The ‘3-D Assessment’ for Refugee, Asylum-Seeking or Trafficked Children

Dr Laura C. Wood

Laura.wood@lancaster.ac.uk Paediatrician & PhD Researcher in Refugee & Migrant Child Health

Twitter: @DrLauraCN

Paediatricians across the UK are increasingly being expected to assess and manage the health of refugee, asylum-seeking and internationally trafficked children. Even attempting to understand such a child’s experience and the impact on their health can feel daunting, especially when no medical history is available – languages need interpretation and cultural differences have to be sensitively navigated. Fear and confusion might also affect your young patient’s ability to communicate with you, as the stress of fleeing home and the unknowns of the immigration system take their toll.

The good news is that excellent paediatric care for refugee, asylum-seeking and trafficked children can have a hugely positive impact far beyond the clinical arena, shaping a child’s ability to integrate successfully into a new community and flourish. In this article I will share my personal strategy for assessing refugee, asylum-seeking and trafficked children in clinic – please do join the conversation and share yours.

A helpful way to start a holistic medical assessment of refugee, asylum-seeking or trafficked children is to visualise the key phases of that child’s journey.

Think about what may have happened to them in three stages of migration:

For each of the above, assess the child’s needs in ‘3D’, considering the three dimensions of:

Remember that a 3-year long war might constitute a relatively small percentage of your life, but it has impacted 100% of the life experiences of the 3 year old refugee in front of you.

Try asking yourself the following questions as you assess your young patient, remembering that even if you have very little information to go on, our understanding of global crisis situations and migration can add a lot to a sensible assessment of potential risk.

Phase 1: Pre-Flight

Development

What was the life context of this child and family in their country of origin? Think about religion, ethnic origin, gender and other individual characteristics that could highlight someone as belonging to a persecuted or at-risk group, even if they have come from an otherwise stable country.

Look up the profile of the country the young person has travelled from; the website UASC Health has excellent country profiles. The World Health Organisation country profiles are also available. In particular, look at the prevalence of disease, and impacts of war, violence and political crisis.

Has this child been born in a country ravaged by longstanding war, leading to inadequate antenatal care, poor maternal nutrition, and the later effects on infants (low birth weight, etc)? Think about parental trauma, mental and physical health and attachment issues too.

What has influenced early childhood and school years – have they been raised in a country that has seen its health, food security, child development and education structures destroyed or inaccessible? It is possible your patient has never seen a health professional before so you should be on the lookout for undiagnosed congenital or chronic conditions, problems with vision and hearing.

Has this child travelled from a country where health professionals and authorities are considered trustworthy or corrupt? There are reasons these children may be suspicious of you! An NHS colleague attending a recent conference in Asia described how local attendees recoiled in horror as she described herself as a ‘doctor for detainees’, associating this role with human torture and cruelty.

Disease exposure

Look at your country profiles again. What is the prevalence of disease and disorder in the countries this child has lived in? Especially:

Blood Borne Infections – HIV, Hepatitis B & C and Syphilis. Follow your local guidelines on testing and consent. Recommended guidelines are available from the UASC Health website
Tuberculosis
Malaria
Intestinal parasites and infections, particularly if the child is from Africa, Asia or South-East Asia.
Genetic disease, anaemias and haemoglobinopathies may be relevant for certain population groups

Refugee children may also be at risk of raised blood lead levels caused by leaded petrol exposure, contamination from lead industries, lead within housing and some folk remedies [1].

The overuse of antibiotics and steroids in the developing world is a real threat to global public health, increasing the risk of antibiotic-resistant organisms and steroid side effects [2].

Damage risk

Threat of severe poverty, forced military conscription, injury or death are major reasons why families and children flee their homeland.

Female Genital Mutilation (FGM) and other forms of deliberate physical scarring (including the ethically-challenging areas of scarification and traditional healing methods that may mark the skin) are still very common among some ethnic groups and areas of the world. If

FGM continues to be practiced at recent levels, an estimated 68 million girls will be cut between 2015 and 2030 across the 25 countries where FGM is routinely practiced (including countries within Africa, Asia, the Middle East, South America, Eastern Europe, the Russian Federation and diaspora across Western Europe), with the age of cutting reportedly getting younger [3]. There can be major physical and psychological consequences of FGM – and the practice may be repeated in the children of refugees if they are not clearly instructed that this practice is dangerous and illegal in the UK. Make sure that FGM-affected children are referred to specialist organisations and clinics in your region.

Torture – children can be tortured for direct purposes or to provoke responses from family members. Children may have witnessed torture of others and may have been forced to violently harm or rape. Torture can have devastating physical, mental & developmental health impacts and can be very difficult for the child to verbalise. Do not prolong questions around torture and abuse if the child appears unwilling to talk – such trauma can be very painful to revisit and potentially loaded with false guilt applied by perpetrators.

If you suspect a history of torture or find unusual marks on the child’s body, complete a detailed injury body map (a good template can again be found on the UASC Health website) and seek advice about local pathways for care. Do not feel under pressure to interpret markings unless you have the experience to do so and remember that many torture techniques leave no physical signs. Helpful organisations for further training in post-torture care include Medical Justice (www.medicaljustice.org.uk) & Freedom from Torture (www.freedomfromtorture.org)

Phase 2: During Flight

Gather as much information as you can about the route and methods of travel or trafficking. The child may well not know where they have been or realise smugglers decided to send them to the UK until they were abandoned at a motorway service station. Who did they travel with? Have they spent months cramped in a dark lorry? Were they detained at any point? Have they had to ‘pay their way’ through physical labour or sexual activity?