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Living in an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, & Health

Introduction

Immigration policy has been and continues to be a controversial topic in the U.S. Over the course of the election and since taking office, President Trump has intensified national debate about immigration as he has implemented policies to enhance immigration enforcement and restrict the entry of immigrants from selected countries the Administration believes may pose a threat to the country (Appendix 1). The climate surrounding these policies and this debate potentially affect 23 million noncitizens in the U.S., including both lawfully present and undocumented immigrants, many of whom came to the U.S. seeking safety and improved opportunities for their families.1 They also have implications for the over 12 million children who live with a noncitizen parent, who are predominantly U.S-born citizen children.2 This brief provides insight into how the current environment is affecting the daily lives, well-being, and health of immigrant families, including their children. The findings are based on focus groups with 100 parents in immigrant families from 15 countries and telephone interviews with 13 pediatricians who serve immigrant communities.

Methods

During Fall 2017, the Kaiser Family Foundation worked with PerryUndem Research/Communication to conduct focus groups with 100 parents in immigrant families. Focus group participants were selected to represent a range of races/ethnicities, countries of origin, and immigration statuses and to provide for geographic diversity of experiences. A total of 10 focus groups were conducted in 8 cities in 4 states (Chicago, Illinois; Boston, Massachusetts; Bethesda, Maryland; and Anaheim, Fresno, Los Angeles, Oakland, and San Diego, California). In addition, 13 telephone interviews were conducted with pediatricians and clinics serving immigrant families. With assistance from the American Academy of Pediatrics, pediatricians were identified who serve different immigrant populations across a range of states (Arkansas, California, District of Columbia, Illinois, Minnesota, North Carolina, Pennsylvania, Texas, and Vermont). The Blue Shield of California Foundation supported the focus groups and interviews conducted in California.

Focus groups were conducted in 5 languages with parents from 15 countries of origin. There were six Spanish-speaking focus groups with parents from Mexico, the Caribbean, and Central and South America; one group with Korean parents; one group with Portuguese-speaking parents from Brazil and Cape Verde; one group with Farsi-speaking parents from Afghanistan; and one group with Arabic-speaking parents from Iraq, Egypt, and Syria. Participants included individuals with a range of immigration statuses, including undocumented individuals, refugees/asylees, and lawful permanent residents (“green card” holders). (See Appendix 2 for an overview of selected immigration statuses.) Four of the groups were held in focus group facilities; the remaining six groups were organized and held in community-based organizations serving the community. Since participants in the groups hosted by community-based organizations were often receiving services through the organization, they generally were connected to more resources and more knowledgeable about their rights compared to the general community.

One-on-one telephone interviews were conducted with pediatricians. Interviewed pediatricians serve a variety of immigrant families, including Latino immigrants from Mexico and Central and South America as well as immigrants from an array of other countries and regions, including Bhutan, Burma, China, India, Korea, Myanmar, Mongolia, Vietnam, Yemen, the Democratic Republic of the Congo, Somalia, Ethiopia, Eritrea, Eastern Europe, and the Middle East.

Key Findings

Overview of Participating Parents and Their Families

Participating parents immigrated to the U.S. to escape war or gang activity in their native countries, for job and educational opportunities, and/or to reunite with family. Some parents told stories of losing loved ones to war or gang violence in their native countries and said they immigrated to the U.S. to find safety. Similarly, refugees and asylees immigrated to escape war or persecution in their native countries. Many parents also noted that their native countries have high rates of poverty, inadequate education systems, and poor job prospects, and that coming to the U.S. provides their families better educational and employment opportunities. Some participants also came to the U.S. to join other family members who had previously immigrated. Participants varied widely in their length of time in the U.S. Some have been in the U.S. for many years, while others arrived more recently. Some came to the U.S. as children and have no experience in their native countries. A number of participants, particularly refugees and asylees escaping war, expressed how grateful they were for the opportunity to be in the U.S.

“They killed three members of my family and… I left.” –Latino Parent, Boston, Massachusetts

“I am Salvadoran and, due to the war, I came here. My brother was killed and then I came here.” –Latino Parent, Boston, Massachusetts

“In Mexico there aren’t opportunities, even for young people. The environment is too violent.”    –Latino Parent, Chicago, Illinois

“Many of us came as children, and we had no idea about the future. Now we have no option but to stay because… we are afraid to go back to a place that we are not familiar with.” –Latino Parent, Bethesda, Maryland

“I’ve been here since I was 6 years-old; I have a daughter who is 6 years-old. I’m not familiar with any other country. I love this country.” –Latino Parent, Bethesda, Maryland

“…my dad brought us here so that way we could have better education.” –Latino Parent, Fresno, California

“The United States government took us in because we were not feeling safe in our countries and because we were being discriminated against. We thank the United States for that.” –Arabic-speaking parent, Anaheim, California

“One of the top reasons is safety in terms of bodily safety, mental, and emotional…” –Afghan Parent, Oakland, California

“…over there [in Mexico], there’s a lot of crime.” –Latino Parent, Fresno, California

Children of participating parents are mostly U.S.-born citizens. Similarly, pediatricians noted that in many families that they serve, the children are U.S. born citizens while one or both parents may be undocumented. Some parents also have older children that they brought with them to the U.S. who either have obtained status under the Deferred Action for Childhood Arrivals (DACA) program or are undocumented, and a few have children who are still in their native country. Parents noted that many of their children have never visited their native countries and that the U.S. is the only home they have known. Children of refugees and asylees include a mix of those that fled to the U.S. with their parents and younger children born in the U.S.

Finances and language barriers are a major concern for many participants. Participants generally have at least one worker in the family, often in service, construction, or landscaping jobs. Many noted that they are trying to find as much work as possible, but still are living paycheck to paycheck. They noted that the costs of rent and groceries continue to increase, making it difficult to make ends meet. Participants who arrived to the U.S. more recently, particularly those from Middle Eastern countries, described challenges assimilating to life in the U.S., noting the pressure to find employment quickly and the difficulty they face finding a job due to language and cultural barriers. Some noted that they had professional careers in their native countries and have had to work in less-skilled service jobs here in the U.S. as they become established.

Fears and Concerns Among Families

Parents and pediatricians said that fears of deportation and overall feelings of uncertainty have increased since the presidential election. Parents who are undocumented or who have an undocumented family member expressed growing fears that they will be separated from their children and/or spouse. Some also fear returning to their native country because of the violence and gang activity there. A number of participants have friends and/or family members who were recently detained or deported. They also described recent immigration raids and enforcement activity in their neighborhoods, along roadsides, and in their workplaces. One pediatrician noted that, although these fears among undocumented immigrants often are perceived to primarily affect Latinos, there are growing numbers of undocumented Asians who also are feeling increased fear.

“The area where I live… the majority of raids happen there. And we hear many cases about deporting people from their apartments in that area… The community is so scared.” –Latino Parent, Bethesda, Maryland

“If my husband is deported, how am I supposed to live here without him? There is no way. It breaks up a whole family.” –Portuguese-speaking Parent, Boston, Massachusetts

“…we wake up every day with the fear of being deported, of the separation of our families, to have to leave the kids.” –Latino Parent, Boston, Massachusetts

“…I am both mom and dad for my children… So, I must be there, and I think, God forbid it, but if I get detained, they will deport me…” –Latino Parent, Chicago, Illinois

“…everybody is afraid because they have their lives here. They don’t have papers, but they’ve got their life here and they don’t have anything in Mexico anymore because, I mean, it’s years ago. There’s no way they can support themselves over there.” –Latino Parent, Fresno, California

“It happened to me several times where you hear somebody knock on your door and they pick up your relatives and they take them and they lock them up.” –Latino Parent, Fresno, California

“They’re putting more pressure at the border. They check everything.” –Latino Parent, San Diego, California

“I think everybody is a lot more scared. There’s more fear in me personally speaking… now I feel it personally. Not before, but now I do.” –Latino Parent, Los Angeles, California

“The worst fears are that they’re going to separate us… that they’re going to be separating families.” –Latino Parent, Los Angeles, California

Feelings of increased fear and uncertainty extend to those with lawful status. For example, Korean parents in Chicago and Afghan parents in Oakland said they feel having a green card is no longer sufficient and that they need to obtain citizenship to secure their status. Some said that, even with a green card, they no longer feel safe traveling out of the country because they worry that they will have problems reentering the U.S. Some parents also said that it has become more difficult to obtain citizenship since the election, and that the length of time to obtain a green card or citizenship has increased. Arabic-speaking parents and a number of pediatricians reported that refugees and asylees feel unstable and worry about whether they will be able to remain in the country. Pediatricians emphasized that refugees and asylees come from histories of government persecution and that it is difficult for them to trust that they will remain protected. In addition, some parents expressed concerns that the government might eliminate Temporary Protected Status (TPS) for people from Nicaragua, El Salvador, and Honduras.3 Some parents said that, although current policies have not affected them, they are worried that rules may change, causing them to lose status or permission to remain in the U.S.

“I feel unsettled. Even though we already have the green card, if we do not apply for citizenship, I don’t think we can be at ease.” –Korean Parent, Chicago, Illinois

“Before this, we were living here with permanent residency without citizenship and we thought it wouldn’t be a problem… but after Trump was elected, I thought, if I want to live here and raise my son, I will need to apply for citizenship.” –Korean Parent, Chicago, Illinois

“Uncomfortable and unstable; we feel that in any moment a new rule could be issued leading to expelling us and sending us back.” –Arabic-speaking Parent, Anaheim, California

“There’s no stability. [The President] could write a tweet on Twitter tomorrow and turn things upside down.” –Arabic-speaking Parent, Anaheim, California

“…The new laws being approved, they have us with a sense of uncertainty… TPS… DACA, what’s gonna happen in six months?” –Latino Parent, Bethesda, Maryland

“The concern is that today it’s one group, and tomorrow it can be another. We may be happy today that we’ve been left alone, but tomorrow might be another story.” –Afghan Parent, Oakland, California

“When President Trump was elected there was just huge, huge fear in our refugee communities and our immigrant communities. It didn’t matter that they had legal status…” –Pediatrician, Vermont

“Even if they, themselves, may not be directly at risk because they should be in an immigration status that helps them, especially for refugees, they are so used to being afraid of government and distrustful of government…” –Pediatrician, California

Parents and pediatricians noted particular concerns among individuals that have obtained DACA. In the focus groups that were conducted prior to the rescission of DACA, parents expressed concerns about the security of DACA, fearing that it would be eliminated. In the groups conducted after the rescission of DACA, parents reported that fear and uncertainty among individuals with DACA had intensified, with many worrying about their current situation and losing hope for the future.

“The kids who are in school are also worried, the ones who are going to college, because we don’t know what will happen with DACA…”—Latino Parent, Boston, Massachusetts

“I speak in the case of DACA. Everybody is on the right path. Everybody is studying, but they still face risks. So it can happen to any of us… Everything depends on [the President] and on the laws they create.” –Portuguese-speaking Parent, Boston, Massachusetts

“It’s going backwards, because everything Obama helped the dreamers– well now everyone is scared because Trump wants to take that away…” –Latino Parent, San Diego, California

“…she was able to get DACA… if she won’t be able to renew it, she’s thinking they’re going to come and pick her up because they have all of her information.” –Latino Parent, Los Angeles, California

“…I have two cousins and they were under DREAM Act… they all have jobs and they were going to schools and… they know their whole lives here. And then for that to all just be taken away.”     –Latino Parent, Fresno, California

“I know someone with DACA who recently got it and…since he got his work permit a lot of doors opened up for him… So his dreams were like enormous, but now stopping DACA, he is so afraid.” –Latino Parent, Bethesda, Maryland

“[I was] in [the DACA application] process when we heard the news. It was really painful… I was doing things right, out on my own… to look for a future for me and my kids. So it’s like depression comes in—what am I going to do now?” –Latino Parent, Bethesda, Maryland

“Recently also, I have a couple of patients… more than a couple… who I’ve talked with recently, who are DACA recipients that are feeling very much unsure as to what their future is going to be.” –Pediatrician, District of Columbia

Parents varied in the levels of fear they felt. A variety of factors influenced the level of fear felt by parents, including their and their family members’ immigration statuses; experiences in their native countries; reasons for immigrating to the U.S.; length of time in the U.S.; the extent of diversity, support, and leadership in their local communities; and exposure to deportations and immigration raids. For example, some participants in California who were from Mexico noted a willingness to reestablish their lives in Mexico if they or a family member was deported, particularly those in San Diego who are close to the border. In contrast, participants from other countries who came to the U.S. to escape war and/or persecution said that returning to their native country is not an option. Parents who have been living in the U.S. for many years generally felt more secure than those who had arrived more recently. Parents connected to local community organizations felt they are more informed about their rights compared to others in the community and that rumors spread through social media or word of mouth often lead to increased fears and panic based on misinformation. One pediatrician noted that, among Asian communities, there is reluctance to talk about immigration status, which limits sharing of information and may contribute to increased fears stemming from rumors or misinformation.

“…the Latino communities here in the valley, specifically here in Fresno, perhaps you don’t feel supported because our leaders, our community leaders, they haven’t achieved the level to be able to offer the support to everyone.” –Latino Parent, Fresno, California

“That is the problem with many people, they don’t get informed, they don’t look for the real information. They are only based on what they heard on the news or what their friend told them.” –Latino Parent, Chicago, Illinois

Children are also feeling increased fear and uncertainty about potentially losing their parents to deportation or having to return to their parents’ native countries. Parents across the groups, including those with lawful status, recounted stories of their children and children in their community coming home in tears immediately after the presidential election and worrying about what would happen to them and if they would have to leave the country. Parents said that, although they try to shield their children from these issues, many children are hearing about them at school. Parents also said that some children have expressed fears and concerns about their parents’ home countries, noting that the U.S. is the only home they know.

“…after Trump was elected, children cried at school and said they had to migrate to Canada. The children talk about it among themselves a lot.” –Korean Parent, Chicago, Illinois

“After the inauguration, my youngest ones were crying because they thought I was going to be deported…” –Latino Parent, Chicago, Illinois

“My children would come home from school and say that at school they were saying that all parents would be deported…” –Portuguese-speaking Parent, Chicago, Illinois

“All the children, even if they were born here, are fearful. They fear that anytime they’ll come back from school and won’t find their parents there.” –Latino Parent, Chicago, Illinois

“And so she’s gotten sad. And she’s even cried just watching the news and seeing how immigration is doing raids and how they pick people up.” –Latino Parent, Fresno, California

“….she worries too much, more than what kids should worry about. I mean she’s just a little girl. I mean you can’t really tell her to not worry.” –Latino Parent, Fresno, California

“[My son] age 15… asks, ‘how am I going back to Brazil if I have to start all over again?…’ He says… ‘If I return, I have to start over and lose a lot of time, and I don’t know if I would adapt there again.’” –Portuguese-speaking Parent, Boston, Massachusetts

“Well my kids got scared for me. You know, when Donald Trump won, the youngest one hugged me and said ‘mom, you don’t have any of your papers.’” –Latino Parent, Los Angeles, California

“I think there’s just general fear and uncertainty that even kids that are in not-mixed citizenship status families, but… are either children of color or children who are Latino or children whose family prefer to speak Spanish…” –Pediatrician, North Carolina

“Honestly, it’s not just undocumented families… but also families where kids are LPRs [Lawful Permanent Residents] or have refugee status. I mean even those families—parents have come to me and said that their kids have been worried.” –Pediatrician, Pennsylvania

“…now to have these increased fears about whether or not they’re going to see their parents at the end of the day, are they going to be able to finish school, are they going to have to move…?  There is a tremendous amount of anxiety.” –Pediatrician, California

Participants and pediatricians said that racism and discrimination, including bullying of children of color in schools, have significantly increased since the election. A number of parents said their personal experiences with racism and discrimination have increased since the election and described recent incidents affecting themselves, friends, and/or family members. Many felt that Latinos, particularly Mexicans, and Muslims have been the primary targets of increased racism and discrimination. They also noted that bullying has increased for children in schools and that it extends beyond immigrants to children of color, regardless of their immigration status.

“There has always been racism, but right now it has come up to the surface.” –Latino Parent, Chicago, Illinois

“When I travel to places like the West or a place without Koreans or ethnically homogenous, when it is predominately white, I am a little scared.” –Korean Parent, Chicago, Illinois

“There are some racist people that became more comfortable since Trump was elected, and they express their hate towards immigrants more freely now.” –Arabic-speaking Parent, Anaheim, California

“…Where I work, I see personally that people discriminate me… and I have to intervene for my employees. I didn’t have to do it before, but now it’s like a rebirth of discrimination.” –Latino Parent, Bethesda, Maryland

“I work in landscaping, and we’re working and they see you working…and they just start yelling stuff at you…” –Latino Parent, Fresno, California

“…the thing is, this President, ever since he’s made some comments that are very racist, now people that are from here in Fresno and wherever you go…now they’re also going against us.”  –Latino Parent, Fresno, California

“…I think before Trump there was not as much discrimination as right now.” –Latino Parent, San Diego, California

“….my sister-in-law was at work and they forbade her from speaking Spanish.” –Latino Parent, San Diego, California

“After the inauguration, my daughter…could not be OK at school because there is a lot of racism.” –Latino Parent, Chicago, Illinois

“I have had both patients and parents just voluntarily tell me that their kids are facing more bullying.” –Pediatrician, Minnesota

“They get bullied…told things like, ‘now you and your family will have to leave.’….And so, even though those kids don’t actually have to worry about their immigration status, I think obviously a child, they don’t know the details of how the system works.” –Pediatrician, Pennsylvania

“…the fear of being one’s self—is it okay to be Muslim, to wear a hijab?—a lot of the kids are getting bullied for the way they look, the way they dress, their cultural identity, and so there’s a lot of anxiety.” –Pediatrician, California

Effects on Daily Lives

Some families, particularly those with an undocumented family member, are making changes in their daily lives and routines in response to fear of deportation. Some said that they only leave the house when necessary, for example, to work; that they limit their driving or only have people with legal status drive; and/or that they limit time out in their neighborhood. For example, parents in Boston said that families used to fill their local park with picnics and barbeques on the weekends but that it now sits empty. A number of parents and pediatricians indicated that families now spend long hours inside their homes behind locked doors, fearful whenever anyone comes to the door. Some parents and pediatricians also noted that school attendance declined immediately after the election and that it dips after an immigration raid or if there is a rumor of a raid in the community. Parents in Maryland and California said that some of the schools sent letters to reassure families of their safety in school, which they believe helped relieve fears. Families also are increasingly fearful of police and authorities, and some parents and pediatricians expressed concerns that individuals may be less likely to report assault, abuse, or other crimes. Other participants, particularly those who have lived in the U.S. for many years and who live in diverse communities with strong support, said that they are carrying on with their daily lives and regular routines despite increased fears.

“Before, there were many kids in the parks… but now… The kids spend more time inside these days because we are afraid of being deported.” –Latino Parent, Boston, Massachusetts

“We are fearful of opening the door or of seeing through the hole on the door who it is…” –Latino Parent, Boston, Massachusetts

“I am also concerned because if anything happens to us on the street, if we get assaulted or something, we won’t even be able to call the police because they will see we are immigrants.”      –Latino Parent, Boston, Massachusetts

“…but now around six or seven in the evening you won’t find anyone in [the neighborhood]… due to the fear we all feel about what is going to happen.” –Latino Parent, Chicago, Illinois

“My spouse does not go out of the house… The last thing she wants is to get stopped and that they start asking her questions…” –Latino Parent, San Diego, California

“Nowadays people are avoiding walking in certain places.” –Portuguese-speaking Parent, Boston, Massachusetts

“…most of them didn’t go to school on the first day after he won because everyone was afraid of something happening.” –Latino Parent, Boston Massachusetts

“At schools, they get up every morning with that fear of dropping their kids off, thinking that maybe they’re going to be detained.” –Latino Parent, Fresno, California

“When I’m driving, and [my son] sees a policeman, he starts to get really nervous, he’s very nervous.” –Latino Parent, Los Angeles, California

“We’ve been sent notes from the schools that we shouldn’t worry… and that we shouldn’t have any fears about sending the kids to school.” –Latino Parent, Los Angeles, California

“…when, in the Latino community, there is a message out to the community that ICE is making, is doing raids, then everybody stops, they stop sending their kids to school and they stop coming into the clinic.” –Pediatrician, California

Many participants said it is more difficult to find employment in the current environment, exacerbating financial challenges. A number felt that employment options had become more limited since the presidential election. They noted that fewer work permits are available and permits are not being renewed. Some also said that increased verification procedures by employers are causing some people to lose jobs, sometimes jobs they have held for many years. Given these challenges, participants said they now often have to go outside of their neighborhoods or community and/or travel long distances to find work, which increases commuting time and costs and makes child care more difficult. In some cases, individuals are no longer seeking work because they fear exposing themselves to authorities. Similarly, some parents in Maryland said they are fearful of volunteering in their children’s schools because the schools have documentation and background checks for parent volunteers.

“Right now, mostly, they are not giving permits; they want us to leave. So when we don’t have a work permit, nobody hires us.” –Latino Parent, Boston, Massachusetts

“The work situation is getting more difficult… if they know you don’t have documents… they start questioning why you are working there…” –Latino Parent, Chicago, Illinois

“It is more difficult to find a job, and we wake up every day with the fear of being deported, of the separation of our families, to have to leave the kids.” –Latino Parent, Boston, Massachusetts

“I would like to find another job, and it’s difficult to be able to go look for work because you don’t feel that same kind of trust or security that you had in previous years where you would just go and leave your information.” –Latino Parent, Bethesda, Maryland

“Many times I don’t work… because I feel I am safer just here in my house. And sometimes what my husband earns isn’t enough and so you have to limit yourself in many things.” –Latino Parent, Bethesda, Maryland

“Because I was working at a company that was a more or less big company… and I had to leave, because they said they were going to check out our documentation.” –Latino Parent, Los Angeles, California

Some parents have arranged for their children’s care in case they are detained or deported, while others are uncertain and fearful about what would happen to their children. Some parents have acquired power of attorney letters to authorize family members or friends to become their children’s guardians in case of detention or deportation. Some also reported receiving requests from neighbors, family members, and/or friends to become guardians for their children. However, other parents said they do not know who would care for their children if they were detained or deported and/or that they do not have friends or family here in the U.S. that they could turn to for help. One pediatrician noted that some parents were asking if they could designate the children’s hospital as a guardian for children with complex needs because they had no one else who could provide the level of care their children need.

Effects on Children’s Health and Well-Being

Increased fear among children is manifesting in many ways, including behavioral issues, psychosomatic symptoms, and mental health issues. Parents and pediatricians reported that fears are contributing to behavioral issues among children, including problems sleeping and eating, regression, increased restlessness and agitation, and withdrawal from family and friends. Children also are experiencing psychosomatic symptoms, including headaches, stomachaches, nausea, and vomiting. In addition, parents and pediatricians indicated that some children are experiencing anxiety, having panic attacks, displaying symptoms of depression, and/or expressing an overall loss of hope for the future. For example, one pediatrician recounted how a child whose father had been deported starting having panic attacks because she was afraid she would also lose her mother and be placed into foster care. Another pediatrician noted that, after the election, “fear of Trump” emerged as a chief complaint in her daily schedule.

“…they don’t express how they feel, they just try to stay close to mom, so she doesn’t go away. If she goes anywhere, then they go with her…” –Latino Parent, Boston, Massachusetts

“Mine is six. I’m not sure if he realizes what is going on, but he gets scared when I tell him I am going to travel. He tells me not to go because he says I am not coming back, that he won’t see me again.” –Portuguese-speaking Parent, Boston, Massachusetts

“…I would go to the library, we would go on the bus, but she said, ‘if we go to the library, immigration is going to take you, let’s not go.’ And so it showed me that her fear is so great that she would rather just not go to the library.” –Latino Parent, Bethesda, Maryland

“They come in with a physical complaint and then we get to the bottom of it, and the bottom of it is anxiety.” –Pediatrician, California

“…But losing… that supporter, that sort of emotional and financial supporter has been really difficult. Those are the families that I’d say probably when it comes to mental health issues, where I see that more intensely, where it’s… more dramatic in terms of the change, the shift in the child either being more withdrawn or acting out more, or being more anxious…”                    –Pediatrician, District of Columbia

“We had a lot of sleep problems that we’re helping kids with and helping parents with. We had a lot of children who were crying and maybe had some regressive behaviors.” –Pediatrician, Vermont

“So you can see some regressions in their development. Maybe they were potty-trained before and now they aren’t, maybe they were no longer wetting the bed at night and suddenly they are, maybe they’re more clingy than they were…” –Pediatrician, Texas

“…So children who might have sort of nonspecific symptoms like stomach pain or headaches.  And then when you talk to them, it’s because they’ve become really worried about their family and their parents and what’s going to happen to them.” –Pediatrician, Pennsylvania

“The kids who come in with concerns that you can kind of trace back to anxiety are usually the upper elementary age students, like the 3rd, 4th graders, to middle school students… 7th and 8th grade, who have nonspecific complaints like abnormal pain or headaches or decreased appetites… And then, in kids that are in the junior high to high school age range, it’s a little more overt: sadness, decreased appetite, not wanting to engage in usual activities, decreased in-school performance, those sorts of things.” –Pediatrician, Arkansas

Parents and pediatricians expressed concerns that increased fear and stress is negatively affecting some children’s performance in school. Parents and pediatricians said some children are having increased difficulty paying attention in school because of their stress and worries about potentially losing their parents. A couple of pediatricians noted an increase in school reports of attention-deficit/ hyperactivity disorder (ADHD), which they believe may be attention problems stemming from fear or anxiety. Others noted that some children are having increased behavioral problems that are interfering with their performance in school. For example, one parent noted that his son recently had issues at school resulting from standing up to other students that were bullying other Spanish-speaking students.

“Their grades go down, they don’t go to school with the same enthusiasm they used to. They go to school with fear of not finding their parents when they come back…” –Latino Parent, Boston, Massachusetts

“They start doing worse in school or they have behavior problems in school.” –Pediatrician, Texas

“…so it tends to be that children are either not interested in finishing assignments or in doing other work, because they’re just sort of focused on what the next thing is that’s going to happen to their parent who’s going through a proceeding.” –Pediatrician, Arkansas

Increased fears have also affected the well-being of parents and made it more difficult for them to focus on caregiving. A number of parents reported that they also are suffering increased anxiety and/or depression due to their fears. Some reported problems sleeping and eating as well as headaches and nausea due to stress and worry. Some pediatricians indicated that, in some cases, these fears have served as triggers for parents who have histories of trauma or persecution leading to depression and/or anxiety. Pediatricians also noted that, as parents experience increased stress and anxiety, they might have more difficulty focusing on caregiving and/or become more withdrawn from their children. A few pediatricians reported concerns about strains on family relationships, particularly when family members have different immigration statuses. For example, a younger sibling in the family may be a U.S.-born citizen while an older sibling may be undocumented or have DACA status.

“I had many nightmares. I would often dream immigration would come, and I would cry a lot. I would wake up shaking…” –Latino Parent, Chicago, Illinois

“And I got depressed, I was not hungry, I couldn’t sleep, I feared going outside. I would cry sometimes. I was not hungry for several days, it was like I was depressed.” –Latino Parent, Boston, Massachusetts

“Headaches from thinking so much because you just think about what’s going to happen. You think about the future; what if this happens, what am I going to do?” –Latino Parent, Bethesda, Maryland

“I think the anxiety would sort of paralyze people and they wouldn’t be able to parent. They wouldn’t be able to function, some people, because they were so overwhelmed and anxious; couldn’t go to work, couldn’t leave their home…” –Pediatrician, Vermont

Effects on Health Care Use

Most parents indicated that they have not made any changes in how they seek health care for their children in response to increased fears; however, some parents and pediatricians described changes in health care use. Most parents noted they are continuing to obtain health care for their children and that they trust their existing doctors and view their doctors’ offices and hospitals as safe spaces. They also noted that they prioritize obtaining care for their children over their fears. Pediatricians also reported that, in general, patients are continuing to get care. However, some parents and pediatricians reported declines in visits and/or changes in the timing of visits. For example, some pediatricians have observed decreases in well-child visits, in follow-ups on referrals with providers that families do not have an existing relationship with, and in expectant mothers seeking prenatal care. One pediatrician also reported that some parents are no longer opening their doors or answering phones for home health visits. Another pediatrician felt that parents had shifted from using scheduled visits to walk-in visits because they may be hesitant about providing information to schedule the visit. In Boston, some parents said that they try to schedule their children’s appointments in the morning because they feel like that is the safest time to be outside. In addition, one pediatrician reported that parents are bundling visits together to minimize the frequency of visits and limit their time outside the home. In Fresno, some parents said that they prefer to utilize Latino providers in the current environment.

“The thing is… if you are at the hospital you are safe. They can’t go into a hospital, a school, or a church… because it is a sanctuary.” –Latino Parent, Chicago, Illinois

“…you have to choose a doctor… that’s more Hispanic… the way things are right now with immigration…” –Latino Parent, Fresno, California

“I try now to make my appointments earlier in the morning so as not to stay too long outside. So, I try to do this early and then I stay calmly at home.” –Latino Parent, Boston, Massachusetts

“…We’ve had families… in particular, those families of high needs; saying things… like, ‘okay I have these three specialists appointments that we need to make. Let’s make them on the same day,’ …because they’re worried about being… out in public too often and at the risk of getting detained.” –Pediatrician, District of Columbia

“I think probably the most striking thing is that our home health workers were noticing that when they would knock on doors people weren’t answering…” –Pediatrician, Minnesota

“…We’ve also seen families making meaningful changes in access to care because of concerns about immigration status. So, families whose children need to see specialists who might’ve delayed those specialty appointments because they weren’t comfortable leaving their house or their neighborhood where they felt safe.” –Pediatrician, Pennsylvania

Pediatricians described some actions they are taking to help families feel safe. Pediatricians reported posting signage in their practices to communicate to families that their children are welcome and safe. One noted that the practice has placed bilingual staff outside the entrance to welcome families and ensure they do not encounter any difficulties when entering the clinic. Some indicated that they are taking steps to reassure families that they will keep their information confidential, so that families feel comfortable discussing immigration-related issues during health care visits. A number said that they have undertaken staff training to highlight the importance of confidentiality and best practices for discussing sensitive topics like immigration status. Two pediatricians also indicated that their practices had developed operational protocols so staff know what steps to take if immigration officials enter the practice. Some pediatricians noted that they have hosted events or provided referrals to help families understand their rights and assist families in planning in case they are detained or deported. Many pediatricians also reported writing letters to assist families involved in deportation proceedings.

“…We put posters all over the office stating that you are welcome or all are welcome… We have signs in the entryway… that we don’t discriminate on the basis of immigration status and refugees and immigrants are welcome in our office… And that’s something we implemented after the election…” –Pediatrician, Chicago

“…We created an ‘all are welcome’ button. It was really big effort to make… broad blanket statements that children were welcome… that the community was supporting… and I think that did help refugee families feel that the community would support them…” –Pediatrician, Vermont

“So we’ve seen a huge increase in the number of people that are just asking for letters just to have either for safety reasons or to give to an attorney or something like that.” –Pediatrician, Arkansas

Some pediatricians expressed concerns about the ambiguity of the borders around safe spaces and uncertainty about how to advise families amid the current environment. For example, one pediatrician indicated that while the hospital itself may be safe, it is unclear how far that border extends and whether protection extends to the parking lot. A pediatrician noted that practices near the U.S.-Mexico border are reporting increased presence of border patrol in parking lots of clinics and said that their presence is dissuading parents from bringing their children to clinics. In addition, a few pediatricians highlighted the challenges developing policies and protocols for staff on immigration related issues because the environment is constantly shifting.

Effects on Participation in Medicaid/CHIP and Other Programs

Parents generally reported that they are maintaining Medicaid and CHIP coverage for their children, but there were some reports of decreased participation in Medicaid and CHIP and other programs. Most participants have their children enrolled in Medicaid and CHIP and said that they intend to keep their children enrolled. Parents said they highly value Medicaid and CHIP coverage and that the coverage enables them to access needed care for their children. However, some parents and pediatricians reported that some families with eligible children are less interested in enrolling in Medicaid and CHIP. In addition, one clinic noted that some patients have asked to be disenrolled because they fear they may be putting undocumented family members at risk or jeopardizing family members’ lawful status. Pediatricians noted that they have observed sharper declines in participation in the Women, Infants, and Children (WIC) nutrition program and the Supplemental Nutrition Assistance Program (SNAP). They believe parents are more likely to view WIC and SNAP as federal programs that could expose their information to authorities. Parents and pediatricians also noted ongoing concerns in the community that use of Medicaid, CHIP, and other programs will negatively affect immigration status among those with lawful status or seeking residency or citizenship. Participants felt it would be helpful if official sources made more information available about how use of benefits could affect families’ immigration status. A few pediatricians indicated that they are uncertain about how to advise families on the use of benefits and enrollment in programs since policies could change. For example, one pediatrician indicated that she is more cautious about encouraging families to enroll in SNAP because doing so could potentially have negative consequences if policies change.

“I personally am afraid of trying to get my MassHealth [Medicaid] or something again, due to my permit… They are requesting many documents…” –Latino Parent, Boston, Massachusetts

“…they also ask for all your information and ICE will go to your house and that’s why you don’t apply yet, because they’re asking for all the information on all of your spouses, your children.”   –Latino Parent, San Diego, California

“…since I became a resident they told me don’t ask for anything from the government because the day you go and request your citizenship you can have problems. That’s what I always heard.” –Latino Parent, San Diego, California

“I’ve heard about the food stamps, that if you get the government to help you, it’s going to affect your status.” –Latino Parent, Los Angeles, California

“I’ve started hearing… questions about whether or not they should access services… So a few new moms of newborns asking if they should enroll their child who is a U.S. citizen and born here in this country, if they should enroll their child in WIC. And, even in some circumstances, deciding not to apply even though they would have qualified…” –Pediatrician, District of Columbia

“What I do have more and more families doing is not taking food stamps, not taking WIC, not wanting to take federal services because they’re afraid…” –Pediatrician, Vermont

“We haven’t seen a dip amongst families who are already enrolled, but we have seen families who had not previously applied decide not to move forward [with enrolling in Medicaid or CHIP].” —Pediatrician, Minnesota

“…I have noticed that more and more people who did not used to be afraid of getting… services like SNAP, for instance, are very nervous about that. And so I had two families last week who did not want to get those services even though they were in need…and then one family who was nervous about even reapplying for Medicaid, because… they thought that it would put in jeopardy the father’s ability to get a visa.” –Pediatrician, California

“…I just personally don’t encourage them the same way, whereas before I was much more confident in saying, ‘this isn’t an issue for you, don’t worry, if you enroll your kid who was born here, it won’t affect you at all.’ I don’t know that’s true anymore, so I can’t, I don’t say that with that confidence anymore.” –Pediatrician, California

Most participating parents are uninsured and said they delay or go without care due to cost. Those who are undocumented are not eligible for Medicaid and generally do not have access to private coverage. They primarily rely on clinics, but often avoid seeking care because of cost. Those parents with lawful status were more likely to have coverage, often through Medicaid, and were better able to access needed care.

Long-Term Implications for Children

Pediatricians uniformly expressed significant concerns about the long-term consequences of the current environment for children. They pointed to longstanding research on the damaging effects of toxic stress on physical and mental health over the lifespan (Box 1). They believe that the current environment is creating toxic stress for children and that this stress will result in physiological changes that contribute to increased rates of chronic disease and mental health disorders through adulthood. One pediatrician that serves families near the Mexico border noted that the stress for children in that environment is extreme, particularly because of the constant visual presence of border patrol and militarization of the area, which she says has increased since the presidential election. Pediatricians expressed concerns that declines in participation in WIC and SNAP will negatively affect healthy development of children. Similarly, they cautioned that reductions in health care use could result in more serious and costly conditions. Some pediatricians expressed concerns that the increased amount of time families are spending inside behind locked doors will compromise children’s development and reduce their enrichment opportunities and physical activity. Pediatricians also emphasized that the loss of a parent due to deportation negatively affects health and development of children in multiple ways, including the loss of economic and social support and disruption to the parent-child bond.

“I don’t want these kids to go to school anxious and depressed and not able to concentrate, but I’m also worried what it’s doing to their heart and their liver.” –Pediatrician, District of Columbia

“When you’re worried every day that your parents are going to be taken away or that your family will be split up, that really is a form of toxic stress …we know that it’s going to have long-term implications for heart disease, for health outcomes for these children in adulthood.”  –Pediatrician, Minnesota

“I think that we are going to have a generation of kids, who, especially in our immigrant homes, who are going to have more adverse childhood experiences than they would have. So, I think that we’re just setting up this generation of kids to have higher incidence of chronic disease, higher incidence of poor mental health, higher incidence of addiction…” –Pediatrician, California

“I think a huge worry is that children who have problems that are minor and fixable now… that, if those children go untreated, those could end up being bigger problems in the future that are going to be harder to treat and are really going to impact the child’s quality of life.” –Pediatrician, Pennsylvania

“I think that’s one of the things I worry about the most is, from a longstanding exposure standpoint, is kids losing the opportunity to have any kind of enrichment experiences because families are afraid to do anything that’s not essential. So I think that’s true, especially in the summer where a lot of the families that we took care of, the kids were at home watching TV all day because parents were uncomfortable leaving the house…” –Pediatrician, North Carolina

“If your parents are afraid to go to work, then you’ve got food insecurity issues. If they’re not signing up for different benefits and you’ve got food insecurity issues. …I mean I think this affects children in so many, so many ways that we can’t even understand. So we have children who are hungry, children who are hungry can’t learn. We have children who are stressed, children who are stressed can’t learn. We have children who are in families in need or have parents who are distressed…they’re worried about their parents, they can’t learn. They can’t be normal kids. They can’t play. They can’t develop. They can’t grow.” –Pediatrician, Vermont 

Box 1: Research on Effects of Toxic Stress on Learning, Behavior, and Health
Toxic stress can negatively affect a child’s physical, cognitive, and emotional development. When children experience prolonged and continuous stress, referred to as “toxic stress,” it can damage connections in the brain, resulting in issues with brain development and lifelong negative mental and physical health effects.

A growing body of literature finds that the threat of parental detention and deportation is a toxic stress.4 Children living with the constant threat of their parents’ deportation may have a constant and heightened state of anxiety that does not allow their body to return to baseline functioning. The American Academy of Pediatrics recently warned that the stress of living in fear of deportation among immigrant children could disrupt a child’s developmental processes and lead to long-term health concerns.5

Research shows that toxic stress has short- and long-term negative effects on physical, mental, and behavioral health.6 In the short term, toxic stress can increase the risk and frequency of infections in children as high levels of stress hormones suppress the body’s immune system. It can also result in developmental issues due to reduced neural connections to important areas of the brain. Toxic stress is associated with damage to areas of the brain responsible for learning and memory. Over the long term, toxic stress may manifest as poor coping skills and stress management, unhealthy lifestyles, adoption of risky health behaviors, and mental health issues, such as depression. Toxic stress also is associated with increased rates of physical conditions into adulthood, including chronic obstructive pulmonary disease, obesity, ischemic heart disease, diabetes, asthma, cancer, and post-traumatic stress disorder.

Pediatricians and parents described how deportation and the rescission of DACA compound challenges for families and increase the risk of cyclical poverty. Pediatricians and parents both noted that losing a family member to deportation often results in loss of family income, leading to financial strains and sometimes food and housing insecurity. One pediatrician noted an increase in homelessness among children due to the loss of family members and income. Pediatricians said that these income losses will increase the likelihood of cyclical poverty among families. They also noted that many individuals with DACA were pursuing education and careers that could potentially move their families out of poverty and that this opportunity is lost with the DACA rescission. They have observed that some adolescents, particularly those who are undocumented or who have DACA, have lost hope for the future and are reconsidering plans to attend college or pursue certain job opportunities. They said this loss of hope and negative future outlook could affect their life choices and limit their potential achievements and economic gains. Parents and pediatricians also expressed concerns that immigrant families may become increasingly alienated from their broader communities as a result of the current environment. Pediatricians worried that this situation may lead families to feel more isolated and that children may face challenges formulating their identities.

“…you’re setting up not only social risk based on immigration status alone, but now also based on all the other social determinants of health. So families who live in a single parent family, meaning one parent was deported and they’re a single parent family are now at risk for poverty, at risk for educational inequity, at risk for all these other things that we know are also adverse childhood experiences, but then further place kids at risk for long-term effects.” –Pediatrician, North Carolina

“In Brownsville we have about 1,700 homeless children in the schools. Many of those children are homeless because of a parent that was deported or placed in detention.” –Pediatrician, Texas

“A lot of these kids are going to face insecurity regarding housing and food and just basic necessities… So long term, the economic and stability and emotional distress…” –Pediatrician, Illinois

“So I think there are a lot of downstream effects… changes in the DACA program don’t affect just the DACA recipient, but their parents if they’re helping out…the children…their siblings, whoever else is in the household…” –Pediatrician, District of Columbia

“…depending on what happens with the DACA program, there are so many kids in our community that were helped by that, that continued through college to get their degrees… I think that would really be a terrible loss for, not just the student and their families, but for our whole community if the work that they were able to do because they got DACA was to be halted where it is.” –Pediatrician, Arkansas

“…My children were born and grew up here and it wasn’t their choice… when they grow up, I am afraid that they might be alienated as well.” –Korean Parent, Chicago, Illinois

“…Not knowing whether or not you can stay, feeling like you don’t belong, not having a foot in, like a toe-hold in a place you can call home. I mean the long-term implications I think it’s just affecting how they formulate their identities.” –Pediatrician, Illinois

Conclusion

Together, these findings show that immigrant families across different backgrounds and locations are feeling increased levels of fear and uncertainty amid the current climate. Parents and children in families with an undocumented family member fear being separated from each other, and those with lawful status worry about the security and stability of their status and whether they may be affected by policy changes in the future. The findings show that these fears are having broad effects on the daily lives and routines of some immigrant families who are fearful to leave their home, limiting their participation in activities, and facing increased employment challenges. In addition, they point to long-term consequences for children in immigrant families, including poorer health outcomes over the lifespan, compromised growth and development, and increased challenges across a range of social and environmental factors that influence health.

 

This brief was prepared by Samantha Artiga and Petry Ubri with the Kaiser Family Foundation. The authors thank the Blue Shield of California Foundation for its support of the focus groups and interviews conducted in California. They also thank the American Academy of Pediatrics for its assistance in identifying pediatricians to interview for this work. Finally, they express their deep appreciation to the parents and pediatricians who shared their time and experiences to inform this brief.

 

Executive Summary Appendices

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