CHAPTER 3
Health Status and Adjustment

The health of children in immigrant families and the extentto which they adapt successfully to American society are very broad topics. Because few surveys or health monitoring systems in the United States use a generational perspective to distinguish among foreign-born children, U.S.-born children with immigrant parents, and U.S.-born children with U.S.-born parents, the scientific evidence is limited. Nevertheless, on the basis of available data, it appears that, along a small number of important dimensions, children in immigrant families experience better health and adjustment than do U.S.-born children in U.S.-born families. This relative advantage tends to deteriorate with length of time in the United States and from one generation to the next. Moreover, as we discuss in this chapter, children in immigrant families may be at particular risk for certain health conditions.

Care must be taken not to overgeneralize, because children from different countries of origin differ greatly, the variation among children from the same country of origin is often substantial, and the available evidence for preliminary conclusions is quite limited. This chapter reviews what is known about the physical and mental health and adjustment of children in immigrant families. It identifies areas in which more research is needed, as well as areas in which children in immigrant families may face risks to healthy development and adjustment.



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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families CHAPTER 3 Health Status and Adjustment The health of children in immigrant families and the extentto which they adapt successfully to American society are very broad topics. Because few surveys or health monitoring systems in the United States use a generational perspective to distinguish among foreign-born children, U.S.-born children with immigrant parents, and U.S.-born children with U.S.-born parents, the scientific evidence is limited. Nevertheless, on the basis of available data, it appears that, along a small number of important dimensions, children in immigrant families experience better health and adjustment than do U.S.-born children in U.S.-born families. This relative advantage tends to deteriorate with length of time in the United States and from one generation to the next. Moreover, as we discuss in this chapter, children in immigrant families may be at particular risk for certain health conditions. Care must be taken not to overgeneralize, because children from different countries of origin differ greatly, the variation among children from the same country of origin is often substantial, and the available evidence for preliminary conclusions is quite limited. This chapter reviews what is known about the physical and mental health and adjustment of children in immigrant families. It identifies areas in which more research is needed, as well as areas in which children in immigrant families may face risks to healthy development and adjustment.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families BIRTHWEIGHT AND INFANT MORTALITY The two most commonly used indicators of infant health are the rate of infants born with low birthweight (defined as less than 2,500 grams) and infant mortality (defined as deaths before age 1 per 1,000 births) (Institute of Medicine, 1985; U.S. Department of Health and Human Services, 1986). A number of studies report significantly lower rates for these two indicators among the immigrant population than among U.S.-born mothers of the same ethnicity, a phenomenon that is referred to as the epidemiological paradox. Initial studies of this phenomenon focused on the Mexican-origin population (Guendelman, 1995; Guendelman and English, 1995; Guendelman et al., 1995; Markides and Coreil, 1986; Scribner and Dwyer, 1989; Ventura, 1983, 1984; Williams et al., 1986).1 Subsequent research has documented a similar pattern for other ethnic groups, although the differences in rates of low birthweight and infant mortality in these groups have often been smaller than they are for Mexican immigrants. For example, in an analysis conducted for the committee, based on single births in the 1989-1991 Linked Birth/Infant Death Data Sets (Landale et al., 1998), the percentages of foreign-born and U.S.-born mothers with low-birthweight infants are, respectively, 4.1 and 5.4 percent for Mexicans, 4.4 and 4.7 percent for Cubans, and 4.8 and 5.2 percent for Central and South Americans. The more favorable measures hold for most Asian immigrants as well (Figure 3-1). Although it is well documented that prenatal care contributes to positive birth outcomes, the more favorable health outcomes of immigrants often occur in the context of lower utilization of pre- 1   Among the hypotheses that might explain the epidemiological paradox are several that point to possible data limitations. Some have argued, for example, that the unexpectedly low rate of infant mortality among Mexican-origin women, especially immigrants, may be due to underreporting of infant deaths or ethnic misclassifications on birth and/or death certificates. These hypotheses have received little support in research on the Mexican-origin population (Guendelman, 1995; Guendelman and English, 1995; Williams et al., 1986). There is no reason to believe that birthweight would be recorded more accurately for immigrants or ethnic minorities than for others, because birthweight is recorded on the birth certificate according to information provided by medical personnel.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families FIGURE 3-1 Percent with low birthweights among births to immigrant and native-born women by country or region of origin and race or ethnicity: 1990. Source: Landale et al. (1998). natal care. There are indications that other factors may be of equal or greater importance. The role of lifestyle, for example, is only beginning to be documented and understood. More detailed studies of previously unmeasured lifestyle differences, such as nutrition and stress, that compare immigrants and natives, coupled with greater attention to alternative sources of information for pregnant immigrant women, could shed light on the precise role of formal medicine in protecting the health of children in immigrant families during infancy. Consistent with the pattern for low birthweight, infant mortality rates are also lower for children of immigrants than for U.S.-born children of U.S.-born women, although sometimes the differences are slight. Among Hispanics, the infant mortality rates for single infants born to foreign-born and U.S.-born women are, respectively, 5.3 and 6.6 percent for Mexicans, 4.7 and 5.3 percent for Cubans, and for 5.0 and 5.2 percent for Central and South Americans. For Asians, infant mortality rates for infants of foreign-born and U.S.-born mothers are 4.3 and 4.6 percent for Chinese, 4.8 and 6.8 percent for Filipinos, 3.7 and 3.7 percent for Japa-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families FIGURE 3-2 Infant mortality rate for children of immigrant and native-born women by country or region of origin or race or ethnicity: 1990. Source: Landale et al. (1998). nese, and 5.3 and 6.2 percent for other Asians and Pacific Islanders. The infant mortality rates for non-Hispanic whites and blacks are also lower for foreign-born than for U.S.-born mothers (4.6 and 5.8 percent for whites, and 10.5 and 12.9 percent for blacks) (Figure 3-2) (Landale et al., 1998). The pattern is less consistent for neonatal mortality rates (deaths at less than 28 days of age). The rate is lower for infants of foreign-born than for U.S.-born mothers for some groups (non-Hispanic whites, non-Hispanic blacks, Mexicans, Cubans, Filipinos), and higher for others (Central and South Americans, Chinese, Japanese, other Asians and Pacific Islanders). In contrast, the post-neonatal mortality rates (deaths between 28 days and 1 year of age) are lower for all immigrant groups except for Cubans, for whom the rates are somewhat higher (Landale et al., 1998). A number of factors may contribute to these positive outcomes for infants in immigrant families. The relatively high levels of educational and occupational attainment among Asian immigrants may explain their superior infant health outcomes.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families However, most immigrants from Latin America (particularly from Mexico) are neither affluent nor well educated; alternative explanations take into consideration the possible protective influence provided by their cultures of origin. For example, there is convincing evidence that cigarette smoking during pregnancy, a well-recognized cause of low birthweight, is substantially lower among immigrant women; statistically excluding the effect of that single factor substantially reduces the differential rates (Landale et al., 1998). With regard to infant mortality, a nurturing and protective prebirth environment for the mother is most important. Along these lines, immigrant women of Mexican origin are less likely to use alcohol and drugs and may have a healthier diet than U.S.-born women (Cabral et al., 1990; Guendelman and Abrams, 1995). These healthful behaviors may be reinforced by strong family bonds among immigrant groups and communities that sustain cultural orientations that lead to healthful behavior, factors that become diluted with duration of residence in the United States. As we look to the future, however, it is possible that the increasing size and the geographic concentration of the immigrant population, especially from Mexico, will act to sustain these protective factors. Additional study will allow researchers to identify the protective factors that contribute to the epidemiological paradox and to determine why, for some groups, acculturation leads to deteriorating health outcomes for infants. Such research should assess another possible explanation, as well: that women who are especially healthy may be more likely to immigrate to the United States than women who are less healthy; that is, that immigrant women are self-selected from among the more healthy women in their countries of origin, and they continue to have comparatively good health after they immigrate. CHILDREN'S GENERAL HEALTH Very little is known about the health of school-age children in immigrant families, and much of what is known derives from parental and self-reports. The 1994 National Health Interview Survey (NHIS) and the 1996 National Health and Nutrition Ex-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families amination Survey (NHANES III) provide some health status parameters for children in immigrant families,2 as reported by parents. However, these data must be interpreted with caution for several reasons. The NHIS responses are not categorized by families' country of origin (across which there may be significant variations); the responses to both surveys reflect parental awareness of conditions rather than medically confirmed diagnoses; immigrant parents may be more hesitant than U.S.-born parents to reveal the existence of health problems to an interviewer, or they may have health expectations that differ from native-born parents, because they come from different cultures; and only the NHANES III has standardized translations of the survey instruments into Spanish and uses bilingual, bicultural interviews. For all these reasons, inconsistencies between parental reports of general health and of the prevalence of specific conditions should be treated as preliminary, and subject to additional study. In the NHIS, first- and second-generation children and adolescents up to 17 years of age were reported by their parents to have fewer acute and chronic health problems (except for certain respiratory conditions) than third- and later-generation children in the same age range. This was reported for all age subcategories (i.e., 0 to 2, 3 to 5, 6 to 11, and 12 to 17). Parents of first- and second-generation children surveyed by the NHIS also reported fewer health problems that limited the children's activity (4 percent for the first and second generations compared with 7 percent for the third and later generations), and they reported that children were less often placed in special classes or unable to attend school because of health problems (2 percent for the first and second generations compared with 5 percent for the third and later generations). Paradoxically, despite reporting significantly fewer individual health problems, immigrant parents reported in the NHIS that their first- and second-generation immigrant children have somewhat less favorable health status than did parents of third- and later-generation children: 75 percent of immigrant parents com- 2   NHANES III has data for children in Mexican-origin families only.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families pared with 81 percent of U.S.-born parents reported their child to be in ''excellent" or "very good" health. Comparable percentages (3 percent compared with 2 percent) reported their child to be in "fair" or "poor" health. Parents were asked to rate their children's health as excellent, very good, good, fair, or poor in NHANES III. A clear difference was seen between all generations of Mexican-origin children and third- and later-generation white children in this measure of health. Mexican-origin children were more likely to be rated in fair or poor health by their parents than were third- and later-generation white children. Moreover, this difference was greatest for the first generation and declined with each generation (Mendoza and Dixon, 1998) (see Table 3-1). Among first-generation Mexican-origin children, about 1 in 4 was rated by their parents to be in poor health. This compares to 1 in 25 for third- and later-generation white children. Third- and later-generation Mexican-origin children had similar rates as third- and later-generation black children, and both were twice as likely to be rated in fair or poor health compared with third- and later-generation white children. Mexican-origin children in all generations are therefore 2 to 9 times more likely to have parents who express concerns about their health than third- and later-generation white parents. Data on migrant farmworker children, who are primarily second-generation children, provide more detail about parents' perceptions of their children's health and other aspects of health status. In a study of preschool children enrolled in the Migrant Head Start program, 56 percent of Hispanic parents considered their children to be in "excellent" or "very good" health, 34 percent to be in "good" health, and 9 percent in "fair" or "poor" health. The parents' impressions were consistent with a review of the children's health records, which indicated that 7 percent had "frequent" health problems, principally repeated upper respiratory infections (Aguirre International, 1997). Among the migrant population, it is likely that those children enrolled in Head Start have better health status than those not enrolled. Although this study did not collect data on health hazards posed by parental working conditions, particularly from pesticide residues on par-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families TABLE 3-1 Percent with Selected Reported Health Conditions for First- and Second-Generation Children by Generation and for Third- and Later-Generation Children by Race and Ethnicity: 1996 Percent with Reported Conditiona First-Generation Mexican American Second-Generation Mexican American Third-Generation Mexican American Perceived health to be fair or poor as assessed by parent < 5 yrs. 23.9 (3.33) 16.8 (1.05) 6.3 (0.83) 6-11 yrs. 27.6 (7.70) 20.0 (2.28) 6.6 (1.43) 12-16 yrs. 28.7 (4.99) 15.4 (2.52) 6.8 (1.63) Asthma < 5 yrs. 2.2 (1.20) 5.2 (0.88) 8.1 (1.72) 6-11 yrs. 3.8 (2.74) 9.8 (2.71) 15.0 (4.09) 12-16 yrs. 3.1 (1.77) 6.6 (1.91) 8.5 (1.92) Possible active infection on physical examination at time of surveyb < 5 yrs. 8.3 (2.68) 9.1 (1.42) 12.3 (1.93) 6-11 yrs. 8.6 (3.66) 5.3 (1.43) 5.9 (1.57) 12-16 yrs. 4.0 (1.13) 2.1 (1.12) 4.7 (1.49) Ever had anemia < 5 yrs. 9.7 (2.18) 14.5 (1.09) 11.0 (1.60) 6-11 yrs. 9.2 (3.14) 11.7 (2.08) 2.8 (0.93) 12-16 yrs. 8.7 (2.64) 7.2 (1.88) 4.3 (1.12) Past 12 months any accidents, injury, or poisoning < 5 yrs. 3.7 (1.65) 5.5 (0.58) 10.0 (1.16) 6-11 yrs. 4.2 (3.26) 5.0 (1.16) 8.1 (1.95) 12-16 yrs. 3.6 (1.58) 7.5 (1.40) 10.7 (2.63) Condition of Teeth - Fair to Poor < 5 yrs. 39.3 (5.10) 26.0 (2.49) 21.0 (1.80) 6-11 yrs. 60.1 (8.15) 42.6 (2.92) 23.5 (3.68) 12-16 yrs. 50.8 (4.65) 36.3 (3.24) 16.4 (1.99) Problems seeing < 5 yrs. 0.2 (0.24) 1.1 (0.35) 0.7 (0.30) 6-11 yrs. 6.8 (2.42) 13.2 (2.42) 7.9 (1.19) 12-16 yrs. 18.8 (2.97) 15.2 (1.86) 13.3 (2.05) a Parental reported condition from Household Youth Questionnaire NHANES III. b Assessed by survey physicians by standardized physical examinations.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Non-Hispanic Black Non-Hispanic White Non-Hispanic Other 4.9 (0.73) 1.8 (0.35) 7.4(1.25) 6.9 (0.91) 2.0 (0.47) 3.5 (1.36) 7.4 (1.20) 3.5 (0.79) 8.4 (4.25) 9.0 (0.75) 5.1 (0.55) 6.6 (1.40) 9.4 (1.00) 10.6 (1.41) 12.4 (6.12) 12.6 (1.63) 12.8 (1.67) 12.9 (4.59) 12.1 (1.74) 7.1 (1.25) 5.1 (1.35) 5.9 (0.94) 5.0 (1.31) 16.0 (6.77) 3.0 (0.83) 4.6 (1.67) 4.4 (3.25) 11.2 (1.06) 6.4 (0.67) 10.7 (1.97) 7.4 (0.74) 7.2 (1.11) 7.4 (3.00) 6.4 (1.17) 8.4 (1.55) 3.6 (2.24) 6.3 (0.61) 12.8 (0.89) 7.4(1.69) 7.0 (0.96) 19.3 (2.31) 4.2 (1.92) 11.0 (1.15) 18.5 (2.15) 9.7 (3.33) 13.7 (1.37) 6.9 (0.89) 17.3 (2.37) 22.7 (1.52) 12.2 (1.20) 18.4 (4.36) 20.2 (2.05) 11.5 (1.64) 8.6 (3.23) 1.8 (0.35) 1.5 (0.34) 1.6 (1.06) 9.8 (1.17) 7.6 (1.07) 4.5 (2.19) 15.2 (1.63) 12.5 (1.80) 16.4 (6.77) NOTE: Non-Hispanic Asians are not included because of small sample size. Source: Mendoza and Dixon (1998).

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families ents' clothing and accidental contamination of the water supply, they are an additional health risk that warrants examination. In a random sample of migrant farmworker women in Wisconsin with children age 16 or younger traveling with them, children ages 3 to 5 had immunization levels for DPT, polio, measles, and rubella roughly comparable to kindergarten children in the state (Slesinger et al., 1986). Children of migrant farmworkers had lower levels of immunization for mumps, and only half of the children under the age of 12 had received an annual checkup. The study also reported that children of migrant farmworkers were less likely to receive dental care than the general population of children in the United States. It should be noted that the sample size in this study was relatively small (330 children) and the children were primarily Mexican-origin. Any overall conclusion from these studies about the general good health and well-being of children in migrant farmworker families must be tempered by the fact that the farmworker and migrant subpopulations are extremely heterogeneous. Factors such as ethnicity, recency of immigration, cultural and linguistic barriers to health care, widely varied living and working conditions, and availability and quality of health care make generalizations difficult. Moreover, inappropriate generalization could obscure significant health problems in specific subpopulations of migrant farmworkers. CHRONIC HEALTH CONDITIONS An accurate assessment of the prevalence of chronic health conditions and disability among children in immigrant families does not exist for the most part. But there is little reason to expect chronic conditions among them to differ from those for other children who belong to the same racial, ethnic, or income groups. Children in the United States with chronic conditions often face significant financial and other barriers that complicate the provision of comprehensive services, and the barriers are likely to be more formidable for immigrants. Chronically ill children may require multiple diagnostic and therapeutic services from the medical, educational, and social service systems. These resources are often located in different institutions, each with spe-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families cific and sometimes complex and changing eligibility criteria. As a result, providing for and coordinating the provision of care for a chronically ill child usually falls heavily to the family. That responsibility can be particularly difficult for the immigrant family, for whom differences in culture, language, access to care, and financial resources can complicate the process (Lequerica, 1993; Smith and Ryan, 1987). Asthma is the most common severe chronic physical condition of children, and the rates of the disease have increased in the past few decades. It is a single condition influenced by several key factors, including access to care, utilization of medical and support services, housing conditions (notably cleanliness), and the influence of cultural values on the pattern of care provided. Asthma also provides measurable and meaningful outcomes for both short- and long-term morbidity and health care costs. Additional careful study of asthma in the immigrant population may serve as a valuable indicator of the health and well-being of immigrant children. The prevalence of childhood asthma varies substantially across ethnic groups for reasons that reflect a combination of biological, cultural, and socioeconomic differences, although the mechanisms by which these factors work are not well understood. Children in immigrant families with asthma often have additional complicating factors. For some with pollen-sensitive forms of asthma, attacks may be exacerbated by the move from a tropical to a temperate climate with higher and more seasonably varying pollen rates (Echechipia et al., 1995; Sin et al., 1997). In addition, infection by viral pathogens to which children have not been exposed previously can trigger acute asthma episodes (Sokhandan et al., 1995). Cultural beliefs among immigrant families about the etiology and treatment of asthma may differ from the general U.S. population as well. For example, studies in the Puerto Rican community have demonstrated that the degree of acculturation is directly related to the likelihood of compliance with medically prescribed asthma therapy for children (Pachter and Weller, 1993). New analyses conducted for the committee from NHANES III indicate that, among Mexican-origin children, the prevalence of asthma as reported by parents increased between the first, second, and third and later generations (Mendoza and Dixon, 1998)

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families   CHINESE FILIPINOS   Immigrant Generation Native-born of Foreign-born Parents Native-born of Native-born Parents Immigrant Generation Native-born of Foreign-born Parents Native-born of Native-born Parents School experiences Ever repeat 0.121 0.029b 0.208 0.119 0.027c 0.2   -0.327 -0.167 -0.415 -0.325 -0.164 -0.414 Currently enrolled in bilingual program 0.144c 0.037 0.043 0.091b 0.009 0   -0.353 -0.191 -0.209 -0.289 -0.096 0 N 134 107 25 108 114 16 a p<.05 b p<.01 c p<.001 Source: The National Education Longitudinal Study of 1988. Kao (1998). volved in school, somewhat more than the 59 percent for Hispanics and 56 percent for blacks. Among children in immigrant families, the proportion with parents highly involved in school was 57 percent, although most of the difference between these children and third- and later-generation white children was accounted for by the higher proportion with a moderate level of parental involvement. Parental involvement was greater for the second generation than the first (58 versus 50 percent highly involved). Among children in immigrant families, Hispanics were less likely then Asians to have highly involved parents (49 versus 57 percent) (Nord and Griffin, 1998). Early childhood programs prior to kindergarten help children prepare for school. The proportions attending early childhood programs among third- and later-generation children were 58, 66, and 47 percent, respectively, for whites, blacks, and Hispanics, compared with 42 percent for children in immigrant families. The

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families MEXICAN OTHER HISPANICS WHITES Immigrant Generation Native-born of Foreign-born Parents Native-born of Native-born Parents Immigrant Generation Native-born of Foreign-born Parents Native-born of Native-born Parents Native-born of Native-born Parents 0.273c 0.214c 0.214c 0.184 0.18 0.212b 0.148 -0.447 -0.41 -0.41 -0.39 -0.386 -0.409 -0.355 0.141c 0.067c 0.047 0.147c 0.062a 0.069b 0.034 -0.349 -0.25 -0.212 -0.356 -0.242 -0.254 -0.182 215 578 763 121 195 242 13952 second generation was more likely than the first to attend such programs, and Hispanic children in immigrant families were slightly less likely than Asians to attend such programs (Nord and Griffin, 1998). Children generally have been found to learn better if the schools they attend are well-disciplined and parental participation may be encouraged by a variety of school practices that foster such involvement. In parental ratings of children's schools along 10 dimensions, the proportion with favorable or very favorable parental responses was 45 to 67 percent for third- and later-generation white children. The proportions with favorable ratings were 2 to 10 percentage points lower along most dimensions for third- and later-generation blacks and Hispanics. These proportions varied between about 15 percentage points less and 15 percentage points more for third-generation children. They also varied substantially but in no specific direction for first- and

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families TABLE 3-5 Percent with Parents Reporting Selected Family Educational and School Experiences for Children Ages 3 to 8 by Generation and for Third- and Later-Generation Children by Race and Ethnicity: 1996     First and Second Generations  Characteristic Children 3-8 Years Total First Generation Total (thousands) 22,959 3,213 430 Family Involvement at Home       In the past week, someone in family:       Taught child letters, words, or numbersa 93% 92% 86% Taught child songs or musica 76 73 68 Took child along while doing errandsa 95 91 97 Number of times read to child:b       Not at all 7 11 13 Once or twice 20 26 34 3 or more times 28 25 23 Every day 44 37 31 Told child a story 77 76 74 Worked on arts and crafts project with child 72 65 59 Played a game, sport, or exercised with child 92 86 82 Involved child in household chores 95 86 83 Worked on a project with child like building, making or fixing somethingc 67 56 51 In the past month, someone in the family:       Visited the library with child 44 38 32 Went to a play, concert, or other live show with the child 30 26 21 Visited an art gallery, museum, or historical attraction with child 20 20 17 Visited a zoo or aquarium with child 17 23 21 Talked with child about family history or ethnic heritage 52 55 60 Attended an event with child sponsored by a community, ethnic, or religious group 50 41 39 Attended an athletic or sporting event in which child was not a player 33 22 12

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families         Third and Later Generations Second Generation Hispanic Asian White Total White Black Hispanic 2,782 1,734 239 837 19,746 14,166 3,326 1,652 93% 90% 97% 94% 94% 93% 96% 91% 73 70 72 78 76 76 83 69 90 88 79 99 95 96 94 94 11 14 6 7 7 6 8 8 25 32 18 17 19 17 25 24 26 25 25 24 29 28 30 29 38 29 51 51 45 48 37 39 77 71 83 84 77 78 73 79 66 59 74 74 73 75 66 72 87 81 92 94 93 94 92 87 86 84 74 90 96 97 95 92 58 47 59 69 68 70 63 67 38 27 54 51 45 47 40 39 27 21 34 33 30 29 36 27 20 15 24 27 20 19 22 20 23 20 32 26 16 14 23 21 54 52 50 61 51 47 65 54 41 35 38 51 51 52 52 43 24 18 19 30 35 36 33 27

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families   First and Second Generations  Characteristic Children 3-8 Years Total First Generation Family Involvement at School       Parents' involvement in schoold       Low 15 17 17 Moderate 21 26 33 High 64 57 50 Parent attended a general school meeting 83 82 78 Parent attended class or school event 67 61 60 Parent volunteered at school 51 38 24 Parent attended parent-teacher conference 79 82 84 NOTE: Hispanic children are designated as such. They are not included in any of the other racial or ethnic categories. The Total columns include all children. Because of rounding, percents may not sum to 100. second-generation children and for Hispanic and Asian children in immigrant families (Nord and Griffin, 1998). Educational Aspirations and School Problems Analyses conducted for the committee based on the National Education Longitudinal Survey of 1988 (Kao, 1998) indicate that children in immigrant families, both the first and second generations, have higher educational aspirations and are more likely to aspire to graduate from college than are third- and later-generation adolescents. Among Chinese, Filipino, and Mexican children, although small sample sizes require that the findings be viewed as preliminary, educational aspirations are highest among Chinese and Filipinos in immigrant families, somewhat lower among third- and later-generation children generally, and still lower for

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families         Third and Later Generations Second Generation Hispanic Asian White Total White Black Hispanic 17 21 13 10 15 13 21 17 25 30 30 20 20 19 23 24 58 49 57 70 65 68 56 59 83 79 81 87 84 84 81 82 61 54 56 73 68 71 57 64 41 29 36 54 53 56 42 46 81 83 88 86 79 79 76 78 a Applies only to children not yet in first grade. b Applies to children age 3 years through grade 3. c Applies to children in grades 1 and above. d Applies to children enrolled in preschool programs or regular school. Source: U.S. Department of Education, National Center for Education Statistics, 1996 National Household Education Survey. Nord and Griffin (1998). third- and later-generation Chinese and Filipino children and all generations of Mexican-origin children. Consistently, the most common school problems identified among youth in immigrant families are behavioral problems and learning difficulties (Aronowitz, 1984; Gil et al., 1994). When asked to assess children in immigrant families, teachers tend to identify more behavioral problems than do parents. It is difficult to assess from the literature whether these higher rates of behavioral problems and learning difficulties that teachers report are due to their misinterpretation of normatively different behavior or the effects of acculturative stresses, such as language difficulties and perceived discrimination at school. It is likely that both of these factors not only are present, but also interact in the school setting. In addition, the negative evaluations that teachers make

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families may have a negative effect on the self-esteem of children in immigrant families, especially among adolescents. Smaller-scale studies present a more complex picture of achievement motivation and school problems among different groups of youth in immigrant families. For example, Gil and colleagues (1994) found that, among second- and third-generation Hispanic adolescents, high acculturation was associated with high academic motivation. They also found that second- and third- and later-generation adolescents with low acculturation who perceived significant discrimination from the host society were most likely of all the adolescents studied to experience low self-esteem and poor school performance. Research by Rousseau and colleagues (1996) in Montreal illustrated that the school's perceptions of different immigrant groups may also interact with student motivation to produce worse outcomes for some groups of children than others. In this study, although the school performance of first-generation Southeast Asian and Central American immigrant children did not vary significantly, teachers identified more learning problems in the Central American children. They also subscribed to the stereotype of Asians as a ''model minority" in their differential perceptions of these groups of students. In another study of Canadian children, Munroe-Blum and colleagues (1989) highlighted the effect of social status on the school performance and mental health of children in immigrant families. In this large study, immigrant status was not associated with either poor school performance or more mental health problems. However, children in immigrant families were more likely to be poor, but less likely to have access to welfare and other social services. The paradoxical nature of the findings was that, given the worse social status of children in immigrant families, there were no overall statistical differences in outcomes, suggesting resilience among these children, an emerging theme in the research literature. What cannot be ascertained from this cross-sectional study is the effect of enduring social disadvantage on children. Other studies indicate that, in the United States, the persistence of disadvantage is structured along racial lines, with black children experiencing more serious problems (Kao and Tienda, 1995;

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Phinney and Chavira, 1995) and Asian children fewer problems. Better statistical analyses are needed to look more closely at different ethnic populations within these broad groupings. However, there are anecdotal indications that Hmong and other tribal people from Southeast Asia are not faring as well as other Asians; that the Cuban experience is quite different from that of Nicaraguans and Salvadorans; and that Jamaicans, Haitians, and blacks also have divergent experiences. SUMMARY Although we reiterate that conclusions based on the committee's analysis must be considered preliminary, many measures reported for children in immigrant families indicate that they are healthier than U.S.-born children in U.S.-born families. This relative advantage tends to decline with length of time in the United States and from one generation to the next. In addition, children in immigrant families are at particular risk for certain health problems. Specifically, children in immigrant families experience fewer specific acute and chronic health problems than do U.S.-born children in U.S.-born families, according to parent reports, including acute infectious and parasitic diseases; acute ear infections; acute accidents; chronic respiratory conditions such as bronchitis, asthma, and hay fever; and chronic hearing, speech, and deformity impairments. For children of Mexican origin, parents in immigrant families report fewer acute injuries and poisonings and fewer limitations on major activities than U.S.-born parents in U.S.-born families. First-generation immigrant adolescents also report lower levels of neurological impairment, obesity, and asthma, and fewer health risk behaviors such as early sexual activity; use of cigarettes, alcohol, marijuana, or hard drugs; delinquency; and use of violence. Many of these health problems and risk behaviors tend, however, to increase with length of residence in the United States or from one generation to the next. Similarly, second-generation infants are less likely to have low birthweight or to die in the first year of life than are third- and later-generation infants. Comparatively low levels of cigarette

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families smoking and alcohol consumption during pregnancy among immigrant mothers contribute substantially to their more favorable birth outcomes; additional potentially important factors include lower levels of drug use and a healthier diet. Perhaps as we look to the future, protective factors that lead to comparatively favorable outcomes for first- and second-generation children will be reinforced, or more easily maintained, as a result of the increasing size and the geographic concentration of the immigrant population, especially from Mexico, providing greater opportunities to retain positive cultural characteristics. Not all indications are favorable, however. Children in immigrant families from Mexico, for example, are more likely to be reported by parents as being in fair to poor health and as having teeth in only fair to poor condition. They are also more likely to exhibit elevated blood lead levels. In addition, parents in immigrant families are, paradoxically, somewhat less likely than those in U.S.-born families to report their child's health as excellent or very good, despite the fact that they report their children to have fewer specific acute and chronic health problems. Tuberculosis, hepatitis B, parasitic infections, and elevated levels of lead in the blood are also of particular concern for children in immigrant families from certain high-risk countries of origin. The paradoxical finding that children in immigrant families have better health than U.S.-born children in U.S.-born families on most available measures—despite their overall lower socioeconomic levels, higher poverty rates, and racial or ethnic minority status—suggests that strong family bonds among immigrants may act to sustain cultural orientations leading to healthful behavior, or that other unknown social or cultural factors may serve to protect them. Thus, children may be protected by key aspects of culture brought from their home country. It is important to also keep in mind that most of these findings (with the exception of the infant outcomes) are based on parental and self-report data, which are themselves likely to be affected by cultural factors. The apparent deterioration of the health of children in immigrant families the longer they reside in the United States and from one generation to the next suggests that protective aspects of immigrant culture may fade as assimilation into the mainstream American culture occurs, allowing deleterious effects of low so-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families cioeconomic status, high poverty, and racial or ethnic stratification to emerge. A more complete understanding of the health situation of children in immigrant families and the reasons for change through time will depend on additional study of these children in the United States that is informed by knowledge about the health of children in countries of origin, and hence providing an explicitly cross-national comparative perspective. Firm conclusions about similarities and differences between adolescents in immigrant and U.S.-born families regarding psychological well-being, academic success, and other measures of successful adaptation to American society are difficult to draw for reasons that include the small immigrant samples in available studies. However, adolescents in immigrant families appear to sustain positive feelings about themselves and their well-being while also perceiving that they have relatively less control over their lives and are less popular with their peers at school. They also report having higher educational aspirations, although these may deteriorate across generations. At early ages, parents can foster school success among their young children by teaching them letters and numbers, reading to them, working on projects with them, taking them on educational outings, and getting involved in the children's school. Young children also learn better in well-disciplined schools and if parental participation is encouraged by the school. Early childhood programs prior to kindergarten help children prepare for school. Children do not differ systematically along most of these dimensions, with the exception that children in immigrant families are much less likely to be enrolled in early childhood programs or attend Head Start if they are eligible. Children in immigrant families nationally have somewhat higher middle school grade point averages and math test scores than do U.S.-born children in U.S.-born families, although reading test scores among the first generation are lower than for later generations. Differences across children with various countries of origin appear quite large, however. For example, adolescents in Chinese-origin immigrant families have grade point averages and higher math test scores than third- and later-generation Chinese-origin or white children. In contrast, Mexican-origin children of all generations have grade point averages and math test

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families scores that are similar to each other, but that are much lower than for third- and later-generation white children. Corresponding to the declines in educational aspirations across generations, however, there is evidence that, among Chinese-origin and Filipino-origin children, the especially strong achievement records of the second generation are not sustained.