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Journal Issue: Immigrant Children Volume 21 Number 1 Spring 2011

The Physical and Psychological Well-Being of Immigrant Children
Krista M. Perreira India J. Ornelas

The Role of Migration in Shaping Children's Health

Migration and the subsequent acculturation experiences of children growing up in immigrant families increase the potential vulnerability of these children and can profoundly shape their health. The concept of acculturation describes the process of cultural change and adaptation that occurs when two or more ethnic groups come into contact with one another. The concept of enculturation describes the opposite—the process of retaining distinct cultural identities, beliefs, and norms of behavior that distinguish one ethnic group from another. Both influence child development and health outcomes.

Cultural-ecological theories argue that the resources in children's families, schools, and neighborhoods influence their lifestyles, daily experiences, and developmental outcomes.9 Because migration exposes children to unique developmental demands and stressors associated with acculturation, it reshapes their normative development. To adapt, immigrant children and their families choose different combinations of acculturation and enculturation strategies.

A modified version of Carlos Sluzki's framework for the stages of migration provides a template for understanding sources of stress throughout the migration process and the health consequences of these stressors.10 In the pre-migration stage, children's parents decide to leave their home country. These decisions typically reflect economic hardships in their home countries, political unrest and persecution, or the desire to reunify with family already living in the United States. This background sets the stage for children's subsequent migration and acculturation experiences and their influence on children's health. The migration stage captures the mobility process of migrating, including whether the children walk, drive, fly, or come by ship; whether they travel with a trusted family member or friend or are smuggled into the country; and whether they experience hardships during travel such as detainment in a refugee camp, assault, or hunger. The post-migration stage pertains to the settlement experiences of children; the process of navigating life in a new country; and the realization of changes in family economic situations, dynamics, and social roles. Pre-migration and migration influences are critical to children of immigrants, whereas post-migration influences are critical to second and later immigrant generations as well.

In this article the term "first-generation immigrant children" refers to foreign-born children with foreign-born parents. The term "second-generation immigrants" refers to U.S.-born children with at least one foreign-born parent. The term "children of immigrants" refers to both first- and second-generation immigrants as a whole. U.S.-born children with U.S.-born parents are considered "native," or third generation and higher.

Pre-Migration Experience and Health
Poverty, family separation, and political violence can substantially influence the health of children who immigrate to the United States. Yet few studies of immigrant health examine these pre-migration influences. For example, in less developed countries, the prevalence of excessive weight (overweight and obesity) tends to increase with socioeconomic status—higher incomes are associated with the adoption of high- calorie diets and an increase in sedentary activities such as watching television. Thus, low-income children who migrate from these countries are more likely to be at risk of malnutrition and stunting than of being overweight. To demonstrate the importance of pre-migration poverty, Jennifer Van Hook and Kelly Balistreri examined differences in body mass index (BMI) by levels of economic development in children's country of origin.11 They found that the BMIs and BMI growth rates were lower for low-income children of immigrants (aged five to eight) from less developed countries than for children of immigrants from high socioeconomic backgrounds in the same countries or for children of immigrants from more developed countries.

In another study of 385 young children of immigrants (aged nine to fourteen), Carola Suarez-Orozco and others found that as many as 85 percent of these children had been separated from one or both parents for a few months to a few years.12 Central Americans and Haitians experienced the highest family separation rates (96 percent), whereas Chinese children had the lowest rates (37 percent). These family separations placed children and their mothers at risk for depressive symptoms. A study focusing on children in Mexico whose primary caregivers had migrated found that these children were more likely than children in nonmigrant households to have frequent illnesses (10 percent versus 3 percent), chronic illnesses (7 percent versus 3 percent), emotional problems (10 percent versus 4 percent), and behavioral problems (17 percent versus 10 percent).13 Thus, as Nancy Landale, Kevin Thomas, and Jennifer Van Hook also highlight in the article in this issue on living arrangements, separation from a parent or primary caregiver who has migrated is associated with poor emotional and physical health among the children left behind.

Although a relatively small population (21,713 children under age eighteen in 2008) the children of refugees can experience additional hardships.14 Studies focusing on refugee populations and forced migration find that 80–90 percent of refugee children have experienced extreme hardships such as witnessing murders or mass killings, enduring forced labor, or going without sufficient food for long periods of time.15 Others survive combat experiences as child soldiers, life in refugee camps, and, for children who migrate to the United States to seek asylum and who do not have a guardian, long waits in detention centers or juvenile jails. Studies of adolescent Cuban and Cambodian refugees have found a high prevalence (50–60 percent) of both post-traumatic stress disorder and depression for up to two years after they arrive in the United States. In addition to exposures that threaten their emotional health, refugee children often have endured diarrheal disease, malnutrition, fractures, and other acute physical health problems, and experience chronic health problems after resettlement. Latent tuberculosis infections, fungal and parasitic infections, and lead poisoning are just a few of the physical health ailments common to refugee children.

These risk factors (poverty, family separation, and political violence), together with low rates of health insurance coverage and health care use, should lead to poorer health among foreign-born children than among U.S.-born children. Nevertheless, researchers consistently find an immigrant health advantage across a variety of medical outcomes. Three causes partially explain this paradox. First, foreign-born immigrant children engage in a variety of more positive health behaviors than their U.S.-born peers. They smoke less, drink less, and eat more nutritional and fewer snack foods. Second, foreign-born children tend to live in two-parent and multigenerational households with high levels of family support and other social support that can mitigate stress, especially during the initial settlement period.16 Third, children who immigrate may be a selectively healthy group. Parents whose children have physical or emotional health problems could be less likely to immigrate or bring their children to the United States or more likely to send ill children back to their home countries. Although skeptics abound, research provides weak support for the selective migration of healthy adults.17 But to our knowledge, no studies have examined the selective migration of children. In addition, most studies of health selection have focused on Mexican populations, and selection effects may vary by country of origin or even by regions within a country.

Migration Experience and Health
Few quantitative survey data exist about the nature of youths' migration experiences, but ethnographers and journalists have written extensively about these experiences. For documented children, migration to the United States may involve a relatively short plane trip and little trauma. For undocumented children, the migration journey can take months and involve severe physical and emotional hardship. Enrique's Journey, the true story of a sixteen-year-old boy's perilous trip from Honduras in search of his mother, typifies the physical and emotional trauma that at least some first-generation children experience on their way to the United States.18

In one mixed-methods study, 59 percent of Latino adolescents, aged twelve to eighteen, who had recently immigrated to North Carolina told researchers that the migration experience was somewhat to very stressful.19 Although only 8 percent of these youth traveled alone or with a smuggler, 46 percent of the adolescents surveyed were concerned for their safety during their travels, 4 percent were robbed, 1 percent were physically attacked, 11 percent were accidentally injured, and 16 percent fell sick. Many of these migrants arrived in the United States injured, emotionally distressed, and in need of either physical or mental health services.

Post-Migration Experiences, Acculturation, and Health
Most of the research on the well-being of first-generation children focuses on their post-migration experiences. These experiences include a large number of acculturation stressors such as learning a new lan- guage, coping with changes in family roles and responsibilities, protecting one's legal status or the legal status of family members, and encountering racism or discrimination. Although these stressors are common, their influence on a child's health can vary tremendously depending on the length of time the child has lived in the United States, the broader social context of settlement, and the child's age or developmental stage at migration.

Studies measuring the influences of these post-migration stressors on the health of Hispanic children typically use stress inventories such as the Hispanic Stress Index and the Societal, Attitudinal, Familial, and Environmental Acculturative Stress Scale. Nearly all of these studies focus on the strong negative relationship between stressors and children's emotional well-being. Researchers have not yet evaluated relationships between acculturation stressors and physical health outcomes; acculturation stress inventories have not yet been developed for use among Asian populations; and many analyses using stress inventories fail to differentiate the consequences of various sources of acculturative stress such as discrimination, family conflict, language skills, or legal status.

The current evidence does clearly indicate a link between racial discrimination and health. Youth who experience or perceive discrimination report more anxiety, more depressive symptoms, more risky health behaviors, lower self-esteem, and reduced academic motivations and expectations.20 Moreover, researchers have begun to link racial discrimination to a variety of physical health outcomes in minority children, including elevated blood pressure, elevated levels of glucocortisol hormones in the blood stream, and insulin resistance—conditions associated with high rates of coronary heart disease and inflammatory disorders.21

Evidence also shows a strong link between immigrants' family environments and health. On the one hand, familism—the strong family ties, trust, loyalty, and spirit of mutual support cultivated by many immigrant parents—and family responsibilities such as language brokering for adult parents can positively influence youths' emotional well-being.22 On the other hand, family conflict, parent-child acculturation gaps, and numerous family obligations can add to the stress experienced by children of immigrants and compromise their well-being.23

Much of the acculturation literature uses first- and second-generation immigrants' preferences for reading, writing, and interacting with friends in English rather than a foreign language as a primary measure of acculturation. These studies find that linguistically more acculturated youth have poorer health and engage in more risky health behaviors. In contrast, researchers know less about how age of migration, legal status, and the institutional and social contexts of reception influence children's health.

Children who immigrate at younger ages have greater language acquisition and better educational outcomes than children who immigrate at older ages, especially after puberty. However, their health risk profiles are more similar to children born in the United States to foreign-born parents. These young migrants find themselves caught between two worlds—the cultures of their parents and the cultures of their new communities. As they struggle to adapt, they tend to adopt more risky health behaviors such as alcohol use, smoking, and early sexual activity than their peers who immigrate at older ages.24 In addition, they face a higher risk of psychiatric disorders such as depression.25

Living in a liminal state between countries and without legal status can create daily hassles and become a source of chronic stress for children and their parents. A recent study of U.S.-born and foreign-born children of immigrants (from birth to age eighteen) whose parents had been arrested, detained, or deported during workplace raids by immigration officers sheds some light on the health consequences of legal status.26 It found that children in these families experienced feelings of abandonment, fear, social isolation, and anger. Moreover, family friends and teachers noticed changes in these children's behaviors immediately after the raids.

Finally, the influence of each of these stressors may vary by an immigrant's state of residence. Several researchers have begun to evaluate the link between how well immigrants are received in an institutional and social context and health outcomes. 27 Historically, immigrants settled in six traditional gateway states—California, Florida, Illinois, New Jersey, New York, and Texas. Since 1990 immigrants have begun settling in new destination states across the Midwest (such as Indiana, Iowa, and Nebraska) and the South (such as Georgia, North Carolina, and Tennessee). These new destination states lack many of the institutional resources and multilingual professionals who help new immigrants settle and navigate complex U.S. health systems. Immigrants settling in these states also have smaller co-ethnic networks on whom they can rely for assistance and who can reinforce positive cultural norms and health behaviors for their children. Consequently, these immigrants have less access to health care and can be at greater risk of worsening health with time in the United States.28