EXECUTIVE SUMMARY

FROM GENERATION TO GENERATION

The Health and Well-Being of Children in Immigrant Families

Donald J. Hernandez and Evan Charney, Editors

Committee on the Health and Adjustment of Immigrant Children and Families

Board on Children, Youth, and Families

National Research Council

Institute of Medicine

NATIONAL ACADEMY PRESS
Washington, D.C.
1998



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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families EXECUTIVE SUMMARY FROM GENERATION TO GENERATION The Health and Well-Being of Children in Immigrant Families Donald J. Hernandez and Evan Charney, Editors Committee on the Health and Adjustment of Immigrant Children and Families Board on Children, Youth, and Families National Research Council Institute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1998

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by the U.S. Department of Health and Human Services through the Office of the Assistant Secretary for Planning and Evaluation (OASPE) under contract number 282-95-0020 and the National Institute of Child Health and Human Development (NICHD) under cooperative agreement number NO1-HD-6-3253, by the Office of Educational Research and Improvement (OERI) in the National Institute on Early Childhood Development and Education of the U.S. Department of Education, the Carnegie Corporation of New York under grant number B6347, the W.T. Grant Foundation under grant number 94160394, the Rockefeller Foundation under grant number SI9522, and the California Wellness Foundation under grant number 9700139. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. The complete volume of From Generation to Generation: The Health and Well-Being of Children in Immigrant Families, from which this Executive Summary is extracted, is available for sale from: National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). This Executive Summary is also available on line at http://www.nap.edu Printed in the United States of America Copyright 1998 by the National Academy of Sciences. All rights reserved.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families COMMITTEE ON THE HEALTH AND ADJUSTMENT OF IMMIGRANT CHILDREN AND FAMILIES EVAN CHARNEY (Chair), Department of Pediatrics, University of Massachusetts Medical Center KATHLEEN GAINOR ANDREOLI, Rush-Presbyterian-St. Luke's Medical Center, Rush University E. RICHARD BROWN, School of Public Health, University of California, Los Angeles DONALD J. COHEN, Child Study Center, Yale University JANET CURRIE, Economics Department, University of California, Los Angeles MICHAEL FIX, Population Studies Center, Urban Institute BILL ONG HING, School of Law, University of California, Davis ARTHUR KLEINMAN, Harvard Medical School, Harvard University ALAN KRAUT, Department of History, American University NANCY S. LANDALE, Department of Sociology, Pennsylvania State University ANTONIO McDANIEL, Population Studies Center, University of Pennsylvania FERNANDO S. MENDOZA, School of Medicine, Stanford University VICTOR NEE, Department of Sociology, Cornell University MARY L. de LEON SIANTZ, School of Nursing, University of Washington DAVID R. SMITH, Health Sciences Center, Texas Tech University ALEX STEPICK, Department of Anthropology and Sociology, Florida International University SYLVIA FERNANDEZ VILLARREAL, Department of Pediatrics, University of California, San Francisco General Hospital DAVID L. FEATHERMAN (Liaison), Institute for Social Research, University of Michigan FERNANDO GUERRA (Liaison), Board on Children, Youth, and Families

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families DONALD J. HERNANDEZ, Study Director KATHERINE DARKE, Research Assistant NANCY GEYELIN, Research Assistant KAREN AUTREY, Senior Project Assistant

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families BOARD ON CHILDREN, YOUTH, AND FAMILIES JACK P. SHONKOFF (Chair), Heller Graduate School, Brandeis University DAVID V.B. BRITT, Children's Television Workshop, New York City LARRY BUMPASS, Center for Demography and Ecology, University of Wisconsin FERNANDO A. GUERRA, San Antonio Metropolitan Health District, Texas BERNARD GUYER, Department of Maternal and Child Health, The Johns Hopkins University ALETHA C. HUSTON, Department of Human Ecology, University of Texas at Austin RENEE JENKINS, Department of Pediatrics and Child Health, Howard University Hospital SARA McLANAHAN, Office of Population Research, Princeton University ROBERT MICHAEL, Harris Graduate School of Public Policy Studies, University of Chicago PAUL NEWACHECK, Institute of Health Policy Studies and Department of Pediatrics, University of California, San Francisco MARTHA PHILLIPS, The Concord Coalition, Washington, D.C. JULIUS B. RICHMOND, Department of Social Medicine, Harvard University Medical School TIMOTHY M. SANDOS, TCI Education Division, Denver, Colorado DEBORAH STIPEK, Graduate School of Education, University of California, Los Angeles DIANA TAYLOR, Women's Health Program, Department of Family Health Care Nursing University of California, San Francisco GAIL WILENSKY, Project Hope, Bethesda, Maryland EVAN CHARNEY (Liaison), Council Member, Institute of Medicine RUTH T. GROSS (Liaison), Board on Health Promotion and Disease Prevention, Institute of Medicine ELEANOR MACCOBY (Liaison), Commission on Behavioral and Social Sciences and Education

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Acknowledgments The committee and staff were assisted, during the course of this study, by many researchers and other individuals who willingly shared their expertise and insights. Without their generous assistance, the committee would not have been able to complete its work. Nearly two dozen researchers participated in the work group convened by the committee to develop new analyses of more than a dozen data sets, preparing papers that characterize the circumstances of children in immigrant and in U.S.-born families along a wide variety of dimensions. These papers are by Donald J. Hernandez and Katherine Darke (National Research Council) on socioeconomic and demographic risk factors and resources; by Nancy S. Landale, R.S. Oropesa, and Bridget K. Gorman (Pennsylvania State University) on infant health; by Fernando S. Mendoza and Lori Beth Dixon (Stanford University) on health and nutritional status; by Kathleen Mullan Harris (University of North Carolina at Chapel Hill) on the health status and risk behaviors of adolescents; by Grace Kao (University of Pennsylvania) on psychological well-being and educational achievement; by Rubén G. Rumbaut (Michigan State University) on the adaptation of children of immigrants in Southern California; by Christine Winquist Nord (Westat) and James A. Griffin (National Institute on Early Childhood Development and Education) on the educational profile of 3- to 8-year-old children; by Sandra L.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Hofferth (University of Michigan) on public assistance receipt among Mexican- and Cuban-origin children; by Peter D. Brandon (University of Massachusetts) on public assistance receipt of immigrant children and families; by E. Richard Brown, Roberta Wyn, Hogjian Yu, Abel Valenzuela, and Lianne Don (University of California at Los Angeles) on access to health insurance and health care; and by Richard Mines (U.S. Department of Labor) on children of immigrant farmworkers. Katherine Darke planned and coordinated the committee's December 1996 workshop in Irvine, California, regarding ethnographic research on the health and well-being of immigrant children and families. A dozen presentations were made by David Hayes-Bautista (University of California at Los Angeles) on children's access to care in Los Angeles; by Ruth E. Zambrana (George Mason University) on access and use of care; by Roberta D. Baer (University of South Florida) on "folk" illnesses of children in migrant worker families; by Sylvia Guendelman (University of California at Berkeley) on prenatal care, nutrition, maternal health, and birth outcomes; by Judy Wingerd (Center for Haitian Studies) on health practices and well-being of Haitian infant-mother pairs; by Katherine M. Donato (Louisiana State University) and Shawn Malia Kanaiaupuni (University of Wisconsin at Madison) on health in Mexican-American communities in Texas; by William Arroyo (University of Southern California) on mental health and adjustment among children in refugee families from Central America; by Nestor Rodriquez (University of Houston) on trauma and stress among Central American adolescents attempting to cross the U.S. border unaccompanied by adults; by Andrea S. Moskowitz (University of California at Los Angeles) on mental health, emotional stress, and family functioning; by Keith T. Kernan (University of California at Los Angeles) on family functioning and resilience among adolescent native blacks, Belizean Creoles, and Garifuna immigrants; by Arturo Cervantes (Harvard University) on social adjustment of Mexican adolescents in Chicago; and by Ellen B. Gold (University of California at Davis) on effects of organophosphate exposure on children of migrant farmworkers. Nearly three dozen people assisted the committee in its deliberations by providing commissioned papers and/or new data

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families analyses in specific areas: Richard Alba (State University of New York at Albany) on assimilation in multicultural America; Ronald J. Angel (University of Texas at Austin) on health practices and beliefs; Katherine Baisden (Stanford University) on cigarettes and substance and alcohol use and abuse; David Battille (Texas Tech University) on health and adjustment of immigrant Hispanic children in Texas; Peter D. Brandon (University of Massachusetts) on public program use across generations; Claire Brindis (University of California at San Francisco) on teen pregnancy; Glorisa Canino (University of Puerto Rico) on mental health, health-seeking behavior, and culture; Cynthia Garcia Coll (Brown University) on immigration and developmental processes; Elena Fuetes-Afflick (University of California at San Francisco) on chronic and disabling conditions and a family-community model of health; Noel Chrisman (University of Washington at Seattle) on the health care seeking process; Noreen Goldman (Princeton University) on the effects of treatments on health outcomes; Peter Guarnaccia (Rutgers University) on mental health and adjustment, health care-seeking behavior, and culture; Robert Gunn (San Diego County Department of Health and Human Services Office of Community Disease Control) on sexually transmitted diseases among adolescents; Sharon Hernandez (Texas Tech University) on the health and adjustment of immigrant Hispanic children in Texas; Ray Hutchison (University of Wisconsin at Green Bay) on marriage, fertility, and education among Hmong adolescents; Grace Kao (University of Pennsylvania) on educational aspirations by generation; Frank Kessell (Social Science Research Council) on culture, health, and human development; Jonathan D. Klein (University of Rochester) on adolescent mortality; Jill E. Korbin (Case Western Reserve University) on child maltreatment among immigrant and refugee children; Peter Kunstadter (University of California at San Francisco) on health and health services among ethnic Hmong children; Maria Elena Lara (University of California at Los Angeles) on chronic and disabling conditions and a family-community model of health; Yvonne A. Maldonado (Stanford University) on the epidemiology of pediatric HIV infection and other infectious diseases; Elizabeth R. McAnarney (University of Rochester) on adolescent mortality; Michael McGinnis (scholar in residence, National Research Coun-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families cil) on the effects of treatments on health outcomes; Lisandro Perez (Florida International University) on health care institutions of Cuban immigrants; James M. Perrin (Harvard University) on asthma; Francisco J. Ramos-Gomez (University of California at San Francisco) on oral health; Melissa Ream (Texas Tech University) on the health and adjustment of immigrant Hispanic children in Texas; Frederick P. Rivara (University of Washington at Seattle) on unintentional injuries; Rubén G. Rumbaut (Michigan State University) on current numbers of children in immigrant families; James Sargent (Dartmouth Hitchcock Medical Center) on iron deficiency and lead poisoning; Linda M. Whiteford (University of South Florida) on health care-seeking behavior; and Min Zhou (University of California at Los Angeles) on the context of reception for the second generation. This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the NRC in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: Shirley Brice-Heath, Department of Linguistics, Stanford University, and Carnegie Foundation for the Advancement of Teaching, Menlo Park, California; Catherine R. Cooper, Departments of Psychology and Education, University of California, Santa Cruz; Ronald Feldman, School of Social Work, Columbia University; David Hayes-Bautista, Center for the Study of Latino Health, School of Medicine, University of California, Los Angeles; Eleanor E. Maccoby, Department of Psychology, Stanford University; Marcelo Suarez-Orozco, Harvard Immigration Projects, Harvard University; Rainer K. Silbereisen, College of Behavioral and Social Sciences, Jena, Germany; Ciro Sumaya, School of Rural Public Health, Texas A&M University; David Takeuchi, Department of Psychology, University of California, Los Angeles; Michael Teitelbaum, Alfred P. Sloan Founda-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families tion, New York; George Vernez, Center for Research on Immigration Policy, RAND, Santa Monica, California; Mary Waters, Department of Sociology, Harvard University; and Virginia V. Weldon, Monsanto Company, St. Louis. Although the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content of this report rests solely with the authoring committee and the NRC. The committee would like to thank Reynolds Farley and Marta Tienda for their contributions in the early stages of the committee's deliberations. The Institute for Social Research at the University of Michigan, with the leadership of its director, David L. Featherman, provided necessary resources for the work group convened by the committee to conduct new data analyses. The Population Studies Center at the University of Michigan provided access to computing facilities and to census data that were essential to the work of the committee, and Lisa Neidert of the Population Studies Center provided invaluable technical assistance in conducting analyses for this study. The National Center for Health Statistics generously assisted with data from the National Health and Nutrition Examination Survey (NHANES III); both Clifford Johnson and Susan Schober provided critical technical assistance, and Margaret Carroll conducted important special data analyses. Funding for this study was provided by the Office of the Assistant Secretary for Planning and Evaluation (OASPE) and the National Institute of Child Health and Human Development (NICHD) in the U.S. Department of Health and Human Services. Our project officers were especially helpful; David Nielsen in OASPE and Rose Li in NICHD provided guidance and technical support, and they contributed to the development of ideas for the special analyses work group. Support was also provided by the Office of Educational Research and Improvement (OERI) in the National Institute on Early Childhood Development and Education of the U.S. Department of Education, the Carnegie Corporation of New York, the W.T. Grant Foundation, and the Rockefeller Foundation. The California Wellness Foundation is providing partial support for the dissemination of this report. The committee also benefited from the support of many individuals at the Board on Children, Youth, and Families and the

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Commission on Behavioral and Social Sciences and Education. For her prescience in conceiving the need and obtaining funding for this study long before the recent welfare reforms, for her extensive contributions to drafts of the report, and for her support and encouragement, we are indebted to Deborah A. Phillips, director of the Board on Children, Youth, and Families. Elena O. Nightingale, scholar in residence with the board, generously contributed insights and draft materials on the needs and rights of the immigrant children who may face the most severe difficulties and those who are undocumented and unaccompanied by an adult, and her enthusiasm for the study was much appreciated. Faith Mitchell drafted important materials on health status and adjustment, as did Michelle Kipke on the culturally competent provision of health care. Katherine Darke conducted literature searches that identified relevant materials throughout the study and performed numerous computer analyses of contemporary and historical census data concerning socioeconomic and demographic risk factors. Adrienne Davis, Tanya Elaine Hamilton, Jim Igoe, and Raymond W. Lemons of the National Research Council library provided essential assistance in identifying and collecting research materials. Special thanks are due to senior project assistant Karen Autrey, who provided administrative support, including meeting arrangements and preparation of several drafts of the report, to Nancy Geyelin for research assistance, and to Carole Spalding for project assistance. Thanks go to Anne Bridgman for careful readings of draft chapters and for critical guidance and planning of report dissemination, and to Nancy Geyelin for supporting the dissemination effort. The committee is indebted to our editor, Christine McShane, whose superb editorial skills contributed substantially to the organization and presentation of the committee's views. Eugenia Grohman provided invaluable guidance and assistance throughout the report review process. Most of all, we want to thank the members of the committee for their dedication and many contributions. Evan Charney, Chair Donald J. Hernandez, Study Director Committee on the Health and Adjustment of Immigrant Children and Families

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Contents     PREFACE   xv     EXECUTIVE SUMMARY   1     Potential Influences on Health and Adjustment   3     Health, Adjustment, and Protective Factors   5     Socioeconomic Risk Factors   7     Risk Factors Specific to Immigrants   8     Public Assistance and Health Services: Participation and Use   9     The Limits to Current Knowledge   11     Recommendations for Research   12     Recommendations for Data Collection and Information Dissemination   14     The contents of the entire report from which this Executive Summary is extracted, are listed below     1   CHILDREN IN IMMIGRANT FAMILIES   17     Charge and Scope of the Study   17     The Policy Context   19     The Scientific Context   22     Terminology and Analytical Distinctions   37     Organization of the Report   39 2   SOCIOECONOMIC AND DEMOGRAPHIC RISK   40     General Childhood Risk Factors   41     Risk Factors Specific to Children in Immigrant Families   54

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families 3   HEALTH STATUS AND ADJUSTMENT   59     Birthweight and Infant Mortality,   60     Children's General Health,   63     Chronic Health Conditions,   68     Infectious Diseases,   70     Environmental Toxins,   72     Nutritional Status,   74     Other Health Problems,   78     Adolescent Health,   78     Mental Health and Adjustment,   83     Summary,   107 4   PUBLIC POLICIES   111     Provision of Public Benefits,   112     Use of Public Benefits,   127     Health Coverage and Access,   136     Use of Health Care,   144     Barriers to Health Care,   148     Summary,   152 5   CONCLUSIONS AND RECOMMENDATIONS   155     Findings and Conclusions,   156     Research and Data Collection,   164     REFERENCES   182     APPENDIXES     A:   WORKSHOP PARTICIPANTS   209 B:   SOCIOECONOMIC AND DEMOGRAPHIC INDICATORS   211 C:   GLOSSARY   272 D:   BIOGRAPHICAL SKETCHES   276     INDEX   285     OTHER REPORTS FROM THE BOARD ON CHILDREN, YOUTH, AND FAMILIES   313

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Preface Children in immigrant families figured prominently in the board's earliest discussions about critical, but neglected, areas of research and policy. They were the subject of a workshop, in September 1994, on the Invisible Immigrant Population: Young Children and Their Families, supported by The David and Lucile Packard Foundation and the National Research Council's internal funds. Appendix A provides a list of the workshop participants. The workshop participants strongly urged the board to undertake a comprehensive study of these children, in part to bring them to the forefront of attention of those who fund research and make policy on behalf of children, youth, and families. The Board on Children, Youth, and Families of the Commission on Behavioral and Social Sciences and Education (CBASSE) of the National Research Council (NRC) and the Institute of Medicine (IOM) established the Committee on the Health and Adjustment of Immigrant Children and Families in March 1996. The committee was composed of 19 members with expertise from public health, pediatrics, child psychiatry, developmental psychology, population studies, anthropology, sociology, economics, public policy, law, and history. The committee's charge was to synthesize the relevant research literature and provide demographic descriptions of immigrant children and families; clarify what is known about the varying trajectories that now character-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families ize the families and development of immigrant children, about the risk and protective factors associated with differential health and well-being of different immigrant groups, and about the delivery of health and social services to these groups; and assess the adequacy of existing data and make recommendations for new data collection and research needed to inform and improve public policy and programs. In order to address the various elements of the study charge, the committee and study staff engaged in a range of information collection activities. It invited presentations and written submissions from many experts involved in immigrant policy and research. A workshop on ethnographic research on the health and well-being of immigrant children and families was held to further expand the knowledge base of the committee. The committee also commissioned new, detailed analyses of more than a dozen existing data sets that constitute a large share of the national system for monitoring the health and well-being of the U.S. population. Because, prior to these new analyses, few of these data sets had been used to assess the circumstances of children in immigrant families, the analyses enormously expand the available knowledge about the physical and mental health status and risk behaviors, educational experiences and outcomes, and socioeconomic and demographic circumstances of first- and second-generation children, compared with those with U.S.-born parents. The results from these analyses will be published in a separate volume tentatively titled Children of Immigrants: Health, Adjustment, and Public Assistance. The committee's early deliberations coincided with congressional actions that made far-reaching changes in immigrants' eligibility for public benefits, effectively reversing years' of precedent by which immigrants residing legally in the United States received most benefits on the same terms as U.S. citizens. These changes, enacted as part of welfare reform, emerged from highly contentious debates about the role of working-age immigrants in today's society—their impact on labor markets, dependence on public assistance, and contributions to the changing ethnic composition of our citizenry. Immigrant children, who will be profoundly affected, were essentially invisible in those debates. As a result, policies for children in immigrant families are being forged

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families by default, without the benefit of an informed discussion about potential impacts on their development and future prospects. This salient policy context lent added urgency to the work of the committee. Although we could not draw any conclusions about the recent policy changes, our work offers a critical ''baseline" portrait of immigrant children prior to welfare reform against which their status can be compared in the coming years. Equally important, the committee has high hopes that this study will ensure that immigrant children will be centrally featured in future discussions of policies that shape their lives. The well-being and development of children are a priority for all America, because they are our future and because the rapid growth in the number of children who live in immigrant families gives them special prominence. The study makes specific recommendations concerning research, data collection, and information dissemination that are intended to expand scientific knowledge about children in immigrant families and to help inform future public policy deliberations. It is the collective product of the entire committee, and it could not have been produced without the generous contributions of time, thought, and hard work of all members. Evan Charney, Chair Donald J. Hernandez, Study Director Committee on the Health and Adjustment of Immigrant Children and Families

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families FROM GENERATION TO GENERATION

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