MORE FROM THE PAGES OF OUR SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY
An immigrant’s journey is a leap of faith—and sometimes desperation. The desire to build a better life for oneself and one’s family is a powerful motivator that can make the enormous hardships and risks involved worth the effort. For many, the lure of promise and opportunity draws them to the shores of the United States. For others, the need to escape violence, war, and oppression leaves them with little choice. No matter what leads them on the path, all immigrants require huge amounts of courage and resilience.
The children who are included on the journey are particularly vulnerable to negative mental health implications associated with migration. Often, they have very little choice or control over the matter, especially when circumstances separate them from caregivers. Growing up with these complex circumstances puts enormous pressure on the mental health of many immigrant children, and this can have far-reaching effects on generations to come. Although stronger government policies are needed to set the proper tone on immigration, the mental health community has an important role to play in the treatment of immigrants, especially children.
See the Table for immigration by the numbers.
The Healthy Immigrant Paradox
Referred to as the first generation, immigrants generally come from countries with poorer health outcomes than the US, and oftentimes they bring with them a lower socioeconomic status.1 When they arrive, they are often subject to intense discrimination and prejudice, which may diminish over time.1 Language barriers and cultural differences can be particularly confusing and disorienting, which can make it extremely difficult to get help for physical or mental health needs as well as to integrate and adapt to a foreign environment.2-4
Despite all these challenges, many immigrants push forward and succeed, often outperforming both native citizens and established immigrants while reporting lower rates of depression and anxiety.1 Compared to US natives, immigrants have a lower risk over their lifetime of developing a psychiatric condition such as anxiety, mood, and substance use disorders.2,5-7 This curious phenomenon is known as the healthy immigrant paradox. It is used to describe how recently arrived immigrants are usually in better health than their non-migrant counterparts. Why does this paradox exist? The answer is unclear, but researchers have made a few educated guesses.
One study suggests that strong family ties, cultural strength, religion, and migrant social networks provide protections.8,9 Another study suggests selective migration as an influence, which favors immigrants who represent a smaller yet healthier subset within a population, one that shows above-average resilience, motivation, and psychological wellbeing.10
The 1.5 Generation
Immigrant children younger than 13 years old are commonly referred to as the 1.5 generation. Their migration story, and its effect on their mental health, is slightly different from their parents and older siblings. Because they are immersed in US schools at an earlier age, the 1.5 generation becomes acculturated much faster. While first-generation immigrants might enjoy good mental health, at least in the beginning, these 1.5 generation children are more vulnerable to issues.11
For these youth, the immigration process affects them the most during adolescence, when a psychiatric illness is most likely to emerge. Those who need mental health services are often stymied by shifts in government policies, the threat of deportation, and cultural attitudes about mental health. Furthermore, a 2007 study found that immigrant children who experienced early socialization in the US showed risk for mood and impulse-control disorders approaching that of native populations.2 The researchers found risk for mood, impulse control, and substance use disorders started to increase soon after immigration, although adjustments are not necessarily consistent across the disorders.2
With the arrival of the second generation (those born in the US to immigrant parents), the protections of the healthy immigrant start to fade. While the first and 1.5 generations register lower rates of mood, anxiety, or personality disorder, rates for the second and third generations are on par with the native population. This suggests that exposure to US culture is linked to rates of mental illness.12
Regardless of which generation they belong to, the length of time spent in the US can reduce the health immigrant effect. Immigrants who had lived in the US for 13 years or more had a higher lifetime prevalence of psychiatric disorders when compared to recently arrived immigrants. Although the risk for substance use disorders was low the first 10 years after immigration, it increased closer to native levels after that.2
Immigration’s Effects on Youth
During the immigration process, first- and 1.5-generation youth experience a number of upheavals, including separation from family, exposure to traumatic events, discrimination, loss of social status, and changes in family rules and role.13
Although parents may be excited about moving to a new country, the child/adolescent often has little input to the decision. For instance, a 2010 report of Latino youths aged 12 to 19 found that 60.4% had little to no involvement in the decision to migrate.13
The researchers found anxiety was the most common condition among youth, with 29% showing symptoms, compared to 13% to 20% among natives. On the other hand, only 7% of youth were symptomatic for depression, which is similar to native youths. Almost a quarter of those surveyed described their migration experience as stressful.13
Children whose parents kept them involved and educated about the immigration decisions reported lower levels of anxiety. Although parents can help mitigate concerns before migration, they often have little control over what happens during the transition. Being robbed, injured, or otherwise traumatized during migration can create a higher risk of anxiety for an average of 5 years after migration.13
Separation during the immigration process can be especially traumatizing for youth, with far-reaching effects. In fact, 75% of immigrant children experience separation from a caregiver during the process for a variety of reasons.13 Perhaps a caregiver traveled ahead to lay a foundation by securing employment and housing. Or, as is the case with many unaccompanied refugee minors from South America, families might intentionally send their children on alone, hopeful that US policy designed to protect children against trafficking might help them secure a court hearing.
In addition, some separation has occurred after families arrived in the US. As a result of the zero-tolerance policy on illegal immigration and to discourage families making the journey, children were intentionally separated from their families at the Mexican border. Among other setbacks, these immigrant children are 35% more likely to experience an education gap compared to their peers.14
Prevalence of Psychiatric Disorders
Once they have arrived, young immigrants must then juggle new stressors, including concerns over their legal status, discrimination, and social marginalization. Thus, youth who are undocumented are at a high risk for experiencing anxiety. This risk is even greater among families in which the parents are documented but the children are not. These children worry they will be sent back to their native country and be separated from their parents. To put this in perspective, about 60% of immigrant Latino youths and their parents lacked documentation when entering the US. In cases in which parents had documents, almost 11% of adolescents did not.13
Although legal status appears linked to anxiety levels, the experience of discrimination is more closely tied to symptoms of depression. Premigration and the immigration process generated depression levels that fell within normal levels. After arriving, about 42% of Latino youth experienced and perceived discrimination. These experiences can affect first-generation Latinos for up to 4.5 years.13
Although attention-deficit/hyperactivity disorder (ADHD) is the most common psychiatric disorder among youth and children, data on rates among immigrant children are limited. A 2013 report analyzing the National Survey of Children’s Health found that immigrant children were 40% to 90% less likely to be diagnosed with ADHD compared to native-born children.15 Similarly, a 2016 study found a pattern of lower rates of ADHD in ethnic minorities, but this is likely due to underdiagnosis and undertreatment rather than a true difference between different populations.16
Rates of schizophrenia in immigrants also show some interesting trends. Although the risk of schizophrenia is about 0.5% to 1% in most countries, it is 2.7 times higher in first-generation immigrants, and 4.5 times higher in second-generation immigrants. Despite these startling statistics, immigrant families were 3 times more likely to drop out of monitoring and treatment programs for early psychosis.17
The risk of conduct disorders, especially those with nonaggressive symptoms, were shown to increase significantly with each generation of Mexican immigrants, suggesting that environmental factors rather than genetic ones exerted a greater influence.18
Suicide and suicidal ideation rates differ among various immigrant ethnicities. Afro-Caribbeans, for example, did not experience a significant association between duration of stay in the US and rates of suicide or suicidal ideation. Asian immigrants experienced a modest association.19 But this experience was different for Latinos. Those who had lived in the US for more than 20 years were 4.27 times more likely to attempt suicide and 3 times more likely to engage in suicidal ideation compared to Latinos who had lived there less than 5 years.19
For first generation immigrants, the risk of alcohol use disorder is low, but rises exponentially with the number of years spent in the US. Second-generation immigrants have a higher risk, and the risk eventually reaches the native-born levels in subsequent generations.20
Barriers to Treatment
Barriers to obtaining health care are common, and yet they varied across ethnic groups. The most common barrier is lack of insurance; others include stigma around mental health, cost, language, distrust of formal services, embarrassment, cultural incompetence, inaccessibility, being undocumented, and lack of knowledge, among others.21 These barriers are particularly challenging for children, who are often at the mercy of their parents when it comes to receiving professional mental health services.
Reluctance. Considering the amount of potential stress involved in the migration story, it may be surprising to note that immigrants rarely seek out professional mental health services. A 2015 systematic review of 62 articles found that only 6% of Asian and Latino immigrants had ever received mental health care.21 Instead, immigrants are more likely to seek out informal care from family, friends, and religious leaders within their social networks. One study of Korean immigrants found that 52% preferred to seek assistance from family and friends, 40% preferred religious consultation, and only 9% sought out a mental health professional.22 Another study found that 15% of Mexican immigrants sought psychiatric help as opposed to 38% of US-born Mexicans with similar problems.23
Language. One study found that more than half of the immigrant families spoke a language other than English at home.15 Despite there being several US laws requiring access to interpretation services, barely half of the hospitals provide them, and the situation does not seem to be improving much over time.24
Confidentiality. Confidentiality between a doctor and a child may be unacceptable to some parents, which could stymie treatment efforts.
Perception. One 2019 study found that Chinese immigrant parents viewed social anxiety as a personality or cultural issue rather than a mental health problem. Despite higher rates of suicidal ideation in the Asian American youth, most parents in the study were hesitant to bring up suicidal ideation.25
Mitigating Negative Effects
Acculturation, especially for recent immigrant youth, appears to be the quickest way to roll back the potentially negative effects of immigration, allowing them to learn the language of their adopted country and navigate social systems with great ease.
In general, second-generation youth who integrate into their adopted society have the most positive psychological well-being when they also involve themselves in their cultural heritage.26 Studies have found that bilingualism and biculturalism may confer significant benefits in terms of cognitive abilities, psychological adjustment, and subjective well-being.27 Youth who do not tend to their bicultural competence in adulthood may experience increased risks for depression and anxiety.13
For some, however, this acculturation can add yet another stress to the immigration experience. First- and 1.5-generation youth eager to assimilate run the risk of abandoning the cultural traditions and familial bonds that previously provided the healthy immigrant protections. This chasm can have further effects. Cultural differences over mental health issues can cause riffs, disagreements, and even barriers to care.
The Role of Schools
Schools play a vital role in detecting mental health issues among all children and especially immigrants. Provided they are properly trained and staffed, teachers and school administrators can assess children during the day and, in some cases, refer them to onsite services. School-based interventions would not only make it easier for parents and children to access mental health screenings, they would also do so regardless of the immigrant’s insurance or financial status.
Onsite interventions can be particularly beneficial for unaccompanied refugee minors, who have higher risk for developing posttraumatic stress disorder (PTSD) compared to other migrants.28 Refugees tend to take more special classes and receive more in-home counseling, likely because they connected to these resources at school.29
One example of school-based service is the Cognitive-Behavioral Intervention for Trauma in Schools, a program designed for immigrant children who experienced violence before, during, or after their migration. It was developed by the RAND Corporation in partnership with the University of California, Los Angeles, and the Los Angeles Unified School District. All 126 students in the pilot program had been a victim of at least 2.8 violent events and witnessed 5.9 violent events just a year earlier. All were experiencing moderate to severe PTSD symptoms. After 3 months, students showed substantial improvement. Compared to a control group that would later go through the program, the initial group reported 86% less-severe PTSD symptoms.30
Immigrant children often arrive in the US after experiencing hardships and even trauma, including the immigration process itself. It is therefore important to identify these children and find ways to support them and their families to prevent (further) psychiatric issues and help ensure they get settled in the healthiest way possible. Programs such as those that offer initial assisted assimilation, language and vocational training, and culture-orientation classes can be effective.31
While we collectively reflect on the social determinants of mental health, let us not alienate the concept of immigration and how it affects those we serve. After all, most of us are immigrants in one way or another.
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