Health and Mental Health Issues:
Immigrant Youth and Families in New York
Report #2, Winter 2001
The Center for New York City Affairs,
Milano The New School for Management and Urban Policy

A project of The New American Youth Initiative
Sponsored by The New York City Council Youth Services Committee, Councilman Kenneth K. Fisher, Chair. With additional support from the J.M. Kaplan Fund.

Child Health Plus and Fear of Health Insurance Enrollment
A high percentage of immigrant children lack medical coverage because their parents work jobs that provide no insurance, nor do they qualify for Medicaid because of recent changes to immigration laws. Yet in New York, nearly all of these children qualify for Child Health Plus, a program that provides affordable insurance to low- and moderate- income people, including both documented and undocumented immigrants.

Many families fail to enroll their children in Child Health Plus or Medicaid because they are not aware of the programs, or of their children's eligibility. Others are afraid that by enrolling in Child Health Plus or Medicaid, they will provide information to the government that can be used against them, even to deport them.

Community-based efforts to promote preventive care are hampered by their inability to assure immigrants that enrolling in Child Health Plus or Medicaid will not be held against them sometime in the future. The government has not offered clear, consistent information in this regard. In order to maximize enrollment in Child Health Plus and Medicaid, action should be taken to counter this fear, and outreach must be enhanced.

Recommendations

• Government agencies (particularly the INS and Department of State) need to give more explicit and formal assurance to immigrants and community organizations that enrolling in Child Health Plus and Medicaid will not endanger immigrants' residency status.
  
• Community-based organizations need to pursue expanded outreach to immigrant parents in order to promote trust in the program and to increase enrollment.

Fear of Using Preventive Health Services
In New York State there is some form of health insurance available for every child regardless of his or her immigrant status. But even parents who do enroll their children in health plans may not use the available medical services because they do not entirely understand the concept of medical insurance, managed care and/or primary care. As a result, even parents with health insurance wait until their children are sick and then take them to the emergency room.

In attempt to address these issues, New York State has implemented a facilitated enrollment process designed to reach low-income and immigrate parents and to sign up their children for health issuance. To assist with the process, the Children's Defense Fund-NY (CDF-NY) is working with more than a dozen state-contracted agencies who are in turn subcontracting with community groups in order to build broad coalitions. Facilitated enrollment has already begun to show results, helping insure tens of thousands of children last year. The campaign also provides an opportunity to educate parents about how to access and use the managed care system. This campaign is not targeted specifically at immigrant communities, however, and there are language barriers and other gaps that have yet to be adequately dealt with.

Recommendation

• Campaign educational material ought to be available in several languages, and increased funding should be targeted toward the labor-intensive work of educating immigrant parents about the best ways to access health care. Without these investments, many parents won't know how to properly use their insurance. Nor will they understand they have to renew Child Health Plus enrollment each year.

Cultural Adjustment and Stress: Mental Health
The transition to life in New York City often places a great deal of stress on young immigrants and their families. Adjustment challenges that can include:

• Culture shock and language barriers
• Intergenerational conflict and role reversals
• Decline in family status and the loss of established networks
• Fear of legal status and expectations of discrimination.
• Hopelessness in the face of unfamiliar bureaucracies.

Children often assimilate more quickly than adults, acquiring language skills and developing an understanding of their adopted system. As a result, children are often put in the position of mediating between adult relatives and service providers or representatives of agencies (such as schools, health providers, and government officials). Children are called upon by their elders to translate documents, interpret conversations, and explain policies and practices.

In contrast to their increased responsibilities within the household, many young immigrants are placed in schools at levels below their knowledge base because of language gaps or age. Meanwhile they are further torn between adopting American values and continuing to take direction from parents who may have become increasingly dependent on their children.

Such pressures are often less likely to be addressed among immigrant youth because of the stigma associated with mental health care in many cultures. Parents are often frustrated with their kids' behavior but are not inclined to access mental health services. Studies have shown that young immigrants are nearly twice as likely to attempt suicide than the highest risk cohort of American-born kids. Too few prevention and support services are targeted to young immigrants, and few resources are available to provide comprehensive services for the entire family.

Recommendations

• Community-based social support and counseling programs should be increased in scope and availability, and should include educational and health promotion components. In some communities there is a shortage of orientation and networking opportunities for young immigrants to socialize with peers and mentors. There are also few accessible and culturally appropriate counseling and support services for many ethnic groups.
  
• Expand community-based outreach and acculturation assistance to parents to improve their adaptation and self-reliance within the American system. Government, working with neighborhood organizations, can use its considerable resources to communicate with immigrants to encourage participation in educational programs that explain how important systems work in our city and country. As parents become better informed and more independent, their children will experience less stress.
  
• Community based organizations, service providers and schools serving immigrant youth should establish relationships with culturally appropriate health and mental health providers. In some neighborhoods, such as Northern Manhattan, progress is being made to create connections among a broad range of government and non-profit agencies. But much more still needs to be done, particularly within the Board of Education. For example, teachers may be unaware that their immigrant students are under stress and in need of counseling services. Providers suggest that faculty in schools with large numbers of immigrants should be better trained to understand the difficulties faced by immigrant students, and school counselors must have a better understanding of appropriate referral resources.

Access to Linguistically Appropriate and Culturally Specific Services
Organizations that receive funding from the U.S. Department of Health and Human Services are mandated to abide by statutes that forbid discrimination on the basis of national origin. Although law mandates the provision of appropriate interpreting services, many clinics, hospitals, and government offices fail to comply. Immigrant families are often put in the unacceptable position of having children translate confidential and complex medical and personal information, compromising both the quality of care and individuals' civil rights.

Particularly in the area of mental health, providers need to be sensitive to patients' cultural adjustment issues. These sometimes include experiences as refugees and as survivors of war trauma and discrimination. Advocates for immigrants from all regions of the world report a shortage of providers who speak their languages. Too few counselors, social workers, and medical practitioners possess the language skills needed to communicate directly with patients in New York City. This shortage results in a reliance on interpreters which can severely limit or delay access to care. Advocates have reported wait times exceeding one month before patients can access counseling services, due to shortages of interpreters. Beyond that, the use of interpreters in the mental health setting alters the therapeutic dynamic and can compromise the nature of care.

There is also a need to improve cultural awareness among educators and administrators. Improved understanding of cultural practices on the part of the Administration for Children's Services, school health and counseling services, and others will reduce problems, including incidents where families are investigated by ACS for using home remedies. Some traditional remedies and practices that are accepted in other regions of the world are viewed as signs of potential neglect or abuse in the United States. Outreach to immigrant families is needed to curb certain of these practices.

Recommendations

• Improve awareness of culturally specific medical and mental health concerns among medical providers and child advocates. Encourage community representatives to promote cultural awareness through more systematic outreach.
  
• In collaboration with enforcement agencies in government, community organizations should build awareness among immigrants that they have rights regarding interpreters and access to care. Make caregivers accountable by increasing the reporting by community advocates and immigrant groups of civil rights violations.
  
• Promote the training of immigrants to enter the health, mental health and social work professions, in order to better meet the needs of under-served and under-represented communities. Engage the philanthropic community in the challenge of creating opportunities for immigrants to become trained professionals.

Sex Education and HIV Prevention
Some service providers assume that immigrant youth from certain cultures have little interest in sex education. Indeed, some cultures have strong taboos against premarital sex. These taboos do not prevent young immigrant men and women from adopting a more Americanized point of view on the topic, however.

It is imperative, however, that sex education be taught in a culturally sensitive manner and include discussions about contraception, sexually transmitted diseases and HIV prevention. Some advocates believe that well-established reproductive health organizations may not always be sensitive to the needs of immigrant youth. Schools with immigrant students should also be sensitive to cultural issues and bring in educators familiar with the students' background.

Some youth organizations are working creatively to integrate issues of sexuality and HIV prevention into their youth programming. The Association for Progressive Dominicans, for example, is one of the sponsors of a 13-member agency basketball tournament. In order for young people to participate they are required to attend an HIV prevention class, and testing is available on-site for those who request it. Peer to peer counseling can also be an effective way to communicate information about HIV prevention and reproductive health.

To learn more about the New American Youth Initiative, see our Web site at www.nayi.org.

Sponsored by New York City Councilman Kenneth K. Fisher.

The Center for New York City Affairs is a program of the Milano The New School for Management and Urban Policy. Please join the Center for New York City Affairs mailing list! Call 212 229-5418 or send an email to: whitea@newschool.edu.