Caring for refugee children

Dr R Pryor

As the children of Asian migrants to Australia, my siblings and I were lucky. Born to educated parents, well loved, fed and dressed, part of a supportive expat community in our new home. Yet, at certain times in our own ways, we all still struggled with life in Australia. The privilege of integrating into Aussie society takes time, and involves navigating a new, sometimes frightening social landscape, which is largely uncharted, and often lacking in adept, multilingual and multicultural guides.

No need to break out the violin just yet — my sibs and I are doing OK, in typical over-achieving migrant fashion.

But what of children who have fled war, atrocity or persecution in their home country?  Those who have hidden in neighbouring states, witnessing their parents' fear of capture or exploitation?  Traveling to Australia on long and perilous journeys, only to be locked in detention for months and years, at risk of neglect, poor schooling and witness to more human suffering?  What happens to these kids, and how will they adjust to life in the 'burbs, if they're found to be 'lucky' refugees.

For newly settled refugees, wherever they're from and however they got here, there are barriers to accessing health care that the average Aussie citizen may not encounter. These include cultural, language and financial constraints, lack of awareness of available services, and a lack of understanding by health providers of the complex health concerns of refugees. The different levels of health entitlements by visa category on arrival in Australia may further complicate matters. Unaccompanied and separated children are at a heightened risk of inadequate healthcare.  

Encouragingly, there is evidence that most refugee families are not totally isolated in Australia.  Many form early connections with cultural, social and religious groups of their own ethnic background, providing education that accelerates their access to health services. 

For some, there are other complications. Prolonged detention can have a profound impact on the wellbeing of children, who are often already traumatised by the conditions that their parents have fled.  The now-famous Australia's Human Rights Commission report, The Forgotten Children: National Inquiry into Children in Immigration Detention, found that one third of children in immigration detention centres have a mental health disorder that requires psychiatric support. The experience of detention often acts to exacerbate this. The documented behaviour of children in Australian detention centres includes language delays, emotional regulation difficulties, excessive tantrums, inappropriate sexualised behavior, bed-wetting, self-stimulation such as head banging, and sad and anxious behaviours such as crying a lot, nail-biting and difficulty eating or sleeping. 

These problems don't cease to exist once children are released into the community. Rather, the experience of sustained stress in early childhood potentiates a host of health problems in adult life. Early chronic stress responses have been linked to the ongoing production of stress hormones, stress-related activation of genes, and patterns of brain connections and behaviours that can carry over into early adulthood. Cumulatively, these responses can predispose children and adolescents to problems such as high blood pressure, obesity, heart disease, anxiety, depression, post-traumatic stress disorder, sensory deficiencies and a host of learning problems.

These will not eventuate in all kids.  Children are renowned for their resilience, and it is likely that, with the right support, many refugee children will mature into content, productive members of society.  But there are other, systemic issues to consider, beyond the wellbeing of the individual.

In the face of these numerous and complex needs of refugee children and their families, what's the average healthcare worker to do? There are no easy answers. But there are models of early success, and starting points to consider.

Whole person, whole life

Consider the 'whole patient' and their wider context. Arguably, nowhere is this more pertinent than in the case of displaced children. This is both a professional attitude and an organisational issue. For instance, planning longer consultation times, particularly for first visits, can create the space to develop the trust and specialised understanding needed.  

Awareness and self-education

Refugee children have often encountered circumstances that are outside the average health practitioner's personal experience. A basic awareness of certain events, such as the civil wars in Sri Lanka or Syria, or conflict between Shia and Sunni Muslims, can go a surprisingly long way in facilitating patient consultations — even if the events themselves are not spoken about.

Language and cultural services

Interpreters and cultural navigators are indispensable, and the most important human bridge in the room, at times. Although not always easy to access, the effort to develop a good relationship with these services and use them whenever possible is a key strength of effective refugee health services.

Engagement with community groups

Community groups, often run by former refugees and migrants, can be your greatest allies in bridging the gap with refugee families. Seek them out, connect with them and utilise them where possible. Non-government organisations involved with refugee children's health include Save the Children, the Refugee Health Network of Australia, and Children Out of Immigration Detention.

Developing a practice policy with a specific focus on refugee children

This may take many forms, formal and informal, where the tone set by practice leadership is key. Mandates can be broad or targeted; for example, specific health issues can be prioritised, such as catch-up immunisations (polio, measles, hepatitis), tuberculosis screening, consideration of other infectious diseases such as leishmaniasis, schistosomiasis and strongyloides, macro/micro-nutritient deficiencies and, obviously, mental health and trauma services.

Refugee-specific services

Where practicable and appropriate, the 'gold standard' in caring for refugee children lies in developing specialised, comprehensive clinics and services. The recognition of this standard has led to the creation of refugee health services in several public hospitals, such as the Children's Hospital at Westmead in Sydney, Princess Margaret Hopsital in Western Australia, and the Immigrant Health Service at the Royal Children's Hospital in Melbourne. Prominent medical colleges, such as the Royal Australasian College of Physicians, have also issued comprehensive policy statements on refugee child health.

Translating human empathy into organisational policies and practices is something that many healthcare services are already doing. With the likely release of more children from offshore detention into the community, as well as our increased intake of Syrian refugees, these issues will only grow in scale. Australian healthcare professionals are well placed to put patients first, stay non-partisan and ahead of the curve, and continue to lead and advocate on behalf of refugee children in immigration detention and in the community.