PEDIATRICS Vol. 100 No. 1
July 1997,
pp. 153-156
AMERICAN ACADEMY OF PEDIATRICS:
Health Care for Children of Immigrant Families
Committee on Community Health Services
 |
ABSTRACT |
The intent of this statement is to inform
practitioners about the special health care needs and vulnerabilities
of immigrant children and their families and to suggest clinical
approaches to various aspects of their care. Immigrant children and
their families, a large and diverse population group, have numerous risks to physical health and functioning and may be unfamiliar with our
health care services. They often face many barriers to care, and their
special risks and needs may not be familiar or readily apparent to many
health care providers. Recently enacted federal welfare and immigration
reform measures may increase the vulnerability of this population by
limiting its access to health and social services. For multiple ethical
and medical reasons, the American Academy of Pediatrics has
historically opposed, and continues to oppose, denying needed services
to any child residing within the borders of the United States.
| |
INTRODUCTION |
The United States is in the midst of the largest wave of
immigration it has ever experienced.1,2 One third of
all growth in our population during the past decade was attributed to
the growth of the immigrant population. The term "immigrant
children" includes those who are legal and illegal (undocumented)
immigrants, refugees, and international adoptees. This group represents
a continually growing part of our childhood population, whose presence in the United States continues the profound tradition of multicultural growth that has been the cornerstone of strength through diversity in
our society.
Every child within the geographic boundaries of the United States,
regardless of that child's "status," should have full access to
all social, educational, and health services that exist at the local,
state, and federal levels for the care and benefit of children. In its
advocacy role, the American Academy of Pediatrics and its member
pediatricians must continue to advance the argument for maintaining
access to all services for all children residing in the United States.
Such advocacy is consistent with supporting efforts to rationalize and
enforce immigration policies. Promoting and regulating legal
immigration are essential matters of national policy, and securing our
borders similarly represents an important national interest. The
national interest also dictates that all children within the United
States be well-educated and have their physical and psychosocial
well-being maintained. Allowing any group of children to be uneducated
or unhealthy will have adverse consequences for all of us. Therefore,
pediatricians should remain committed to the care of all children and
their families who reside in our communities.
| |
BACKGROUND |
Virtually all new waves of immigrants have been met with
ambivalence and concern about what effect the new immigrants might have
on those who came before them.1,2 Arguments focus on whether immigrants contribute to the economy or create a drain on
public and private resources. Concerns, although largely
unsubstantiated, also include perceived threats to both the public
health and public order from imported infectious diseases, increased
crime, and diverse social mores. The current debates about the
government's role and expenditures have raised the issue of
eligibility of immigrants, both legal and illegal, for health, social,
and educational services.1,3 Little attention has been
directed toward the development of policies and practices that will
affect the well-being and future contributions of immigrant children
who are unable to choose where they live.4
Some have argued that immigrants should not be entitled to any publicly
supported benefits. Others alternatively have argued that if such
benefits are to be extended, then benefits should be a federal
rather
than a state or localresponsibility.1 In border states
such as California, Texas, and Florida, which have experienced a large
influx of immigrants, there have been calls for removing access and
eligibility for illegal immigrants to publicly supported health,
social, and educational services. Some individuals have gone further
and advocated the same disenfranchisement of legal immigrants, making
eligibility for public education, social services, and health services
dependent upon both citizenship and residency and no longer residency
alone. This is reflected in the Personal Responsibility and Work
Opportunity Act of 1996 (96 Public Law 104-193). It bans most forms of
public assistance and social services for legal immigrants who have not
become citizens unless the states choose to continue those services.
Two thirds of the projected $60 billion in welfare-spending reductions
between 1996 and 2002 will affect legal and illegal immigrants.
Although access to some emergency health services for immigrants will
be preserved under current federal law (Consolidated Omnibus Budget Reconciliation Act 86 Public Law 99-272), the web of conflicting legal
requirements and professional ethics and motivations confronts pediatricians with important moral challenges.
| |
FACTS ABOUT RECENT IMMIGRANTS |
Demographics
- During the past 10 years, approximately 9 million immigrants legally
attained permanent residence in the United States and approximately 3 million entered illegally.2 This combined wave of 12 million new arrivals in the past decade exceeds the largest previous
wave of approximately 10 million immigrants, which occurred between
1905 and 1914.5
- Since the mid-1960s, immigration to the United States has been
primarily from Latin America, Asia, and the Caribbean.1,2
- "Linguistically isolated households," those in which no one over
the age of 14 years speaks English, were identified for the first time
in the 1990 US Census. Of all US households, 4% are linguistically
isolated; this figure includes 30% of Asian households, 23% of
Hispanic households, and 28% of all immigrant households with
school-age children.6 This factor has significant
implications for pediatricians, teachers, and others who serve these
families, including such difficulties as understanding and
communicating basic concerns and instructions. Additional implications
involve potential infringements on rights to privacy, confidentiality, and informed consent when translators must be used.7,8
- Illegal immigrants, the majority of whom are from Mexico, are arriving
in the United States at a rate of 300 000 to 500 000 per
year.2,9
| |
OVERVIEW OF RISK FACTORS |
- New immigrants may be without gainful employment and they may be
unfamiliar with English. They may have health problems that are often
undiagnosed, including tuberculosis, parasites, human immunodeficiency
virus infection, and lack of immunizations. They also may have limited
understanding of care-seeking behaviors and the US health care
system.7,10,11
- International adoptees arrive without adults who can provide
information about their medical and social history. They often join
families with whom they have no common language or physical similarities and might be adopted by parents who have no experience with child-rearing.12
- Many immigrant children have significant problems accessing health care
services. Their utilization of medical services often is episodic and
frequently occurs in settings such as emergency rooms. This factor
limits the provision of comprehensive, longitudinal care. Issues of
day-to-day survival that include insecurity about lack of food,
clothing, and shelter often override other concerns. Legal immigrants
residing in the United States before passage of the Personal
Responsibility and Work Opportunity Act of 1996 are eligible for
Medicaid unless the state opts to impose a ban. Legal immigrants
entering the country after the date of passage of this welfare reform
legislation are eligible for Medicaid only after 5 years in residence.
Illegal immigrants, however, qualify for very little public assistance.
Legal and illegal immigrants not eligible for Medicaid are covered for
emergency services, such as labor and delivery, but not for preventive
services, such as prenatal or well-child care.
- Because of cost, language and cultural barriers, and fear of
apprehension by immigration authorities, illegal immigrants
underutilize health services, especially preventive services such as
prenatal care, dental care, immunizations, and health supervision. They also often delay seeking care for minor conditions until those conditions become more serious.7 A complicating factor to
providing access to health care for immigrant families is the
possibility that various family members may have different immigration
statuses. When one member of the family is in this country illegally,
the entire family may limit access to care for fear of triggering investigation.
- Public health initiatives by intent and design are universal, and the
protection of the public health requires access by the entire
community. Restrictions on access to services placed on immigrants
would seriously limit the effectiveness of outreach, case finding, and
prevention and treatment programs related to infectious diseases.
Patients needing prenatal care and family planning services would
similarly lose access to important preventive care, resulting in
increased risks for poor pregnancy outcomes and the major long-term
disabilities associated with such outcomes and their subsequent costs.
Denying legal and illegal immigrants access to basic health care would
not only deprive them of needed services but also disrupt the provision
of services to other children by redirecting resources from providing
services to sorting and enforcement of more restrictive eligibility
standards.
Infectious Diseases
- Immigrant children may harbor infectious diseases that US
pediatricians may be inexperienced in diagnosing and
treating.9,13-19 These include conditions such as malaria,
amebiasis, schistosomiasis, and other helminthic infections; congenital
syphilis, for which foreign-born children are not necessarily screened
at birth; hepatitis A; hepatitis B, particularly in immigrants from
Southeast Asia; and tuberculosis. It is possible to screen for many of
these infections, and they should be considered in any unusual clinical
presentation of a foreign-born child or child whose family travels
between the United States and the country of origin.
- International adoptions have increased to the current rate of more than
10 000 per year. These children are for the most part from Korea and
Central and South America but are also from Romania, the Balkans,
China, Eastern Europe, and the Caribbean. More than 50% of these
children have at least one health problem at the time of arrival in the
United States.20 Sixty percent of these problems are
infectious diseases. As many as 80% of these problems may not be
evident by history and physical examination alone; therefore, the use
of screening tests for helminthic infections, syphilis, tuberculosis,
and hepatitis B appear to be indicated for these children (routine
screening tests for hepatitis A, C, D, and E are not
indicated).21 Many foreign-born children have not been
immunized adequately; therefore, appropriate immunizations should be
initiated immediately according to the Academy's recommended schedule
for healthy infants and children.21,22
Psychosocial Factors
- Immigration poses unique stresses on children and
families.7,11,23-30 These include separation from support
systems; disparities between social, professional, and economic status
in the country of origin and the United States; and ongoing depression,
grief, or anxiety resulting from relocation to a new community and
culture and traumatic events that may have occurred in the country of origin.
- Immigrant and refugee children may have difficulties adapting to
school. Prior education or lack of schooling, lack of proficiency in
English, and separation from family while attending school may affect
school performance and result in learning disabilities.
- Extended families are prominent in many immigrant cultures. They are an
important source of strength, but they also may create conflicts with
use of health services and adaptation to American health care customs.
- Many refugees may have been uprooted because of war or persecution.
Children and families with this background have often experienced
terrible losses and witnessed atrocities and are in need of mental
health and social services.7,31 Careful attention to
possible posttraumatic stress disorder is warranted.
Dental Disease
- Dental problems are more frequent among immigrant children.
Immigrant elementary school children have been found to have twice as
many dental caries in primary teeth as their US counterparts, with as
many as 75% having dental disease identified on first screening in the
United States.32
Nutritional Problems
- Immigrant children have been found to be at risk for being
deficient in meeting current height-for-age and weight-for-age measures
shortly after entry into the United States.33 Within 1 year, many have experienced significant catch-up growth.
Internationally adopted children, many of whom resided in orphanages or
group foster homes before their placement in adoptive homes in the
United States, also have high rates of delay in meeting anthropometric measures, in addition to increased rates of developmental
delay.34
| |
RECOMMENDATIONS |
- Pediatricians should oppose denying needed services to any
child residing within the borders of the United States.
- Pediatricians should take advantage of educational
opportunities and resources to achieve a better understanding of
immigrant cultures and the health care needs of immigrant children and
families. These can be obtained from local universities, health
departments, cultural groups, chapter and district Community Access To
Child Health facilitators, as well as through continuing medical
education sessions at national meetings held by the American Academy of Pediatrics. Important to the care of these children is an awareness of
the family's culture, health beliefs, and the possible use of
traditional or folk medicines. Pediatricians may need to ask families
to describe or explain their beliefs, values, attitudes, and practices
to educate parents and other care takers on safety and health in a way
that will complement, rather than replace, existing beliefs and
practices. Pediatricians should also explore their own attitudes toward
the parents' and child's use of English; eating habits; health
practices; folk remedies; understanding and perceptions of illness; use
of health care services and medications; and family structure and
roles.
- To provide culturally effective health care, pediatricians
should tolerate and respect differences in attitudes and approaches to
child-rearing. However, this does not include any traditional practices
that are clearly injurious to children and reportable under the Child
Abuse Prevention and Treatment Act.
- Pediatricians should be aware of the special health problems
for which immigrant children are at risk. These include
vaccine-preventable diseases, eg, hepatitis B; tuberculosis, syphilis,
and parasitic infestations; poor nutritional status; delayed growth and
development; poor dental health; poor mental health; and school
problems.
- Pediatricians in training and in practice should be educated
about the unique stresses that immigration may place on children and
families. Education should include information on the availability of
local resources that provide services in the language spoken at home.
- Pediatricians should recognize and support the extended
family in health care activities with the approval of the child's parent or legal guardian. In many cases it is useful to identify and
communicate with key authority figures in the extended family (who may
not be the child's parents). It also is important to be aware of
whether the extended family resides nearby or in the country of origin
and whether family support still exists. Pediatricians also should be
aware of whether the child is living with the extended family and
receiving medical care in the country of origin on a part-time basis.
- Any health screening that immigrants or refugees receive
before US entry should be followed up with continuing health
supervision and, in many cases, mental health and social services.
Academy chapters should familiarize members with linkages between
public health and the private sector to ensure comprehensive health
supervision.
- In communities where immigrant families reside, health
service providers should be encouraged to develop linguistically and culturally-appropriate services in concert with public health, social
services, and school systems.
- Academy chapters should define the health care needs of
immigrant children in their areas. In addition, chapters should work with state legislatures and agencies to assess the local impact of
welfare and immigration reform measures and advocate responses that
assure unimpeded access to all medically necessary services for all
children, as well as assure care for catastrophic illness or injury.
- Pediatricians should be encouraged to support and participate
in locally developed, community-based activities that increase access
to health care for immigrant children.
COMMITTEE ON COMMUNITY HEALTH SERVICES, 1996 TO 1997
Michael Weitzman, MD, Chair
Helen M. DuPlessis, MD, MPH
Stanley I. Fisch, MD
Robert E. Holmberg, Jr, MD
Arthur Lavin, MD
Carolyn J. McKay, MD
Paul Melinkovich, MD
R. Larry Meuli, MD, MPH
Yvette L. Piovanetti, MD
Denia A. Varrasso, MD
LIAISON REPRESENTATIVES
William Bithoney, MD
Ambulatory Pediatric Association
Anne E. Dyson, MD
AAP Partnership for Children
Lindsey K. Grossman, MD
Section on Community Pediatrics
Cheryll Jones, CPNP
National Association of Pediatric Nurse
Associates and Practitioners
Jennie A. McLaurin, MD, MPH
Migrant Clinicians Network
Charles Poland III, DDS
American Academy of Pediatric Dentistry
CONSULTANTS
Donna O'Hare, MD
Harry Wilson, MD
| |
FOOTNOTES |
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
| |
REFERENCES |
-
Dunlap JC. America's newcomers: a state and local policymaker's guide to immigration and immigrant policy. Presented at the National Conference of State Legislatures; February 1993; Denver, CO
-
Public Agenda Foundation. Admission Decisions: Should Immigration Be Restricted? Dubuque, IA: Kendan/Hunt Pub Co; 1994
-
Ziv TA,
Lo B
Denial of care to illegal immigrants: proposition 187 in California.
N Engl J Med
1995;
332:1095-1098 [Free Full Text]
-
Board on Children and Families
Immigrant children and their families: issues for research and policy.
Future Child
1995;
5:72-89 [CrossRef][Medline]
-
Pallarito K
Bridging the gap: healthcare reform and illegal aliens.
Mod Healthcare.
1994;
24:24-32
-
The Center for the Study of Social Policy, the Population Reference Bureau. The Challenge of Change. What the 1990 Census Tells Us About Children. Washington, DC: The Center for the Study of Social Policy; 1992
-
Dunlap JC, Hutchinson F. America's newcomers: health care issues for new Americans. National Conference of State Legislatures; July 1993; Denver, CO
-
Woloshin S,
Bickell NA,
Schwartz LM,
Gany F,
Welch HG
Language barriers in medicine in the United States.
JAMA
1995;
273:724-728 [CrossRef][Medline]
-
Hayani KC,
Pickering LK
Screening of immigrant children for infectious diseases.
Adv Pediatr Infect Dis
1991;
6:91-110 [Medline]
-
Kraut AM
Healers and strangers: immigrant attitudes toward the physician in Americaa relationship in historical perspective.
JAMA
1990;
263:1807-1811 [Abstract]
-
Muecke MA
Caring for Southeast Asian refugee patients in the USA.
Am J Public Health
1983;
73:431-438 [Abstract/Free Full Text]
-
Barnett ED,
Miller LC
International adoption: the pediatrician's role.
Contemp Pediatrics
1996;
13:29-46
-
Centers for Disease Control and Prevention, Center for Prevention Services, Division of Quarantine. Health Information for International Travel. Atlanta, GA: US Department of Health and Human Services; 1995. Centers for Disease Control and Prevention Publication No. 95-8280
-
Christenson JC,
Fischer PR
Health risks of travel: back in the USA.
Contemp Pediatrics
1993;
10:39-56
-
Emanuel B,
Aronson N,
Shulman S
Malaria in children in Chicago.
Pediatrics
1993;
92:83-85 [Abstract/Free Full Text]
-
Franks AL,
Berg CJ,
Kane MA,
Hepatitis B infection among children born in the United States to Southeast Asian refugees.
N Engl J Med
1989;
321:1301-1305 [Abstract]
-
Iseman MD,
Starke J
Immigrants and tuberculosis control.
N Engl J Med
1995;
332:1094-1095 [Free Full Text]
-
McKenna MT,
McCray E,
Onorato I
The epidemiology of tuberculosis among foreign-born persons in the United States, 1986 to 1993.
N Engl J Med
1995;
332:1071-1076 [Abstract/Free Full Text]
-
Wolfe MS
Tropical diseases in immigrants and internationally adopted children.
Med Clin North Am
1992;
76:1463-1480 [Medline]
-
Hostetter MK,
Iverson S,
Thomas W,
Medical evaluation of internationally adopted children.
N Engl J Med
1991;
325:479-485 [Abstract]
-
American Academy of Pediatrics. Medical evaluation of internationally adopted children. In: Peter G, ed. 1994 Red Book: Report of the Committee on Infectious Diseases. 23rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 1994:111-114
-
American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care
Initial medical evaluation of an adopted child.
Pediatrics
1991;
88:642-644 [Abstract/Free Full Text]
-
Barankin T,
Konstatareas MM,
de Bosset F
Adaptation of recent Soviet Jewish immigrants and their children to Toronto.
Can J Psychiatry
1989;
34:512-518 [Medline]
-
Flaherty JA,
Kohn R,
Levav I,
Birz S
Demoralization in Soviet-Jewish immigrants to the United States and Israel.
Compr Psychiatry
1988;
29:588-597 [CrossRef][Medline]
-
Hulewat P
Resettlement: a cultural and psychological crisis.
Soc Work
1996;
41:129-135 [Medline]
-
Lequerica M
Stress in immigrant families with handicapped children: a child advocacy approach.
Am J Orthopsychiatry
1993;
63:545-552 [Medline]
-
Ring JM,
Marquis P
Depression in a Latino immigrant medical population: an exploratory screening and diagnosis.
Am J Orthopsychiatry
1991;
61:298-302 [Medline]
-
Saracho ON, Spodek B, eds. Understanding the Multicultural Experience in Early Childhood Education. Washington, DC: National Association for the Education of Young Children; 1983
-
Munroe-Blum H,
Boyle MH,
Offord DR,
Kates N
Immigrant children: psychiatric disorder, school performance, and service utilization.
Am J Orthopsychiatry
1989;
59:510-519 [Medline]
-
Verhulst FC,
Althaus M,
Versluis-Den Bieman HJ
Damaging backgrounds: later adjustment of international adoptees.
J Am Acad Child Adolesc Psychiatry
1992;
31:518-524 [Medline]
-
McCloskey LA,
Southwick K
Psychosocial problems in refugee children exposed to war.
Pediatrics
1996;
97:394-397 [Abstract/Free Full Text]
-
Pollick HF,
Rice AJ,
Echenberg D
Dental health of recent immigrant children in the newcomer schools, San Francisco.
Am J Public Health
1987;
77:731-732 [Abstract/Free Full Text]
-
Miller LC,
Kiernan MT,
Mathers MI,
Kleinn-Gitelmann M
Developmental and nutritional status of internationally adopted children.
Arch Pediatr Adolesc Med
1995;
149:40-44 [Abstract]
-
Schumacher LB,
Pawson IG,
Kretchmer N
Growth of immigrant children in the newcomer schools of San Francisco.
Pediatrics
1987;
80:861-868 [Abstract/Free Full Text]
Pediatrics (ISSN 0031 4005). Copyright ©1997 by the American Academy of Pediatrics
Top
Abstract
Introduction
