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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.