Nearly 5.5 million children between the ages of 0–5 in the US have at least one immigrant parent, and 22% of these children live below the poverty line. Emerging research highlights the importance of examining the neighborhood- and parenting-level risks and resources that are most impactful for young children of immigrants’ social development. Using a subsample of 3–5-year-old children (N = 1134) from the National Survey of Children’s Health (CAHMI, 2018), this study tested a conceptual model of cross-level interactions between neighborhood socioeconomic status (SES), behavior problems and flourishing in young children who have at least one foreign-born parent. Structural equation modeling results suggested an indirect effect of neighborhood SES on child flourishing and behavioral problems through neighborhood- (collective efficacy, resources) and parent-level characteristics (mental health, aggravation, parent-child interaction). The relations between neighborhood structure and child outcomes were fully mediated by parenting. Specifically, disadvantages in neighborhood structure had significant direct effects on parental mental health, parenting aggravation, and parent-child interaction, which explained relations between neighborhood structure and child outcomes. Results point to future research areas and potential policy and prevention interventions at neighborhood and parental levels.
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The ecological systems theory asserts that children are affected by several interacting proximal and distal social influences and environments—called ecologies (Bronfenbrenner & Morris, 2006). Of these ecologies, the conditions of children’s neighborhoods, in particular, strongly influence developmental outcomes (Leventhal et al., 2015). Compared to children with US-born parents, children with foreign-born parents disproportionately live in economically-strained, low-resource neighborhoods (Batalova et al., 2020; Huang & King, 2018). Living in a low socioeconomic status (SES) neighborhood is a well-established contributor to adverse development (Chase-Lansdale et al., 1997; Johnson et al., 2013; Lara-Cinisomo et al., 2013; Leventhal et al., 2015; Shonkoff et al., 2009). Nonetheless, the specific mechanisms through which neighborhood SES affects children of immigrants and their immediate ecologies (e.g., parents) are unclear. Further, although individual factors that may offset poverty-related risk are studied (e.g., Crouch et al., 2022; Wherry et al., 2016), the specific characteristics of young children of immigrant’s ecologies and mechanism of how they affect each other are understudied. Identifying specific factors within the ecologies children interact with daily, particularly their neighborhoods and homes, may clarify the relation between neighborhood SES and children’s health.
Using a subsample from the National Survey of Children’s Health (Child and Adolescent Health Measurement Initiative; CAHMI, 2018), this study tested a conceptual model of direct and indirect neighborhood SES effects on preschool-aged children who have at least one foreign-born parent (Fig. 1). The developmental outcomes of interest in this study were young children of immigrants’ flourishing, which involves emotion regulation, goal pursuit, and interest in learning (Bethell et al., 2019), and behavioral problems. The proposed model integrates two key ecologies—neighborhood and family—and includes characteristics that could act as risk or promotive factors in one cohesive model to examine the interactive and compounding influences of neighborhood disadvantage on children and offer specific targets of prevention, intervention and policy change. Specifically. we identify patterns of risk and promotive factors from neighborhood (i.e., structure, resources, safety) and parental (i.e., mental health, aggravation, interaction) ecologies as indirect pathways through which SES influences young children of immigrants’ behavior and flourishing.
Fig. 1
Conceptual model of direct (sold lines) and indirect (dashed lines) neighborhood socioeconomic status effects on preschool-aged children of immigrants’ flourishing and behavioral problems
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Young Children of Immigrants in the United States
Accounting for 26% of the 70 million children in the United States, nearly 18 million children in the US have at least one immigrant parent (Migration Policy Institute, 2019). The majority of these children (88%) are US-citizens. Nearly 5.5 million (24.3%) children of immigrants are between the ages of 0 and 5 (Migration Policy Institute, 2019). Emerging evidence suggests that having a foreign-born parent is a determinant of children’s health (Castaneda et al., 2015; Rojas-Flores & Vaughn, 2019) that is associated with heightened risk of living in poverty (Batalova et al., 2020). Indeed, children of immigrants make up roughly 30% of the nation’s low-income children (Children’s Defense Fund, 2017). The combination of parental nativity and poverty have the potential to negatively impact development during the pivotal developmental stage of early childhood.
Compared to native children, children with foreign-born parents appeared substantially more impacted by the presence of risk factors such as neighborhood disadvantage (Pong & Hao, 2007). For example, in a sample of 1040 youth, despite all living in low-income neighborhoods, adolescents with foreign-born parents had higher levels of internalizing behaviors compared to those with native-born parents (Lara-Cinisomo, Xue, & Brooks-Gunn, 2013). Heightened susceptibility may be due to immigrant parents’ cultural preferences for informal care (Brandon, 2004; Fuller-Thomson & Minkler, 2007), the experience of cultural barriers when attempting to access formal care (Buriel & Hurtado-Ortiz, 2000), misunderstandings regarding the government-sponsored programs children qualify for due to precarious parental legal status (Suarez-Orozco & Suarez-Orozco, 2015), and perceived immigration threat (Barajas-Gonzalez et al., 2022; Ursache et al., 2022). Parental perceived immigration threat in the neighborhood for example, has been linked to lower self-regulation and greater overanxious behaviors among preschool-aged children of immigrants (Barajas-Gonzalez et al., 2022). More specifically, the higher the perceived threat of immigration enforcement, the more fear and separation anxiety these young children demonstrated. Given that children of immigrants are estimated to comprise 50 million of the 117 million people added to the US-population by 2050 (Passel & Cohn, 2008), it is essential to develop a more nuanced understanding of children of immigrants’ emotional and mental health and interacting ecological domains that impact it.
Theoretical Frameworks for Understanding Ecological Influences on Development
There are two primary theoretical frameworks that inform this study: ecological systems theory and the integrative model for the study of competencies in minority children. Bronfenbrenner and Morris’ (2006) ecological systems theory provides a useful framework for understanding the influence of children’s various interacting ecological domains—neighborhoods and parenting—on development. The ecological systems theory emphasizes person-context interactions wherein the child’s individual characteristics influence and are influenced by the ecologies in which they develop. For example, being a child with immigrant parents influences their neighborhood of residence by increasing the likelihood of living in a low-income and low-resource neighborhood (Batalova et al., 2020). At the same time, children’s ecologies have a reciprocal influence upon children. The level of parental engagement for example, has a profound impact on children’s behavior (Dallaire et al., 2006). Finally. these systems contribute to development in a transactional manner wherein ecologies offer risk or promotive characteristics that influence other ecologies. For example, using a nationally representative sample of urban families, Ma & Grogan-Kaylor (2017) found interactions between neighborhood collective efficacy, parental punishment, and children’s behavior problems.
Garcia Coll and colleagues’ (1996) integrative model for the study of competencies in minority children expands the socioecological model by emphasizing the core role of culture, race, and discrimination. The integrative model posits that social position variables such as race, culture, and ethnicity indirectly create segregated environments (e.g., neighborhoods) through social processes such as racism and discrimination. These environments are segregated in that they include different proportions of inhibiting and promotive characteristics. Due in part to the nativity of their parents, children of immigrants tend to live in impoverished neighborhoods (Batalova et al., 2020). Impoverished neighborhoods structurally tend to contain fewer promotive characteristics like parks, libraries, and community centers (Wen et al., 2003). At the same time, these neighborhoods also have inhibiting characteristics such as reduced safety due to racial policing, gang activity, and immigration enforcement (Deane et al., 2020). Finally, though not a focus of the present model, children of immigrants often experience marginalization and exclusionary policies such as racial profiling within their communities (Ayón, 2015). The integrative model in the present study evaluates neighborhood structure discrimination by including characteristics at the neighborhood and parenting level that are promotive if present and contribute to risk if absent (e.g., resources, safety, collective efficacy).
Neighborhood SES
Though it is much more limited among immigrant populations, there is substantial literature demonstrating the relation between neighborhood financial disadvantage and childhood development. Low neighborhood SES is associated with poorer social, emotional, and behavioral development in children (Leventhal et al., 2015). In one of the few studies of SES effects in young children of immigrants, preschool-aged children of immigrants with high levels of economic and immigration stress exhibited more behavioral problems (Mendoza et al., 2017). Similarly, low-income immigrant parents reported high levels of immigrant threat, which were then associated with problems in their preschool-aged children’s self-regulation skills (Barajas-Gonzalez et al., 2022). Given that children of immigrants are disproportionately likely to reside in low-SES neighborhoods (Children’s Defense Fund, 2017), additional research is warranted to identify the means through which neighborhood SES influences children of immigrants’ flourishing and behavioral problems.
Neighborhood Structure
Neighborhood SES influences structural conditions including access to resources and safety. For example, living in an economically-limited neighborhood limits children’s access to early childhood care and other forms of high-quality services (Johnson et al., 2013). However, it remains unclear which specific structural characteristics of low-SES neighborhoods contribute to risk or resilience in children of immigrants and how these characteristics might interact with other ecologies to influence behavior and flourishing. A theoretical framework proposed by Leventhal & Brooks-Gunn (2000) offers direction for isolating specific neighborhood characteristics, and accordingly, informed the present study’s conceptualization of neighborhood structure. They identified institutional resources, relationships, and norms and collective efficacy, as three important neighborhood structure characteristics that influence children’s experiences with their neighborhoods.
First of Leventhal and Brooks-Gunn’s (2000) neighborhood structure characteristics - institutional resources - are the formal (e.g., early childhood education) and informal (e.g., social groups) resources available to residents (Leventhal & Shuey, 2014). Among immigrant children, greater access to neighborhood resources (e.g., youth services) has been found to be associated with lower levels of internalizing problems (e.g., fear and anxiety; Leventhal & Shuey, 2014). When evaluating neighborhood resources, barriers to access are also influential. Research indicates that perceptions of neighborhood safety can impact the actual utilization of institutional resources (see McCormack et al., 2010 for review). For example, in a study of structural barriers to physical activity among female immigrants, lack of facilities and safety concerns were identified as prevalent barriers (Evenson et al., 2002). Additionally, detracting elements in one’s neighborhood (e.g., graffiti, litter, etc.) can reduce perceptions of safety (McCormack et al., 2010; Veitch et al., 2006) and accordingly, reduce familial use of available resources. For households that include foreign-born members, risks associated with heightened immigration enforcement are equally important deterrents (see Barajas-Goznalez, 2021). In times of restrictive, anti-immigrant sociopolitical climate, even immigrant parents who are in the US legally fear contact with immigration enforcement officials. As a result, many choose to isolate themselves and their families as much as possible (Garcia et al., 2020; Vargas et al., 2017) and often do not access safety net services for their citizen preschoolers (Barajas-Goznalez, 2021).
The second characteristic of importance is relationships. Relationships in the neighborhood include access to social support and relational ties, which can serve a protective function against childhood mental health problems (Leventhal & Shuey, 2014). Among Chinese children of immigrants for example, teacher-child relationships were protective against behavior problems (Ly & Zhou, 2018). Relationships and ties also impact children indirectly through their parents. High perceived levels of parental social support for example, have been shown to mediate risks associated with inadequate resources among Hispanic children of immigrants (Johnson-Motoyama & Wu, 2018).
Finally, Leventhal and Brooks-Gunn (2000)’s neighborhood norms and collective efficacy involve a sense of social cohesion and shared values within one’s neighborhood (Leventhal & Shuey, 2014). Among a national sample of 3- and 4-year-old children not stratified by parental nativity, this perception of neighborhood unity and trust appeared to be protective against behavioral problems among children living in poverty (Ma & Klein, 2018). Among Latinx children with immigrant mothers, food insecurity was higher when mothers perceived low social cohesion (Denney et al., 2018).
In sum, institutional resources, relationships, and norms/collective efficacy are proposed as potential mechanisms through which neighborhood SES operates on young children of immigrants. Theoretically, these neighborhood structure characteristics may have a direct influence on children’s behavior and flourishing while simultaneously influencing them indirectly through their parents.
Parenting Characteristics
In addition to considering neighborhood-level characteristics, the present study’s model also includes parent-level characteristics as mediators of the relation between neighborhood SES and young children’s behavior and flourishing. Models of food insecurity in children of immigrants have identified connections between neighborhood and parental ecologies as key mediators of the effects of neighborhood SES. Specifically, Denney and colleagues (2018) found evidence of a “disadvantage paradox,” wherein families in the most disadvantaged communities had surprisingly lower rates of food insecurity compared to those in less disadvantaged neighborhoods. They suggested that parent-level factors such as accessing informal supports interrupted detriments that would otherwise be associated with neighborhood-level risk.
To identify how parenting characteristics are associated with child outcomes, their effects on children of immigrants’ behavior and flourishing are modeled in two ways in this study: (1) direct paths between parenting characteristics (i.e., parental mental health, stress, and parent-child interaction) and child outcomes; (2) cross-level interactions between neighborhood structure and parenting on child outcomes, with parenting acting as a mediator between neighborhood characteristics and children of immigrants’ behavior and flourishing.
Parental Mental Health
According to Masarik and Conger’s family stress model (2017) living in a low-SES neighborhood, as many immigrant families do, is associated with economic stress that can compromise parental mental health. Financial strain creates household economic pressures and may lead to food insecurity and housing instability which contribute to parental psychological distress, depression, and anxiety (Neppl et al., 2015; Newland et al., 2013; Nievar et al., 2014). Detriments to parental mental health can subsequently affect parenting and impact children’s development (Masarik & Conger, 2017).
Parenting Stress
Economic stress can also exacerbate parenting stress, defined as negative feelings toward the self and child(ren) associated with parenting demands. There has been increased recognition of the relation between parenting stress and children’s externalizing behavior problems through parenting (Neppl et al., 2015). Specifically, parental stress heightens the risk for harsh parenting, abuse, and neglect, which is associated with behavioral problems including attention challenges (e.g., difficulty sitting still) and aggressive behaviors (e.g., hitting; Neppl et al., 2015). Alternatively, efforts to reduce parental stress and improve parental mental health are associated with increased resilience and flourishing in children despite the level of adversity they may be facing (see Garner & Yogman, 2021).
Parent-Child Interaction
Low neighborhood SES and associated economic strain can also influence parent-child interaction. For example, among young children of immigrants specifically, living in poverty reduced the amount of developmental stimulation parents gave to their children and the presence of learning materials in the home (Yoshikawa, 2011). Alternatively, there is evidence supporting the benefits of promoting positive practices (e.g., parental warmth and monitoring) among parents of young children (Patrick et al., 2005; Webster-Stratton, 1998). For example, warm and sensitive parenting, provision of stimulating materials and social environments, and consistent responsive interaction support development (Bradley et al., 2014). Nonetheless, little is known about the association between parent-child interaction, child flourishing, and behavioral problems among community samples of young children in low-income immigrant families.
The Current Study
In this study, we use a nationally representative sample of 3-to-5-year-old children with at least one foreign-born parent to identify specific characteristics from neighborhood and parental ecologies as pathways through which SES influences flourishing and behavior (see Fig. 1). The means through which living in a low-income neighborhood influences young children’s ecologies, flourishing, and behavioral problems have not been explored using an integrative pathway model, namely, one that incorporates neighborhood SES, multiple ecologies, and positive and negative developmental outcomes. As such, the aims of the current study were to identify: (1) What is the relation between neighborhood SES and children of immigrants’ flourishing and behavioral problems? (2) What are the relations between neighborhood characteristics and parenting? (3) Which parenting characteristics are associated with child outcomes? and (4) How do neighborhood structure and parenting mediate the relation between neighborhood SES and child outcomes? We hypothesize:
1.
a positive direct effect between neighborhood SES and flourishing (H1a) and a negative direct effect with behavioral problems (H1b) in children of immigrants.
2.
a positive direct effect between neighborhood structure characteristics and parental mental health (H2a), a negative direct effect with parenting stress (H2b), and a positive direct effect with parent-child interaction (H2c).
3.
a positive direct effect between parenting characteristics and flourishing (H3a) and a negative direct effect with behavioral problems (H3b) in children of immigrants.
4.
an indirect effect of neighborhood structure on children of immigrants’ flourishing (H4a) and behavioral problems (H4b) through parenting characteristics.
5.
an indirect effect of neighborhood SES on children of immigrant’s flourishing (H5a) and behavioral problems (H5b) through neighborhood structure and parenting.
Method
Archival Data Source
The 2016 National Survey of Children’s Health (NSCH) is a cross-sectional survey of households in the US with at least one child under the age of 18 (CAHMI, 2018). The NSCH provides a wide range of data related to children’s lives including mental health, access to resources, and ecological context. All data in the NSCH were provided by a single informant—the parent/caregiver of the identified child and collected through mail and web-based surveys by the Census Bureau, Associate Director for Demographic Programs on behalf of the US Department of Health and Human Services (HHS), and the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB) between June 2016 and January 2017. Survey developers oversampled households with children and households in high poverty blocks. Of those invited to participate in the NSCH, the estimated proportion who completed the topical questionnaire was 33.0% (United States Department of Commerce, 2018). Permission was secured from the Data Resource Center for Child and Adolescent Health to access and utilize the 2016 NSCH data and codebook for the purposes of this study.
Current Study Sample
An analytic subsample of 1134 US-citizen children aged 3–5 years with at least one foreign-born parent was drawn from the NSCH for the purposes of this study. Children with a diagnosed neurodevelopmental disorder (e.g., Autism, Pervasive Developmental Disorder, etc.) were excluded from the study because neurodevelopmental disorders are chronic conditions with early onset that often require lifelong care and increase the demand placed on parents (Baxter et al., 2015; Croen et al., 2006). This points to an important area of future study. Full inclusion criteria are provided in Fig. 2. The children in the present sample were relatively balanced across ages (32.8% age 3; 34.4% age 4; 32.8% age 5) and gender (57.1% female). Ethnically, children were identified by their parents as primarily as Hispanic (27.5%), Caucasian (26.5%), or Asian (25%) followed by Other/Multiracial (14.2%), and Black (6.7%). Of the parents/caregivers who completed the questionnaire on behalf of the selected child, 57.1% were female with a mean age of 37.89 years. Parental ethnicity data and country of origin were not available through the NSCH dataset. This study was exempt from review by the Human Subjects Review Committee because the data set was deidentified and publicly available.
Fig. 2
Current sample inclusion criteria
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Measures
Data for the current study were drawn from the NSCH, therefore, the decision of which variables to examine from each context was practically driven, based on NSCH items, as well as theoretically driven based on literature operationalizing constructs similarly and supporting the variables’ contribution to development. Given the NSCH’s focus on child health in general and physical health in particular, the breadth and depth of concepts related to concepts such as parental mental health, child flourishing, and child behavior are limited. Accordingly, the measurement of certain concepts used in the present study is constrained by survey limitations and may not fully capture all aspects of that concept. Acknowledging this challenge, we have used combinations of NSCH items that have been used or validated in previous studies whenever possible. All indicators have been used in the same or similar format in existing literature examining children’s health and wellbeing (e.g., Bethell et al., 2019; Singh et al., 2010). The following NSCH items (CAHMI, 2018) were included:
Demographics
Respondents of the survey reported the child’s sex, age, and race/ethnicity. Parent(s) reported their own age, sex, and place of birth (in or out of the US).
Neighborhood SES
By virtue of the NSCH’s design and sampling strategy, the present study’s sample inherently consisted of families in low SES neighborhoods. Stratifying the participants by poverty level further nuanced this sample. The variables household income and household size were combined to form the Family Poverty Level (FPL) for the child’s household. Households were divided into 4 categories derived from the Census Bureau’s 2015 poverty thresholds which are updated yearly, accounting for changes in cost of living: 0–99% FPL, 100–199% FPL, 200–399% FPL, and 400% FPL and greater. A family whose before-tax income was less than the identified threshold was classified as living in poverty. In 2015, the poverty threshold for a family of 4 was $24,350 and the threshold for a family of 6 was $32,570.
Neighborhood structure
Informed by the neighborhood characteristics identified by Leventhal and Brooks-Gunn (2000), neighborhood structure characteristics in this study were resources (including perceptions of safety), relationships, and norms/collective efficacy.
Resources
Neighborhood resources were assessed based on parental responses to four yes (1) or no (2) questions about the presence of resources including sidewalks, playgrounds, recreation centers, and libraries. Responses were recoded to yes (1) and no (0) and summed making higher scores reflective of a greater number of neighborhood resources. Parents responded to three yes (1) or no (2) questions about the presence of neighborhood detracting elements including litter or garbage, poorly kept or rundown housing, and vandalism. Responses were recoded to yes (0) and no (1) and summed making higher scores reflective of a lower number of detracting elements. To assess perception of neighborhood safety, parents indicated their level of agreement with the statement, “This child is safe in our neighborhood.” Responses were rated on a Likert-type scale ranging from definitely agree (4) to definitely disagree (1) with higher scores indicating higher levels of perceived safety.
Relationships and norms/collective efficacy
Relationships and norms within the neighborhood were collectively assessed based on based on parental responses to three items. Parents rated to which extent they agreed with the following statements: (1) people in my neighborhood help each other out, (2) we watch each other’s children in this neighborhood, and (3) when we encounter difficulties, we know where to go for help in our community. Responses were rated on a Likert-type scale ranging from definitely disagree (1) to definitely agree (4) with higher scores indicating higher levels of perceived relationships and collective efficacy in the neighborhood.
Parenting characteristics
The parenting characteristics assessed in the current study included parental mental health, parenting aggravation, and parent-child interaction.
Parental mental health
Parental mental health was assessed through parental response to the self-rated mental health item, “In general, how is your mental and emotional health?” Responses were based on a five-point Likert scale ranging from excellent (1) to poor (5). Scores were reverse coded where high scores reflected better mental health. Though this item has been used as an indicator of mental health across national and local surveys (i.e., Ahmad et al., 2014), it is a single item and as such, results must be interpreted with caution.
Parenting stress
Parenting stress was assessed through parental response to three items. Parents rated how often in the past month they felt: (a) that this child is much harder to care for than most children his or her age, (b) that this child does things that really bother you a lot, and (c) angry with this child from never (1) to always (5). High scores indicated high parenting stress. These items are part of the Aggravation in Parenting Scale, which was originally derived from the Parenting Stress Index (Abidin, 1990). They have been used in several national surveys, including the National Survey of America’s Families (NSAF), and empirical studies with children (e.g., Herbell et al., 2020).
Parent-child interaction
Parent-child interactions were assessed based on parental report of the number of days during the past week they or other family members: (a) read to this child, (b) told stories or sang songs to this child, and (c) ate a meal together. Response options were 0 days, 1–3 days, 4–6 days, and every day. Though not part of a validated measure, these three items have been used in other empirical studies of the effects of poverty on interactive caregiving practices (e.g., Crouch et al., 2022; Nomaguchi & Johnson, 2016).
Child flourishing
Child flourishing was assessed as a latent construct based on parental responses to seven questions. In the first set of four questions, which are part of the Child Flourishing Index (Bethell et al., 2019), parents were asked to report how well each phrase (e.g., this child is affectionate and tender with you) described their child from definitely true (1) to not true (3). To assess flourishing in social relationships outside of the parent-child relationship, parents were then asked a series of three questions about children’s ease with making friends (e.g., how much difficulty the child has making or keeping friends) from a lot of difficulty (1) to no difficulty (3). In the final two questions, parents were asked to report how often their child (a) plays well with others and (b) shows concern when others are hurt or unhappy from all of the time (1) to none of the time (4). Scores were reverse coded for each question so that high scores reflected a high level of parent-reported child flourishing.
Child behavior problems
The prevalence of childhood behavior problems was assessed as a latent construct based on parental response to seven questions about their child’s behavior (e.g., easily distracted, loses control of temper, etc.). Responses were rated on a Likert-type scale ranging from all of the time (1) to none of the time (4). Where necessary, responses were reverse scored with high scores reflecting a high incidence of parent-reported child behavior problems.
Analytic Strategy and Data Cleaning
Analytic strategy
We used structural equation modeling (SEM) to examine the proposed model, in which we considered both neighborhood-level (i.e., structure), and parental-level characteristics (i.e., mental health, stress, and parent-child interaction), highlighting direct and indirect pathways through which neighborhood SES effects operate on young children. Within the full structural model, we tested the independent direct effects of SES (H1a,b) and parent-level characteristics (H3a,b) on both children’s behavior and flourishing. We also tested the direct effect between neighborhood structure and parent-level characteristics (H2a,b,c). Moreover, we included two indirect effects within the full model. The first indirect effect was that of neighborhood structure on child outcomes through parenting (H4a,b). We also included the indirect effect of neighborhood SES on child outcomes through both neighborhood structure and parenting (H5a,b).
All statistical analyses were conducted using Mplus (Version 7.4, Muthén & Muthén, 2015). The structural equation modeling (SEM) process in this study included two steps for validating the measurement model and the SEM. First, the measurement model was evaluated using confirmatory factor analysis (CFA) to define latent variables. Once the relationship between latent factors and their indicators was established, the full structural model incorporating the expected direct and indirect pathways between neighborhood SES, neighborhood structure, parenting, and child flourishing and behavioral problems was tested.
All models were evaluated based on the comparative fit index (CFI), standardized root-mean-square residual (SRMR), and root-mean square error of approximation (RMSEA). A CFI of a minimum of 0.90 or 0.95 was considered acceptable (Hu & Bentler, 1999). General guidelines for the SRMR and RMSEA recommended values of less than 0.08, and ideally below 0.05 (Hu & Bentler, 1999; Kline, 2005). Examining statistical fit through the chi-square goodness-of-fit tests was not recommended given these tests tend to be inflated by large sample sizes, making it challenging to achieve a non-significant chi-square statistic under most circumstances (Hu & Bentler, 1999).
Missing data
The NSCH (CAHMI, 2018) developers imputed a small number of variables in the dataset for use in weighting and estimation of the FPL (see CAHMI, 2018). Race, ethnicity, and sex of the identified child were imputed using hot-deck imputation (CAHMI, 2018). Household size and total family income were multiply imputed through sequential regression modeling imputation.
In the current study sample, the missing rate in item-level data was less than 1%. Given the low level of missing data, the data were assumed to be missing completely at random (MCAR; (Little, 2013). Missing data were addressed through the default full information maximum likelihood (FIML) in Mplus when estimating all relevant models. FIML has been identified as appropriate in the case of data MCAR because it shows less bias compared to other methods such as deletion or imputation by mean replacement (Enders, 2001).
Results
Confirmatory Factor Analyses
Confirmatory factor analyses (CFAs) were conducted for each latent construct in the proposed model. When necessary, item parceling was utilized to create more parsimonious models, reduce sources of sampling error, and reduce the likelihood of correlated residuals (Little et al., 2002). Table 1 contains standardized and unstandardized factor loadings for each latent construct. All factor loadings of each observed variable to underlying latent constructs were statistically significant (p < 0.001) and substantive with most loadings larger than 0.45 and factor loadings in the anticipated direction. All CFAs terminated normally, with the following fit index ranges across all models, CFI: 0.98–1.00, RMSEA: 0.000–0.052, SRMR: 0.014–0.039. Thus, the hypothesized latent factor structures appeared reasonable with close fit to the data.
Table 1
Confirmatory factor analyses standardized and unstandardized factor loadings for total sample
Constructs and Indicators
Standardized factor coefficients
Unstandardized factor coefficients
Neighborhood structure
People in my neighborhood help each other out
0.85 (0.02)
3.27 (0.62)
We watch each other’s children in this neighborhood
0.80 (0.02)
3.48 (0.66)
When we encounter difficulties, we know where to go for help in our community
0.63 (0.03)
2.75 (0.52)
Sum of neighborhood resources
0.17 (0.03)
1.00 (0.00)
*This neighborhood is safe/Sum of detracting elements
0.52 (0.03)
1.30 (0.26)
Parenting aggravation
This child is much harder to care for than most children
0.67 (0.03)
1.00 (0.00)
This child does things that really bother me a lot
0.89 (0.03)
1.40 (0.08)
I have felt angry with this child
0.68 (0.03)
1.01 (0.06)
Parent-child interaction
Read to this child
0.81 (0.05)
1.00 (0.00)
Told stories or sang to this child
0.75 (0.05)
0.94 (0.13)
Ate a meal together
0.21 (0.03)
0.26 (0.03)
Child flourishing
This child is affectionate and tender with you
0.52 (0.06)
1.00 (0.00)
This child bounces back quickly when things do not go his or her way
0.44 (0.04)
1.80 (0.30)
This child shows interest and curiosity in learning new things
0.56 (0.07)
0.80 (0.14)
This child smiles and laughs a lot
0.53 (0.07)
0.91 (0.14)
*Ease with making friends/Plays well with others/Shows concern for others
0.39 (0.04)
1.18 (0.19)
Child behavior problems
How often can this child calm down when excited or all wound up
0.51 (0.03)
1.00 (0.00)
How often does this child lose control of his or her temper when things do not go his or her way?
0.41 (0.04)
0.75 (0.09)
How often is this child able to sit still?
0.51 (0.03)
1.07 (0.09)
*How often does this child become angry or anxious when going from one activity to another?/How often does this child keep working at something until her or she is finished?
0.74 (0.03)
1.05 (0.08)
*How often is this child easily distracted?/How often can this child follow instructions to complete a single task?
0.71 (0.03)
0.99 (0.07)
N = 1134. All factor loadings are significant at p < 0.001. Standard error provided in parentheses.
*Items were parceled
Full Structural Model
The present study uses data from a national, cross-sectional study of US children to examine a conceptual model of the mechanisms through which the effects of neighborhood SES influence young children of immigrant’s flourishing and behavior problems. Analysis of the full structural model incorporated neighborhood SES, neighborhood structure, parenting, flourishing, and behavior problems with the expected directional relations among constructs. Specifically, direct effects between each neighborhood/parent characteristic and children of immigrants’ behavior and flourishing were modeled as were indirect effects mediated through neighborhood structure and./or parenting. Further, to account for potential additional relations among parenting constructs (mental health, aggravation, parent-child interaction), these were allowed to correlate. Cross-level interactions between neighborhood and parenting level characteristics were also assessed.
The full structural model yielded a significant chi-square index, χ2(df = 193, N = 1134) = 613.12, p < 0.001, which is understandable due to the large sample size, yet fit closely according to the RMSEA (0.044; 90% CI = 0.040, 0.048), CFI (0.90), and the SRMR (0.046). Standardized coefficients and standard error for pathways between latent constructs are presented in Fig. 3. Standardized and unstandardized estimates and standard errors for each structural path are provided in Table 2.
Fig. 3
Neighborhood SES on child flourishing and behavioral problems. *p < 0.05; **p < 0.001
Table 2
Standardized and unstandardized estimates and standard errors in the final model
Predictor
Outcome
β
SE β
B
SEB
Neighborhood SES
N. Structure
0.286**
0.032
0.059**
0.013
Flourishing
0.120*
0.046
0.015*
0.008
Behv. Problems
−0.062
0.034
0.015
0.012
N. Structure
P. Mental Health
0.261**
0.034
1.035**
0.226
P. Aggravation
−0.194**
0.039
−0.482**
0.136
P-C Interaction
0.272**
0.066
0.392**
0.142
Flourishing
−0.028
0.059
−0.017
0.038
Behv. Problems
−0.041
0.048
−0.072
0.086
P. Mental Health
Flourishing
0.051
0.045
0.008
0.007
Behv. Problems
−0.075*
0.037
−0.034*
0.017
P. Aggravation
Flourishing
−0.353**
0.077
−0.089**
0.016
Behv. Problems
0.518**
0.043
0.369**
0.040
P-C Interaction
Flourishing
0.227*
0.082
0.098*
0.039
Behv. Problems
−0.244**
0.069
−0.300**
0.090
N. Structure Neighborhood Structure, P. Mental Health Parent Mental Health, P. Aggravation Parent Aggravation, P-C Interaction Parent-Child Interaction, Behv. Problems Behavior Problems
*p < 0.05; **p < 0.001
×
Direct effects
Hypothesis 1, which tested the relation between neighborhood SES and child behavior and flourishing, was partially supported. Specifically, there was a positive direct effect between neighborhood SES and child flourishing (H1a), such that children in high SES neighborhoods had high levels of flourishing (direct effect = 0.012, p < 0.05). However, the effect between neighborhood SES and children of immigrants’ behavior problems (H1b) was non-significant (direct effect = −0.062, p = 0.067).
The next direct effect tested the cross-level interactions between neighborhood structure (e.g., resources, collective efficacy) and parent-level characteristics (e.g., mental health, stress, parent-child interaction). Hypothesis 2 stated that neighborhood structure would have a positive direct effect on parental mental health (H2a) and parent-child interaction (H2c) and a negative effect on parenting stress (H2b). Hypothesis 2 was fully supported, with neighborhood structure having direct effects on each of the parenting characteristics in the expected direction. Specifically, parents in neighborhoods with favorable structural components (i.e., high levels of resources, perception of safety, and collective efficacy) reported better mental health (H2a), lower parenting stress (H2b), and higher parent-child interaction (H2c). Direct effects were 0.261, −0.194, and 0.272, respectively, with all direct effects significant at p < 0.001.
Direct effects of parenting characteristics (i.e., mental health, stress, parent-child interaction) and children of immigrants’ behavior and flourishing were tested for hypothesis 3. Hypothesis 3 was partially supported, with all parenting characteristics having direct effects on behavioral problems (H3b), but only parenting stress and parent-child interaction having significant effects on child flourishing (H3a). More specifically, good parental mental health (direct effect = −0.075, p < 0.05), low parenting stress (direct effect = 0.518, p < 0.001), and high parent-child interaction (direct effect = −0.244 p < 0.001) were associated with low child behavioral problems. With regard to child flourishing, low parenting aggravation (direct effect = −0.353 p < 0.001) and high parent-child interaction (direct effect = 0.227, p < 0.05) were associated with child flourishing. The direct effect of parental mental health on child flourishing was not significant.
Indirect effects
For hypothesis 4, our model tested an indirect effect of neighborhood structure on children of immigrants’ flourishing and behavior problems mediated by parenting characteristics (i.e., mental health, stress, parent-child interaction). Hypothesis 4 was fully supported as there were significant indirect effects of neighborhood structure on both child outcomes through parenting. Specifically, the relation between neighborhood structure characteristics and flourishing (H4a) was fully mediated by parenting characteristics (indirect effect = 0.090, p < 0.01). Similarly, the relation between neighborhood structure characteristics and behavioral problems (H4b) was fully mediated by parenting characteristics (indirect effect = −0.330, p < 0.001).
Finally, hypothesis 5 tested the indirect effect of neighborhood SES on children of immigrants’ flourishing and behavior mediated by neighborhood structure and parenting characteristics. Hypothesis 5 was fully supported. First, there was a positive direct effect between neighborhood SES and neighborhood structure, with low neighborhood SES being associated with poor neighborhood structure. Next, neighborhood SES, indirectly through neighborhood structural conditions, was significantly associated with parenting stress, mental health, and parent-child interaction in the expected directions (i.e., low neighborhood structure −> low parent-child interaction). In turn, parent-child interaction and parenting stress were significantly associated with child flourishing. Likewise, parent mental health, stress, and parent-child interaction had direct effects on behavioral problems in children. The indirect effects between neighborhood SES and child flourishing (indirect effect = 0.004, p < 0.01) and behavioral problems (indirect effect = −0.024, p < 0.001) through neighborhood- and parent-level characteristics were both significant. Having a very large sample size may skew observed effects, making small effects significant when they might otherwise not be, though this is rare (Fritz et al., 2012).
Between-Group Differences
Differences between families with one immigrant parent compared to two immigrant parents were also analyzed. We found that there were group mean differences for three of the indicators (i.e., neighborhood resources, collective efficacy, and parent-child interaction). Though the differences were significant, the means themselves did not differ in any meaningful ways. For example, families with one foreign-born parent reported slightly higher collective efficacy (M = 3.21) compared to those with 2 foreign-born parents (M = 3.16). Likewise, model fit was tested for both groups independently. The model fit was acceptable for both groups (two foreign-born parents CFI = 0.982, RMSEA = 0.026; one foreign-born parent CFI = 0.981, RMSEA = 0.026), but the overall models were not significantly different from one another. This is consistent with literature suggesting that merely having one foreign-born parent is sufficient to contribute to notable risk (e.g., Rubio et al., 2020).
Discussion
The specific characteristics of young children of immigrants’ ecological contexts—families and neighborhoods—and the way they connect to influence development are understudied. Using a subsample of 3-to-5-year-old children (N = 1134) from the National Survey of Children’s Health (CAHMI, 2018), this study tested a conceptual model of direct and indirect neighborhood SES effects on young children who have at least one foreign-born parent. Structural equation modeling results suggested cross-level interactions between ecologies as well as indirect effects between neighborhood SES and child outcomes (behavioral problems and flourishing) through neighborhood structure and parenting. Direct and indirect effects within the full model are discussed below.
In general, results of the model were consistent with expectations. There was a positive direct effect between neighborhood SES and parent-reported child flourishing. The present study extends research with older children (i.e., Bethell et al., 2019) by illustrating the neighborhood SES-flourishing relation with a younger sample of children ages 3-to-5 in immigrant families. Specifically, this study’s finding suggests that living in a low-SES neighborhood has negative effects on social and emotional development in young children of immigrants as early as preschool ages.
The direct effect between neighborhood SES and child behavior problems was non-significant, suggesting that SES alone does not predict behavioral problems in preschool-age children of immigrants. Rather, consistent with the family stress model (Masarik & Conger, 2017), results indicated that economic strain was experienced through neighborhood structural disadvantage which then had negative effects on immigrant parents. Collectively, these cross-level effects explained the relation between SES and children of immigrants’ behavior in this study. Specifically, low-SES and structural disadvantage were associated with poor parental mental health, low parent-child interaction, and high parenting stress, which are detrimental to young children of immigrant’s development and consistent with the literature (e.g., Newland et al., 2013; Nievar et al., 2014). The absence of parental support at the neighborhood level, especially among families who would rely heavily on neighborhood-level resources were they available, may better explain what were thought to be direct effects between poverty and behavior. Pointing to a more complex relation between neighborhood risk and outcomes, it appears that perhaps something occurring at the familial level (e.g., accessing informal supports) interrupted potential detriments otherwise associated with neighborhood-level risk. With regards to behavioral problems and flourishing, the present study’s results suggest that providing formal and informal supports at the neighborhood level may bolster parents’ ability to offset low SES-related risk.
Cross-level interactions between neighborhood characteristics, parenting, and child outcomes provide further support for the direct and reciprocal connections between children and their neighborhood and familial ecologies. The present study extends evidence of an accumulation of risk in low-SES neighborhoods wherein neighborhood level disadvantages and family characteristics combine to negatively impact children of immigrants’ flourishing and behavior. This affirms the need to understand development as the product of interactions between multiple domains and offers insight into some specific characteristics in the neighborhood (resources, collective efficacy, safety) and parenting (mental health, stress, parent-child interaction) domains. Further, the fully mediated paths between neighborhood structure characteristics and child outcomes provide evidence of the pathways through which neighborhoods may affect children’s health and highlight the importance of intervention at the parental level. Specifically, it appears that monitoring how parenting stress and the quality of parent-child interactions are impacted by neighborhood disadvantage and finding ways to reduce this impact could help to support young children of immigrants’ optimal development.
In sum, this study integrates characteristics of two key ecologies within one cohesive model to provide insight into the interactive and compounding influences of neighborhoods and parenting on young children of immigrants. The indirect effect between neighborhood SES and child flourishing and behavior problems operated through neighborhood structural conditions and parenting. By identifying specific neighborhood and parenting characteristics, this study has increased capacity to inform effective prevention, intervention, and policy recommendations.
Limitations
As with any research, there are limitations to this study. First, the cross-sectional nature of this study prevents any assumptions of causality between study variables. Longitudinal research testing this conceptual model across time would be necessary to further examine which combinations of neighborhood and parental level characteristics are most impactful for children’s flourishing and behavior. In addition, use of a single source self-report (i.e., parent/caregiver) can inflate or deflate the associations between study variables due to shared-methods variance (McHugh et al., 2011). Future studies integrating SES, structure, parenting, and child outcomes would benefit from multi-informant and multi-method data. Finally, the NSCH does not provide data about the specific country from which parents have immigrated to the US, limiting the ability to compare groups and consider the implications of country of origin.
At the measurement-level, the NSCH is limited with regard to data gathered for some of the concepts in this study. This limitation may further contribute to inflation or deflation of associations between variables as not all key characteristics of a given concept are fully assessed. Construct deficiency may be especially apparent when constructs are measured using single items. For example, using a single item measure of neighborhood SES may not fully reflect the diversity of low-SES neighborhood. Survey developers intentionally oversampled low-income neighborhoods and stratified participants by poverty level to offset this limitation (CAHMI, 2018). Though not possible given the NSCH’s design, future research could use a more comprehensive measure of neighborhood SES that includes factors like affluence, education, family structure, and employment (see Kohen et al., 2008). Likewise, the use of use of a single item measure of self-reported mental health can be problematic. Although this item has been used in several national and local health surveys and demonstrated concurrent validity with other measures (see Ahmad et al., 2014), this has not been replicated consistently among diverse samples. Research by Zuvekas and Fleishman (2008) indicated that Hispanics were more likely to indicate excellent health on the single item measure of self-reported mental health despite having lower scores on the mental health component summary of a different measure. This apparent contradiction indicates that this particular indicator may not be sufficient as a standalone measure of mental health among all ethnicities or circumstances (i.e., immigrant status) and may not fully reflect the impact of neighborhood structural disadvantage on parental mental health.
Recommendations
Supporting the development of children of immigrant should involve a multi-pronged approach. Consistent with our conceptual model, we recommend prioritizing the safety and structure of immigrant neighborhoods, bolstering immigrant parents’ supports, and advocating for immigrant families at the policy level. Specifically, we recommend (1) improving immigrant neighborhood structure (see Ursache et al., 2022); (2) empowering immigrant parents (see Garner & Yogman, 2021); and (3) advocating for pro-immigrant policy change (Perreira & Pedroza, 2019).
Improve immigrant neighborhood structure
By isolating specific neighborhood structural characteristics (i.e., resources, safety, collective efficacy) impacted by SES and appearing to matter for children of immigrants’ development, this research provides empirical evidence of the influence of neighborhoods on development and offers potential targets for intervention. Recommendations to help counteract neighborhood disadvantage at the structural level include: (1) enhancing collective efficacy in immigrant neighborhoods through expansions in social services and mobilization of community networks (Hyde et al., 2022; Mair et al., 2021) and; (2) promoting neighborhood safety to encourage residents to access available resources (Barajas-Gonzalez et al., 2022).
Enhance collective efficacy
Building and nurturing a socially supportive neighborhood for immigrant parents and their children benefits all community residents. Community stakeholders and existing institutions (e.g., schools, libraries) should expand social services so that, in addition to providing for basic needs to immigrant families, they prioritize the development of formal and informal networks of social support for immigrant parents and their children. For example, schools can offer intervention programs that build parent-teacher communication and connect parents to one other (Crosnoe & Kalil, 2010; Knotek & Sánchez, 2017). Likewise, practitioners can weave social support building lessons and strategies into existing parent training and education programs. Given the cross-level interactions between neighborhoods and parenting, building neighborhood collective efficacy in this manner could also translate into increases in shared resources between families that would improve neighborhood structural conditions.
Promote neighborhood safety
Perceptions of neighborhood safety affect resource use. As such, addressing safety concerns can improve parents’ willingness to access resources and to allow their children to do so. One method of improving perceptions of safety is to reduce the presence of detracting elements like graffiti and litter (McCormack et al., 2010). In addition, given that the children in this study were children of immigrants, it is important to consider real and perceived risks associated with immigration enforcement (Barajas-Gonzalez et al., 2022). One way to reduce perceptions of threat for immigrant families is to build strong relationships between law enforcement officers and the communities they serve, fostering trust and mutual understanding. Further, local governments can elicit and address specific concerns and issues expressed by immigrant families.
Empower immigrant parents
The present model highlights the mediating role of parenting and suggests that parent-level interventions may offset risk and promote child health and positive parent-child relationships. Promoting positive parenting strategies (e.g., parent-child interaction) and parental support for parents raising young children in disadvantaged neighborhoods can promote young children of immigrants’ health even in disadvantaged neighborhoods (Barajas-Goznalez, 2021; Fisher et al., 2016; Patrick et al., 2005). As such, we recommend investing in parents by (1) developing and promoting parent education programming (Dawson-McClure et al., 2017) and (2) offering mental health promotion services (Garner Garner & Yogman, 2021).
Develop and promote accessible parenting education programming
Practitioners, community stakeholders, and local governments should promote and incentivize immigrant parents’ engagement in community-based parent support and education services through informational campaigns and community organizing. Parent training is empirically validated, compatible with the needs of low-income parents, associated with high satisfaction ratings from many immigrant parents of young children (Brotman et al., 2011; Dawson-McClure et al., 2017), and implementable in various community settings, including early childhood education centers (Barajas-Gonzalez, 2021) and Head Start settings (Webster-Stratton, 1998). One example of such a program is ParentCorps, a group-based early childhood education program that helps equip parents with positive parenting practices, offer strategies for increasing parent-child interaction, and curtail the use of punitive parenting practices (see Brotman et al., 2011 for more information). In communities where such programs do not already exist, providers and community stakeholders must prioritize the development and wide dissemination of parent training and support programs within immigrant neighborhoods. To promote sustainability and build community partnerships, such programs should take place in settings that are familiar to immigrant parents, such as within faith-based settings, and must be offered in parents’ native language. Promising research has indicated that preventative services can be successfully delivered to under-served populations via faith-based settings (see Peterson et al., 2002 for review).
Offer mental health promotion services to address immigrant parents’ stress
Providing accessible parent mental health promotion services for immigrant parents may help to reduce parenting stress and increase positive interactions with their children. These programs should be carefully adapted or developed with mindfulness of immigrant families’ unique situations, stressors, and needs. Examples of some of these interventions include Meditational Intervention for Sensitizing Caregivers (MISC; Cardoso et al., 2018) and Promoting Emotional Wellness and Spirituality (PEWS), which provides psychoeducation, promotes help-seeking behaviors, and addresses mental stigma among faith communities of color (Williams et al., 2014). Ideally, such programming would be made available through settings such as local churches or community of faith that have established trusting relationships with immigrants (Lopez et al., 2022).
Advocate for policy change
In addition to mobilizing resources from the bottom-up, policy change initiatives from top-down must also be prioritized. Accordingly, we recommend supporting policy changes that will increase immigrant access to safety net programs including health, housing, and resource initiatives.
Increase immigrant access to safety net programs
Despite being eligible for public safety net programs that could reduce the effects of poverty, children of immigrants are less likely to be enrolled (Acevedo-Garcia et al., 2021). Exclusionary and restrictive policies have prompted immigrant parents to avoid enrolling or re-enrolling themselves and their citizen-children out of fear of jeopardizing immigration proceedings and/or apprehension by immigration enforcement (Batalova et al., 2018). Policymakers must develop and promote inclusionary policies that make public safety net programs easily accessible to a larger group of immigrant parents and their children and do not penalize them for enrolling. These policies should be consistent across state-lines in order to reduce confusion. In addition, practitioners and policymakers should collaborate to lead a nationwide informational campaign to promote awareness of the programs and resources available for children of immigrants. The message that enrollment will not affect immigration proceedings must be made abundantly clear in such campaigns.
Future Directions
One important area of future research involves further stratifying children of immigrants according to their parents’ legal status to demonstrate sensitivity to risks associated with legal status that are over and above living in an impoverished neighborhood. Though the NSCH (CAHMI, 2018) offers no direct or indirect measure of legal status, future research would benefit from gathering this information or using proxy measures (see Yoshikawa, 2011) to examine group differences in low-income young children of immigrants’ development by parental legal status. Another future direction involves examining additional variables of interest, such as marginalization, discrimination, and familial and communal support, that are particularly salient for immigrant families (Ayón, 2015; Ursache et al., 2022). For example, incorporating experiences with discrimination and contact with immigration enforcement into this model would help capture structural level factors that shape children of immigrants’ development.
Summary and Conclusion
The population growth of children of immigrants in the US and their disproportionate likelihood of living in poverty (Batalova et al., 2020) warrant additional attention and intervention. Research examining the mediators of economic disadvantage on preschool-aged children of immigrants’ well-being is critical to develop interventions that offset poverty and its associated adversities. This study highlights two key ecological dimensions—neighborhoods and homes—through which neighborhood socioeconomic status appears to influence preschool-aged children of immigrants’ flourishing and behavioral problems. Few studies have integrated neighborhood- and parenting-level dimensions into one model in this manner, particularly with an under-researched population of young children of immigrants. Doing so offers insight into the connection between two pivotal social ecologies and identifies specific characteristics within each one, providing tangible target areas for future intervention.
As one of the first studies to examine the behavior and flourishing of preschool-aged children of immigrants in low-income neighborhoods through an integrative conceptual model, the results of this study suggested that living in a low-SES neighborhood has detrimental effects at the neighborhood and home level. Together, neighborhood- and parent-level characteristics act as pathways through which SES acts upon children of immigrants’ flourishing and behavior. Findings suggest that if the main goal is to positively impact children of immigrants’ psychosocial development, both neighborhood structural and parental factors should be targeted simultaneously. Accordingly, bettering neighborhoods and improving the support provided to immigrant parents may improve children of immigrants’ psychosocial development, especially among those who live in poverty. In addition, interventions targeting enhancement of parent-child interaction may further help to offset disadvantage for this vulnerable population of young children.
Acknowledgements
The preparation of this article was supported in part by a Dissertation Research Funding Award by the Student Early Career Council of the Society for Research in Child Development.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
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