Walking into a new patient appointment, you encounter a mother with two children ages 8 and 14 years old. The mother and older sibling understand some Spanish, but primarily speak Mam, a Mayan dialect for which there are no medical interpreters at the moment. The younger sibling speaks English. Your medical assistant explains that the family moved to your town two months ago to afford better housing. The older sibling emigrated from Guatemala on her own four months ago and reunited with her mother after nine years. She is enrolling in school and needs a routine physical and vaccines, and she is not sleeping well. Mom has behavioral concerns regarding the younger sibling, and you also note a body mass index above the 95th percentile.
Children in immigrant families (CIF) represent a growing population across the country, with children and families seeking asylum at the highest numbers in recent history. While states like California, New York and Texas hold a significant number of immigrant families, other states are becoming home to many CIF at a rapid rate.
As health care providers increasingly encounter this diverse and dynamic patient population, they may experience scenarios like the one above but may not have a foundation from which to construct a clinical strategy.
Pediatricians need to establish a clinical approach that acknowledges the potential health effects of migration, particularly forced migration, as well as how the sociopolitical environment influences health outcomes for CIF.
A new AAP policy statement Providing Care for Children in Immigrant Families, from the Council on Community Pediatrics, updates and expands on concepts presented in the 2013 policy Providing Care for Immigrant, Migrant, and Border Children. Since then, the practice and evolution of immigrant health has gained traction with exploration of evidence-based clinical approaches; the interplay of social determinants of health and biopsychosocial development, particularly as it relates to the legal and political constructs of immigration status; and the importance of advocacy.
The policy is available at https://pediatrics.aappublications.org/content/early/2019/08/15/peds.2019-2077 and will be published in the September issue of Pediatrics.
Diverse experiences
The term “children in immigrant families” allows for the consideration that family structures vary by composition and immigration status. It invites practitioners to broadly consider the dynamics and implications of immigration status for the child and how that shifts depending on the status of primary caretakers and family members.
For example, how might social determinants of health and the general well-being of a U.S.-born child with parents who have yet to obtain protected legal status differ from that of a child whose parents have been granted asylum? And how might this child’s health trajectory change if immigration enforcement actions led to the removal of a family member from the home? Additionally, the term CIF reflects the subpopulations within immigrant health.
Supporting equity
While CIF present with a variety of experiences, all may face inequities that threaten their health and contribute to population-level disparities. As such, the policy statement offers core competencies and the opportunity for experts and practitioners to develop unifying principles and guidelines that apply to the care of CIF whether they are refugees or migrant farm workers, for example.
Through the policy, the AAP continues to recognize the importance of human rights and frameworks that align with its commitment to diversity, inclusion and health equity. The AAP endorses the United Nations Convention on the Rights of the Child, an internationally recognized legal framework for the protection of children’s basic rights that has not been ratified by the United States. Along with using the frameworks of cultural humility and cultural safety, the policy statement grounds itself in health equity and recognizing the resilience and cultural assets of CIF.
The policy also highlights common barriers to the care of CIF, many of which are rooted in structural barriers defined by discriminatory legal and policy constructs.
The recommendations aim to strengthen the medical home for CIF and ensure that health care is being delivered in an equitable manner where families feel that they are participants in their care.
Recommendations for pediatricians
- Recognize inherent biases and improve skills in cultural humility and effective communication through professional development.
- Consider co-located or integrated mental health, social work, patient navigation and legal services.
- Use trained medical interpreters — via phone, tablet or in-person — to facilitate mutual understanding and a high quality of communication.
- Remain sensitive to and screen for multigenerational trauma.
- Screen for social determinants of health, including risks and protective factors.
Advocacy/policy recommendations
- Interagency collaboration among service providers (e.g., medical, mental health, public health, legal, education, social work, ethnic community-based) can enhance care, prevent marginalization of immigrant families and build resilience.
- Health coverage should be provided for all children regardless of immigration status.
- Immigration policy that prioritizes children and families by ensuring access to health care, educational and economic supports, keeping families together, and protecting vulnerable unaccompanied children is fundamental for comprehensive immigration reform.
- Medical education should promote core competencies for the care of immigrant populations and advocacy curricula.
- AAP chapters can work with state governments to adopt policies that protect and prioritize immigrant children’s health, well-being and safety.
Dr. Gutierrez is a member of the AAP Council on Immigrant Child and Family Health Executive Committee.
