Practitioners Can Help Children Who Are Immigrants

The United States is celebrated as a melting pot for its unique blend of cultures, languages, and races.

Approximately 14%, or 1 in 7, US residents are immigrants, including an estimated 2.5 million children, according to the American Immigration Council.¹

Additionally, 25% of children in the United States have at least 1 parent who was not born in this country,² and 6.1 million children live with at least 1 undocumented family member.¹ Children who are immigrants may face unique emotional, health, and social challenges. Pediatric advanced practice providers must be thoroughly prepared to face these challenges with families to promote the health and well-being of these children.

Language barriers can result in worse health outcomes.³ In addition to using trained medical interpreters, however, it is important for pediatric providers to go beyond bridging the language gap. Recognizing cultural bias when caring for immigrant children is of paramount importance, as health care providers’ implicit biases can result in worse care to patients with diverse cultural backgrounds.⁴ Cultural competency allows practitioners to effectively interact with patients from other cultures. However, the concept of “cultural competency” is problematic, because the term suggests that practitioners can obtain definitive knowledge about each culture and that there is a finish line for learning to interact with other cultures.⁵ In recent years, there has been a marked shift away from cultural competency to cultural humility, which recognizes the rich complexities of cultures and acknowledges that practitioners cannot possibly be completely competent in another culture, though they can strive daily to address their own biases to provide the best care possible.⁵ A common tool for communication with other cultures is the LEARN framework (Listen, Explain, Acknowledge, Recommend, Negotiate), which can improve the patient experience and quality of care.⁶ Practitioners should assess for potential cultural concerns or concerns and should always discuss and elicit feedback regarding treatment plans with patients and their families.

Mental health is a primary concern when providing health care to children who are immigrants. Immigration inherently disrupts typical childhood experiences, which may affect development. Children who are immigrants are at increased risk for trauma and violence and often require more mental health support than their US-born peers.⁷ Children who are immigrants should be initially screened for mental health concerns after their arrival in the United States and screened at least annually thereafter. The Ages and Stages Questionnaire – Social Emotional,⁸ the Child Behavioral Checklist,⁹ and the Strengths and Difficulties Questionnaire¹⁰ are all validated tools that may be used to assess for behavioral or mental health concerns, in addition to the commonly used PHQ-9 screening for depression and GAD-7 screening for anxiety.¹¹

Another consideration when caring for children who are immigrants is social determinants of health, which have extensive effects on health and quality of life. Children who are immigrants are disproportionately negatively affected by social determinants of health.¹² Children who are immigrants may face difficulty accessing health care or legal services, food and housing insecurity, lack of education, and poverty.¹² Pediatric providers should routinely screen for social determinants of health and address needs by referring to community agencies as indicated. Both patients and providers may search for assistance programs by zip code using FindHelp.Org, which is available in a wide variety of languages.¹³ Services on FindHelp include, but are not limited to, childcare assistance, food pantries, general medical care, health education, housing resources, job placement, legal services, maintenance and repairs, medical supplies, and transportation.¹³

In addition to these complex issues, pediatric practitioners must focus on overall physical health. They should obtain a birth, dental, developmental, family, and general medical history and review available diagnostic imaging and laboratory results, growth charts, and newborn screening and vaccination records. Pediatric providers should also ask about the use of OTC and prescription medications, as well as cultural or herbal therapies, which are common among immigrants and may lead to negative health outcomes.¹⁴

In addition, pediatric providers should conduct a thorough physical exam, including hearing and vision screenings.¹⁴ Providers should pay particular attention to the oral exam and provide dental referrals, as children who are immigrants experience increased rates of dental disease compared with their US-born peers.¹⁵ When conducting skin assessments, practitioners should be careful not to confuse signs of traditional healing measures, such as coining or cupping, with integumentary disease.¹⁴ A genital exam is also important, but pediatric providers must determine cultural barriers that would preclude this.¹⁴ If barriers exist, referrals should be provided to a practitioner that the family deems appropriate.

Vaccines schedules vary by country and can differ in both the types of vaccines given and the number and timing of vaccines recommended.¹⁶ Timely vaccination should be a focus for children who do not yet have all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). Accept vaccines given outside the United States if the timing and types align with ACIP recommendations. Providers should use the CDC’s catch-up immunization schedule as a resource for the timing of these catch-up vaccinations.¹⁷

Blood work should be a routine part of the care for children who are immigrants shortly after their arrival to the United States. A complete blood count with differential is recommended for immigrants of all ages, and a urinalysis is recommended if the child is developmentally able to provide a clean catch specimen.¹⁴ All children who are immigrants aged 6 months to 16 years should be screened for lead.¹⁴ Children aged 6 months to 6 years should be tested again between 3 and 6 months later.¹⁴ Standard newborn screening is recommended for any newborns who are immigrants.¹⁴ As newborn screening may not have been done in the child’s native country, evaluation for hemoglobinopathies, hypothyroidism, and metabolic abnormalities may be performed.²

Tuberculosis screening should also be considered. Children aged 2 to 14 years who immigrate to the United States from a country with a tuberculosis incidence rate of greater than or equal to 20 cases per 100,000 population should have an interferon gamma release assay (IGRA) blood test to screen for tuberculosis exposure.¹⁸ Children aged 15 years and older must have a chest X-ray, regardless of tuberculosis incidence in their country of origin.¹⁸

Regardless of age and tuberculosis incidence in their country of origin, any child with confirmed HIV infection must have both a chest X-ray and IGRA and should also undergo sputum testing.¹⁸ HIV testing is recommended for all children who are immigrants aged 13 years and older.¹⁴ Adolescents should also be offered comprehensive reproductive care, as should children with a history of trafficking or other suspected abuse.² Additional screening for infectious disease should be considered based on travel history and exposure risk.¹⁴

Conclusion

Children who are immigrants may face a host of unique health challenges, which can be wide-ranging and difficult to address. It is important for practitioners to approach the care of these children in an evidence-based, holistic, and supportive manner. With the right expertise and tools, pediatric practitioners can make a positive impact in the lives of these children.

References

1. Immigrants in the United States. American Immigration Council. September 21, 2021. Accessed April 8, 2022. https://www.americanimmigrationcouncil.org/research/immigrants-in-the-united-states

2. Linton JM, Green A, Council on Community Pediatrics. Providing care for children in immigrant families. Pediatrics. 2019;144(3):e20192077. doi:10.1542/peds.2019-2077

3. Pandey M, Maini RG, Amoyaw J, et al. Impacts of English language proficiency on healthcare access, use, and outcomes among immigrants: a qualitative study. BMC Health Serv Res. 2021;21(1):741. doi:10.1186/s12913-021-06750-4

4. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Eth. 2017;18(1):19. doi.org/10.1186/s12910-017-0179-8

5. Khan S. Cultural humility vs. cultural competence — and why providers need both.Boston Medical Center – HealthCity. March 9, 2021. Accessed April 8, 2022. https://healthcity.bmc.org/policy-and-industry/cultural-humility-vs-cultural-competence-providers-need-both#:~:text=Cultural%20competence%20is%20loosely%20defined,knowledgeably%20with%20people%20across%20cultures.&text=The%20term%20%22cultural%20humility%22%20was,critique%2C%20acknowledging%20one's%20own%20biases

6. Ladha T, Zubairi M, Hunter A, Audcent T, Johnstone J. Cross-cultural communication: tools for working with families and children. Paediatr Child Health. 2018;23(1):66-69. doi.org/10.1093/pch/pxx126

7. Betancourt TS, Newnham EA, Birman D, Lee R, Ellis BH, Layne CM. Comparing trauma exposure, mental health needs, and service utilization across clinical samples of refugee, immigrant, and U.S.-origin children. J Trauma Stress. 2017;30(3):209-218. doi.org/10.1002/jts.22186ASQ:SE-2.

8. Ages & Stages Questionnaires. Accessed April 22, 2022.https://agesandstages.com/products-pricing/asqse-2/

9. Mansolf M, Blackwell CK, Cummings P, Choi S, Cella D. Linking the child behavior checklist to the strengths and difficulties questionnaire. Psychol Assess. Advance online publication.2022;34(3):233-246. doi:10.1037/pas0001083

10. Bryant A, Guy J, CALM Team, Holmes J. The strengths and difficulties questionnaire predicts concurrent mental health difficulties in a transdiagnostic sample of struggling learners. Front Psychol. 2020;11:587821. doi:10.3389/fpsyg.2020.587821

11. Kroenke K, Wu J, Yu Z, Bair MJ, Kean J, Stump T, Monahan PO. (2016). Patient health questionnaire anxiety and depression scale: initial validation in three clinical trials. Psychosom Med. 2016;78(6):716-727. doi:10.1097/PSY.0000000000000322

12. Chang CD. Social determinants of health and health disparities among immigrants and their children. Curr Probl in Pediatr Adoles Health Care. 2019;49(1):23-30. doi.org/10.1016/j.cppeds.2018.11.009

13. FindHelp. 2022. Accessed April 22, 2022. https://www.findhelp.org/

14. Immigrant, refugee, and migrant health. CDC. Updated March 10, 2021. Accessed April 22, 2022. https://www.cdc.gov/immigrantrefugeehealth/index.html

15. Crespo E. (2019). The importance of oral health in immigrant and refugee children. Children (Basel). 2019;6(9):102. doi:10.3390/children6090102

16. Vaccine Knowledge Project. Oxford Vaccine Group. Updated March 25, 2022. Accessed April 22, 2022. https://vk.ovg.ox.ac.uk/vk/vaccination-schedules-other-countries

17. Catch-up immunization schedule for persons aged 4 months–18 years who start late or who are more than 1 month behind, United States. CDC. February 17, 2022. Accessed April 22, 2022. https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html17

18. Tuberculosis technical instructions for panel physicians. CDC. October 17, 2019. Accessed April 22, 2022. https://www.cdc.gov/immigrantrefugeehealth/panel-physicians/tuberculosis.html