Introduction

Healthcare providers are uniquely positioned to both care and advocate for immigrant children, from their arrival through supporting integration into their new community. In 2022, one in four children identified as part of an immigrant family; about 4% of all children in the United States, approximately 2.6 million, were estimated to be foreign born [1]. Immigrant children have different pathways to migration to the United States. It is estimated that in 2022, 40% of refugees entering the United States were under the age of 18 years, and similarly, around 40% of forcibly displaced individuals globally were children [2]. Between 2022 and 2024, over 100,000 unaccompanied children were released to sponsors through the Office of Refugee Resettlement [3].

Ties to community and one’s culture serve as protective factors after migration, and most children are resilient despite a difficult past journey [4•]. Many children and families face traumatic experiences in their home country prior to migration; armed conflict, stress and trauma of displacement are associated with poor health and mental health outcomes [5,6,7,8,9,10]. Family support during migration is associated with higher levels of resilience.

There are several resources reviewing recommendations about initial screening and evaluation of immigrant children arriving in the US [11,12,13,14], the importance of their migration path, and general reviews detailing approaches to primary care for immigrant children [15,16,17,18]. There are fewer reviews, however, about the ongoing adjustment children face after migration and how their new environments impact their health. Once in the United States, immigrant children experience both health promoting and detracting factors. The experience of migration –both the path before and after US arrival – is a social determinant of health (SDOH) for children [19].

Despite interacting with many immigrant patients and families, pediatricians often report feeling unprepared to care for immigrant children, including not understanding the complexity of care needs and influences [20]. The goal of our narrative review is to assess the impact of environmental factors on the adjustment of immigrant children after migration to the United States. This review summarizes recent evidence on the environmental factors impacting the health of foreign-born children under 18 years old arriving in the US (from now on referred to as “first-generation immigrant children” or FGIC), and the role healthcare providers can serve in supporting these children and families.

Methods

This review used narrative review methodology [21] to explore: what environmental factors impact the health of FGIC in the US, and how can healthcare providers promote the health of FGIC? This methodology is well suited to provide a general overview on this topic with room to interpret the findings and note research gaps; it is not an exhaustive literature review approach and it does not include grading the evidence quality.

The authors and a university librarian searched 3 databases (PubMed, Embase, and CINAHL) for English-language articles published in the last 5 years on the health of FGIC in the US. Search terms used included: immigrant, migrant, first generation, refugee, asylee, unaccompanied, undocumented, special immigrant visa, temporary visitor, legal permanent resident, child health, adolescent health, United States. When articles included both first-generation and later-generation immigrant children, or did not specify whether immigrant children were first-generation, articles were included per authors’ discretion. In order to draw conclusions from the widest range of papers, the authors (familiar with the field) added articles by personal suggestion, articles through reference lists of previously found articles, as well as policy statements and guidelines from professional organizations. All included materials will be referred to as publications moving forward. Commentaries, editorials, and gray literature were excluded. The publication search and selection process were stopped when authors felt that topic saturation was reached.

Results

There were 349 publications identified for this narrative review; 10 additional publications were found through author suggestions, and 8 additional publications through reference lists of reviewed publications. AZ and PN reviewed publications to choose relevant ones based on relevance to the research question (focused on FGIC in the US) and the addition of a novel perspective to the review, yielding a total of 74 publications, which were included in the final review. Authors then categorized publications into one of four categories of environmental impact on the health of FGIC – relational environment (21 publications), built environment (21 publications), community environment (17 publications), and policy/political environment (15 publications). Eight publications addressed multiple environments. Figure 1 shows the definition of each environment. Authors then reviewed publications to describe each publication’s population, methods, and health outcomes and associations considered (Table 1) and summarized main findings below.

Fig. 1
figure 1

Categories of environmental impact on the heath of first-generation immigrant children

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Table 1 Publications included in this narrative review: methods and health outcomes addressed
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Relational Environment

Relationships are a major source of resilience and well-being in the lives of all people, including immigrant children. A total of 21 publications in our search examined the impact of the relational environment on the health of FGIC. Most publications focused on the association between family relationships and mental health outcomes, and some addressed the association between relationships with peers and other adults in the community and physical health outcomes.

In many immigrant families, strong family ties provide major sources of resilience, and separation from family before, during, or after the migration journey is a toxic stress for children. In a study of affidavits of minors seeking asylum in the US, most of whom reported migration-related family separation and multiple traumatic stressors in their home country, 80.5% presented with significant symptoms of trauma-related disorders, depression, and/or anxiety [22•]. Additionally, the well-being of parents is impactful on the well-being of children; for example, in a study of West African immigrant children, parental post-traumatic stress disorder (PTSD) was associated with externalizing behaviors in children, which was strongest in parent-child dyads that experienced more than 1 year of separation [23]. In a survey of Latinx middle schoolers in Atlanta (12% of whom were born outside the US), family member detention or deportation once in the US was associated with an increased risk of suicidal ideation, alcohol use, and externalizing problems in youth [24]. Even the fear of family member detention or deportation can negatively impact youth mental health [25, 26•]; Latinx youth with unauthorized parents have more internalizing symptoms and a higher allostatic load—a combination of physiologic parameters including BMI, blood pressure, pulse, glucose metabolism, lipid regulation, and inflammation [26•].

When immigrant children come to the US after a period of parental separation either before migration, during migration, or at the border, reunification brings its own challenges. Reunification with family is a sensitive process of reattachment, especially given prior trauma of separation [22•, 27]. Additionally, some unaccompanied minors resettle with non-parental relatives or with non-family caregivers; youth living with non-family caregivers had less sources of resilience and less friends, while those living with non-parental relatives reported having more friends [4•]. Challenges with family reunification or placement with a non-parent sponsor can also contribute to an increased risk for labor and sex trafficking/exploitation of unaccompanied immigrant children; other factors that increase the risk of exploitation for this population include exposure to xenophobia, adjustment challenges, lack of familiarity with new culture and laws, and trouble accessing resources [28].

Another theme of the relational environment is the impact of acculturation and parents’ own mental health on parenting practices, parent-child relationships, and children’s mental health. Both children and families face acculturation stress with a new environment, social norms, language, and systems. Children, however, often acculturate faster than parents [29], leading to changes in family power dynamics, challenging parents’ abilities to uphold traditional family values [30] and monitor health behaviors such as substance use [31]. Additionally, in the US, families often have much less support from extended family and other community members compared to their home countries [30]. Parents of Syrian refugees voiced trouble finding time to spend with their family given long work hours, an experience likely shared by other immigrant groups [29]. Additionally, acculturation stressors are associated with increased risk of intimate partner violence (IPV) in immigrant populations, especially with more time spent in the US [32]. IPV negatively impacts children’s mental health, including increased rates of PTSD, anxiety, and depression [32]. Given such high prevalence of IPV in immigrant families (30-60% self-reported rates) and barriers to seeking help, it is very important for healthcare providers to screen for IPV using culturally sensitive tools when taking care of immigrant children [32].

Acknowledging the impact of family relationships on children’s physical and mental health, several publications examined interventions to support family well-being. The Family Strengthening Intervention for Refugees (FSI-R) demonstrated improved family power dynamics and child mental health [33, 34], and a culturally based intervention with the Filipino community demonstrated promising engagement by families [35]. Additional proposed sources of support are faith communities and nonparental adult mentors [36].

For many children, especially adolescents, peer relationships are also incredibly impactful. Immigrant adolescents who reported greater peer and family social support reported greater resilience during adversity, and ethnic identity searching (learning about and engaging in activities related to one’s culture) enhanced the relationship between peer social support and resilience [37]. Adolescents are more likely to form friendships with peers who share their immigrant generation status, and first-generation youth with more same-generation friends are less likely to report several risk-taking behaviors [38]. Peer relationships, however, can also negatively impact physical and mental health after arrival to the US. Through the process of acculturation, efforts to gain more peer acceptance can lead to conflict in family relations [39]. A study among first-generation Hispanic children had lower rates of obesity compared to later generations; having a social network with more second-generation friends was associated with a higher BMI among first-generation Hispanic children [40]. While rates of alcohol use were lower among first-generation Latinx youth at baseline compared to their peers, rates of alcohol use were among the highest when reassessed two years post-resettlement [41]. Additionally, perceived discrimination by peers is a source of distress and isolation [39]. Thus, overall, peer relations can both promote and detract from physical and mental health outcomes.

Built Environment

In our search, 21 publications addressed the impact of the built environment on FGIC’s health. The main themes that emerged were the poor conditions of immigration detention; the impact of poverty on immigrant children; and risks of toxin exposure.

One of the first environments that some FGIC are exposed to is the border of entry into the United States, and for some, the physical environment of detention. A significant portion of literature touches upon time in detention, which is correlated to poorer health outcomes for children, higher rates of developmental delays, hyperactivity and conduct disorder, as well as higher rates of PTSD and stress [42,43,44]. Reports of medication confiscation were also common, placing children at risk for medical crises both in detention and in the community without needed medications [45]. Congregate and unsanitary living situations increase the risk of infectious diseases, and requirements for safe and sanitary conditions in Customs and Border Protection custody do not include provision of soap [46•]. Numerous publications discussed that the physical environment of detention is not safe for children and should be avoided at all costs [47]; these sentiments are further supported by the American Academy of Pediatrics’ policy statement, reaffirmed in 2022 [48].

Upon arrival into a community in the US, neighborhood poverty was found to be a risk factor for parent-reported poor physical health of children [49]. Food insecurity is higher among some immigrant communities compared to US-born communities [50], and food insecurity is associated with poorer socioemotional health for children [49]. Food insecurity screening rates were as high as 75% amongst some immigrant families in the US, and one publication found food insecurity as high as 100% in asylum seeking families [50, 51]. FGIC are reported to also have lower access to telehealth services than non-immigrant children due to barriers to accessing stable internet [52], which has implications for schoolwork, parental work options and healthcare access.

FGIC face numerous challenges due to pollution and toxin exposures as well, making physical activity unsafe or less healthy [53, 54]. FGIC are at increased risk of elevated lead levels both from pre-migration exposures, particularly in those who spent time in refugee camps [55], as well as in post arrival environments. One study found that 30% of refugee children had elevated lead levels at repeat screening after arrival in the US, suggesting ongoing exposures post arrival such as paint, pipes, pots, make-up, and toys [56•]. Current recommendations highlight the importance of repeat screening three to six months after arrival given such risks [57]. Parents and children are often under pressure to take jobs with poorer working conditions and fewer protections, such as agricultural work, which increases risk for pesticide exposure, heat stroke and asthma exacerbation risks [58,59,60,61]. Even if not the agricultural worker themselves, having a parent involved in farm work increases exposure risks [61, 62]. Children in migrant seasonal worker families are also more likely to live in environments with more asthma triggers [62].

Community Environment

In addition to the immediate relationships in immigrant children’s lives, the community environment within which they live influences health. A total of 17 publications in our search addressed community impact on the health of FGIC. The main themes of these publications included the health impacts of the school environment, neighborhood culture, discrimination, and healthcare utilization.

In the school environment, belonging amongst peers was a common theme across the included publications. In a cohort of US high school students, 43% of whom were FGIC, a higher level of perceived school belonging for students was associated with higher resilience and lower suicidal ideation, while an increased number of stressful life events and specific regions of birth were associated with increased risk for suicidal ideation [63]. In qualitative interviews with Syrian refugee adolescents and parents, they reported several challenges in the new school environment that impact their sense of belonging, including language barriers, different social norms, and trouble communicating with the school system [29]. Additionally, FGIC are more likely to experience isolation and victimization in the classroom than their nonimmigrant peers [30], and perceived discrimination can impact mental health [64]. In a study of Somali and Hispanic immigrant youth, perceived discrimination was associated with symptoms of depression and anxiety [65]. Further, youth who used problem-focused coping strategies, rather than emotion-focused coping strategies, had less symptoms, providing a possible avenue for intervention to enhance coping strategies [65].

Neighborhood community characteristics influence immigrant child health as well. Some parents of Syrian refugees perceived their neighborhood to be unsafe, which made them afraid to leave the house and was a barrier to seeking healthcare services [66]. In a survey of children with foreign-born parents, neighborhood trust (feeling like people can be trusted and help each other) was associated with parental reports of increased overall physical and socioemotional health for children [49]. Parents of Syrian refugees reported that having their cultural community living around them is helpful in maintaining values and identity [29], and members of the cultural community can assist with answering questions, transportation, translation, and emotional support [66].

Health system access is also a part of the community environment. Health insurance coverage is a key factor influencing health system access (discussed in the policy/political environment section), and there are many additional barriers for families to access medical care. These include linguistic barriers (English-language automated reminders, lack of interpreters, difficulty understanding available interpreters, lack of adequate translation and cultural considerations in health education), limited health literacy, disjointed or non-existent care coordination, and difficulties with transportation [66, 67]. When families interact with the health care system, there are also individual, family, and cultural level factors that interplay with the community environment such as cultural perceptions of health care, family members’ mental health and prior experiences with the system which may have been traumatic, and the need to have time away from work [29]. Such barriers make it more difficult for immigrant children to access preventive health services, and immigrant children have lower immunization rates, lower likelihood of being prescribed preventative asthma medications, and higher rates of infectious diseases compared to native US born children [51]. Language barriers and lack of culture-centered support have also been shown to contribute to sexual and reproductive health inequities among immigrant youth [67]. However, the presence of a primary care physician in the neighborhood was associated with improved parent-reported child health status [49], and the ability to access acute visits for asthma in Federally Qualified Health Centers (which often have culturally and linguistically concordant services) was associated with lower emergency department visits and hospitalization rates among children of migrant seasonal farm workers [62]. Access to a medical home and school-based health can help mitigate some of the barriers to care that FGIC and their families experience [66,67,68].

There are parallel and additional barriers to accessing mental and behavioral health services for children in immigrant families. FGIC are less likely to access mental health services, and speaking a language other than English at home was associated with decreased access [69]. Parents of Latino children (not limited to immigrant children) reported language barriers, poverty, lack of empowerment, and confusion about the diagnostic process as contributors to delays in autism spectrum diagnosis among Latino children [70]. In a study of Latinx youth admitted for suicidal behavior to psychiatric hospitals, 20% had not accessed any formal mental health services prior to hospitalization (including outpatient mental health care, primary care support, school staff support) [71]. Being a FGIC and higher caregiver enculturation (maintaining the beliefs and values of one’s culture of origin) were associated with lower likelihood of use of formal mental health services, and speaking Spanish was associated with lower social support [71].

In contrast to the many challenges in accessing mental health services, there is a growing focus on solutions. For example, the Trauma Systems Therapy for Refugees (TST-R) is a multi-tiered prevention and intervention model developed with community-based participatory research that provides mental health services in a community-based, trauma-focused, culturally responsive way by collaborating with the school, family, and cultural brokers [72•, 73]. TST-R addresses stressors in a social ecological framework and has been successfully implemented across cultural groups including with youth in the Somali and Bhutanese communities in the US [72•]. This model demonstrates promise in reducing inequities to accessing mental health services among immigrant populations [72•]. A study among Asian-American immigrant youth showed that even when school-based mental health services are available, it is important to provide education about mental health services, engage families, and explain confidentiality to decrease inequities in utilization [74].

Policy and Political Environment

Immigration policy shapes not only legal outcomes for FGIC and their families but also health outcomes through access to programs and services. The policy/political environment that a child interacts with may extend from their first experience entering the US to the rhetoric and policies in place at the community, state, and federal levels. Our search resulted in 15 publications addressing the impact of the policy/political environment on an FGIC’s health, with an emphasis on the influence of negative political rhetoric on healthcare seeking behaviors, and impact of insurance coverage on health outcomes.

The policy/political environment an FGIC is welcomed into has a significant impact on family and child acclimation and sense of belonging. Negative immigration rhetoric and anti-immigrant legislation (defined as legislation that “serves to restrict immigrant access to basic services, public benefits, or employment, or increase the threat of legal consequence or deportation” [75•]) impacts family stress levels and limits access to medical and social services through the “chilling effect”: regardless of true eligibility for services, such rhetoric and policies instill fear, confusion about eligibility, and fear of becoming a public charge [76], decreasing willingness to access services families are eligible for [77,78,79,80,81,82]. Insurance rates are lower in communities with more restrictive access to health care benefits, and medical insurance is a positive predictor of health outcomes [79]. The impact of immigrant unfriendly policy/political environments on mental health, in particular, has been an area of active research [80]. The presence of harsher state-level and national immigration policies and stricter enforcement is associated with negative mental health impacts on children [24, 25], as well as decreased health-seeking behaviors and decreased access to social services [75•, 80].

On the contrary, policy/political environments that were viewed as friendly or inclusive to immigrants were associated with positive health outcomes, largely due to increased insurance rates, resulting in improved preventative care and decreased morbidity, as well as improved self-assessment of mental health [79, 83, 84•]. One publication by Koball showed a positive correlation between the ability of an undocumented immigrant to receive a driver’s license and positive health outcomes [84•]. The Deferred Action for Childhood Arrivals (DACA) program eligibility among adolescents had a positive impact on their mental health and health seeking behaviors [85, 86]; however, uncertainty about the future of DACA due to changes in federal administration led to worsening in parent-reported child health to pre-DACA levels among DACA-eligible immigrants and their children [87]. More publications focus on negative policies and a gap that remains is further studying the impacts of friendly, sanctuary policies on health [80].

Discussion

This narrative review summarizes recent evidence about the impact of the relational, built, community, and policy/political environments on the health of FGIC and their families after arrival to the United States. Based on our literature review and our collective clinical experience, table 2 summarizes our recommendations for how providers can screen for environmental factors that may influence FGIC health and best support the well-being of FGIC and their families. It is critical to remember that establishing a trusting therapeutic relationship over time and multiple visits is the cornerstone of effectively partnering with families of FGIC to help families adjust to their new environments. It is also imperative to continually incorporate cultural humility, cultural safety, and cultural sensitivity into clinical care to reduce healthcare disparities [88,89,90].

Table 2 Addressing environmental impacts with first-generation immigrant children and their families during routine clinical care
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While our search yielded publications with a variety of methods and health outcomes which are clinically useful in the care of immigrant children and families, we also identified several gaps in recent literature based on our clinical experience. Identified gaps include exploring the relationship between physical and mental health outcomes and the role of: care coordination between schools and health systems; early childhood and infant learning; communities of faith; social media; job environments, adultification, and employment off record; and sanctuary policy impact on health. From our collective experiences, housing instability also plays a significant role in health outcomes for families, and we did not identify any publications focused on this area. While a few publications discussed community and family-based interventions, these were limited and there is an opportunity for more health promotion and resiliency fostering interventions. On the contrary, the experience of detention felt more frequently studied, with less publications studying other pathways of migration and health outcomes. While several research gaps were identified, it is important to acknowledge that the environments surrounding FGIC are dynamic, and evidence gaps are inevitable. In these cases, healthcare providers can lean on their collective clinical expertise, including consultations with colleagues and adapting evidence from other patient populations and professional fields as appropriate.

Conclusions

The health of FGIC is influenced by a myriad of ever-changing environmental factors within the United States. Providers caring for FGIC must continually reassess not only the influences of pre-migration environments and the migration journey, but also the environments that become home for FGIC and their families in the US. More research is needed to elucidate the impact of different post-migration environmental factors on FGIC’s health, considering the heterogeneity of this large group of children, including different migration journeys, legal status designations, and resources post-resettlement. Additional research, ideally rooted in community participation, will help hone and refine best practices for immigrant child health care.