefit from system-level supports for integration of mental health and social work supports into schools, the medical home, and protected community settings.284

    Evidence-based programs can systematically build resilience among CIF by supporting integration into US culture while preserving home cultural heritage. Although specific evidence regarding CIF is limited, home-visiting programs offer opportunities to celebrate unique strengths and mitigate stress in a natural environment.258,285 Programs that support literacy and encourage play, such as Reach Out and Read, can reinforce parent-child relationships, build parenting skills, support development, and prepare children for academic success.150,286,287 For children experiencing parental reunification after prolonged separation, mental health services and educational support are particularly critical.238 Given the strong role of communities in many cultures, community-based interventions may be particularly effective for immigrant families.

    Opportunities to investigate strategies, mitigate barriers, and optimize health and well-being for CIF include research, medical education, and community engagement, including community-based participatory research and health education. Research used to examine acculturative stress and resilience of immigrant children over time is limited. Among CIF, diversity within and between racial and ethnic groups (eg, Hispanic, Asian, African, and Caribbean) and between CIF of varying socioeconomic statuses is also understudied and underappreciated.288 Medical education has become increasingly responsive to health disparities for immigrants and to the opportunities for experiential broadening of global health. By implementing core competencies in the care of immigrant populations, trainees can learn to support a culture of health equity for CIF. Pediatricians can support families within and beyond the medical home through efforts supported by cross-sector community collaboration, including fields such as education and law, innovative research, and thoughtful advocacy, to inspire progressive policy.171,180,289 Grants that are focused on minority and underserved pediatric populations have the potential to mitigate inequities for immigrant children.171

    Summary and Recommendations

    With ever-increasing levels of migration worldwide, the population of CIF residing in the United States grows. The following practice- and policy-level recommendations offer guidance for pediatricians caring for CIF. Although it is aspirational to fully implement all recommendations in all situations, most are achievable by intentionally enacting practice- and systems-based changes over time.

    Practice-Level Recommendations

    1. All pediatricians are encouraged to recognize their inherent biases and work to improve their skills in cultural humility and effective communication through professional development.

    2. CIF benefit from comprehensive, coordinated, continuous, and culturally and linguistically effective care in a quality medical home with an identified primary care provider.

    3. Co-located or integrated mental health, social work, patient navigation, and legal services are recommended to improve access and minimize barriers.

    4. Trained medical interpreters, via phone or tablet or in-person, are recommended to facilitate mutual understanding and a high quality of communication. Family members, friends, and especially children are not recommended for interpretation. Materials may be translated into the patient’s preferred language by qualified translators whenever possible. Consideration should be given for the extended time needed for interpretation during medical encounters.

    5. It is recommended that pediatricians and staff receive training on working effectively with language services and that bilingual providers and staff demonstrate dual-language competency before interacting with patients and families without medical interpreters.

    6. Pediatricians and pediatric trainees are encouraged to engage in professional development activities that include specific competencies (including immigrant health; global health, including the global burden of disease; integrative medicine; and travel medicine) and to incorporate these competencies into the evaluation and care of CIF.

    7. Pediatricians caring for CIF are urged to apply a trauma-informed lens, with sensitivity to and screening for multigenerational trauma. Mental health professionals adept at treating immigrants can be integrated into the medical home or identified in the community.

    8. Screening for social determinants of health, including risks and protective factors, is recommended.

    9. Assessment of development, learning, and behavior is warranted for all immigrant children, regardless of age. Pediatricians can support dual language as an asset and as part of cultural pride reinforcement.

    Advocacy and Policy Recommendations

    1. The AAP endorses the United Nations Convention on the Rights of the Child and the principles included in this document as a legal framework for the protection of children’s basic rights.

    2. All US federal government, private, and community-based organizations involved with immigrant children should adopt policies that protect and prioritize their health, well-being, and safety and should consider children’s best interests in all decisions by government and private actors.

    3. Interagency collaboration is recommended between service providers (eg, medical, mental health, public health, legal, education, social work, and ethnic-community based) to enhance care, prevent marginalization of immigrant families, and build resilience among immigrant communities.

    4. Health coverage should be provided for all children regardless of immigration status. Neither immigrant children with legal status nor their parents should be subject to a 5-year waiting period for health coverage or other federal benefits.

    5. Private and public insurance payers should pay for qualified medical interpretation and translation services. Given the increased cost-effectiveness and quality of care provided with medical interpretation, payers should recognize and reimburse for the increased time needed during a medical encounter when using an interpreter.

    6. Both the separation of children from their parents and the detention of children with parents as a tool of law enforcement are inhumane, counterproductive, and threatening to short- and long-term health. Immigration authorities should not separate children from their parents nor place children in detention.

    7. Immigration enforcement activities should not occur at or near sensitive locations such as hospitals, health care facilities, schools (including child care and Head Start), places of worship, and other sensitive locations. Pediatricians have the right to report and protest any such enforcement. Medical records should be protected from immigration enforcement actions. Health systems can develop protocols to minimize fear and enhance trust for those seeking health care.

    8. Children in immigration proceedings should have access to legal representation at no cost to the child. Medical-legal partnerships that include immigration representation (eg, Terra Firma290) and efforts to increase legal representation (eg, KIND,291 the Young Center for Immigrant Children's Rights,292 RAICES293) should be supported practically and financially at local, state, and federal levels.

    9. Immigration policy that prioritizes children and families by ensuring access to health care and educational and economic supports, by keeping families together, and by protecting vulnerable unaccompanied children is of fundamental importance for comprehensive immigration reform. Humanitarian protection (eg, refugee resettlement and protection for victims of trafficking and asylum seekers) supports trauma-informed care of children and is an essential component of immigration policy.

    10. All children with LEP merit early, intensive, and longitudinal educational support with culturally responsive teaching. Literacy skills are necessary for health literacy, an essential health need.

    11. Enhanced funding is recommended to support research regarding immigrant child health, including, but not limited to, health outcomes; screening tools for development, mental health, and social determinants of health that are culturally and linguistically sensitive; developmental and/or learning difficulties in children whose home language is not English; and reduction of barriers to health access and equity.

    12. Medical education can facilitate education of trainees and health care professionals through implementation of core competencies in the care of immigrant populations and through advocacy curricula that incorporate special populations, including CIF.

    13. AAP chapters can work with state governments to adopt policies that protect and prioritize immigrant children’s health, well-being, and safety.

    Conclusions

    CIF represent a growing, diverse demographic in the United States. Pediatricians play an essential role in addressing vulnerabilities, minimizing barriers to care, and supporting optimal short- and long-term health and well-being of CIF within the medical home and in communities across the nation. With compassionate, respectful, and progressive policy, CIF can achieve their full potential for health and well-being.

    Lead Authors

    Julie M. Linton, MD, FAAP

    Andrea Green, MD, FAAP

    Council on Community Pediatrics Executive Committee, 2017–2018

    Lance A. Chilton, MD, FAAP, Chairperson

    James H. Duffee, MD, MPH, FAAP, Vice-Chairperson

    Kimberley J. Dilley, MD, MPH, FAAP

    Andrea Green, MD, FAAP

    J. Raul Gutierrez, MD, MPH, FAAP

    Virginia A. Keane, MD, FAAP

    Scott D. Krugman, MD, MS, FAAP

    Julie M. Linton, MD, FAAP

    Carla D. McKelvey, MD, MPH, FAAP

    Jacqueline L. Nelson, MD, FAAP

    Liaisons

    Gerri L. Mattson, MD, MPH, FAAP – Chairperson, Public Health Special Interest Group

    Kathleen Rooney-Otero, MD, MPH – Section on Pediatric Trainees

    Donene Feist – Family Voices North Dakota

    Staff

    Dana Bennett-Tejes, MA, MNM

    Jean Davis, MPP

    Tamar Magarik Haro

    Acknowledgment

    We thank Jennifer Nagda, JD (Young Center for Immigrant Children’s Rights).

    Footnotes

    • Address correspondence to Julie M. Linton, MD, FAAP. E-mail: Julie.linton@prismahealth.org

    • Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

    • The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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    Pediatrics
    Vol. 144, Issue 3
    1 Sep 2019
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    Providing Care for Children in Immigrant Families
    Julie M. Linton, Andrea Green, COUNCIL ON COMMUNITY PEDIATRICS
    Pediatrics Sep 2019, 144 (3) e20192077; DOI: 10.1542/peds.2019-2077
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