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Immigration, Trauma, and Children & Youth with Disabilities

Fernando S. Mendoza, MD, MPHDepartment of Pediatrics

Stanford University, School of Medicine

18th Annual Developmental Disabilities: An Update for Health ProfessionalsMarch 14-15, 2019

Disclosure

� I have nothing to disclosure

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Children of Immigrants U.S. Immigration Laws

Hope Reality

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Mexican Repatriation 1929-1936Mexican and Mexican-American families wait to board Mexico-bound trains in Los Angeles on March 8, 1932. County officials arranged these mass departures as part of "repatriation campaigns," fueled by fears that Mexicans and Mexican-Americans were taking scarce jobs and government assistance during the Great Depression.

Los Angeles Public Library/Herald Examiner Collection

Can History Repeat Itself? Overview

� Children in Immigrant Families (CIF)–Demographics–Social Determinants leading to

increased risk–Health Status of CIF–Health Care Utilization–Immigration and Social Policies–Needed System Change

Learning Objectives

� Describe the effect of Children in Immigrant Families on the demographics of US children

� List the social determinants that effect the health status of CIF

� Describe how the health status of CIF differs from 3rd generation US children

� List factors the affect the health care utilization of CIF with disabilities

� Describe how federal/ state/ and local policies affect the health of CIF

� Describe methods that can be use to improve the care of children and youth with disabilities from immigrant families.

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Demographics of Children in Immigrant Families

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Children in Immigrant Families(CIF- One parent born outside of U.S.)

NH Blac

k27%

Hispanic52%

Asian/Pacific10%

American India

n2%

2 or mor

e race

s9%

Minorities 2018

2050: 1 in 3 CIF

2016: 1 in 4 CIF75%

62%39%

23% 16% 12%

5%9%

19%26%

26% 28%

4%

6%8%

17% 23% 30% 29%

3% 11% 16% 22% 22% 24%10% 9% 6% 4% 3% 2%

0%10%20%30%40%50%60%70%80%90%

100%

1960 1970 1980 1990 2000 2010

Profile of US Immigrants:1960-2010

North AMLatin AMMexicoOceniaAfricaAsiaEurope

1965 Immigration and Naturalization Act: Hart-CellerAct

Most Common Immigrant Group by Region• Urban Institute – CIF

parents• 40% from Mexico -32%

of growth of CIF• 11% from Central

America – 17% of growth of CIF

• 9% Middle East and Asia-23% of growth of CIF

Language Diversity in the US• 2017 U.S Census

Populations • 21.3% speak a

language other than English at home

• 8.5% with very limited or no English ability

• 2017 California• 44% speak a

language other than English at home

• 18.4% speak English less than very well

(350 languages in U.S.)

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61.638 32.8 39.9 33.5

17.638.8

26.9 25.122.6

5.6 14.735.6 28.3

29.5

13.3 6.5 2.9 2.9 11.8

0102030405060708090

100

US Census 2015 (US Census Fast Facts 2016)

Native AmAfrican AmAsian AmHispanicNH White

Social Determinants of Children in Immigrant Families

Social Determinants of CIFWHO/CDC Model of Health Social Determinants

– Poverty– Low education levels– Race and ethnicity– Culture differences– Language and Literacy– Societal “ISMs” – Disenfranchisement from

social institutions– Immigration Policies

Adverse Childhood Experiences, Violence,anti-immigrant messages and activities

UN High Commissioner For Refugees

� Definition of Immigrants: Migrant vs. Refugee– Migrants, especially economic migrants, choose to move in order to improve

the future prospects of themselves and their families. – Refugees have to move if they are to save their lives or preserve their

freedom. � They have no protection from their own state. � If other countries do not let them in, and do not help, then they may be

condemning them to death - or to an intolerable life in the shadows, without sustenance and without rights

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D. Hernandez and W. Cervantez, Children in Immigrant Families: Ensuring Opportunity for Every Child in America. First Focus and Foundation for Child Development, March 2011

Citizenship as a Social Determinant

74 million U.S Children18.5 million CIF1.1 million undocumented children4.4 to 5.5 million children withundocumented parents.

NHW=77%

CIF in Two Parent Families Parental Education

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Limited English Proficient Parents Poverty Levels of CIF

Health Status of CIFFactors Affecting the Health Status of CIF

� Immigration Status of Parents and Child– Migrant versus Refugee– Family’s SES in Country of Origin – Trauma during trip to US– Current immigration status – Family/Community support for housing, travel, and employment

� Child/Youth Health status in Country of Origin– Disease type- malnutrition, infectious diseases, congenital, chronic

� The Immigrant Paradox and Acculturation– CIF have better health outcomes but this worsens as they acculturate

to US

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Percent With Low Birth Weights Among Births To Immigrant And Native-born Women

Source: Landale et al 1998

Disabilities and Chronic Conditions in CIF –National Survey of Children’s Health 2007Singh, G.K., Yu, S.M., Kogan, M.D. Public Health Reports Nov-Dec 2013

Indicator CIF (%) 3rd Generation (%)

All Children AOR

Insured Children AOR

Fair/Poor Health

5.93 2.86 1.33

Beh./Emo Prob. 3.01 6.50 0.61 0.75Depression 0.54 2.31 0.32 0.39Autism SD 0.72 1.19 0.63 0.74

Asthma 4.37 10.18 0.44 0.43ADD/ADHD 2.86 7.25 0.62 0.70

Develop. Delay 1.43 3.66 0.33 0.37Learning Disab. 5.20 8.37 0.58 0.63

Speech Prob. 2.41 4.07 0.53 0.58Hearing Prob. 0.69 1.52 0.53 0.50

Chronic Conditions in CIF Over Time- NSCH 2007Singh ,G.K., Yu, S.M., Kogan, M.D. Public Health Reports Nov-Dec 2013 Health Care Utilization of CIF

Enculturation Acculturation

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No Health Insurance, Employer Health Insurance, and Parental Employment:2008

46

12.8 6.1 7.127.5

69 70.7

42.1

88 93 9173

0102030405060708090100

Uninsured

Employer healthinsuranceWorking parents

Health Care Utilization -NSCH 2007Singh,G.K., Yu, S.M., Kogan, M.D. Public Health Reports Nov-Dec 2013

Utilization CIF % 3rd Gen % Hisp. CIF % NHW CIF % NHB CIF % Asian CIF % Other CIF %

No Health Insurance

16.20 7.33 24.08 5.72 14.56 5.28 6.25

No preventive care in yr.

13.04 11.12 16.06 8.31 7.36 11.94 10.48

Did not receive needed mental

health care

50.85 38.64 57.13 43.11 24.98 56.57 40.28

Immigrant Status Medicaid CHIP ACA SubsidiesPregnant Women May be eligible May be eligible Not Applicable

U.S. Citizen Children with Undocumented parents

Eligible Eligible Eligible

Lawful Permanent Resident (<18yrs)

5 year waiting period in some states

5 year waiting period in some states

Eligible

Lawful Permanent Resident over 18yrs.

5 year waiting period in some states

5 year waiting period in some states

Eligible

Refugees, Asylees, Victims of Human Trafficking and others

Eligible Eligible Eligible

Unauthorized Immigrants (children and pregnant women)

Emergency Medicaid Only

Not Eligible Barred

Health Insurance for Immigrants Immigrant children

• First Generation children• Undocumented children

are not eligible under federal law

• Documented children are able to use federal services but need to wait five years before services can be used in some states

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Utilization Barriers for CIF with Disabilities

� CIF with ASD and DD– Twice as likely to lack usual source of care and poor communication with MD� Lin, S.C., et al Pediatrics 2012 – 2007 NCHS data

� Working with CIF with disabilities – Canadian Pediatric Perspective– Identified challenges: lack of cultural competency, communication issues,

health beliefs, lack of rapport, developing patient centered care and self advocacy.

� Language needs- Limited English Proficient Parents- one third of parents in California– LEP parents in California are 60% less likelihood of having effective

communication with their physician ( Cueto, V & Mendoza, F)

Utilization Barriers for CIF with Disabilities� Use of Health Services Among International Migrant Children

(Makkulal, N. et. al globalization and health 2018, 14:52)– Literature Review 2006-16 – 107 articles– 54% European and 37% North American– Findings� Higher use of hospitals and ER� Seeking care affected by: Cultural norms, Models of Disease, Lack

of safety networks, Language barriers, Economic and Social adversity

� Access Factors: Family related difficulties, Navigating health care system, Lack of awareness of rights

� Health Professionals Barriers: Biases, Stereotypes, Prejudices, Language and communication barriers, Cultural misunderstanding

Immigration and Social Policies

Policies Effecting Refugees

• Asylum Policy and Effects• Refugee application process

• Changing administrative process without congressional oversight

• Parents and Children• Fear• Stress• Family Disruption

• Success is not All• Adapting to environment• Post-traumatic stress

The WALL

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Children and Youth and Immigration Policy

• Immigration Policy has not adapted to the needs of children and youth

• Families with undocumented parents are more likely to suffer from the daily stress of loss of a parent.

• This modifies their use of health and other social services for both undocumented children and those who are US citizens or documented.

• Documented non-citizen families are likewise in stress- (Public Charge)

• DACA individuals are in limbo• Lack of understanding the long term

effects on children and youth in immigrant families

Needed Change for CIF with Disabilities

� Immigration Policies Sensitive to CIF– Federal� Family supportive processes by ICE and Refugee processing� DACA and develop path to first documentation for undocumented

parents of CIF (90% US Citizens) then citizenship� No change in public charge for adults and don’t make services for

children and youth a public charge– State and Local� Support CIF with health, social services and educational

opportunities

o Healthy Kids, SB75- “Health 4 All KIDS”, SMC and SCC “Children’s Bill of Rights”

Needed Change for CIF with Disabilities

� Health Care Providers– Greater diversity of health professions– Cultural Competency training; including unconscious bias training– Great use and simplification of interpreter services– Partnership with community workers/community liaisons

� Health System– Improve health literacy access for families– Improve access with outreach clinics and transportation– Truly create family centered health care for all families– Enhance empowerment of families to care for their children

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An American Value?“Golden Rule”Rockwell - 1961I’d been reading up on comparative religion. The thing is that all major religions have the Golden Rule in Common. “Do unto others as you would have them do unto you.” Not always the same words but the same meaning .–Norman Rockwell