Caring for Children in Immigrant Families

Transcription

1 Caring for Children in Immigrant Families Shobhna Shukla, RN, MSN, CFNP Family Nurse Practitioner Catholic University School Based Health Center at Gaithersburg High School

2 An immigrant child is just like any other child.

3 Permanent Legal Status Citizen born in the US or abroad to a US citizen Naturalized citizen Granted citizenship after LPR status x 5 years Lawful Permanent Resident (LPR) Legally allowed to live and work permanently in the US. Eligible for citizenship after 5 years. Has a green card.

4 May Be Eligible for Permanent Status Refugee Persecuted in home country. Applied for and granted status while OUTSIDE the US. May apply for LPR status 1 year after entering the US. Asylee Persecuted in home country. Applied for and was granted status while INSIDE the US. May apply for LPR status 1 year after entering the US.

5 Marie 16 yo female from Ivory Coast, arrived 3/2016. Speaks French only. Lives with aunt and older sister, says her parents to arrive in the summer. Her father has lived in the US for many years. She is enrolled in 9 th grade b/c her official school records haven t arrived yet. Presents to your clinic for a sports PE. Used to play basketball in the Ivory Coast until she had a knee injury last year. She says she fell hard on top of another player after jumping for a rebound. Doesn t remember position of her knee just that it was red and swollen for several days. She says she was told she might need surgery but doesn t know why. Has had on and off knee pain since then just plays through the pain.

6 Marie Has recently been getting in lots of fights with other girls at school. Has 3 absences in last 1 week. Says she hates school, that it is all work she has done before. She is sexually active, uses condoms usually, and does not drink, smoke or use drugs but has many friends that do. PE: Very well dressed, designer sneakers, polite, smiling. Height > 99%. Exam unremarkable except for positive anterior drawer test. Marie is an asylee applicant. She has emergency Medicaid.

7 No Legal Status Undocumented Entered and resides in US without official sanction by US immigration or once had legal status that has since expired ore been terminated. Also referred to as unauthorized.

8 Leyla 17 yo girl from Honduras, brought to your office by the school counselor b/c she thinks Leyla seems very down, tired, doesn t eat and counselor thinks Leyla is having trouble adapting to school. Leyla is uninsured. She is eligible for coverage for basic primary care services through the County s program for the uninsured, Care for Kids. Our School Based Health Center is her assigned PCP. but does not have any personal documents proving her identity or age. PMHX: healthy, hosp birth in capital city, no complications or childhood illnesses. Social hx: Lived with MGM, younger brother. Older brother murdered 2 years ago. Mother here in US x 8 years. Father unknown.

9 Leyla 6 mos ago, Leyla was raped by local gang members as an initiation ritual for gang membership. After being raped, threatened with abduction to become the girlfriend of the head gang member. Teen borrowed money from a relative and left home w/o telling MGM, brother, or informing mother here in the US. Crossed border with a friend and called mom from detention. Teen did not reveal rape to immigration officials when detained at the border or to her mother when they were reunited. PE: Normal vitals, normal weight, small horizontal scars on arms, and thighs. She has a positive pregnancy test.

10 Unaccompanied Minors Undocumented/unauthorized Younger than 18 years old No parent or legal guardian in the US (often children deemed unaccompanied minors at time of first detention by immigration officials and then are often connected to family who become their legal guardians) Care and custody is delegated to Health and Human Services Many different travel routes (cars, buses, vans, trains, on foot hidden in freight or out in the open, with a paid coyote or with family who have made the trip before) all go through Mexico

11 Guatemalan family crossing the Mexican Border Guatemalans Crossing into Mexico [Photograph found in NY Times, Guatemala Mexico border]. (2007, November 14). Retrieved May 2, 2016, from archives 79/1004 mexico guatemala the otherborder (Originally photographed 2007, July 13)

12 La Bestia Villalon, C. (n.d.). La Bestia [Photograph found in Villalonsantamaria.com, Oaxaca, Mexico]. Retrieved May 2, 2016, from

13 Taming the Beast Dannemiller, K. (2014, September 20). Taming the Beast [Photograph found in International Organization for Migration, Mexico]. Retrieved May 2, 2016, from mexican authorities blockinfamous route north taming beast (Originally photographed 2014, September)

14 US Mexico Border Olson, S. (2014, June 27). A fence marks the U.S. Mexico border near Sasabe, AZ. [Photograph found in Getty Images, LA Times, Sasabe, AZ]. Retrieved May 4, 2016, from nn mexican law enforcement helicopter fired at usagents story.html

15 Border Patrol of the Rio Grande Moore, J. (2014, August 19). U.S. Border Patrol agents look for immigrants crossing the Rio Grande from Mexico to the United States at dusk [Photograph found in Getty Images, Mission, Texas]. Retrieved May 3, 2016, from take different immigrationstrategies woo voters (Originally photographed 2014, July 24)

16 Area stats Latinos are the fastest growing ethnic minority in DC Highest percentage of children settling in the DC MD VA area are from the following countries: Guatemala, El Salvador, Honduras, Mexico, Ecuador 1 in 10 African born immigrants in the US live in the DC Metro Area The DC Metro area has the largest proportion of African born individuals of all US cities African immigrants in the DC area largely come from Ethiopia, Nigeria, Egypt and Ghana, with increasing numbers from French speaking countries due to civil wars there Migration Policy Institute: migrationpolicy.org

17 Children in Immigrant Families Immigrant Foreign born OR born in the US who live with at least 1 parent who is foreign born. Immigrant children are the fastest growing segment of the US population 1 in every 4 children in the US lives in an immigrant family 17.5 million children 31% of children living in poor families (family incomes 200% below the federal poverty level) were children of immigrants 89% of children living with an immigrant family are born in the U.S. and are U.S. citizens Migration Policy Institute: migrationpolicy.org

18 Children in Immigrant Families In the period , 5.1 million children lived with an unauthorized immigrant parent, or 7% of children in the US 79% of these children were US citizens, 19% were unauthorized, and 2% had other legal status (LPR or temporary visas) In Maryland, 90,000 children live with at least one unauthorized parent. 74% of these children are US citizens Migration Policy Institute: migrationpolicy.org

19 Mode of Entry Impact on health screenings Patient s legal status is important when approaching the clinic visit Refugees will have had comprehensive physical exams, laboratory testing, and often pre treatment for intestinal parasites prior to entering the U.S. Asylees will also have had medical screenings, possibly but not definitely including treatment for intestinal parasites, as part of their application process.

20 Mode of entry and health screenings Undocumented/unauthorized immigrants, if detained by immigration officials at the border, will have had basic screening for lice, diarrhea, rashes and cough at the time of entry. If registered for school, they will have had immunizations placed. But they will not have had a comprehensive physical exam, laboratory testing, or treatment for intestinal parasites. Many may have had little access to health care prior to arriving in the US. The one exception are pregnant minors. Pregnant minors are processed separately, often detained in a separate facility where they may receive fairly comprehensive care, including mental health counseling

21 Outside a detention center at the US Mexico border The US Mexico border fence [Photograph found in Public Domain, Wikipedia, El Paso]. (2007, August 12). Retrieved May 2, 2016, from United_States_border#/media/File:US Mexico_border_fence.jpg (Originally photographed 2007, August 12)

22 Children of Unauthorized/Detained/Deported Parents When a parent or guardian is unauthorized, detained by immigration officials (ICE), or deported: Mental health o Anxiety fear of raids, detention, locating parent, child s own status, rehousing of child with another relative Financial Hardship o Limited work options, fear of accessing social services which could alleviate food insecurity or housing support; detention/deportation leads to loss of income, loss of housing, potential loss of social service benefits Transportation Barriers o Lack of driver s licenses School completion Increased risk for domestic violence

23 An immigrant child is just like any other child.

24 Of course Basic needs safe housing, adequate food, clothing, access to quality health care, access to education, economic security Growth Developmental stage Parental guidance, family support, connection to community and culture

25 So

26 Immigrant specific clinical issues? Growth delays, malnutrition, socioeconomic factors which foster unhealthy habits Infectious diseases Exposure to toxins Developmental delays esp speech/language Vaccination delays

27 Clinical issues Poor management of chronic diseases Injuries Obesity PTSD, IPV, Depression, Anxiety, Self harm behaviors (cutting) Risk behaviors substance abuse, unsafe sexual practices ACES

28 Vitals Approaching the Clinic Visit How to tailor your history taking HPI Ask about move to US when, how did he/she get here, details about border crossing (trauma during crossing*) PMHx Previous access to health care and vaccination history. *Do they have their medical records here in the US? Can they get them? FMHx parents, grandparents, aunts, uncles, brothers, sisters. *Are they here in the US? How long was the minor separated from them?

29 Social History Why did he/she leave (was there any trauma in their home country)? Housing Type/Age? With whom and how many? Pests? Safety home and in neighborhood? Relationship with family (reunification can be stressful)? Food insecurity? Access to safe and reliable transportation? Source of income for parent or guardian? Health insurance? Legal status and if not with parent, who is handling legal process for minor?

30 The dilemma with formal screenings of immigrant patients Developmental Screenings o Is the screening tool you are using validated? Although many tools are translated into multiple languages, ideally you would be sure that your tools are validated with immigrant populations Eg. Denver the language used in this tool does not translate well with immigrant populations not real life for them o Problems with translating tools on the spot may interfere with validity so try to access official translations Reassess development every 3 4 months

31 Laboratory Testing CBC with diff Lead 6 mos 16 years (repeat lead screen 3 6 months after placement in a new residence for children 6 mos to 6 years) TB o 5 and older quantiferon blood test o Less than 5 PPD (wait 4 weeks after live virus vaccine; ignore BCG status when reading ppd result) HIV* o Screen all refugees, repeat 3 6 mos after resettlement o Screen all pregnant refugee women o Screen children less than 12 yo unless mom confirmed neg and no history of exposure risk STI risk assessment/screening

32 Additional possible labs Consider on a case by case basis, if indicated by clinical presentation, co morbidities, other risk factors: BMP/CMP Lipid panel UA Pregnancy test Other STI screening: Gonorrhea/chlamydia, RPR Hep B screening Malaria H pylori

33 Special issues Intestinal Parasites Screen or treat pre emptively? Screening: Stool O&P x 3, stool Giardia & Crytosporidium, Serologies for schistosomiasis and strongyloidiasis Soil transmitting helminths: single dose albendazole Schistosomiasis: praziquantel Strongyloidiasis: Ivermectin (be aware of contraindications) Was the patient s mode of entry via legal immigration channels (work visa, refugee, or asylee) or via unauthorized entry? Authorized immigrants will likely have had pre departure treatment Unauthorized immigrants will not need to balance cost (of CBC, O&P, serologies for specific parasitic infections) with likelihood that pre emptive treatment will be sufficient CDC: domestic.html

34 Mental Health All immigrants, legal and unauthorized, are at high risk for mental health issues Trauma/PTSD o Sexual assault o Kidnapping o Witnessed death of loved ones, friends, family accidental or intentional o Brutal conditions while crossing Anxiety/Depression o Separation from family o Reunification o Uncertain legal status CHALLENGES: lack of availability of mental health providers, lack of affordable services, lack of mental health providers who are MULTILINGUAL

35 Jose 19 yo from Guatemala, arrived in the US 10/2015, started school 1/2016, is in 9 th grade, comes to the clinic to establish care. Reports he sometimes feels chest tightness at random times in class, in bed at night, occ when walking up stairs. No other assoc sxs. PMHX: home birth, no complications, varicella at 4 6 yo had some kind of surgery on his heart, was in treatment for 2 years (no medications, just tests), and then told he was fine. No other conditions, hosps, ED visits. No medical records available. Social hx: Parents came to US when he was 3 yo, raised by his maternal grandmother w/ his 2 younger sibs, went to school in a neighboring town, 1 hr by bus each way, excellent student, hopes to be civil engineer, no risk behaviors.

36 Jose No high school near by where he could study engineering so had to go to the capital city a 2 hr bus ride and pay to enroll. On his way to school the 1 st day, he was robbed and threatened with further violence unless he quit school and joined the gang. They also threatened to kill his grandmother and sibs. Parents then sent for him to come to the US. Jose is uninsured. Jose s vital signs are normal for age and his PE is unremarkable.

37 Obstacles Provider patient communication LANGUAGE, cultural sensitivity/knowledge gap Health Literacy of patient and family Resources in clinic to assess, diagnose and treat complex medical conditions Insurance status/ income to cover health care costs Fear of accessing health system if patient or family does not have legal status Referral options provider networks for uninsured and underinsured patients very limited (more so after ACA?) Patient/family barriers to make appointments or keep up with treatment plan (work schedules, transportation, $$) Lack of stable housing

38 Ely Ely is a 14 yo male from El Salvador. He arrived in the US 3 months ago and is now registering for school. Ely and his mother were referred to the School Based Health Center by administration when registering for school because he was missing vaccines. Ely crossed the border with his mother. After 6 weeks in detention, they relocated to Maryland. They live in a 1 BR apt with 13 people, some of whom are family, but with whom Ely s mother has a tense relationship. His mother pays $300 for rent. PMHx: Ely has Epidermolysis Bullosa. He received basic care in El Salvador but access to health care was limited.

39 Ely Ely and his mother fled El Salvador 24 hours after receiving serious threats from local gang members. Ely s uncle was murdered by the same gangs last year. During the crossing, Ely developed many new lesions on his lower extremities which worsened after being thrown onto a moving train by the coyote leading them, and then having to wade through a river near the border. He received limited supportive care in detention (changing bandages and applying antibiotic ointment) before he was allowed to leave detention. He has had numerous episodes of sepsis, has a contracture on his left foot, and extensive scarring and post inflammatory hypopigmentation on his extremities. Ely s wounds are still very painful, bleed often, and have developed a foul odor. Ely is uninsured. Although he is eligible for the County s health care program for the uninsured, Ely has not yet applied.

40 Take Home Points An immigrant child first and foremost is a child like any other same basic needs Our immigrant patients have many obstacles to accessing care and optimizing their health but there are ways to help them Working with an interdisciplinary team is key: primary care clinician, mental health provider, social worker, case manager, parent educator, peer educator, as well as specialists, hospitals and legal service providers in the community If interdisciplinary teams are not available to you *know your community resources Use trained interpreters and language lines it is the standard of care Know the health insurance, social service regulations in your state and county (programs for the uninsured, Medicaid eligibility, SNAP and housing assistance) Keep up to date on changing guidelines for the care of refugee, adopted, and immigrant families they are constantly under revision Know your population history, political context, etc. as much as you can because it helps you better understand the specific needs of your patients Be aware of your own bias, fatigue, self care needs

41 References American Academy of Pediatrics. Medical Evaluation of Internationally Adopted Children for Infectious Diseases. In: Pickering LK, ed Red Book: 2012 Report of the Committee on Infectious Diseases. 29 th ed. Elk Grove Village, IL: American Academy of Pediatrics American Academy of Pediatrics. Policy Statement: Providing Care for Immigrant, Migrant, and Border Children. Pediatrics 131: 6, June American Academy of Pediatrics. Immigrant Medicine Tool Kit the aap/committees Councils Sections/Council on CommunityPediatrics/Pages/Immigrant Child Health Toolkit.aspx CDC. Division of Global Migration and Quarantine. Summary Checklist for the Domestic Medical Examination for Newly Arriving Refugees. July Gray, M., MD, & Chapman, J., MD. (2015, July). Guidelines for Pediatric Immigrant Health. Retrieved May 5, 2016, from site/files/healthcare providers/cnhn/fop 2015/7gray chapmanpediatric immigrant health.ashx Rusin, S. (2015, August 13). Origin and Community: Asian and Latin American Unauthorized Youth and U.S. Deportation Relief. Retrieved May 10, 2016, from andcommunity asian and latin american unauthorized youth and us deportation relief Watts, Jonathan. (29, August 2015). Driven by fear: the Salvadorean children sent on the perilous journey to the US. Retrieved from: salvador childrenjourney us Zong, J., & Batalova, J. (2015). Frequently Requested Statistics on Immigrants and Immigration in the United States. Retrieved May 6, 2016, from requestedstatistics immigrants and immigration united states 4