The Immigrant, Refugee, or Internationally Adopted Child

Objectives After completing this article, readers should be able to: As never before, the United States is becoming a population of immigrants. In the year 2000, more than 28 million persons born in other countries were resident in the United States, a 43% increase during the decade of the 1990s. Over the same period,immigrants and children born to immigrants accounted for 70% of the population growth.Immigrant health is a complex topic. Not only do many immigrant children arrive with multiple unaddressed health issues, but there is evidence that the health of some immigrant children actually declines after living in the United States.Becoming an immigrant is never easy. Although our emphasis is on the health-care needs of this diverse population, the most important long-term issues may be those of identity and acculturation. As one immigrant author so eloquently notes, “We have to live these half-lives of people who cannot forget what they used to be and who are afraid of being addressed in a foreign language, no longer able to utter anything meaningful.” (Hemon A. The Question of Bruno. London, England: Picador; 2000)Immigrant children are a diverse group and are encountered in every pediatric practice (Table 1). By far, the largest category is the temporary visitor. More than 3 million children, 0 to 19 years of age, arrive each year to the United States, usually accompanying their parents, who are visitors,temporary workers, diplomats, or students. Small percentages of these children are students or exchange visitors. The majority of these visitors arrive from Asia, Western Europe, and North America. Although not technically immigrants, some of these children present for medical care with issues similar to those of immigrant children.A special class of nonimmigrant visitor is comprised of the several thousand children brought to the United States by various humanitarian organizations for medical care. Some may remain with foster families for several years while undergoing treatment and rehabilitation for various cardiac, orthopedic, and congenital defects.Almost 200,000 legal immigrant children enter the United States annually under various forms of permanent residency visas. Most eventually become naturalized citizens. In the past decade, the majority of legal aliens have emigrated from Asia, North America, and the countries of the former Soviet Union. Nearly all immigrant children arrive with or to family members, although each year several thousand adolescents immigrate unaccompanied. About 4,000 teens, 75% of them female, are married at the time of immigration.Several special classes of legal immigrant are likely to be seen in the pediatrician’s office. Each year, United States citizens adopt more than 15,000 foreign-born children. Since 1990, the majority has been adopted from China and countries of the former Soviet Union. Because the adoption process usually is completed in the country of origin, most of the new parents have spent some time (although possibly only hours or days) with the child prior to the adoption. About 10% of families adopt two or more unrelated children at the same time.Refugees are persons living outside the United States who cannot or who are unwilling to return to their native country because of persecution. Persons seeking asylum (asylees) have the same issues but already reside in the United States. More than 75,000 refugees arrive in the United States each year, most recently from the countries of the former Yugoslavia and Soviet Union, Vietnam, and other war-torn regions such as Somalia. The majority of applications for asylum come from persons who have emigrated from Central America or China. Although most asylees live in the community, some are held in detention camps awaiting immigration court proceedings. Children may be refugees or asylees based on the situations of their parents or on their own history.An estimated 5,000,000 illegal aliens reside in the United States at any one time. Most are persons who entered the country illegally, and almost all are from Mexico and other Latin American countries. Others may have entered as legal immigrants or visitors but either overstayed their visas or lost legal status by committing a crime. Unaccompanied minors who are illegal aliens may be held in special detention camps, often for many months, until a relative or other responsible adult is located to take custody.In a special category are children who are born to immigrants or who live in immigrant households or communities. Although born in the United States, some of these children may have issues similar to those faced by the foreign-born members of their communities, such as infectious disease exposure, poor access to health care, and acculturation and mental health problems.No medical evaluation is required for nonimmigrant children, that is, tourists and other temporary visitors. Visas are not required for stays of fewer than 90 days from 26 countries, mostly in western Europe and the Pacific rim. A visa may be denied if the consular officer suspects that the child has an infectious disease that is a threat to the public health of the United States, such as active tuberculosis or leprosy. In practice, no medical evaluation typically is performed, and short-stay visiting children may arrive with a history ranging from excellent comprehensive prior medical care to virtually no medical attention.The medical examination for a permanent residency visa is limited, requiring only a physical examination for certain“excludable conditions,” such as active tuberculosis, human immunodeficiency virus (HIV) infection,syphilis, gonorrhea, lymphogranuloma venereum, chancroid, leprosy, or any severe physical or mental disability that might cause the immigrant to become a public charge. No laboratory testing is required of children younger than age 15 years. This visa examination is neither comprehensive nor a guarantee of health. All immigrants must provide evidence of immunization to meet United States age standards, although there are certain exemptions, such as if the vaccine is not available in the country of origin. The visa medical examination form is collected at the point of entry into the United States and is not available to the physician providing care in the United States.Some special provisions apply to certain groups of immigrants. For example, children adopted by United States citizens, entering on an“orphan visa,” are exempt from the immunization rule if they are younger than 10 years of age.Refugees receive a more comprehensive medical evaluation, tailored to the local conditions, and usually are screened for infectious, nutritional, and other diseases prior to immigration. The evaluation is determined by the authority administering the refugee program, which may be the United States government, the United Nations, or other refugee organizations. When there is a mass arrival of refugees, such as from Kosovo,screening may be carried out in special temporary camps at the point of entry into the United States. The results of this examination are forwarded to the public health department of the county in which the refugee intends to reside.When presented with an immigrant child, the immediate concern is almost always for exotic infectious diseases and ethnic conditions. Indeed, most standards for the medical care of children born in other countries have emphasized screening for infectious diseases and, to a lesser extent, consideration of genetic conditions such as the thalassemias,lactose intolerance, or glucose-6-phosphate dehydrogenase(G-6-PD) deficiency. However, many additional issues affect the health of children born in other countries; some may present life-long risks (Table 2). Although all applicants for a permanent residency visa must provide an Affidavit of Support showing sufficient financial resources,immigrant children are less likely to have health insurance or well-educated parents and are more likely to live in crowded conditions and in poverty. With the exception of the state of New York,which has provided for coverage of all children otherwise eligible for State Children’s Health Insurance Plan and Medicaid, children arriving after 1996 are subject to a 5-year waiting period for public benefits such as Medicaid, food stamps, and Supplemental Security Income. Recent reports from the Institute of Medicine note that the health condition of immigrant children actually declines after arrival in the United States because of fewer health-care visits and a lower probability of having an identified health-care practitioner.Most refugees are eligible for Medicaid or for at least 8 months of care subsidized by the federal Office of Refugee Resettlement. However, many refugee benefits and supports are time-limited, leaving less acculturated groups with little ability to negotiate the complex system of health care and social services. Children accompanying illegal immigrant relatives are a particularly vulnerable group medically because many parents are unwilling to seek health care, fearing deportation.Depending on the reason for immigration, the child may have had traumatic life experiences. In general, the more involuntary the reason for immigration, the more negative the former living circumstances. Witness to or experience of war, torture, or natural disaster or involuntary migration due to social or economic factors may place the child at risk for numerous mental health problems, including depression, posttraumatic stress disorder,unresolved grief, and chronic anxiety. Indeed, many of these issues are not recognized or are overlooked when dealing with medical, language, and acculturation problems.Even the child who immigrates for more positive reasons, such as to join family members or for educational opportunities, usually has language and cultural adjustments. Because children may become fluent in English more quickly than their parents, they may be required to translate and interpret medical,legal, and other sensitive information for adults.All immigrants go through the processes of acculturation (learning the culture of the new society) and assimilation(becoming a member of the new society) to some degree; these processes may create great tension within the immigrant community and with the larger society. Many immigrants, especially children, are poorly prepared to deal with the additional stresses of racist and anti-immigrant attitudes prevalent in some communities.The medical care of an immigrant child may be affected by any number of acculturation issues, including: Finally, immigrant children may remain at risk for repeated exposures to the conditions of their native land. For example, visiting relatives or later immigrants may transmit infectious diseases not found in this country. An outbreak of rubella affecting many immigrants and spreading to the local community in Nebraska was traced to employees of a meat-packing plant who grew up in Latin America when rubella immunization was not standard. Immigrant mothers may transmit tuberculosis, malaria, or other infections to their children born in this country. Travel to the homeland may expose the child to infections, toxins, or dangerous medical practices.The life or travel history of the child is probably the best screening tool to determine the need for an extensive initial medical evaluation after immigration. In general, voluntary immigrants from market economy countries (Canada, Western Europe, New Zealand,Australia, and Japan) have received comprehensive quality medical care. Typically, the only health issues are those of routine well child care and updating of immunizations to United States standards. Similarly,wealthy urban migrants from many countries will have received medical care far above the standard care of their homeland, resulting in few health issues specific to immigration.In contrast, adopted children, refugees, illegal aliens, and less privileged immigrants from developing nations may have received inadequate, irregular, or no medical care. No single standardized protocol is appropriate for all such children. The health risks for a Latin American family joining migrant worker relatives in Texas are very different from those of a well-educated Jewish family fleeing Russia for political reasons. Some general principles apply,however, to the initial medical evaluation of most immigrant children (Table 4) (Table 5). A complete translation of the records is not always necessary. Immunization records, results of laboratory tests, and growth data often are discerned easily. When the child has an unusual diagnosis or complicated medical history, a full translation may be helpful. There are professional medical translators in most big cities. University foreign language departments are also good resources. Medical terminology from other countries may be obscure, such as the Russian term “perinatal encephalopathy,” used loosely to describe any perinatal risk factor that could affect normal development. Unfortunately, there is no comprehensive single reference to medical terminology used in other countries.In most cases, any previous diagnosis that is not immediately apparent should be reconfirmed. For example, neurologic, cardiac, and metabolic diseases may be overdiagnosed or missed completely. A typical example is hemiplegic cerebral palsy that is diagnosed as congenital clubfoot. Foreign medications often can be identified by a regional poison control center or by using the publication Unlisted Drugs,published monthly with periodic indices by Pharmaco-Medical Documentation, Inc, Chatham, NJ 07928.Immunization records documenting the date, dose, and name of the vaccine are acceptable from around the world. The most common problems are doses administered at too short an interval (typically 4 wk instead of the minimal 6 wk) or at younger ages than in the United States. Occasionally records appear to be fraudulent(eg, doses were administered before the child was born or vaccines were used that were not available at that date). Children who have received all their immunizations in an institutional setting such as an orphanage, especially from the countries of the former Soviet Union and China, may not have produced an adequate immunologic response. If the child is very young, the questionable doses or vaccines can be repeated. For older children, it is more cost-effective to determine serum immunity for the major antigens. The most common infectious diseases are tuberculosis,intestinal parasites, and hepatitis B. A few children are at increased risk of congenital syphilis or HIV infection. It usually is most efficient to screen all children for these five infections, regardless of foreign laboratory study results or immunization status because it is impossible to predict the quality of any individual report from abroad. To detect infection incubating at the time of arrival, should be repeated 6 months later the child is or at the initial Immigrant children have a more than risk of tuberculosis than children born in the United States. for almost of all new of tuberculosis in the United States, with most diagnosed within the years of immigration. tuberculosis is a major public health in many countries from which children are especially Europe and However, this has not been a in The most is to screen the In a persons of the tuberculosis after to a from the who had not been screened at the time of with is common and may be Some in immigrant health all with a single of as a more cost-effective than and The and of such a in children have not been is with the risk from Asia, and countries of the former Soviet Union. 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