The United States is home to many immigrants and refugees, with 22% of households speaking a language other than English.1 Of the 44.5 million immigrants living in the US in 2017, 18.2 million were children with the majority living in California, Texas, New York, and Florida.1 Although some of these children live in homes in which everyone has immigrant status, many others live in homes in which some family members may be US citizens and others may be undocumented immigrants. About 88% of children in immigrant families are US citizens, whereas others were brought to the US as young children.1
Although there are many reasons children and their families immigrate to the US, many children have come to the US either with their families or as unaccompanied minors fleeing extreme violence, poverty, and political unrest in their native country. After a surge in 2014, the number of unaccompanied minors coming to US has risen again with more than 72,000 minors between October and August of fiscal year 2019.2 Some of these minors were refugees who were resettled in the US after being displaced from their homes due to violence and fear of persecution. In 2018, 70.8 million people worldwide were forcibly displaced from their homes, including nearly 25.9 million refugees, half of whom are younger than age 18 years.3 Of these 25.9 million refugees, fewer than 1% are considered for resettlement through the United Nations.3 In 2016, 84,995 of these refugees were admitted to the US; however, this number has declined due to recent changes in immigration policy. Most recent data show that a total of 22,491 refugees were admitted to the US in fiscal year 2018 and 30,000 for fiscal year 2019.4
A final, yet important, population to remember is the 1.3 million children and young adults as of 2018 who met eligibility for the Deferred Action for Childhood Arrivals (DACA). This program offered work permits and deferred action from deportation for people who came to US without legal status when they were younger than age 16 years.1 In 2017 it was announced that DACA would be rescinded, but this was challenged in federal courts. The program remains in place due to a nationwide injunction, but only for those who currently or previously received DACA benefits.
Due to the special medical needs of children who are immigrants and refugees, we review the medical needs of these patients while focusing on mental health and other important social, legal, and educational needs of this patient population.
Illustrative Case 1
A 7-year-old girl from Honduras presented to a primary care clinic for a routine well-child visit. The patient and her mother arrived in the US about 9 months ago, fleeing domestic violence in their home country. The patient has not had regular medical care and on physical examination was noted to have extensive dental caries requiring dental treatment. The patient is currently uninsured and the family is paying out of pocket for the visit.
Illustrative Case 2
A 15-year-old Rohingyan boy from Myanmar (formerly known as Burma) presented to a primary care clinic for an initial health examination. He had recently been rescued from a “work camp” and resettled in the US within the past week. The patient reported significant violence in his past, including burns to his legs from when he escaped his burning home. He reported meeting a man who promised to get him across the border to safety but instead he was kept in a small jail cell for 3 years with 50 other refugees. He managed to escape and was rescued by a refugee resettlement agency working in the area, and resettled in the US.
Basic medical care for immigrants and refugees is an essential component of the resettlement and immigration process. For refugees, the evaluation typically begins overseas with a comprehensive medical examination overseen by the Centers for Disease Control and Prevention (CDC).5 The main objective for this health examination is to identify conditions that have public health significance, such as communicable diseases, missing vaccinations against vaccine-preventable diseases, drug abuse or addiction, or physical or mental disorders associated with harmful behavior. If any of these conditions are identified, a waiver will be required for entrance into the US. Once in the US, refugees will undergo another initial screening physical examination with a primary care physician. During this examination, similar objectives of screening for communicable diseases occur, with more focus on the broader context of health, including mental health, social, and educational concerns. It is important to recognize that translation services are likely to be needed during these initial examinations, which will prolong the clinical visit. Extended visits of at least 30 minutes should be considered for these initial examinations.
Migrants in the US who are applying to update or change their immigration status may be required to undergo a medical examination as well.5 In addition, asylum seekers will frequently visit clinics for routine assessment or acute visits where initial screening will need to take place. Children arriving in the US without refugee or asylum status have varying degrees of previous medical care. Unaccompanied children who have gone through the US immigration system will have received a basic medical examination, screening for communicable diseases, and routine vaccinations while in unaccompanied minor shelters. However, children and families in family detention or those who did not pass through the legal system may have a history of inconsistent health care and may not have interacted with the medical system in many years. On first presentation to a primary care provider, obtaining an accurate history is important to determine what medical care these patients may still need.
There are many resources available to help guide pediatricians with the initial assessment and evaluation. Many organizations have created screening checklists and protocols that easily describe the necessary or recommended components of the medical visit for newly arrived immigrants and refugees. The CDC's “Medical Examination of Immigrants Refugees”5 and the American Academy of Pediatrics' (AAP) Immigrant Child Health Toolkit6 both have specific guidelines with screening recommendations and resources for physicians and medical providers caring for this population.
Refugees and immigrants frequently suffer from mental health conditions related to previous violence and trauma that they have experienced in their home country, during their displacement, or on their journey to America. It has been well established that depression, anxiety, and sleep disturbance are more common in children who are refugees than in other populations.7,8 Similarly, Latinx youth who have come to the US fleeing violence in Central America are also at risk for posttraumatic stress disorder, depression, and anxiety.9 Families of mixed legal status are also vulnerable due to the stress, anxiety, and fear associated with potential family separation due to risk of deportation. Therefore, it is essential that mental health screening and interventions are a component of the initial and ongoing health examinations for these patients.
Recent studies on forcibly displaced populations have described interventions delivered to children and adolescents at risk of developing mental health concerns as well as to parents and family members.10 Focusing on parental mental health needs, how stressors are discussed and managed in the family, and current stressors may improve mental health outcomes for these children.11 Incorporating validated screening questionnaires into the medical visit is one way to identify mental health needs. Although they have not been validated specifically for refugee and immigrant populations, screening tools like The Patient Health Questionnaire for generalized anxiety disorder,12 Strengths and Difficulties Questionnaire,13 and Pediatric Symptom Checklist14 are available for free in multiple languages and can screen for common mental health disorders and behavioral concerns.
Once identified, providing appropriate treatment, referrals, and support to families throughout the process is crucial. Accessing services may be challenging in some settings due to limited availability or eligibility of patients. School-based interventions may be the key to allowing children increased access to mental health services in a safe, effective setting.7 Other models such as integrated mental health services, telemedicine, and telepsychiatry may also be an option in certain settings.15 Because of the high prevalence of mental health conditions among this population, a full health assessment must include thorough evaluation of mental health.
Many immigrants and refugees have been exposed to trauma including sexual abuse, violence, and combat trauma; therefore, providing medical and mental health services using a trauma-informed care model is critical. Trauma-informed care is a framework that involves recognizing the impact of trauma on health and responding to all types of trauma without re-traumatizing the patient. It also focuses on physical and emotional safety, collaboration, empowerment, and cultural sensitivity.16 The National Child Traumatic Stress Network (NCTSN) provides training and clinical resources for medical and mental health providers caring for children who have experienced trauma. The NCTSN and AAP have developed toolkits with information on reducing trauma associated with medical events, developing a trauma-informed office, and promoting resilience.17,18 How pediatric providers respond to trauma can affect recovery for the child and family and also affect their willingness to seek further intervention. Using trauma-informed care models can help provide optimal care and foster resilience for the child and family.19
Many immigrant and refugee families live in poverty. According to the National Center for Children in Poverty, 51% of children with immigrant parents are living in low-income families, compared to only 38% of children with US-born parents.20 These families may be more likely to have various social needs that may affect their health and well-being. Providers caring for this population should be aware of these needs and may even consider using a validating tool to screen for social determinants of health. Tools like WECARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education),21 SEEK (Safe Environment for Every Kid),22 PRAPARE (Protocol to Respond to and Assess Patient Assets, Risks, and Experiences),23 and IHELLP (Income, Housing, Education, Legal Status, Literacy, and Personal Safety)24 have been commonly used and assess for needs like housing, transportation, employment, legal needs, family mental illness, and safety. More targeted screening tools are available as well for intimate partner violence, food insecurity, and mental health concerns. By understanding these needs providers can then link families to resources in their community, help address barriers to health care, and encourage supportive environments for children.
Screening immigrant and refugee families for legal needs deserves special attention. Parental and child immigration status can pose various barriers to accessing health care and public services. The AAP Immigrant Child Health Toolkit6 discusses the health insurance and public benefit options that are available to families based on their immigration status. However, some immigrant families may be unaware they can qualify for legal status in the US. Placing appropriate referrals to legal aid organizations can help families find a legal pathway for residence in the US. In addition to expanding access to services, programs such as DACA that provide even temporary legal status may improve overall well-being and mental health in their recipients and recipient's children.25,26
Although refugee patients have similar legal needs, they have access to a case worker and resettlement agency that works with them on their legal needs and citizenship process. Some families may already be involved in legal proceedings in immigration court and could benefit from legal aid in presenting their case if not already available. Immigrants with legal representation were twice as likely to be granted immigration relief than those without counsel.27 Physicians may also be asked to provide letters of support for families involved in immigration proceedings. These may include attestations of a child's health care status or parent's standing as caregiver or referrals to medical-legal partnerships if available in your community. Guidance for physicians in writing these letters is available on the AAP Immigrant Child Health Toolkit.6
All children living in America have the right to a free public education, no matter their legal status.28 However, many immigrant and refugee parents may have problems navigating the American school system due to language barriers, low literacy, or general differences in the education system compared to their home countries. This can specifically impact children with learning difficulties or those performing poorly academically who may require extra support or services in school. Ensuring that children obtain the educational services they need is critical for their long-term academic success and integration. Children who are immigrants and refugees and parents also have the right to language-assistance programs if they have limited English proficiency. Health care providers can help families by empowering them to advocate for their children and assisting with understanding how the school system works.
Early childhood education should be another area of attention for providers because many children who are immigrants lack school readiness, which can affect their future educational outcomes.29 Immigrant families are also less likely to read or share books with their children, which can affect language development and early literacy, and can potentially have long-term effects on academic achievement.30 Participating in programs like Reach Out and Read31 or encouraging families to enroll their children in early childhood education can help reduce these disparities and better prepare children who are immigrants and refugees for success in school.
For refugees, English language classes are the main focus of education in the first few months of arrival to the US. Basic English language skills have been shown to increase resilience and are a key to future independence.32 In addition to language classes, many refugees begin school immediately in modified settings. It is not uncommon for refugees to be years behind in their studies as many have been living a nomadic life or in refugee camps for many years. Educational attainment varies depending on country of origin, with the majority of refugees obtaining at least a high school degree.33 Encouraging refugee patients to determine their goals helps foster their hopes and dreams for their new life in the US.
Physician Education Needs
Recent interest in global health has been increasing in pediatric residencies, with a specific curriculum continually being developed.34,35 Furthermore, although reported student and resident experiences with refugee populations are usually limited to traditional clinical exposures and extracurricular volunteer opportunities, reports of refugee and immigrant health electives for trainees are occurring throughout the literature.36,37 With increasing global international migration projecting to double by 2050,38 the AAP has focused on culturally effective care for all pediatricians defined as “the delivery of care within the context of appropriate physician knowledge, and an understanding and appreciation of cultural distinction leading to optimal health outcomes.”39
Similarly, the AAP has been the lead pediatric voice advocating for immigrant and refugee health. Local chapters to the Federal Affairs Office have focused on creating a national movement to support these vulnerable patients. It has been shown that residency continuity clinics provide care to more underserved patient populations. As immigrants and refugees are more likely to be part of this socioeconomic group, residency continuity clinics must be prepared to evaluate and treat these patients in this important educational setting.40 Enhancing curricula that address refugee and immigrant health in undergraduate and graduate level medical education is important to providing quality care for this vulnerable population. In addition, providing continuing medical education credits for board certified pediatricians is another crucial step for all pediatricians to be knowledgeable in refugee and immigrant child health.
Additionally, due to the high rates of mental health needs and general lack of available services, primary care providers should be knowledgeable in providing basic mental health treatment. Advocating for integrated services, mental health training, and trauma-informed care is essential to improving access and reducing stigma for these services. Pediatric and family medicine residency programs should also prioritize training in mental health so physicians feel competent providing basic services.
Pediatricians play a crucial role in the health of families who are immigrants or refugees. Understanding this population's unique medical and mental health needs can allow for appropriate screening, treatment, and referrals. Social determinants of health also play an important role in the care of this population, with many affected by poverty, toxic stress, language and educational barriers, limited access to public benefits, and legal concerns. Additionally, in the current political climate, the future is uncertain for many immigrant and refugee families, which can cause undue stress on children and affect their physical health and overall well-being. Pediatric providers should be attuned to these concerns and assist families as needed. Providing services in a culturally sensitive manner and with a trauma-informed framework can help pediatricians build trusting relationships with families and aid in their transition to life in the US.
- Zong J, Batalova J, Hallock J. Frequently requested statistics on immigrants and immigration in the United States. https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states. Accessed October 22, 2019.
- US Customs and Border Protection. Southwest border migration FY2019. https://www.cbp.gov/newsroom/stats/sw-border-migration. Accessed October 22, 2019.
- United Nations High Commissioner for Refugees. Figures at a glance. http://www.unhcr.org/en-us/figures-at-a-glance.html. Accessed October 22, 2019.
- US Department of State. Admissions and arrivals. http://www.wrapsnet.org/admissions-and-arrivals/ Accessed October 22, 2019.
- Centers for Disease Control and Prevention. Medical examination of immigrants and refugees. https://www.cdc.gov/immigrantrefugeehealth/exams/medical-examination.html. Accessed October 16, 2019.
- American Academy of Pediatrics Council on Community Pediatrics. Immigrant child health toolkit. https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-Community-Pediatrics/Pages/Immigrant-Child-Health-Toolkit.aspx. Accessed October 16, 2019.
- Montgomery E. Trauma, exile and mental health in young refugees. Acta Psychiatr Scand Suppl. 2011;124(440):1–46. https://doi.org/10.1111/j.1600-0447.2011.01740.x PMID: doi:10.1111/j.1600-0447.2011.01740.x [CrossRef]
- Jakobsen M, Demott MA, Heir T. Prevalence of psychiatric disorders among unaccompanied asylum-seeking adolescents in norway. Clin Pract Epidemiol Ment Health. 2014;10(1):53–58. https://doi.org/10.2174/1745017901410010053 PMID: doi:10.2174/1745017901410010053 [CrossRef]25006343
- Cleary SD, Snead R, Dietz-Chavez D, Rivera I, Edberg MC. Immigrant trauma and mental health outcomes among Latino youth. J Immigr Minor Health. 2018;20(5):1053–1059. doi:10.1007/s10903-017-0673-6 [CrossRef]
- Tyrer RA, Fazel M. School and community-based interventions for refugee and asylum seeking children: a systematic review. PLoS One. 2014;9(2):e89359. https://doi.org/10.1371/journal.pone.0089359 PMID: doi:10.1371/journal.pone.0089359 [CrossRef]24586715
- Fazel M, Betancourt TS. Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018;2(2):121–132. https://doi.org/10.1016/S2352-4642(17)30147-5 PMID: doi:10.1016/S2352-4642(17)30147-5 [CrossRef]30169234
- Pfizer, Inc. Patient Health Questionnaire (PHQ) screeners. http://www.phqscreeners.com/. Accessed October 16, 2019.
- Massachusetts General Hospital. Pediatric Symptom Checklist. http://www.massgeneral.org/psychiatry/services/psc_home.aspx. Accessed October 16, 2019.
- Information for researchers and professionals about the strengths & difficulties questionnaires. http://www.sdqinfo.org/. Accessed October 16, 2019.
- Caballero TM, DeCamp LR, Platt RE, et al. Addressing the mental health needs of Latino children in immigrant families. Clin Pediatr (Phila). 2017;56(7):648–658. https://doi.org/10.1177/0009922816679509 PMID: doi:10.1177/0009922816679509 [CrossRef]
- The National Child Traumatic Stress Network. Fact sheet: glossary of terms related to trauma-informed, integrated healthcare. https://www.nctsn.org/resources/glossary-terms-related-trauma-informed-integrated-healthcare. Accessed October 16, 2019.
- The National Child Traumatic Stress Network. Fact sheet: trauma-informed integrated care for children and families in healthcare settings. https://www.nctsn.org/resources/trauma-informed-integrated-care-children-and-families-healthcare-settings. Accessed October 16, 2019.
- American Academy of Pediatrics. Trauma toolbox for primary care. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Trauma-Guide.aspx#trauma. Accessed October 16, 2019.
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- Koball H, Jiang Y. Basic Facts about Low-Income Children: Children Under 18 Years, 2016. New York, NY: National Center for Children in Poverty, Columbia University Mailman School of Public Health; 2018.
- Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296–e304. https://doi.org/10.1542/peds.2014-2888 PMID: doi:10.1542/peds.2014-2888 [CrossRef]25560448
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- National Association of Community Health Centers. PRAPARE implementation and action toolkit. http://www.nachc.org/research-and-data/prapare/toolkit/. Accessed October 16, 2019.
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