Immigrant Health Toolkit

Introduction

• “Children of immigrants are the fastest growing population of

children in the United States and have contributed to the entire
growth in the nation’s child population over the past decade.”
• “Pediatricians can play a special role in supporting the health and
well-being of immigrant children in the United States. By
recognizing the unique challenges and strengths that many
immigrants experience; pediatricians can identify effective
practice strategies and relevant resources that support health
within the community.”
 Key Facts About Immigrant Children
• Definitions and Demographics
• Foreign born or born in US who live with 1+ foreign born parent
• ¼ US children are immigrant children, 89% are US born / US citizens
• Access to Health Care and Health Status
• 2x as likely to be uninsured
• Less likely to have medical home or be fully immunized
• Socioeconomic Factors
• More likely to live in poverty with less access to resources, including education
• Less likely to graduate from high school
• Unique Stressors / Family Separation
• Risk of parents being deported, loss of family income or housing
• Abuse, exploitation, trauma
Clinical Care
Screening
• AAP Policy • Environmental exposures
• Birth country, countries of • Drug use (betel nut, khat)
transit • Allergies
• Medical and vaccination • Dental hx
records
• Education, parental literacy
• Prenatal, perinatal, medical hx
• Social hx
• Sexual hx
• Mental health evaluation
• Nutrition hx
• Developmental screening
• CAM use
Are some diseases or conditions more
prevalent among immigrant children?
 Infectious Disease
• Very common
• PPD or quantiferon for everyone
• No prenatal / parental labs 
screen for HBV, HIV, syphilis
• Immunize asap
 Nutritional Issues
• Undernutrition, obesity
• Fe deficiency most common
• Vitamin D
• Vit A, B12, iodine, B3, tryptophan, B1, C
 Toxic and Environmental Exposures
• Pb exposure most common
• Contaminated home remedies or cosmetics
• Prenatal insults (FAS)
• Workplace injuries
 Other General Health Issues
• Congenital infections
• Dental disease
• Undiagnosed vision, hearing problems
• Genetic conditions
• Female genital mutilation (Africa, Middle East)
• Developmental delays
• Mental health
Medical Screening and Treatment Recommendations
for Newly Arrived Immigrant Children
Access to Health Care and Public Benefits
What health insurance options are available
to immigrant children and families?
Are immigrant children and families eligible to receive public
benefits such as SNAP, TANF, public/subsidized housing?
 What rights do immigrant children have in
schools?
• Immigrant children have the right to free public K-12 education
• Public schools may not:
• Require proof of citizenship or legal residence
• Make inquiries that expose immigration status
• Require SSNs
• Treat a student differently to determine residency
• Hinder access to education
• Homeless children are allowed to enroll
• Right to secondary services in school
• Should have access to transportation, school nursing, meals, special education, counseling
• Language assistance programs
 How can I help immigrant children access the
benefits that they are eligible to receive?
• Screen for basic needs: food or housing insecurity
• Work with community partners to provide public benefits information: departments
of health, legal service organizations
• Work with the care team and community partners to help encourage families to
access public benefits
• Reassure families that the information they provide in the health care setting is
confidential and that the practice is not involved in immigration enforcement
Immigration Status and Related Concerns
 What is the impact of parental separation or
deportation on child health?
• Sleeping and eating disturbances, anxiety, depression, poor school performance, and
other types of distress
• Food instability
• Ask if family members may leave the family
• Ensure confidentiality
• Safety plan for children
 How do I assist families that face deportation
or removal of a child’s caregiver?
• Advise parents to:
• Appoint power of attorney
• Maintain copies of a medical records
• Keep copy of child’s birth certificate, social security, passports, school records, public benefits
• Refer to legal aid organizations, non-profit advocacy groups
 What should I do if a family asks me to write a letter of
support to prevent deportation of a child’s primary care giver?
• You may be asked to state
• Parents appear to be providing good care for a child
• The child seems to be emotionally or physically well
• Attest the child has conditions and it is in his/her best interest not to disrupt care or send him/her somewhere where adequate care may not be available
• If writing a letter, you should
• reference medical notes when appropriate
• clearly identify as opinion any opinions offered
• release or disclose HIPAA-protected information only after obtaining proper consent or authorization
• restrict his/her comments to fact with which he or she is personally familiar; care should be taken not to include false statements or to mislead officials
• When writing a letter of support or affidavit
• Write the letter specifically for your patient. Honestly address your patient’s issues and situation without exaggeration or falsehood.4
• Provide an overview of the physician's education, training, expertise, and the number of years in practice. This may persuade the immigration judge to accept the
physician as an expert witness.
• Provide an objective and individualized description of the child’s medical diagnosis, treatment, and prognosis. The letter must be factual, unbiased and authoritative.
• Discuss the instrumental role the parent plays in seeking, supporting and maintaining treatment, e.g. taking child to treatment, administering medication or otherwise
providing care.
• Discuss how the child will be harmed physically, emotionally, and psychologically if the parent is detained or deported. Provide examples of the health consequences
the child would face without their parent participating in their health care. If possible, discuss how the child would not get the care they need in their parent’s
country. Overall, your written testimony should support the parent’s assertion that the child will suffer extreme hardship if the parent is detained or deported.8
• Always provide facts and rationale for your medical opinion.
• Provide supporting medical documents or reports.
Mental, Emotional, and Behavioral Care
 What considerations should be included in a
mental health assessment of immigrant children?
• Screening for trauma
• Violence and extreme poverty
• Unaccompanied minors
• The influence of acculturation
• First generation: more recent trauma but less willing to seek mental health help
• Second generation: more emotional and behavioral problems, more willing to get help
• Third generation: cumulative risk and chronic stressors
• Consideration of changing social support structure
• Resilience
• Biculturalism most adaptive response
 What risk and protective factors should be
included in a mental health assessment?
Risk factors Protective factors
• Children of isolated/depressed/ • High family cohesion, two parent
linguistically-challenged families families, interpersonal support
• Pre-existing disorders • Being of engaging community of
fellow immigrants from same
• Unaccompanied children
country
• Disrupted family composition • If foster child, same ethnic origin
• Persistent poverty • Perceived acceptance
• Living in ethnic enclaves
• Prejudice
• High intelligence and education
do NOT protect
 How can I help link immigrant children to
treatment?
• Obstacles
• Risk of detection and deportation
• Stigma
• Shortage of appropriate therapists
• Lack of interpreters
• Limited funding
• Multi-disciplinary medical home
• Reach out to community health workers
 What are some treatments for children with
behavioral health problems?
• General
• CBT for anxiety
• Child focused play therapy
• FFT (functional family therapy), MST (multi-systemic therapy): adolescents with substance abuse,
conduct disturbance
• Incredible years and parent child interaction therapy
• Immigrant-specific
• CBITS: cognitive behavioral intervention for trauma in schools: bilingual therapy sessions, trauma
narratives that use music settings familiar to the children and group treatment that may include
faith tradition activities such as forgiveness rituals to improve social problem solving
• Group TF-CBT (trauma focused CBT), FFT: successful in Hispanic children
 What are some high risk circumstances that
may require special attention?
• Mixed status families
• 4.5 million children with 1+ parent undocumented
• 40% children had not seen doctor in 1 year
• Poor school performance, higher school dropout rate
• Foster care
• 5,100 children in foster care due to parental deportation
• Withdrawal, depression, oppositional defiance
• Unaccompanied minors and asylum seekers
• 2014: >50,000 children from Central America apprehended trying to cross the border, over half
displaced faced significant harms (gang violence, domestic abuse, drug cartel related activities);
5,000 Mexican nationals recruited into human trafficking
• LGBT
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