Executive Summary

The children of today offer a preview of the nation's future citizens, workers, and parents. One of every five children under age 18 living in the United States—that is, 14 million—is an immigrant or has immigrant parents. Available evidence suggests that, on many measures of health and well-being, they perform as well as or better than U.S.-born children with U.S.-born parents. Over time and across generations, however, as immigrant children become part of American society, many of these advantages do not appear to be sustained.

The vast majority of children in immigrant families are admitted legally or are citizens by dint of birth in the United States to parents who are immigrants. Family reunification is a cornerstone of U.S. immigration policy, and many immigrants enter as family members of U.S. residents or as spouses or children of persons who enter legally under various immigration statuses. Three-fourths of all children in immigrant families have been U.S. citizens all their lives because they were born in this country, and one-fourth immigrated to the United States from elsewhere. Since 1990, the number of children and youth in immigrant families has expanded almost seven times faster than the number in U.S.-born families.

The majority of these children are of Hispanic or Asian origin and, as such, are contributing to the growing racial and ethnic



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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Executive Summary The children of today offer a preview of the nation's future citizens, workers, and parents. One of every five children under age 18 living in the United States—that is, 14 million—is an immigrant or has immigrant parents. Available evidence suggests that, on many measures of health and well-being, they perform as well as or better than U.S.-born children with U.S.-born parents. Over time and across generations, however, as immigrant children become part of American society, many of these advantages do not appear to be sustained. The vast majority of children in immigrant families are admitted legally or are citizens by dint of birth in the United States to parents who are immigrants. Family reunification is a cornerstone of U.S. immigration policy, and many immigrants enter as family members of U.S. residents or as spouses or children of persons who enter legally under various immigration statuses. Three-fourths of all children in immigrant families have been U.S. citizens all their lives because they were born in this country, and one-fourth immigrated to the United States from elsewhere. Since 1990, the number of children and youth in immigrant families has expanded almost seven times faster than the number in U.S.-born families. The majority of these children are of Hispanic or Asian origin and, as such, are contributing to the growing racial and ethnic

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families diversity of the U.S. child and youth population. As the predominantly white baby-boom generation reaches retirement age, it will depend increasingly for its economic support on the productivity, health, and civic participation of adults who grew up in minority immigrant families. Indeed, the long-term consequences of contemporary immigration for the American economy and society will hinge more on the future prospects of children in immigrant families than on the fate of their parents. Because of the burgeoning importance of children and youth in immigrant families to the vitality of the nation, the Committee on the Health and Adjustment of Immigrant Children and Families was appointed to conduct a study to: synthesize and supplement the relevant research literature and provide a demographic description of children in immigrant families, clarify what is known about the development of children in immigrant families regarding the risk and protective factors associated with differential health and well-being of different immigrant groups and 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. The committee was keenly aware throughout its deliberations that children who live in poverty—many of them racial and ethnic minorities—often experience restricted access to many of the resources, programs, and benefits that it considered specifically with respect to immigrant children and children with immigrant parents. African-American children, in particular, whose historical legacy arises from one of this nation's earliest immigration policies and from the abiding significance of race in American culture, face life chances that are often characterized by the same risks and foreclosed opportunities that are thought to apply to many immigrant children. In its calls for new research, the committee is explicit about the importance of making comparisons between today's children in immigrant families and U.S.-born black children whose immigrant ancestry is many generations re-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families moved (as well as to other children in "at risk" groups) in order to better understand the successes and failures of our nation's child and family policies and to understand fully the forces that shape successful adaptation and incorporation. POTENTIAL INFLUENCES ON HEALTH AND ADJUSTMENT All children share the same basic needs. Children in immigrant families are no different from others in the United States in their need for food, clothing, shelter, physical safety, psychological nurturing, health care, and education. They also share a dependence on adults in their families, communities, and governments to ensure their healthy development. And many of the factors that affect children's future opportunities for employment, stable families, and constructive roles as citizens undoubtedly affect all children similarly. Beyond shared needs, however, the conditions associated with immigrant status have important and distinct consequences. The extent to which children in immigrant families experience healthy development and successful adjustment depends on: (1) the assets and resources they bring from their country of origin, (2) how they are officially categorized and treated by federal, state, and local governments, (3) the social and economic circumstances and cultural environment in which they reside in the United States, and (4) the treatment they receive from other individuals and from health and social institutions in the receiving community. Most immigrant children and youth have origins in Latin America or Asia, regions with dozens of languages and enormous diversity in cultural beliefs and practices. Those who speak English or acquire English quickly—and who have parents who speak English—are likely to have an advantage as they adjust to school, attempt to fit into peer groups, and, in general, navigate within American culture. Immigrants who live in a U.S. community with a large network of family members and other people from their home country may receive substantial personal, social, and economic support, including information about medical and health services, schools, jobs, and other resources, that ease the adaptation process. Immigrants who are more isolated may face

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families greater difficulties, although, depending on where they settle, they may avoid some of the deleterious aspects of living in the large U.S. cities where many immigrant families reside. Immigrants also differ greatly in their reasons for migrating and in the socioeconomic resources they bring to the United States. Some arrive with limited education, seeking work as manual laborers in unskilled jobs; others may be characterized by high educational accomplishments and come in search of skilled, technical, or professional positions. Immigrants motivated by family ties may wish to join family members already in the United States or to accompany family members who are emigrating. Refugees arrive in the United States having fled war-torn or politically repressive or unstable countries and sometimes to avoid persecution or death. Prior to passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA, hereafter referred to as welfare reform), eligibility rules for most health and welfare programs were nearly identical for legal immigrants, refugees, and native-born citizens. Under welfare reform, the extremely restrictive eligibility rules for many programs that applied historically only to illegal immigrants are now also applied to legal immigrants who arrived after August 22, 1996 (when the law was enacted), unless they become citizens, and to refugees beginning five to seven years after their arrival in the United States. In addition, the locus of many decisions affecting the eligibility of immigrant children and families for many benefits has shifted from the federal government to the states—a situation that is likely to lead to more variability in their access to benefits. The law's impact on immigrant children will derive in large part from the programmatic reach of the new restrictions on immigrants' eligibility for public benefits, which go beyond welfare as conventionally known to encompass Medicaid, Supplemental Security Income (SSI), the Food Stamps Program, and noncash services. And yet these policy changes were made with virtually no explicit debate about their potential effects on children and without consideration of the need for new scientific evidence on these effects. Low income is a well-documented negative risk factor for the healthy development of children generally. The income level of

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families children in immigrant families is determined largely by the employment opportunities of their parents, although publicly funded health and social programs have historically provided a safety net for very low-income families. Since 1980, employment and real wages have declined for men with less than a college education, which includes many immigrants, and the earnings gap separating Hispanics and blacks from whites has expanded among both men and women. Children and parents in immigrant families belonging to these racial and ethnic minorities may assimilate to native minority groups and thus find their opportunities restricted in ways similar to these nonimmigrant minorities. Children in immigrant families who belong to racial and ethnic minorities may face more or less discrimination depending on where they live, which can also affect their access not only to economic opportunities, but also to medical, health, educational, and housing resources. Access to valuable or necessary services can be facilitated for those who do not speak English well if those services are provided in the native language of immigrants or in a culturally competent fashion. HEALTH, ADJUSTMENT, AND PROTECTIVE FACTORS The physical and mental health of children and youth in immigrant families and the extent to which they adjust successfully to U.S. society is a very broad topic for which available evidence is sparse. Along a number of important dimensions, children in immigrant families appear to experience better health and adjustment than do children in U.S.-born families. There are important exceptions, however. Parental reports suggest that, compared with children in U.S.-born families, children in immigrant families have fewer specific acute and chronic health problems and have lower prevalences of accidents and injuries. Rates of low birthweight and infant mortality also are lower among children born to immigrant women than to U.S.-born women. In fact, the substantial positive differential in neonatal outcomes for foreign-born women has been called an epidemiological paradox because it would be expected, based on their lower socioeconomic status and sometimes lower

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families utilization of prenatal care, that they would have worse birth outcomes than U.S.-born women. There may also be increased risk for some adverse health conditions: children in immigrant families from specific countries of origin may experience elevated risks from malaria, helminthic infections, congenital syphilis, hepatitis B, and drug-resistant tuberculosis. Children of migrant farmworkers may be exposed to damaging environmental toxins. And Mexican-origin children in immigrant families are considerably more likely to be reported by their parents as having poor health and dental problems, and they have been found to exhibit elevated blood lead levels. Among adolescents overall and for most specific countries of origin studied, immigrants are less likely than U.S.-born adolescents with immigrant and U.S.-born parents to consider themselves in poor health or to have school absences due to health or emotional problems. First-generation immigrant adolescents are also less likely to report that they engage in risky behaviors, such as first sexual intercourse at an early age, delinquent or violent behaviors, and use of cigarettes and substance abuse. Yet immigrant adolescents living in the United States for longer periods of time tend to be less healthy and to report increases in risk behaviors. By the third and later generations, rates of most of these behaviors approach or exceed those of U.S.-born white adolescents. Adolescents in immigrant families also appear to experience overall levels of psychological well-being and self-esteem that are similar to, if not better than, adolescents in U.S.-born families. At the same time, however, immigrant adolescents report feeling less control over the outcomes in their own lives and less popular with their classmates. For young children generally, success in school is fostered by family members who teach their children letters and numbers, read to them, and work on projects with them; take them on a variety of educational outings; and become involved at their children's schools. Three- to 8-year-old children in immigrant families are as likely, or only slightly less likely, as children in U.S.-born families to have parents that contribute to their educational adjustment and success in these ways. However, children in immigrant families, compared with their U.S.-born peers, are

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families much less likely to experience the benefits of attending a prekindergarten program. Several studies have reported that educational aspirations, grade point averages, and math test scores for adolescents in immigrant families are comparable to or higher than those for adolescents in U.S.-born families. However, Mexican-origin adolescents of all generations have grade point averages and math test scores that are substantially lower than those of white adolescents in U.S.-born families. The positive achievements of immigrant Chinese students appear to deteriorate, such that by the third generation they reach levels about the same as white adolescents in U.S.-born families. Thus, along several important dimensions, immigrant children and youth appear to be protected from negative risks, but this advantage tends to decline with length of time in the United States and from one generation to the next. The social, economic, or cultural factors that may be responsible for providing this protection are largely unexplored and unknown. Care must be taken not to overgeneralize these findings, in light of the diversity that characterizes children from different countries of origin with different histories of migration, family circumstances, and experiences at school and in their neighborhoods. SOCIOECONOMIC RISK FACTORS One of the best-documented relationships in epidemiology and child development is that children who have family incomes below the poverty threshold, parents with low educational attainments, one parent or many siblings in the home, or overcrowded housing conditions are at risk of negative health, developmental, and educational outcomes. Children in immigrant families in 1990 experienced, on average, a somewhat higher poverty rate—largely attributable to the high poverty rate for first-generation immigrant children—but were less likely than children and youth in U.S.-born families to have only one parent at home and, for most countries of origin, had fathers with high rates of labor force participation. They were also, however, more likely to have many siblings, much more likely to have parents with very low educational attainments, and to live in overcrowded housing. Along

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families each dimension, second-generation children (those born in the United States with at least one immigrant parent) experienced substantially less risk than did first-generation children (the foreign-born). Socioeconomic risk levels differed enormously among children in immigrant families with different countries of origin. Of particular concern are children with origins in 12 specific countries that account for close to half of all children in immigrant families; their average poverty rates exceed 25 percent; their parents tend to have very little formal education; and they are at high risk of living in overcrowded housing. Interestingly, poverty within this subgroup of countries was not consistently related to low rates of labor force participation by fathers or to living in a single-parent family or a family with many siblings. Many officially recognized refugees come from five of these countries (the former Soviet Union, Cambodia, Laos, Thailand, and Vietnam) and immigrants from four of these countries have fled countries experiencing war or political instability (El Salvador, Guatemala, Nicaragua, and Haiti). Two are small countries sending many migrants seeking unskilled work (Honduras and the Dominican Republic). The 12th country is Mexico, which currently sends the largest number of both legal and illegal immigrants and which has been a major source of unskilled labor for the U.S. economy throughout the twentieth century. RISK FACTORS SPECIFIC TO IMMIGRANTS Lack of English fluency and other cultural differences may not pose enormous difficulties for immigrants in communities with a large number of individuals from the same country of origin, but they can limit their effective functioning in the broader society in health facilities, schools, and other settings that provide essential resources to children in immigrant families. Children from the 12 countries noted above with especially high socioeconomic risks are highly likely to live in linguistically isolated households in which no one age 14 and over speaks English very well. Overall, the proportion of children with non-English-speaking parents today is similar to the level at the turn of the century. Nevertheless, there is considerable documentation of the very

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families rapid rate at which immigrant children and youth acquire English proficiency. Access to needed services may be further complicated by cultural beliefs that differ from Western concepts, most notably with regard to perceptions of illness, health care-seeking behavior, and response to treatment. In recognition of these facts, the medical community through its major professional arms has repeatedly called for the provision of services that are provided in a culturally competent and sensitive manner and that take language barriers into account. Implementation of these ideals, however, remains limited and data regarding the health consequences of culturally sensitive practices remain largely anecdotal or based on small, nonrepresentative samples. PUBLIC ASSISTANCE AND HEALTH SERVICES: PARTICIPATION AND USE Benefits and services provided by health and social programs, whether from public or private sources, represent important investments in and critical resources for all children and youth, including but not restricted to those in immigrant families. Prior to welfare reform, children in immigrant families were about as likely as, or only slightly more likely than, children in U.S.-born families to live in families receiving public assistance, particularly noncash assistance. Most of the differences that existed reflected higher participation for first-generation children. The comparatively high rates of reliance on public assistance among first-generation families are largely attributable to their disadvantaged socioeconomic and demographic characteristics, not to their immigrant status per se. When comparisons are made between children in immigrant and U.S.-born families at the same socioeconomic levels, either the differences disappear, or children in immigrant families, including those of Mexican origin, are found to rely less on many public assistance programs than children in U.S.-born families. In addition, the special refugee status of many immigrants from Southeast Asia and the former Soviet Union appears to involve comparatively high participation rates for the first generation. Access to health services, particularly for children, is essen-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families tial to ensure that preventive services are provided as recommended, acute and chronic conditions are diagnosed and treated in a timely manner, and health and development are adequately monitored so that minor health problems do not escalate into serious and costly medical emergencies. Access, in turn, is facilitated by health insurance coverage and having a usual source of care. Immigrant children and youth are three times as likely and second-generation children and youth are twice as likely, compared with the third and later generation, to lack health insurance coverage, mainly because of its high cost and lack of employer coverage. Even among children whose parents work full-time, year-round, those in immigrant families are less likely to be insured than those in U.S.-born families. Hispanic children are the most likely of all immigrant groups studied to lack health insurance. Medicaid has played an important role in reducing the risk of uninsurance among children and youth in immigrant families, with about one in four receiving their coverage through this source. Moreover, in large part due to the automatic eligibility of refugees for Medicaid, Southeast Asian children exhibit very low rates of uninsurance despite their very low socioeconomic status. Immigrant children—regardless of whether they are Hispanic, Asian, or white—are considerably less likely than U.S.-born children with either immigrant or U.S.-born parents to have had at least one doctor's visit during the previous 12 months. They are also less likely to have a usual health care provider or source of health care. Children in immigrant families who are uninsured are less likely to have a connection to the health care system than those with Medicaid or private or other coverage. Those who are uninsured and who have no usual source of care have the lowest probability of having seen a doctor. These associations replicate those found in the pediatric health services literature for children in general, suggesting that the health of children in immigrant and U.S-born families depends on the same factors and benefits from the same supports. It is thus of particular concern that, unlike any other group of children in the United States, those in immigrant families have been barred from eligibility for Medicaid, Supplemental Security

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Income, and, in all likelihood, the new State Child Health Insurance Program (SCHIP) that is designed to extend coverage to children not presently eligible for existing health benefits. THE LIMITS TO CURRENT KNOWLEDGE Valid conclusions about differences across generations for children from diverse countries of origin require that they be identified according to their own and their parents' countries of birth and their immigrant and citizenship status. Such inferences also require sample sizes by generation, immigrant status, and country of origin that are large enough to support statistically reliable estimates. Meaningful conclusions about the circumstances and causal processes affecting children in immigrant families require, in addition, the identification and measurement of those aspects of the immigrant experience, context, and culture that are unique to immigrants, as well as those factors that are relevant to the healthy development of all children living in the United States. Few national information systems currently collect the full array of data needed on country of origin and immigrant status, few have samples large enough to support conclusions for more than three or four specific countries of origin, and none has progressed significantly in collecting information on aspects of healthy development and adjustment that may be unique to children in immigrant families. Thus, most conclusions regarding children in immigrant families in the United States must be viewed as first steps toward acquiring more definitive knowledge. In this context, our recommendations for new research and data collection are intended to lead to increased knowledge in a wide range of areas, including the extent to which and the reasons that (1) high poverty and other socioeconomic and demographic risk factors among children in immigrant families do or do not lead to negative outcomes, compared with children in U.S.-born families, (2) beneficial circumstances and outcomes for children in immigrant families appear to deteriorate over the life course and across generations, and (3) recent and continuing changes in welfare and health care policy have positive or negative consequences for children in immigrant families.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families RECOMMENDATIONS FOR RESEARCH Recommendation 1. The federal government should fund a longitudinal survey of children and youth in immigrant families, measuring physical and psychosocial development and the range of contextual factors influencing the development of these children. The healthy development, assimilation, and adjustment of children in immigrant families involves developmental issues and processes that are in some ways different from the experience of children in U.S.-born families. Yet many commonalities exist, and the assimilation and adaptation experience occurs within the same broad social, economic, and cultural context for children in both immigrant and U.S.-born families. Trajectories of healthy development, assimilation, and adjustment occur across periods of years or decades for individuals, and the nature of individual outcomes depends on the timing and sequencing of specific personal, family, neighborhood, and historical events in the child's life. These are best measured and analyzed through longitudinal data collection and research that follows the same individuals over extended periods. No existing research effort provides an adequate basis for a national assessment of these issues. Moreover, several of the most intriguing findings in the current literature on immigrant children—notably those pertaining to unexpected positive outcomes and deteriorating outcomes over time—require longitudinal data and substantial contextual information if their causes and pathways are to be clarified. In addition, it is critical that the sampling strategy of the survey allows for explicit comparisons not only among the various immigrant groups, but also to U.S.-born black, Hispanic, and white children with U.S.-born parents so that lessons can be learned about policies and practices that either have worked or failed for different groups of children in the United States. Only with appropriate comparison groups will knowledge about the development of children in immigrant families be placed in the context of the range of experiences and outcomes experienced by

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families native groups and, particularly by minority children whose immigrant origins are generations removed. Recommendation 2. A series of ethnographic studies on the physical and mental health of children and youth in diverse immigrant families should, insofar as possible, be embedded in the proposed longitudinal survey of children in immigrant families or in other national surveys. The proposed longitudinal survey of children in immigrant families can provide statistically reliable estimates of major outcomes and processes for children in immigrant families as a whole, and for important social and cultural subgroups. But survey methodology is limited in its ability to study the meaning and interpretation that individuals give to their situations. Ethnographic studies have small samples that may not statistically represent the larger population, but they can provide rich interpretations of the processes that can only be highlighted, not probed in depth, with survey methodology. The origins and effects of health-promoting behaviors; individual, family, and community coping strategies; and the role of biculturalism in child development are examples of issues that lend themselves to this methodology. Recommendation 3. Both quantitative and qualitative research should be conducted on the effects of welfare and health care reform for children and youth in immigrant families, and on how access to and effectiveness of health care and other services are affected by the provision of culturally competent care. The consequences of recent and continuing changes in welfare and health policies may be more immediate and profound for children in immigrant families than for others because eligibility has been cut most drastically, or made a state option, for noncitizen legal immigrants. Yet none of the major evaluations of welfare and health reform is focused particularly on consequences for children in immigrant families, nor have these children been identified as a major subgroup for study. At a minimum, efforts to assess the consequences of health and welfare reforms need to

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families include substantial subsamples of children in immigrant families. They should also pay attention to factors uniquely relevant to outcomes for these children, such as their circumstances of migration, the duration of child and parental residence in the United States, and the immigrant status of siblings and parents. The need for care to be provided in a culturally competent manner, including immigrant involvement in programs for their own care, has being widely recognized by numerous federal and international health agencies and professional associations of physicians, nurses, and social workers. Efforts supported by federal and state governments, professional organizations, and health care institutions should be systematically assessed to provide the basis for implementing and evaluating community intervention programs that are also culturally sensitive. RECOMMENDATIONS FOR DATA COLLECTION AND INFORMATION DISSEMINATION Recommendation 4. The federal government should collect and code information on country of birth, citizenship status, and parents' country of birth in key national data collection systems. This information should be made available through public use microdata samples and other vehicles for public distribution of data. Federal agencies currently conduct or fund major data collection and research efforts that constitute the core of the national information system for monitoring and understanding changes in the physical and mental health of the U.S. population, as well as the circumstances and risk factors related to the family, education, employment, income, participation in public benefit programs, housing, and crime. Despite the growing importance of children in immigrant families to the well-being of the nation, few of these information-gathering efforts provide a sound basis for monitoring changes in the conditions and needs of children in immigrant families, as distinct from children in U.S.-born families, because immigration and citizenship status and country of origin are not collected or are not made available for research purposes.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Recommendation 5. As the federal government develops new surveys or draws new samples to supplement or extend existing surveys, it should select and include subsamples that are large enough to reliably monitor the circumstances of children and youth in immigrant families as a whole and, where feasible, for specific countries of origin. New samples are drawn periodically for continuing surveys and will be drawn for new national surveys in the future. Despite growth of the immigrant population, samples in most national surveys are too small to sustain statistically reliable estimates for the foreign-born population as a whole. This difficulty can be resolved by drawing samples in which the foreign-born and their families represent a larger proportion than they are in the general population. Recommendation 6. Key indicators of child well-being published in the annual report of the Federal Interagency Forum on Child and Family Statistics should, insofar as possible, distinguish among foreign-born immigrant children (first generation), U.S.-born children in immigrant families (second generation), and U.S.-born children in U.S.-born families (third and later generations). Children in immigrant families are the fastest-growing component of the child population, and often their language and culture make them a distinguishable minority group. Although a recent presidential executive order mandates the Federal Interagency Forum on Child and Family Statistics to publish an annual report on children (U.S. Department of Health and Human Services, 1996, 1997), as yet there is virtually no public dissemination of information on even the most basic indicators of the conditions and well-being of children in immigrant families. We recommend that key indicators of child well-being published in this report should distinguish insofar as possible between immigrant children, U.S.-born children in immigrant families, and U.S.-born children in U.S.-born families.

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