Immigrants & Refugees
There are about 40 million immigrants, refugees, and migrants in the United States, about 8 million of whom are children.
Definitions (from Centers for Disease Control and Prevention, Immigrant, Refugee and Migrant Health)
Immigrant: An individual admitted to the United States (or any other country) as a lawful permanent resident.
Refugee: Any person who is outside of the country of their nationality or, does not have a nationality, or is outside the country where they last lived and who is unable or unwilling to return to and unable or unwilling to avail themselves of the protection of that country because of persecution, or a well-founded fear of persecution, on account of race, religion, nationality, membership in a particular social group, or political opinion.
Migrant: A person who moves away from their place of usual residence, whether within a country or across an international border, temporarily or permanently.
The Migrant Experience
The migrant experience differs widely among individuals, families, ethnic, racial and cultural groups, and by country of origin and country of relocation. Immigrant and refugee children and their families, however, share certain common experiences.
Pre-migration life: The decision to emigrate from one’s country is not made lightly. “Push” factors may include war, famine, environmental disasters (including climate change), persecution based on ethnicity, religion, sexuality, or political beliefs, and lack of economic opportunity.
The migration journey: Migrants face many dangers and stressors while moving from their country to the host country. They may be victims of robbery, extortion, abuse, vehicular or boat accidents, heat, cold, and starvation.
Post-migration life: Life in the host country, often idealized in the minds of immigrants and refugees, may be more averse than anticipated. Lack of housing, abusive working conditions, the difficulty of navigating new systems and possibly a new language, racism or anti-immigrant sentiment and behaviors may be major stressors for already stressed children and families.
Traditionally, immigration was undertaken by adult males with the goal of earning money and sending it back to family members at home (remittances), or by male-head households seeking to flee persecution or economic disadvantage and start a new life. Increasingly, women migrate independent of men. Children may wait in their home country and reunite sooner or later with parent(s) after a period of separation or may be sent off alone to attempt to join a relative already in the host country (unaccompanied minors). All aspects of family separation, migration and reunification (or failure of reunification) can be a psychological challenge for children.
Range of mental health issues
Immigrant and refugee children and adolescents may present any childhood mental health disorder. In general, recent immigrants tend to have lower rates of mental health disorders, suicide attempts and completed suicides than do native-born residents and foreign-born citizens of the host country (Filion et al., 2018; Saunders et al., 2017). This relative “immigrant advantage” may be mitigated by risk and protective factors as outlined below.
Migrant child mental health
- Exposure to violence (premigration and/or postmigration)
- Female gender
- Parental exposure to violence
- Parental mental health concerns
- Poor financial situation
- Single-parent household
- Unaccompanied minor
- Perceived/experienced discrimination
- Multiple relocations
- Fear of deportation and return to dangerous conditions in country of origin
In Country of Origin
- Lack of legal and human service protections for survivors of child abuse and domestic violence
- Corruption of government officials and law enforcement
- Unchecked gang/cartel violence
- Easy temperament, self-regulation skills
- Intellectual functioning, academic achievement
- Sense of self-efficacy and positive self-concept
- Social skills, ability to make new friends
- Belief in higher power/belief that life has meaning
- Future goal orientation (academic and career goals)
- High parental support and family cohesion
- Supportive caregiver, mental health of caregiver
- Support from friends
- English language supports, educational advocacy to test into the appropriate grade level, and supports with social integration
- Case management services to alleviate financial hardship, housing and food insecurity, establish primary and dental care
- Participation in positive youth development or extracurricular activities
Adapted from Kroening & Dawson-Hahn, 2019.
The role of the pediatric clinician
The pediatric clinician is in a unique position to provide appropriate, strengths-based, trauma-informed care to immigrant and refugee children. This begins by showing compassion and respect and demonstrating that one’s clinical setting is a safe and welcoming environment. It also begins with becoming familiar with immigrant and refugee health needs.
While it may be therapeutically beneficial to identify and acknowledge trauma associated with migration, it is essential to ensure children and parents that this information will be kept confidential. The clinician should NOT document immigration status in the medical record as records are subject to subpoena.
Mental health screening should be carried out per clinic protocol, ideally in the language of the caregiver and child. Recognize that the understanding of mental health and mental illness may be markedly different for immigrant families depending on attitudes toward and knowledge of mental health in their home country.
Pediatric clinicians who work with refugee populations may wish to receive training in forensic evaluation and collaborate with attorneys, human rights experts and immigration officials in facilitating asylum applications for their patients (McKenzie et al., 2019).
AAP – Immigrant Child Health Toolkit
Loyola University Chicago Newswanger Institute for Bioethics & Healthcare Leadership Sanctuary Doctor
Physicians for Human Rights Asylum Network Trainings
Partnering with Communities to Promote Positive Parenting in Immigrant Families: Pediatric Mental Health Minute Series
Mental Health of Newcomer Children and Adolescents: Pediatric Mental Health Minute Series
If you are a patient or are a provider working with a patient who does not yet have legal representation, and you think they may qualify for immigration relief, consider contacting:
Burnett-Zeigler, I., Walton, M. A., Ilgen, M., Barry, K. L., Chermack, S. T., Zucker, R. A., Zimmerman, M. A., Booth, B. M., & Blow, F. C. (2012). Prevalence and correlates of mental health problems and treatment among adolescents seen in primary care. In J Adolesc Health (Vol. 50, Issue 6, pp. 559–564). https://doi.org/10.1016/j.jadohealth.2011.10.005
Ciaccia, K. A., & John, R. M. (2016). Unaccompanied Immigrant Minors: Where to Begin. Journal of Pediatric Health Care, 30(3), 231–240. https://doi.org/10.1016/j.pedhc.2015.12.009
Filion, N., Fenelon, A., & Boudreaux, M. (2018). Immigration, citizenship, and the mental health of adolescents. PLoS ONE, 13(5), e0196859. https://doi.org/10.1371/journal.pone.0196859
Kroening, A. L. H., & Dawson-Hahn, E. (2019). Health Considerations for Immigrant and Refugee Children. Advances in Pediatrics, 66, 87–110. https://doi.org/10.1016/j.yapd.2019.04.003
Majumder, P., O’Reilly, M., Karim, K., & Vostanis, P. (2015). ‘This doctor, I not trust him, I’m not safe’: The perceptions of mental health and services by unaccompanied refugee adolescents. International Journal of Social Psychiatry, 61(2), 129–136. https://doi.org/10.1177/0020764014537236
McKenzie, K. C., Bauer, J., & Reynolds, P. P. (2019). Asylum Seekers in a Time of Record Forced Global Displacement: The Role of Physicians. Journal of General Internal Medicine, 34(1), 137–143. https://doi.org/10.1007/s11606-018-4524-5
Saunders, N. R., Lebenbaum, M., Stukel, T. A., Lu, H., Urquia, M. L., Kurdyak, P., & Guttmann, A. (2017). Suicide and self-harm trends in recent immigrant youth in Ontario, 1996-2012: A population-based longitudinal cohort study. BMJ Open, 7(9), e014863. https://doi.org/10.1136/bmjopen-2016-014863
Schapiro, N. A., Kools, S. M., Weiss, S. J., & Brindis, C. D. (2013). Separation and Reunification: The Experiences of Adolescents Living in Transnational Families. Current Problems in Pediatric and Adolescent Health Care, 43(3), 48–68. https://doi.org/10.1016/j.cppeds.2012.12.001