J Immigrant Minority Health DOI 10.1007/s10903-016-0373-7

REVIEW PAPER

The Healthy Immigrant Paradox and Child Maltreatment: A Systematic Review Lina S. Millett1

Ó Springer Science+Business Media New York 2016

Abstract Prior studies suggest that foreign-born individuals have a health advantage, referred to as the Healthy Immigrant Paradox, when compared to native-born persons of the same socio-economic status. This systematic review examined whether the immigrant advantage found in health literature is mirrored by child maltreatment in general and its forms in particular. The author searched Academic Search Premier, CINAHL, CINAHL PLUS, Family and Society Studies Worldwide, MEDLINE, PsychINFO, Social Work Abstracts, and SocINdex for published literature through December 2015. The review followed an evidence-based Preferred Reporting Items for Systematic reviews and MetaAnalyses checklist. The author identified 822 unique articles, of which 19 met the inclusion criteria. The reviewed data showed strong support for the healthy immigrant paradox for a general form of maltreatment and physical abuse. The evidence for emotional and sexual abuse was also suggestive of immigrant advantage though relatively small sample size and lack of multivariate controls make these findings tentative. The evidence for neglect was mixed: immigrants were less likely to be reported to Child Protective Services; however, they had higher rates of physical neglect and lack of supervision in the community data. The study results warrant confirmation with newer data possessing strong external validity for immigrant samples.

Introduction The increasing number of children living in immigrant families in the United States (US) requires that we better understand the problem of child abuse and neglect (CAN) among these families [1, 2]. Negative consequences of CAN have been linked to increased mortality, long-term poor physical and mental health, reduced productivity, subsequent violence, and a significant burden on the public services sector [3–5]. Prevalence estimates for CAN among the general population range anywhere from 3 to 30 %, depending on the data source and referent period [6, 7]. However, there is very little epidemiological knowledge about immigrant parenting in general and CAN behaviors in particular. For example, in the US no systematic national data exist on immigrant families involved with Child Protective Services (CPS), a system responsible for responding to child maltreatment allegations [6]. While immigrant status has been collected by some local CPS jurisdictions as well as included in a number of survey studies (using both CPS and community data), no systematic effort has been undertaken to synthesize this information. Consequently, prevalence rates as well as immigrants’ risk for child maltreatment relative to nativeborn groups remain unknown, hindering policy, practice, and research efforts with this population.

Keywords Child maltreatment  Immigrants  Healthy immigrant paradox  Systematic review  Epidemiology Background

& Lina S. Millett [email protected] 1

College of Nursing, University of Missouri-St. Louis, One University Blvd, St. Louis, MO 63121, USA

The foreign-born population is one the fastest growing demographic groups in the US Between 1990 and 2010 the immigrant population doubled, contributing to one-third of the total population growth in the nation [2]. In 2013, approximately 41.3 million or 13 % of all US residents

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were immigrants [8]. Among all children under 18, 25 % live with at least one foreign-born parent while 13 % have two foreign-born parents [8, 9]. The largest immigrant sending countries include Mexico (28 %), India (4.9 %), Philippines (4.5 %), and China (4.4 %), suggesting that immigration in the US is very culturally diverse [8]. Still, Hispanic or Latino immigrants comprise almost half of the total immigrant population (46 %). Using Census defined categories of race, 48 % of immigrants are white, followed by Asian (26 %), Black (9 %), and other (17 %) immigrants [8]. In the US, like other developed nations, the majority of immigrants are of lower socio-economic status (SES) than the native-born groups [10]. For example, compared to US-born individuals, immigrants are less likely to be high school graduates (30 vs. 10 %); their median income is about one-fifth lower than US-born families’ median income and their poverty rate is about 50 % higher [10, 11]. Immigrant families with children are half as likely to receive public benefits and, prior to the Affordable Care Act, be insured [11, 12]. However, immigrants are not a homogeneous group. While there are some commonalities among immigrant groups, there is also considerable amount of variability. For example, among broad categories of race/ethnicity, some groups of Asian immigrants have considerably higher education and income than Latino immigrants [13, 14]. The SES status of documented immigrants is substantially higher than those who are undocumented [15]. At the same time all immigrant groups experience varying degrees of challenges related to immigration and acculturation processes, which in turn may be associated with individual’s health and parenting behaviors [16, 17]. There is strong empirical evidence that CAN, including neglect and all types of abuse (physical, sexual and emotional), is associated with low SES. Studies have found associations between CAN rates and parental and neighborhood income, parental employment, family poverty and low parental education [18–23]. The mechanisms linking poverty or low SES and maltreatment can be both direct and indirect. Lack of income or budget constraints may directly translate into substandard levels of care for those caregiving domains that are financially depended (e.g. lack of food, inadequate clothing, or unsafe childcare arrangements) [24, 25]. Likewise, living in poverty may affect parental emotional and physical health that in turn lead to suboptimal parenting practices and behaviors (indirect effects) through increased stress and reduced capacity to care via altered neurobiological processes [26–28]. The link between poverty and CAN is mirrored by wellestablished empirical links between poverty and other child health outcomes, particularly birth outcomes (e.g. low birth weight, prematurity, infant mortality; see [29–31]). Thus, the literature above might lead us to hypothesize that given

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immigrants’ disadvantaged position in society they would have higher rates of all types of child maltreatment, and especially neglect. From a theoretical perspective, the argument could be made that neglect is more easily equated to child well-being than physical abuse. This is because there is substantial overlap between common categories of neglect (failure to provide health care, failure to supervise, failure to provide adequate food and shelter) and child physical health. Additionally, although poverty has been convincingly linked to all kinds of maltreatment, it may be most strongly related to neglect [19, 23]. The health literature suggests that immigrants may be at a lower risk for a range of negative child well-being outcomes, including infant mortality, low birth weight and prematurity, posing that ‘‘Healthy Immigrant Paradox’’ (HIP) may be in play [32–34] (see [14] for a review). The HIP proposes that immigrants have better health related outcomes compared to the native-born population despite immigrants’ higher socio-economic risks, including lower educational attainment, lower wages and higher poverty rate [35]. Findings from studies examining HIP, or the similar ‘‘Hispanic paradox’’, suggest that immigrants have far better outcomes than equally at risk (relative to SES) non-Hispanic White children [36]. Although the explanations for the HIP vary with the outcomes examined, the most common include cultural reasons, differences in parental risk profile, under-reporting by a particular system, effects of social networks, and self-selection hypothesis [35]. If applied to child maltreatment problem, this would suggest that immigrant parents may possess more positive culture-specific parenting practices and/or have fewer risks associated with CAN other than poverty (e.g. substance abuse, depression). Alternatively, immigrants possess more social networks than native-born families that play a protective role in buffering the risk played by low SES status. Still another explanation for HIP is that it is an artifact of underreporting to CPS. Finally, there may be other, as yet unidentified strengths in those individuals who elect to immigrate. These hypotheses have largely remained unexamined empirically. In sum, this line of literature suggests that despite their lower SES status, immigrants seem to be doing as well as non-Hispanic Whites on a number of different health and behavioral outcomes. Thus, it may lead us to hypothesize that despite immigrants’ disadvantage they will be at a lesser risk for child maltreatment than the native-born population. Furthermore, it is reasonable to expect that this effect may diminish over time as families acculturate and struggle to address basic needs [37–39]. Prior studies examining the HIP have been primarily conducted on Latino, mostly Mexican, immigrants and important immigrant characteristics, such as legal status, age of arrival in the US, and length of stay have not been consistently collected and/or accounted for [35].

J Immigrant Minority Health

The purpose of this study is to better understand child maltreatment behaviors among immigrant families by systematically collating findings from existing research to examine the HIP relative to the child maltreatment outcome. Specific research questions include: (1) What are the best available estimates of the prevalence rate of child maltreatment, in general and by type (neglect, physical, sexual and emotional abuse), among immigrants? (2) Is there a relationship between immigrant status and child maltreatment? (3) Does this relationship vary in regard to type of maltreatment? These questions are pursued with close attention to other factors known to predict child maltreatment which may also be associated with immigrant status (e.g. education, poverty).

Methods This systematic review was conducted following an evidence-based Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 27-item checklist to ensure the highest standard of the review [40]. Databases included Academic Search Premier, CINAHL, CINAHL PLUS, Family and Society Studies Worldwide, MEDLINE, PsychINFO, Social Work Abstracts, and SocINdex with full text. Search terms included two parameter categories: (1) ‘‘immigra*’’ OR ‘‘refugee’’ OR ‘‘asylum’’ AND (2) ‘‘child maltreat*’’ OR ‘‘child abuse’’ OR ‘‘child physical abuse’’ OR ‘‘child sexual abuse’’ OR ‘‘child neglect’’ OR ‘‘child mistreat*’’ in order to capture the broadest possible sample of relevant articles. Additional articles were identified through searching reference lists of the published articles and Google Scholar. Articles were restricted to peer-review articles, books and reviews published in the English language. The search was conducted in December 2015, not imposing a limit as to when the study could be published and/or conducted. Inclusion Criteria For the purposes of this review CAN was defined as omission of basic needs, care or treatment (neglect) or commission of physical, emotional or sexual abuse against a minor (under 18) child by a child’s caregiver. Child had to be living in parental care and not placed in foster care. Nativity was defined in terms of parental country of birth. Those born in the country of residence were referred to as US-born or native-born while others were called foreignborn or immigrants. Both first generation (born in another country) and second generation (born to immigrant parents) immigrants were included in the review. Foreign-born included voluntary (immigrants) and/or involuntary (refugees and asylum seekers) migrants. In order to be included

in the review, studies had to include prevalence of child maltreatment for an immigrant group either in the general population or in a reported system and/or include nativity as an independent or control variable when examining maltreatment as an outcome in a multivariate analysis. Studies also had to include a comparison group of nativeborn of either the same or other race or ethnicity (e.g. foreign-born Latinos compared to US-born Latinos or USborn Whites) or present data from other data sources regarding CAN prevalence among native-born groups in the same geographic area. Studies that were focused exclusively on immigrants and did not include native-born groups in their samples or used comparative statistics from other sources outside study’s geographic area were excluded. Studies were excluded if their titles or abstracts indicated that maltreatment focused on adults; maltreatment that was perpetrated by a non-caregiver, such as assault by strangers, commercial and sexual exploitation; descriptive studies focusing on immigrant needs, attitudes or hypothetical maltreatment reporting behaviors; theoretical articles; and maltreatment among families living in refugee camps. Studies were also excluded if they contained out-of-home samples. The review included both individual and aggregate level studies. Lastly, only US based studies were included in this review in order to achieve a greater control of country-to-country differences. The author read all the abstracts to determine if the studies focused on CAN and foreign-born caregivers. Those studies that met the inclusion criteria and those for which it was impossible to determine if they met the above criteria by reading an abstract/title were included for further review. All articles were read in full to determine if they met all the inclusion criteria. Articles were excluded if they had any of the exclusion topics listed on Fig. 1. Data Coding Extracted data (see Table 1) included study relevant information on the following: sampling frame, sampling strategy and a study name if known, information on immigrant and comparison groups (individual level studies) or percentage of immigrant concentration (aggregate level studies), measures of maltreatment, data analysis, control variables, and findings. The form also included measures of study quality as described below. Assessment of Study Quality Each study was assessed for its methodological rigor using a quality assessment tool specifically developed for this study to accommodate differences in sampling and measurement between survey and administrative/reporting system data. The tool was based on research regarding

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Identification

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Records identified through database searching (n = 806)

Additional records identified through other sources (n = 16)

Eligibility

Screening

Records after duplicates removed (n =526 )

Records excluded based on reviewing title and abstract (n = 481)

Records screened (n = 526)

Full-text articles assessed for eligibility (n = 43)

9 did not disaggregated by nativity 2 not empirical articles 3 did not measure child maltreatment 1 assessed maltreatment in a refugee camp 6 did not have a comparison group of U.S.-born families 1 used case-control design 2 were out of home care samples

Included

Studies included in quantitative synthesis (n = 19)

Full-text articles excluded, with reasons (n = 23)

Fig. 1 Flow diagram of study selection for systematic review of published research on examination of healthy immigrant paradox for child maltreatment

methodological concerns in observational studies and issues with surveying immigrants and measuring CAN [35, 41, 42]. Studies were assessed across four domains: selection bias, measurement error, analytic bias, and degree of control employed (confounder bias). Selection bias was assessed by degree of external validity of the sample selection (sampling procedure and response rate where applicable) and inclusion of immigrant relevant indicators (legal status, length of stay or language use). Measurement bias was assessed by use of standardized instruments and protections taken to collect sensitive information pertaining to maltreatment measurement in survey studies (e.g. training of interviewers, using computer assisted software) and the degree to which a study addressed potential sources of bias in the service system data. Assessment of analytic bias considered whether a study reported handing of missing data, used appropriate analytic procedures (e.g. control for design effects) and statistical tests. Studies that addressed 50 % of applicable items in this category were considered to have low analytic bias. Lastly, confounder bias assessed whether a study controlled for confounding

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factors (e.g. SES) when examining a relationship between nativity and maltreatment. Data Analysis To account for each study’s methodological rigor in the analysis, a total score was created by summing five methodological rigor items. The study was considered to have good methodological quality if it scored at least in the 67th percentile of the total score; the study had a fair quality for scores in the 34–66 % range and poor quality if the score was below 34th percentile [42] (Table 2).

Results The search process is described in Fig. 1. Overall, 19 [43– 61] studies met the inclusion criteria to examine the relationship between nativity and maltreatment. Of these, 12 studies also examined CAN prevalence. Most studies used a cross-sectional research design (n = 17) even though some

Sampling frame, sampling strategy, and study name

National birth cohort probability study in 20 large US cities; FFCWB

Stratified probability sampling of national CPS data; NSCAW-II

Stratified probability sampling of national CPS data; NSCAW-I

Stratified probability sampling of national CPS data; NSCAW-I

Author

Altschul and Lee [43]

Cardoso et al. [44]

Dettlaff and Earner [45]

Dettlaff et al. [46]

Latino immigrants (n = 230) versus US-born Latinos (n = 406)

Immigrants (n = 351) versus US-born (n = 3366)

US-born Latinos (n = 542) versus foreign-born US citizen Latinos (n = 77) versus foreign-born legal resident Latinos (n = 74) versus foreign-born undocumented Latinos (n = 129)

Immigrant Hispanic mothers (n = 328) versus US-born Hispanic mothers (n = 517) of 3–5 year old children

Immigrant and comparison groups (individual level); immigration concentration (aggregate level)

CPS screened-in reports, most serious type of CAN for children 0–18 years

CPS screened-in reports, most serious type of CAN for children 0–18 years

CPS screened-in reports and substantiated reports for the most serious type of CAN for children 0–18 years

Parent–child physical aggression with PCCTS

Measure of child maltreatment

Bivariate

Bivariate

Bivariate

Bivariate, multivariate

Data analysis

N/A

N/A

N/A

Education, income, psychosocial risks, child factors, relationship status and acculturation

Control/stratification variables

Table 1 Summary of included studies for systematic review to examine healthy immigrant paradox for child maltreatment

PN: 1.4 versus 18.4 %, p \ .001

NS: 22.7 versus 30.0 %

EA: 16.9 versus 13.0 %

SA: 22.1 versus 5.8 %, p \ .001

PA: 36.5 versus 29.2 %

Bivariate by maltreatment type

PN: 2.4 versus 21.0 %, p \ .001

NS: 17.6 versus 28.3 %

EA: 19.7 versus 6.2 %, p \ .001

SA: 20.7 versus 10.4 %, p \ .05

PA: 36.0 versus 27.0 %

By maltreatment type

PN: 6.0 versus 1.0 versus 0 versus 3.0 %

NS: 33.0 versus 18.0 versus 41.0 versus 38.0 %

EA: 3.0 versus 17.0 versus 1.0 versus 0%

SA: 4.0 versus 3.0 versus 2.0 versus 5.0 %

PA: 16.0 versus 28.0 versus 23.0 versus 15.0 %

Bivariate for screened-in reports by maltreatment type and comparison population

Foreign-born mothers were less likely to use aggression (b = -0.21) (p B .01) towards their children than US-born Hispanic mothers

Foreign-born Hispanic versus US-born Hispanic versus US-born White versus US-born Blacka (mean): 6.09 versus 9.21 versus 10.46 versus 15.16, p \ .001 Multivariate

Bivariate

Findings

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Sampling frame, sampling strategy, and study name

Probability sample of one census track in Boston

County level CPS data aggregated by census tracks

National prospective cohort probability sample; the National Longitudinal Study of Adolescent Health

Random telephone survey of households with at least one child 0–12; 50 cities in California

Author

Earls et al. [47]

Freisthler [48]

Hussey et al. [49]

JohnsonMotoyama [50]

Table 1 continued

123 Foreign-born Latinos (n = 283), USborn Latinos (n = 351), and US-born Whites (n = 1625)

1st, 2nd generations of immigrations versus US-born, N = 15,197

N = 940 census tracks; 25.4 % immigrant concentration

West Indies (n = 28), Cape Verde (n = 11), US-bornb (n = 29)

Immigrant and comparison groups (individual level); immigration concentration (aggregate level)

One-item questions

Retrospective one item self-reports of PN, NS, PA, and SA before 6th grade among adolescents.

CPS substantiated reports

Parent–child physical and verbal aggression with PCCTS of 0–17 year old children

Measure of child maltreatment

Bivariate, multivariate

Bivariate, multivariate

Multivariate

Bivariate

Data analysis

Caregiver age, marital status, number of children, income, education, psychosocial factors and child characteristics

Gender, race, parental education, family income, region of residence

County, population density, impoverishment, childcare burden, residential instability, Hispanic concentration

N/A

Control/stratification variables

Lack of supervision: 3.72 (1.79–7.71) versus 1.07 (0.42–2.74)

Medical neglect: 2.42 (1.53-3.82) versus 1.50 (0.89–2.50)

Lack of food: 4.24 (2.40–7.51) versus 1.43 (0.72–2.84)

Multivariate (aOR, White-reference group)

Lack of supervision: 10.3 versus 2.6 versus 1.8 %, p \ .05

Medical neglect: 20.9 versus 6.7 versus 3.0 %, p \ .05

Lack of food: 16.1 versus 4.7 versus 1.8 %, p \ .05

Bivariate

1st generation had an increased risk of NS (aOR = 1.55, p B .01) compared to youth with US-born parents

Multivariate

1st and 2nd generation of immigrants had an increased risk for NS (OR = 1.49 and OR = 1.34, p \ .01), PN (OR = 1.35, OR = 1.30, p \ .05) and PA (OR = 1.35 and OR = 1.44, p \ .05) but no differences for SA (OR = 0.94 and OR = 1.06, p [ .05 compared to adolescents with US-born caregivers

Bivariate

CAN rates (b = -0.48, p [ .05)

Concentration of immigrants did not predict

Multivariate

Physical: 4.5 versus 2.5 versus 5.1 %

Verbal: 4.0 versus 0.7 versus 5.6 %, p \ .01

Bivariate

Findings

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Sampling frame, sampling strategy, and study name

Stratified probability sampling of national CPS data; NSCAW-II

Statewide (California) CPS records for Hispanic mothers with infants born 2000–2006

Author

JohnsonMotoyama et al. [51]

JohnsonMotoyama et al. [52]

Table 1 continued

Foreign-born Latina mothers (n = 1,208,411) versus US-born Latina mothers (n = 663,605)

Latino immigrants (n = 153) versus mixed nativity (n = 90) versus USborn Latinos (n = 470)

Immigrant and comparison groups (individual level); immigration concentration (aggregate level)

CPS screened-in and substantiated reports for children 0–1 years old

CPS screened-in reports, most serious type of CAN

Measure of child maltreatment

Bivariate, multivariate

Bivariate

Data analysis

Maternal education, medical insurance

N/A

Control/stratification variables

0.9 versus 3.6 %a

Rate for substantiated CAN reports stratified by high school or less(foreign-born versus US-born)

0.9 versus 4.3 %a

Rate for substantiated CAN reports stratified by public insurance (foreignborn versus US-born)

Cuban: 1.1 versus 2.8 %, Central/S. American: 0.9 versus 1.5 %

Puerto Rico: 2.3 versus 3.7 %

All: 0.8 versus 2.8 %, Mexican: 0.8 versus 2.8 %

Rate for substantiated CAN reports for all and by country of origin (foreignborn versus US-born)a

2.9 versus 9.1 %a

Rate for CAN reports stratified by high school or less (foreign-born versus US-born)

3.1 versus 10.7 %a

Rate for CAN reports stratified by public insurance(foreign-born versus US-born)

Puerto Rico: 6.2 versus 10.0 %, Cuban: 3.0 versus 6.5 %, Central/S. American: 2.9 versus 4.8 %

Rate for CAN reports for all and by country of origin (foreign-born versus US-born)a All: 2.7 versus 7.2 %; Mexican: 2.7 versus 7.2 %

PN: 4.0 versus 4.0 versus 11.0 %

NS: 37.0 versus 15.0 versus 30.0 %

EA: 27.0 versus 13.0 versus 14.0 %

SA: 4.0 versus 9.0 versus 3.0 %

PA: 18.0 versus 9.0 versus 18.0 %

Bivariate by maltreatment type

Findings

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Sampling frame, sampling strategy, and study name

Probability sampling of a population based survey of US residents 20 years old and older; NESARC

One county CPS data aggregated by census tracks

One county CPS data aggregated by census tracks

Author

Kimber et al. [53]

Klein [54]

Klein and Merritt [55]

Table 1 continued

123 N = 2052 census tracks; 35.54 % immigrant concentration

N = 2052 census tracks; 27.93 % immigrant concentration

1st generation immigrants (n = 5037) versus 2nd generation immigrants (n = 4832) versus US-born (n = 24,164)

Immigrant and comparison groups (individual level); immigration concentration (aggregate level)

Screened-in reports for children 0–17

Screened-in reports for children 0–5

Questions adapted from PCCTS and CTQ

Measure of child maltreatment

Multivariate

Multivariate

Bivariate, multivariate

Data analysis

Racial-ethnic heterogeneity, poverty, child care burden, residential instability, housing stress

Child population density, disadvantage, affluence, residential instability, child care burden, ethnic/racial heterogeneity

Age, gender, race, education, income, psychiatric disorder, substance abuse

Control/stratification variables

Multivariate Immigrant concentration did not predict CAN rates for Black (b = 0.01, p [ .05) and Hispanic (b = 0.001, p [ .05) children but predicted lower rates for White children (b = -0.01, p \ .001)

Neighborhoods with larger concentration of US-born experienced higher CAN referral rates (b = 0.01, p \ .001) compared to those with concentration of foreign-born

Multivariate

Any: 1.08 (0.93–1.25) versus 0.95 (0.87–1.04)

EA: 0.69 (0.55–0.87) versus 0.90 (0.77–1.06) PN: 1.30 (1.11–1.52) versus 0.96 (0.87–1.07)

SA: 0.74 (0.62–0.90) versus 0.93 (0.81–1.08)

Multivariate (1st and 2nd generations compared to the 3rd generation) (aOR) PA: 0.86 (0.73–1.02) versus 0.98 (0.87–1.11)

Any: 38.2 versus 35.7 versus 37.3 %

PN: 29.6 versus 22.9 versus 23.3 %

EA: 5.2 versus 7.1 versus 8.4 %

SA: 7.3 versus 9.8 versus 10.9 %

PA: 14.8 versus 17.0 versus 17.8 %

Bivariate by maltreatment typea

Findings

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Sampling frame, sampling strategy, and study name

Multistage stratified probability sampling; National Latino and Asian American Study

National birth cohort probability study in 20 large US cities; FFCW

Author

Lau et al. [56]

Lee et al. [57]

Table 1 continued

Immigrant Hispanic fathers (n = 155) versus US-born Hispanic fathers (n = 217) of 3–5 year old children

Immigrant Asian (n = 1,11) and USborn Asian (n = 174)

Immigrant and comparison groups (individual level); immigration concentration (aggregate level)

Parent–child psychological and physical aggression with PCCTS

Parent–child minor and severe physical aggression with PCCTS

Measure of child maltreatment

Bivariate, multivariate

Bivariate, multivariate

Data analysis

Education, income, psychosocial risks, child factors, relationship status, acculturation

Age, gender, number of children, education, age at immigration, ethnicity

Control/stratification variables

Immig. Hispanic fathers had lower physical (b = -0.29, p B .01d; b = -0.59, p B .001e) and psychological (b = -0.62, p B .01d; b = -0.68, p B .05e) aggression towards their 3- and 5-year old children than US-born Hispanics

Multivariate

Child 5 years old Psychological: 8.86 versus 16.56 versus 17.26 versus 17.87, p \ .00; Physical: 3.34 versus 6.23 versus 7.26 versus 8.44, p \ .001

Psychological: 7.01 versus 14.93 versus 15.99 versus 17.81, p \ .001; Physical: 3.39 versus 7.71 versus 9.35 versus 10.46, p \ .01

Immig. Hispanic versus US-born Hispanic versus US-born White versus US-born Blacka

Bivariate (mean) child 3 years old

When proximal contextual stressors were added to the model age of immigration became ns

Parents who immigrated to the US as adults were less likely to report minor assault than those who immigrated as youth or were US-born (aOR = 0.57, 0.34–0.96; aOR = 0.56, 0.37–0.86; aOR = 0.86, 0.17–1.05; for 18–28 years at immigration, 29–39 years, and 40 and older)

Multivariate

Severe physical assault: 2.4 versus 0.3 % (p = .07)

Minor physical assault: 29.8 versus 52.4 % (p \ .05)

Bivariate

Findings

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Sampling frame, sampling strategy, and study name

Stratified cluster probability sampling; Project on Human Development in Chicago Neighborhoods

Statewide (California) CPS records

Statewide (California) CPS records

Author

Molnar et al. [58]

PutnamHornstein and Needell [59]

PutnamHornstein et al. [60]

Table 1 continued

123 Latino immigrants (n = 169,450) versus US-born Latinos (n = 94,388) versus US-born Whites (n = 165,192) versus US-born Blacks (n = 31,418)

Immigrants (n = 246,396) versus USborn (n = 284,436)

Neighborhood clusters (n = 80), caregivers of 3–15 year-olds (N = 3465)

Immigrant and comparison groups (individual level); immigration concentration (aggregate level)

CPS screened-in reports for children 0–5 years old

CPS screened-in reports for children 0–5 years old

Parent–child aggression: physical assault scale of the PCCTS

Measure of child maltreatment

Bivariate, multivariate

Bivariate, multivariate

Multilevel multivariate

Data analysis

Child factors, maternal education, age, prenatal care, abortion history, birth abnormality, paternity, medical insurance

Child factors, maternal education, age, prenatal care, abortion history, birth abnormality, paternity, medical insurance

Aggregate level: disadvantage, residential stability

Individual level: child’s sex and age, parental age and sex, SES, race, unemployment, single female, social support

Control/stratification variables

Latino immig. mothers were less likely to have CPS reports than US-born White mothers (aRR = 0.30, 0.29–0.31)

Multivariate within public insurance subsample

Immig. Latinos versus US-born White: RR = 0.32 (0.31–0.33)

11.9 versus 29.7 versus 38.3 versus 41 %a

Rate within public insurance subsample

Immig. Latinos versus US-born Whites: RR = 0.80 (0.79–0.82)

10.7 versus 20.8 versus 13.4 versus 30 %a

Rate for the full sample

US-born mothers were twice as likely to have CPS reports than foreign-born mothers (aRR = 2.13, 2.10–2.17); while the risk for those receiving public health insurance was even higher (aRR = 2.47, 2.42–2.52)

US-born versus immigrants: RR = 2.03 (2.00–2.06) Multivariatec

9 versus 18.3 %a

Rate

Parent–child physical aggression was less prevalent in neighborhoods with high immigrant concentration (b = -.09, p \ .05)

Multivariate

Findings

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child at 3 years of age

The original study compares descriptive statistics to other US-born groups that were not part of the study

child at 5 years of age e

d

c

US-born includes Puerto Rico

Table 2 Methodological rigor assessment in systematic review of published studies examining healthy immigrant paradox for child maltreatment

b

CAN child abuse/neglect, CTS childhood trauma questionnaire, EA emotional abuse, FFCW fragile families and child well-being study, NESARC national epidemiologic survey of alcohol and related conditions, NSCAW national survey of child and adolescent well-being, CI confidence interval, PA physical abuse, SA sexual abuse, NS neglectful supervision, PN physical neglect, PCCTS parent–child conflict tactic scale, OR crude odd ratio, aOR adjusted odd ratio, RR relative risk, aRR adjusted relative risk a No statistical testing performed

SA: 11.1 versus 21.3 %, p \ .001

PA: 13.0 versus 6.7 %, p \ .05

Bivariate N/A Bivariate

Retrospective 1–2 item self-reports of CAN before age 18 Foreign-born Latinas (n = 906) versus US-born Latinas (n = 521) Multistage stratified probability sampling; National Latino and Asian American Study Warner et al. [61]

Data analysis Measure of child maltreatment Immigrant and comparison groups (individual level); immigration concentration (aggregate level) Sampling frame, sampling strategy, and study name Author

Table 1 continued

Control/stratification variables

Findings

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Study

Methodological rigor

Altschul and Lee [43]

Good

Cardoso et al. [44]

Good

Dettlaff and Earner [45] Dettlaff et al. [46]

Good Good

Earls et al. [47]

Fair

Freisthler [48]

Good

Hussey et al. [49]

Good

Johnson-Motoyama et al. [50]

Good

Johnson-Motoyama [51]

Fair

Johnson-Motoyama et al. [52]

Good

Kimber et al. [53]

Good

Klein [54]

Good

Klein and Merritt [55]

Good

Lau et al. [56]

Good

Lee et al. [57]

Good

Molnar et al. [58]

Good

Putnam-Hornstein and Needell [59]

Good

Putnam-Hornstein et al. [60] Warner et al. [61]

Good Fair

of them were part of larger longitudinal studies. Service system reported samples all came from CPS and were utilized in 10 studies, both national (n = 4) and local (n = 6). Other studies used general population samples that had either national (n = 6) or local (n = 3) scope. Latinos were the focus in nine studies; Asian and immigrants from West Indies/Cape Verde were included in two other studies while the rest did not specify ethnicity or national origin of immigrants included in their samples. Most studies did not disaggregate immigrant groups by country of origin (such as Latinos grouped together), acculturation, legal status or other indicators. The majority of studies used a comparison group consisting of a general US-born population (n = 9) without referring to a racial composition of the sample. On the other hand, eight studies used a comparison group within the same ethnic group as an immigrant group while two other studies used both a general US population and ethnic group born in the US Of these, two studies disaggregated US-born groups by ethnicity. Overall maltreatment was assessed in six studies while CAN type was examined in 12 publications. Additionally, one study reported both overall CAN and CAN by type. Prevalence of Child Maltreatment Among Immigrants The twelve studies included estimates of the overall and/or by type CAN prevalence among immigrants (Table 1).

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Estimates of immigrants reported by a service system irrespective of CAN type and ethnicity ranged from 2.7 to 10.7 % (n = 3). All three studies came from California statewide CPS records but varied in time frame and national origin of the immigrant subsample. However, the prevalence rate for the general immigrant sample fell in between the two studies with Latino immigrants. Physical abuse, physical neglect, neglectful supervision, emotional abuse, and sexual abuse reports for immigrants within a reported service system ranged from 15 to 37 (n = 4), 0 to 4 (n = 4), 18 to 41 (n = 4), 0 to 27 (n = 4), and 2 to 22 % (n = 4) respectively. All the data came from two studies of the National Survey of Child and Adolescent Well-Being (NSCAW) (survey methodology as opposed to actual CPS counts) and contained either exclusively Latino samples (n = 3) or had a substantial proportion of Latinos in the overall study sample (n = 1). In fact, maltreatment estimates in the latter study and the one with Latinos using the same NSCAW sampling frame were very similar for all CAN types. Comparing the two NSCAW studies, the rates for physical abuse and sexual abuse significantly dropped in a more recent study but the rate for neglectful supervision increased. It was also possible to compare maltreatment rates for Latinos by citizenship status [44]. Foreignborn Latinos with US citizenship had higher rates of physical abuse but lower rates of neglectful supervision than either undocumented Latinos or Latinos with permanent residency, however, these differences were not statistically significant. Community estimates of physical abuse, physical neglect, neglectful supervision, emotional/psychological abuse, and sexual abuse for immigrants came from nine studies and ranged from 1 to 30 % depending on CAN type and population group. In contrast from the studies using CPS samples, community studies contained a greater variability in the construct measurement, geographic scope and study populations but looked at fewer forms of maltreatment. More specifically, the studies ranged from small local samples [47], to big national data [53, 56, 61] containing Latino (n = 2), Asian (n = 1), West Indies/Cape Verde (n = 1) and general immigrant samples (n = 1). Physical abuse measures containing a range of populations and severity dimensions resulted in the widest interval. For example, Asian immigrants experienced 2 % of severe physical abuse but 30 % of minor or less severe physical abuse nationally [56]. Another study using a combined form of severe and less severe physical abuse found that immigrants from West Indies and Cape Verde in Boston experienced 4.5 and 2.5 % of physical abuse respectively [47]. On the other hand, national physical abuse rates for the general sample of immigrants and Latino immigrants ranged from 13 to 17 % [53, 61]. Physical neglect, measured in two studies with Latino samples, containing items

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for lack of food security, medical neglect and lack of supervision was considerably higher (30 %) in a national study combining these items [53] rather than measuring them separately in one US state (16 %) [50]. Community estimates of immigrant emotional abuse came from one small local and a big national study and were fairly close in range (1 and 7 % respectively) [47, 53]. Estimates of sexual abuse were national, containing general immigrant and Latino immigrant samples, ranged from 7 to 11 % [53, 61]. Nativity and Child Maltreatment General Form of Maltreatment In six studies, the relationship between a general form of maltreatment and nativity was examined either in bivariate and/or multivariate analyses. This assessment was made by individual (n = 3) and aggregate (n = 3) studies. All data came from either local or statewide CPS records in California. Studies measured maltreatment by screened-in CPS referrals (i.e. calls to CPS that met initial screening-in criteria for further response) (n = 4), substantiations (i.e. disposition to whether there is enough evidence to deem a report as maltreatment) (n = 1) or both (n = 1). Bivariate analyses revealed that immigrants were significantly less likely to be present in service reporting systems (n = 3) than their ethnic (all Latino samples) counterparts or the US-born general population. These findings remained unchanged when statistical controls for SES were added. In addition, three aggregate level studies revealed similar results: areas with large concentration of immigrants either had significantly lower rates of CAN than areas with a small concentration of immigrants (n = 2) [54, 55] or no relationship existed between nativity and substantiated (n = 1) or screened-in CAN rates (n = 1) [48, 55]. One of the studies found no relationship between aggregate rates of nativity and screened-in CAN rates for Black and Hispanic children but White children experienced lower CAN rates living in neighborhoods with a higher concentration of immigrants [55]. Maltreatment Type Thirteen studies assessed the relationship between nativity and distinctive CAN types using bivariate and/or multivariate analyses. The majority of studies were individual (n = 12) while one was aggregate. There was a mix of community (n = 9) and service reporting (n = 4) samples. Maltreatment measures varied from CPS screened-in reports (n = 4), to the Parent–Child Conflict Tactic Scale (PCCTS) (n = 5), single-item (n = 3), and other (e.g. combination of several scales) (n = 1) measures. The

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majority of studies in this category contained complex probability sampling procedures to produce national estimates (n = 10) using a variety of data sources (e.g. the NSCAW, the National Latino and Asian American Study, the Fragile Families and Child and Adolescent Well-Being; see Table 2). Overall, the results in regards to the relationship between CAN type and nativity were mixed and varied by type of maltreatment and data source. Physical abuse was examined in 12 studies. With the exception of one small community study, all other studies were national. Some community studies (n = 3) found that immigrants had lower physical abuse than native-born while all CPS (n = 4) and two community studies found no differences between the two in the bivariate analyses. These studies contained Latino (n = 5), Asian (n = 1), West Indies (n = 1), Cape Verde (n = 1), and general immigrant samples (n = 3). On the other hand, two community studies, including Latino and general immigrant population, found that immigrants had higher rates of physical CAN than their US-born counterparts [49, 61]. Multivariate analyses came exclusively from the community studies (n = 6), which found that immigrants either had a lower propensity to maltreat (n = 4) or no differences existed (n = 2). First and second generation immigrants were no longer at a higher risk to be physically abused when multivariate controls were added [49]. The other study with higher rates for Latino immigrants compared to US-born Latinos did not conduct a multivariate analysis and while, similarly to the other studies, it had a probability sampling strategy to produce national estimates its measures were retrospective single-item measures with long referent period [61]. Two forms of neglect, physical (n = 7) and neglectful supervision (n = 6), were examined in both community (n = 3) and CPS (n = 4) data. With an exception of one large community study in one state, all other data were national. The community studies found that immigrants, primarily Latinos or the general immigrant population, had higher rates of physical neglect (n = 3) and neglectful supervision (n = 2) that remained present after multivariate controls were added. In particular, Latino immigrants were at risk for not having enough food at home, not being able to take a child to a doctor when needed and leaving a child in unsafe places compared to US-born Whites [50]. In addition, the 1st generation immigrants had significantly higher risk for lack of supervision, lack of food and medical attention to child’s needs when compared to the USborn population [49, 53]. In contrast to community studies, CPS data found that immigrants, primarily Latinos, had either lower (n = 2) or non-significantly different (n = 2) rates of physical neglect from and similar rates of neglectful supervision (n = 4) to the US-born population. These studies were bivariate without controls for SES.

Emotional or psychological abuse (EA) was examined in seven studies included in this review. Bivariate results were mixed: immigrants were at a lower risk for EA in community studies (n = 3) but were at a higher (n = 1) or similar (n = 3) risk in CPS studies using the national NSCAW data. Two national community studies that employed multivariate analyses found that immigrants, in particular Latino immigrants compared to US-born Latinos and 1st generation immigrants compared to US-born, were at a lower risk for EA [53, 57]. On the other hand, 2nd generation immigrants did not vary from the US-born population [53]. CPS samples did not use multivariate analysis and it is unclear if increased risk for the general immigrant population found in the bivariate analysis would have remained had the SES controls been used [45]. Seven national studies using both CPS (n = 4) and community (n = 3) samples examined sexual abuse (SA) among immigrants. The results were mixed. CPS data from the first NSCAW study found that immigrants, in particular Latino immigrants and the general immigrant population, were at a higher risk for SA compared to the US-born population [45, 46]. The second NSCAW study, however, did not find that Latino immigrants were a higher risk for SA compared to US-born Latinos [44]. Community studies found that Latino immigrants and the first generation of immigrants were at a lower risk for SA compared to USborn Latinos and the general US-born population (n = 2) respectively [53, 57, 61] but no advantages were found for the 2nd immigrant generation (n = 1) [53]. Assessment of Methodological Rigor Although studies varied in the methods used, the majority had good methodological quality while three studies were rated as fair. All studies with lower methodological rigor came from community samples, including one national study. Across all studies, the greatest risks to the methodological quality were selection bias, threat for measurement error and lack of controls employed. Few studies included immigrant related indicators and many survey studies failed to report their response rate, which increased the risk for selection bias. Only two studies utilizing survey methodology used protections to collect information pertaining to maltreatment, thus, increasing the measurement error. Six studies did not employ control variables in the analyses. In contrast, all studies had low analytic bias.

Discussion This systematic review provides an examination of the relationship between nativity and child maltreatment. Collectively, the findings are rather mixed. There seems to

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be a strong support for presence of a HIP for a general form of CAN using individual level CPS data in that immigrants are at a lower risk for CAN than similar or lower risk (from SES perspective) US-born population. Evidence from the aggregate level CPS studies suggests that there may be advantages in living in areas with high concentration of immigrants for all children. The evidence with regards to PA based on CPS and community studies is strong and convergent in showing immigrants to be at a lower or equal risk for PA compared to non-immigrants controlling for SES. These studies found that Latino, Asian, and the general immigrant population were at a lower risk for PA compared to US-born Latinos, US-born Asians and the general US-born population respectively. In addition, Latino immigrants were at a lower risk for PA compared to US-born Whites and US-born Blacks. With regard to neglect, the data are less clear. While immigrants are at a lower or similar risk for physical neglect (PN) and neglectful supervision in the CPS system even before SES is controlled, community studies indicate that immigrants may be at a higher risk for the two forms of neglect. Community studies found that Latino immigrants compared to US-born Whites and the first generation of immigrants compared to US-born remained at risk for lack of food, medical neglect and lack of supervision even after income was held constant [49, 50, 53]. While food insecurity due to poverty reasons is not considered maltreatment by many jurisdictions, intentional withholding or chronic lack of food in presence of other psychosocial problems and/or family dynamics may warrant CPS involvement [6]. Although measures used in these studies do not allow determining whether these cases would be deemed as maltreatment by CPS, the findings, however, indicate that immigrants are at a high risk for neglect. Interestingly, the above studies also found that the second generation of immigrants was no longer at risk for neglect when other factors were controlled for [49, 53]. This suggests that economic difficulties are considerably more acute in immigrant families with immigrant children than in immigrant families with children born in the US, partly due to social and medical assistance programs’ eligibility and partly due acculturation and structural difficulties [14, 62]. These findings also suggest that the effect of poverty in immigrant families may be more direct than it is in USborn families. With regard to EA, the overall evidence is suggestive of HIP. Community data found immigrants (Latinos and 1st generation of immigrants) to be at a lower risk for EA than their native counterparts controlling for SES. In CPS data, immigrants were either at a similar or higher risk for EA when examined bivariately, and it is impossible to determine if the higher risk found in one study would remain after controlling for SES. Evidence for SA is less clear but

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still suggestive of HIP. With the exception of two CPS studies with earlier NSCAW data, most recent NSCAW data and all community studies suggest that immigrants are at a lower or equal risk for SA compared to US-born population with or without SES controls. Studies using data from the first NSCAW survey found that Latino immigrants and the general immigrant population were significantly at a higher risk for SA in the bivariate analyses. Again, it is not clear if the risk would have changed if SES was held constant. The review showed that there was little variation in studies’ findings by immigrants’ ethnicity/race and a comparison group although few studies with samples other than Latinos prevent making these conclusions firm. Only one study in this review looked at immigrants’ legal status [44]. The finding of this study that foreign-born Latinos with US citizenship had higher rates of PA but lower rates of NS than legal residents and undocumented Latinos is consistent with the overall findings from other studies, suggesting that over time immigrants resemble the USborn population. Likewise, only one study disaggregated Latinos by country of birth, and found that Mexican immigrants had the strongest protective advantage among all Latino groups [52], consistent with prior studies [14, 36]. Overall, this review suggests that the HIP found in health literature can be extended to a general form of child maltreatment and physical abuse in the US Studies using CPS and community data suggest that immigrant (mostly Latino) parents may have lower propensity to maltreat their children when compared to US-born families. The data are also suggestive that the HIP may extend to emotional and perhaps to sexual abuse among immigrants. What is unclear currently is the degree to neglect is or is not consistent with the HIP. Lower rates of neglect found in CPS studies but higher rates found in population studies suggest that underreporting for immigrants could be a substantial concern. Mixed results for physical neglect are inconsistent with child health outcomes but consistent with national household studies showing immigrants to be at a higher risk for food insecurity [37]. Theoretically, the study results suggest that poverty is more likely to have a direct effect on maltreatment in immigrant families as opposed to being mediated through decreased capacity to care and impulse control, more commonly associated with other forms of maltreatment that were more prevalent among US-born families. The major limitations of this study include a small sample size and lack of multivariate controls in a number of studies of this review, which prevented making stronger conclusions regarding the presence of HIP for specific CAN types. Another limitation is reliance on a small number of data sources. The possibility of selection bias

J Immigrant Minority Health

also could not be ruled out. By limiting inclusion to published data, a number of unpublished manuscripts were excluded, resulting in publication bias. The small number of studies that included immigrant related indicators prevented testing effects of acculturation and legal status as well as understanding external validity of the results. Lastly, lack of reporting and availability of ethnicity information limit understanding whether the findings pertain across different immigrant ethnic groups, given heterogeneity in outcomes of prior studies [63, 64]. Despite these limitations, the study contains a number of strengths. This is the first known systematic review to synthesize empirical evidence regarding the HIP in relation to child maltreatment. The study included both service system and population level data allowing assessment of the degree of visibility bias. Lastly, the use of the PRISMA statement and the methodological assessment assured that the study followed the highest methodological standards and assessed risk of bias by individual studies.

Conclusions While these findings provide an initial picture of child maltreatment epidemiological trends among immigrants, more studies are needed to continue tracking maltreatment among this population. National studies provide an ideal means of generating generalizable findings, but it is important to understand the degree to which studies generally believed to be nationally representative do, in fact, adequately represent various immigrant subpopulations. For example, although the NSCAW sampling frame includes those US states containing the largest number of immigrants, some socio-demographic characteristics (e.g. language use and comfort with English) of immigrants in the NSCAW are not nationally representative in comparison to the Census data questioning the external validity of the studies’ findings [10]. Studies are needed with more recent cohorts of immigrants given that 35 % of the US foreign-born population arrived in or after 2000 [10] prior to the sampling frame of many studies. Given methodological limitations that exist in all types of study design, both service reporting and community samples are needed to answer questions about immigrants’ risk for and propensity to maltreat. When possible, longitudinal methods should be selected to study the HIP, allowing us to follow behavioral change over time. Future research should determine if the HIP pertains equally across different maltreatment types, immigrant racial and ethnic groups, and various community settings and social contexts. Work including immigrant groups other than Latinos, especially Mexicans, is particularly needed. Many questions remain: Does the HIP pertain only to newly arrived immigrant

populations or also to those who have lived in this country for a while but maintained traditional practices? If yes, what are those traditional practices that help maintain healthy behaviors? How long does it take before healthy behaviors start to deteriorate? While general theories to explain the HIP have been proposed [35], specialized theories to explain why some ethnic immigrant groups show the HIP for certain outcomes (including maltreatment) while other groups do not also need to be developed. Acknowledgments This research was supported by National Quality Improvement Center on Differential Response in Child Protective Services doctoral dissertation award through Administration of Children and Families, Department of Health and Human Services and the Brown Center for Violence and Injury Prevention, Washington University in St. Louis, doctoral fellowship (R49CE00151001) through Centers for Disease Control and Prevention. Opinions expressed in the study do not necessarily reflect those of the funders. The author is grateful to Dr. Brett Drake from the Brown School of Social Work, Washington University in St. Louis, for his comments throughout the development of this manuscript.

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The Healthy Immigrant Paradox and Child Maltreatment: A Systematic Review.

Prior studies suggest that foreign-born individuals have a health advantage, referred to as the Healthy Immigrant Paradox, when compared to native-bor...
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