Key Points

Question What is the association between immigration-policy concerns and the health outcomes in US-born Latino adolescents from immigrant families?

Findings In this cohort study of 397 US-born adolescents in California, fear and worry about the personal consequences of current US immigration policy were associated with higher anxiety levels, sleep problems, and blood pressure changes. Reported anxiety statistically significantly increased after the 2016 presidential election, particularly among young people in the most vulnerable families.

Meaning The current immigration policy and rhetoric appear to be associated with adverse mental health outcomes among US citizen children of immigrants.

Abstract

Importance Current US immigration policy targets immigrants from Mexico and other Latin American countries; anti-immigration rhetoric has possible implications for the US-born children of immigrant parents.

Objective To assess whether concerns about immigration policy are associated with worse mental and physical health among US citizen children of Latino immigrants.

Design, Setting, and Participants This study of cohort data from the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS), a long-term study of Mexican farmworker families in the Salinas Valley region of California, included a sample of US-born adolescents (n = 397) with at least 1 immigrant parent. These adolescents underwent a health assessment before the 2016 presidential election (at age 14 years) and in the first year after the election (at age 16 years). Data were analyzed from March 23, 2018, to February 14, 2019.

Exposures Adolescents aged 16 years self-reported their concern about immigration policy using 2 subscales (Threat to Family and Children’s Vulnerability) of the Perceived Immigration Policy Effects Scale (PIPES) instrument.

Main Outcomes and Measures Resting systolic blood pressure, diastolic blood pressure, and mean arterial pressure; body mass index; maternal- and self-reported depression and anxiety problems (using Behavioral Assessment System for Children, 2nd edition); self-reported sleep quality (using Pittsburgh Sleep Quality Index [PSQI]); and maternal rating of child’s overall health. All measures except sleep quality were assessed at both the aged-14-years and aged-16-years visits. Health outcomes at age 16 years and the change in outcomes between ages 14 and 16 years were examined among youth participants who reported low or moderate PIPES scores vs high PIPES scores.

Results In the sample of 397 US-born Latino adolescents (207 [52.1%] female) and primarily Mexican American individuals, nearly half of the youth participants worried at least sometimes about the personal consequences of the US immigration policy (n = 178 [44.8%]), family separation because of deportation (177 [44.6%]), and being reported to the immigration office (164 [41.3%]). Those with high compared with low or moderate PIPES scores had higher self-reported mean anxiety T scores (5.43; 95% CI, 2.64-8.23), higher maternally reported anxiety T scores (2.98; 95% CI, 0.53-5.44), and worse PSQI scores (0.98; 95% CI, 0.36-1.59). Youth participants with high PIPES scores reported statistically significantly increased levels of anxiety over the 2 visits (adjusted mean difference-in-differences, 2.91; 95% CI, 0.20-5.61) and not significantly increased levels of depression (adjusted mean difference-in-differences, 2.63; 95% CI, –0.28 to 5.54).

Conclusions and Relevance Fear and worry about the personal consequences of current US immigration policy and rhetoric appear to be associated with higher anxiety levels, sleep problems, and blood pressure changes among US-born Latino adolescents; anxiety significantly increased after the 2016 presidential election.

Introduction

Eighteen million children (or 25% of all children) in the United States live in immigrant families, most of whom originate from countries in Latin America.1 Although most of these young people are US-born citizens, 7.3% of school-aged children have at least 1 undocumented immigrant parent2; this proportion is higher in California (10.2%) and other immigrant destination states.

The United States has not offered large-scale, congressionally supported amnesty to undocumented immigrants since the 1990s.3 The 2012 Deferred Action for Childhood Arrivals (DACA) policy offered transitory protections to undocumented immigrants brought to the country as minors. However, since the 2016 presidential election, US policy toward immigrants has turned notably hostile. The Trump Administration has suggested an end to birthright citizenship,4,5 characterized Mexican immigrants as criminals,6,7 championed the construction of a wall along the US-Mexico border,6,8,9 attempted to rescind DACA protections,10,11 and forcibly separated migrant children from their parents.12,13 These actions and statements have generated considerable anxiety in the immigrant community.14

Many studies have been conducted on the well-being of undocumented immigrants,15-20 but relatively few studies have focused on US citizen children of immigrant parents. Small, qualitative studies have suggested an association between US punitive immigration policy and family and economic instability, adverse growth and mental and physical health, and more limited access to health and social services.21-28 A large cross-sectional study using 2000 to 2002 data found that US citizen children of undocumented mothers experienced more internalizing and externalizing problems compared with children of naturalized, documented, or US-born mothers.29 More recent data indicated that children of DACA-eligible mothers had fewer Medicaid mental health claims compared with children of non–DACA-eligible immigrants.30 Mothers from mixed-status undocumented families have also reported worse child health status compared with mothers from legal resident or citizen families.31

In the present study, we examined the association of US-born adolescent self-reported concern about immigration policy with their mental and physical health. We used data from the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS), a study of primarily Mexican farmworker families in California. We used multiyear data to investigate the change in adolescent health status assessed before the 2016 presidential election (at age 14 years) and in the first year after the election (at age 16 years).

Methods

This study was approved by the University of California, Berkeley Committee for the Protection of Human Subjects. Written informed consent or assent was obtained from all study participants. Data were analyzed from March 23, 2018, to February 14, 2019.

Study Sample

The youth participants in the CHAMACOS study were born from 2000 through 2002 in the California agricultural region of Salinas Valley. Participants were enrolled in 2 waves. From October 1999 to October 2000, the first cohort was recruited: 601 pregnant women who spoke either the Spanish or English language, were 18 years of age or older, were under 20 weeks’ gestation, qualified for low-income health insurance (available to undocumented immigrants for prenatal care), and planned to deliver at a public hospital. These women delivered 536 live-born infants who remained in the study at birth.32 The second cohort was enrolled from January 2010 to September 2011 and consisted of 305 US-born children who were 9 years of age as well as their Spanish- or English-speaking mothers who had received prenatal care in Salinas Valley, qualified for low-income health insurance during pregnancy, and were aged 18 years or older at delivery.33

Of the 412 children who completed study visits at age 16 years between December 28, 2016, and January 8, 2018, we included 397 adolescents with at least 1 immigrant parent. Visits at age 14 years spanned from May 5, 2014, through August 22, 2016. At each visit, the mothers were interviewed in Spanish or English, the adolescents completed a questionnaire in English, and youth anthropometrics were measured.

Perceived Immigration Policy Effects Scale

The main independent variable was adolescent self-reported concerns about immigration policy at age 16 years, which were collected with a portion of the Perceived Immigration Policy Effects Scale (PIPES) instrument.34 PIPES was originally developed and validated in Arizona to assess the implication of state-level immigration policies for immigrant parents. The original Spanish-language PIPES included 24 items representing 4 factors. The version of PIPES we administered was in English and with all of the items from 2 subscales: (1) Threat to Family (worry about the impact of immigration policy, fear that you or a family member would be reported to immigration officials, and worry about family separation due to deportation) and (2) Children’s Vulnerability (stressed about family members being deported or detained, felt unsafe, emotionally upset, feared authorities, and difficulties focusing in school due to immigration policies). Questions were adapted from the parent-report to the adolescent self-report format. Items were rated on a 5-point scale, with 1 indicating never to 5 indicating always. Points were summed to generate the total PIPES score and separate subscale scores.

Outcome Measures

At the aged-14-years and aged-16-years visits, blood pressure (BP) was assessed with an automatic digital sphygmomanometer (Dinamap 9300 or Dinamap Carescape 100; Critikon). Resting systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured in triplicate. If any readings were elevated (>95th percentile for age and sex), a fourth measurement was taken on the other arm. We calculated the mean of the last 2 measurements for analysis. Mean arterial pressure (MAP) was calculated as [(2 × DBP) + SBP] divided by 3. We categorized youth prehypertension or hypertension according to sex, age, and height.35

At both visits, adolescent barefoot height was measured in triplicate using a wall-mounted stadiometer, and mean measures were calculated for analysis. Weight was measured using a bioimpedance scale (TBF-300A; Tanita). Body mass index (BMI) was calculated and categorized as underweight (<5th percentile), normal (5th to <85th percentile), overweight (≥85th to <95th percentile), or obese (≥95th percentile).36

At both visits, mothers and adolescents completed parent-report and youth self-report versions of the Behavioral Assessment System for Children, 2nd edition, or BASC-2.37 The BASC-2 Depression and Anxiety subscales were analyzed as standardized T-score values and as a binary at-risk or clinically significant variable (T score ≥60).

At the aged-16-years visit only, adolescents completed an adapted version of the Pittsburgh Sleep Quality Index (PSQI)38 to report sleep quality in the preceding month. The PSQI scores could range from 0 to 21, with lower scores indicating better sleep. Poor sleep quality was defined as a score of 5 or higher.

At both visits, mothers rated their child’s health as excellent, very good, good, fair, or poor. For this analysis, we analyzed the responses continuously (1 to 5). We also compared excellent or very good to good, fair, or poor responses.

Statistical Analysis

The distribution of PIPES scores was right skewed. We dichotomized total and subscale scores into either low or moderate (ie, a mean response of less than sometimes responses for all questions) or high (ie, a mean response of sometimes responses for all questions).34 We constructed separate multivariable regression models for each end point. Covariates were selected using directed acyclic graphs (eFigure 1 in the Supplement).

We estimated the difference-in-differences over the 2-year study period between youth participants with high PIPES scores and youth participants with low or moderate PIPES scores using generalized estimating equations with an interaction term between binary PIPES and the study period. Specifically, we calculated the change from the aged-14-years visit to the aged-16-years visit separately within the low or moderate PIPES group and within the high PIPES group. Next, we calculated and reported the difference in these 2 within-group changes (ie, the difference in slopes). That is, we examined the additional change in outcomes in the high PIPES group above and beyond that experienced in the low or moderate PIPES group. All generalized estimating equations models used an exchangeable correlation structure and robust SEs.

Final covariates were coded as shown in Table 1 unless indicated. Covariates included youth sex; maternal educational level and number of years in the United States (≤5 years and >5 years) at delivery; and maternal marital status, maternal depression risk, and household poverty status at the aged-16-years visit. For change in outcome analyses between visits, we included time-varying covariates from the aged-14-years visit or before this time, including maternal depression risk at the aged-9-years visit as well as household poverty and marital status from the aged-14-years visit. Poverty status was calculated by dividing the mother-reported household income by the number of people supported compared with the US federal poverty index for that year.39 Mothers were deemed at risk for depression if their score on the Center for Epidemiologic Studies Depression Scale40 was 16 points or higher.

We never asked mothers directly about their immigration documentation status, but we created a proxy variable for likely status on the basis of the length of time the mother had been living in the United States by the time she delivered (we did not have this information for the father). If the mother had resided in the country for 5 years or less at delivery (between 2000 and 2002), she was likely undocumented given that the most recent major amnesty was enacted in 1995 (Immigration and Nationality Act, Section 245[i] Amnesty, 1994). We tested for effect modification by the mother’s likely documentation status and by youth sex.

All analyses were performed with Stata, version 14.2 (StataCorp LLC). Two-sided P = .05 or less was considered statistically significant. We presented 95% CIs. In interaction models, P = .20 or less from a likelihood ratio test was considered statistically significant.

Results

In total, 397 US-born Latino adolescents were included in this study. These youth participants (including more female [207 (52.1%)] than male [190 (47.9%)]) were primarily Mexican American (385 [98.2%] had a mother or father born in Mexico, and 337 [86.0%] had parents both born in Mexico), and the remainder of the sample had an immigrant parent born elsewhere in Central America. Almost half of the mothers had been living in the United States for 5 years or less at delivery and had a sixth grade education or less (Table 1). At the aged-14-years visit, most mothers were married or living as married and were living in poverty.

The items in the PIPES instrument that were the most endorsed by youth participants were under the Threat to Family subscale (eTable 1 in the Supplement). Specifically, they were concerned at least sometimes about the implications of the US immigration policy for the family (178 [44.8%]), family separation because of deportation (177 [44.6%]), and being reported to the immigration officials (164 [41.3%]). Female adolescents had higher PIPES scores compared with male adolescents (29.5% vs 11.1% were within the high PIPES score range). Youth participants whose mothers more recently immigrated to the United States (≤5 years at delivery) had somewhat higher PIPES scores compared with other participants (48 [24.5%] vs 34 [16.9%] were within the high PIPES score range; P = .06) (Table 1).

Although few adolescents had hypertension, 56 (16.0%) were prehypertensive (Table 2). More than half were overweight (69 [17.6%]) or obese (141 [36.1%]), with mean BMIs of approximately 27 (75th percentile). The self-reported mean (SD) anxiety T score was 50.8 (11.1); 83 of 386 adolescents (21.5%) were within either the at-risk or clinically significant range. The self-reported mean (SD) depression T score was 48.1 (10.0); 57 of 386 adolescents (14.8%) were within either the at-risk or clinically significant range.

Sixty-five adolescents (16.3%) reported fairly bad or very bad sleep quality, with 85 (21.3%) taking a long time to fall asleep and 43 (10.8%) experiencing daytime dysfunction because of sleepiness at least once a week (eTable 2 in the Supplement). Poor sleep quality was associated with higher self-reported anxiety (Pearson correlation = 0.36; P < .001) and depression (Pearson correlation = 0.35; P < .001) levels but with lower SBP (Pearson correlation = –0.15; P = .006) and DBP (Pearson correlation = –0.18; P < .001). Self-reported anxiety and depression were not associated with BP (eTable 3 in the Supplement). Overall, 41 mothers (10.6%) rated their child’s health as fair or poor.

Youth participants with high total PIPES scores compared with those with low or moderate PIPES scores had higher self-reported mean anxiety T scores (difference, 5.43; 95% CI, 2.64-8.23), higher maternally reported anxiety T scores (difference, 2.98; 95% CI, 0.53-5.44), and worse PSQI scores (difference, 0.98; 95% CI, 0.36-1.59) (Table 3). Youth participants with high total PIPES scores were statistically significantly more likely to report anxiety symptoms in the clinically significant or at-risk range (incidence rate ratio, 1.62; 95% CI, 1.00-2.63) and poor sleep quality (incidence rate ratio, 1.54; 95% CI, 1.03-2.33) (eTable 4 in the Supplement).

Results were stronger under the Children’s Vulnerability subscale than the Threat to Family subscale for both continuous (Table 3) and categorical outcomes (eTable 4 in the Supplement). Compared with youth participants with low or moderate Children’s Vulnerability scores, those with high scores had lower MAP (–2.24; 95% CI, –4.38 to –0.10) and somewhat lower DBP (–1.85; 95% CI, –3.83 to 0.13). PIPES scores were not associated with BMI, depression, or overall health when examined as continuous or categorical outcomes.

We observed a statistically significant sex interaction: among males but not among females, a higher PIPES score was associated with decreased SBP (–6.00; 95% CI, –11.19 to –0.81; likelihood ratio P = .05), DBP (–3.47; 95% CI, –6.78 to –0.17; likelihood ratio P = .16), and MAP (–4.68; 95% CI, –8.25 to –1.11; likelihood ratio P = .05) (Figure, A). We also observed statistically significant interaction by the length of time the mother had lived in the country; higher PIPES score was associated with increased PSQI score (1.36; 95% CI, 0.55-2.18; likelihood ratio P = .15) and self-reported anxiety T score (7.49; 95% CI, 3.86-11.13; likelihood ratio P = .08) only among youth participants whose mothers had resided in the United States for 5 years or less at delivery (ie, more likely to be undocumented) (Figure, B). No statistically significant effect modification by sex or by the length of time the mother had lived in the country was observed for other measures.

With regard to changing health outcomes between the aged-14-years and the aged-16-years visits (Table 4; eFigure 2 in the Supplement), youth participants with high PIPES scores at 16 years of age reported an increase in anxiety level that statistically significantly exceeded that experienced by those with low or moderate PIPES scores (difference in differences, 2.91; 95% CI, 0.20-5.61). The change in depression level, although higher, was not statistically significant (difference in differences, 2.63; 95% CI, –0.28 to 5.54). Neither association differed by sex (likelihood ratio P = .37 and P = .97, respectively). Maternally reported youth symptoms did not increase substantially (difference in differences: anxiety, 0.75 [95% CI, –1.40 to 2.90]; depression, 1.29 [95% CI, –0.93 to 3.51]). We found no overall change in BP associated with PIPES scores between visits (difference in differences: SBP, –2.19 [95% CI, –4.88 to 0.50]; DBP, –1.66 [95% CI, –3.84 to 0.52]; and MAP, –1.20 [95% CI, –3.34 to 0.94]). Adolescents with high PIPES scores whose mothers had resided in the United States for 5 years or less at delivery showed less increase in SBP (likelihood ratio P = .10), DBP (likelihood ratio P = .11), and MAP (likelihood ratio P = .13) compared with their peers (Table 4).

Discussion

We hypothesized that the vulnerability perceived by adolescents from immigrant families in the face of the current restrictive anti-immigrant policy and rhetoric in the United States has an adverse association with their physical and mental health. The adolescents in this study lived in Salinas Valley, in which Latino people constitute approximately 75% of the population41 and the proportion of undocumented residents likely exceeds 29%.42 The city of Salinas is promoted as a welcoming city nestled within the sanctuary state of California.43 Nevertheless, nearly half of the adolescent study participants reported worrying at least sometimes about the consequences of US immigration policy for their family and themselves, concerns that are aligned with recent data from US-born Latino adults.14

Study results indicate that adolescents’ degree of worry in the first year after the 2016 presidential election was associated cross-sectionally with higher anxiety and poor sleep quality as well as lower MAP and SBP for male participants; these findings possibly reflect a physiologic desensitization in males in response to chronic stress. Comparing a youth’s well-being before and after the 2016 election, we observed that self-reported anxiety symptoms increased markedly among individuals who reported more worry about immigration policy. The smaller changes in BP associated with high levels of anxiety were most pronounced in youth participants whose mothers had lived in the United States for 5 years or less at delivery, the proxy for presumed undocumented status. Thus, this study provides, to our knowledge, the first long-term evidence of the association between the rapidly changing immigration policy environment and alterations in certain aspects of the health trajectory of US citizen adolescents from immigrant families.

These results support the conclusions of previous research that found US-born Mexican American children may experience collateral health damage29-31,44-46 from immigration policy that targets their families. In a 2008 study of children separated from parents after raids by the US Immigration and Customs Enforcement, two-thirds were reported to have experienced changes in sleep pattern after the raids.44 Sleep quality is key to academic achievement and to overall health and well-being.47,48 This research and several other studies46,49 have reported adverse associations between a punitive immigration policy and children’s anxiety and depression symptoms. Latino children with undocumented parents potentially facing policy-related burdens may be at greater risk of both internalizing and externalizing behaviors compared with peers with documented or US citizen parents.29 Mental health stress in adolescence may be associated with short-term disturbance in school performance, increased risk for substance abuse, and long-term employment and health consequences.50-52 Conversely, an inclusive policy that prevents deportation of parents has demonstrated protective properties, easing the minds of US citizen children.30

In a previous report,53 mothers participating in the CHAMACOS study who had a lot of worry about deportation in 2012 were more likely to be obese and have higher pulse pressure, but they were not more likely to be hypertensive or have elevated DBP or MAP. In the present analysis, no association was found between PIPES scores and BMI of youth participants. These findings suggest that, although immigrant adults may experience chronic concern about deportation, it is possible that their US citizen children were relatively buffered from this fear in 2012 until recently. In this case, the follow-up period of only 1 year after the election, with many youth participants who were weighed soon afterward, may have been too short to observe a change in BMI. Likewise, it may have been too short a period to move the needle on mothers’ overall assessments of their children’s health.

Given the previous findings of higher pulse pressure in mothers who worried more about deportation, the finding in the present study of lower MAP among the most worried male (but not female) participants was somewhat unexpected. However, this decreased MAP may reflect sex-specific physiologic differences in response to adversity; male individuals tend to adapt by calibrating downward to achieve homeostasis, whereas female individuals tend to calibrate upward.54 For the most worried males in this sample, increased fear of family deportation and perception of vulnerability could be associated with a reduction in physiologic responsivity; lowered BP may reflect a move to a lower resting state.

Strengths and Limitations

The present study has both strengths and limitations. To our knowledge, this study is the first (or perhaps only) sample of adolescents from immigrant families to undergo physical and mental health outcomes measurement at time points almost immediately before and after a historical event that has fear-evoking implications for their families. The sample answered the call for long-standing research into the implications of this event for the well-being of children from immigrant families.16,31,55 Other important strengths include repeat assessments of multiple health end points, including both maternal and youth participants’ reporting on adolescent mental health using a widely used tool validated in both English and Spanish.37 The use of PIPES34 is another strength, allowing us to capture a more nuanced picture of youth participants’ concerns compared with previous studies, which largely relied on parental immigration status as the independent variable.

Nonetheless, we recognize that not knowing the immigration status of parents was a limitation of this study. We also did not have measures of self-reported immigration stress or sleep quality at age 14 years. Because these participants likely lived in an immigrant-friendly community, which may have served as a buffer, our results may have underestimated the implications for youth in communities that are less receptive to immigration.56

This study provides epidemiologic support for the American Academy of Pediatrics 2017 statement on protecting immigrant children, which stated that “Far too many children in this country already live in constant fear that their parents will be … deported… When children are scared, it can impact their health and development.”57 The findings underscore the call of adolescent health experts for “action… (to) alleviate the detrimental effects of this status on millions of children and youth,”55 including provision of legal and mental health services within trusted immigrant-supportive institutions, support for DACA, and, ultimately, enactment of comprehensive federal immigration reform. Future research should track these potentially lasting implications as adolescents exposed to anti-immigrant policy and rhetoric become young adults.

Conclusions

These study results suggest that the current immigration policy environment has negative implications for the mental health of US citizen children of immigrants. Anxiety among this population statistically significantly increased after the 2016 presidential election.

Back to top Article Information

Accepted for Publication: March 14, 2019.

Corresponding Author: Brenda Eskenazi, PhD, Center for Environmental Research and Children’s Health, School of Public Health, University of California, Berkeley, 1995 University Ave, Berkeley, CA 94720 (eskenazi@berkeley.edu).

Published Online: June 24, 2019. doi:10.1001/jamapediatrics.2019.1475

Author Contributions: Dr Eskenazi and Ms Fahey had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Eskenazi, Fahey, Kogut, Gonzales, Deardorff.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Eskenazi, Fahey, Kogut.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Fahey, Gunier.

Obtained funding: Eskenazi, Deardorff.

Administrative, technical, or material support: Eskenazi, Fahey, Gunier, Holland.

Supervision: Eskenazi, Kogut, Gonzales.

Conflict of Interest Disclosures: Drs Deardorff, Eskenazi, Fahey, and Kogut report receiving grants from the National Institutes of Health during the conduct of the study. Drs Eskenazi and Fahey report receiving grants from the Environmental Protection Agency during the conduct of the study. Dr Torres reports receiving grants the National Institute on Aging not directly related to this research for this article. No other disclosures were reported.

Funding/Support: This work was funded by research grants R01 ES021369, R01 ES026994, P01 ES009605, and R01 ES017054 from the National Institute of Environmental Health Sciences, National Institutes of Health; grant R01 DA035300 from the National Institute on Drug Abuse; and grants R82670901, RD83171001, and RD83451301 from the Environmental Protection Agency.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Stephen Rauch, MPH, Kyna Long, MS, and Helena Hutchins, MPH, Center for Environmental Research and Children’s Health, University of California, Berkeley, for their support in manuscript preparation. We also thank our research team for their hard work on collecting these data. These individuals received no additional compensation, outside of their usual salary, for their contributions. Most of all, we are grateful to the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) study families for their years of participation in the study.