Dr Laura C. Wood
Laura.email@example.com Paediatrician & PhD Researcher in Refugee & Migrant Child Health
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
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.
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
- 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 .
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 .
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 . 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?
At what stage in the child’s physical, emotional and cognitive development has this child had to flee their homeland – and how has this affected them? Has malnutrition hampered their growth and development of skills? Have the child’s speech, language and social skills been delayed through lack of play, free interaction and increased anxiety? Self-esteem, emotional and psychological development can be severely damaged through human trafficking.
Recent research has also suggested that strain on refugee mothers during migration can result in stress-induced epigenetic changes (modification of gene expression) in the fetus . This may be at least part of the reason certain migrant communities have a higher prevalence of autism.
Children travelling alone (particularly females) are at high risk of sexual assault with risks of blood borne infections, sexually transmitted diseases, uro-genital damage, pregnancy and risk of unsafe birth or abortion. Sanitary conditions on route and in refugee camps can be poor and menstruation can be hard to manage hygienically.
Cramped conditions in refugee camps, temporary accommodation and transport vehicles increase risks of contagious diseases, infestations and fungal growth. Children may have had to drink contaminated water or eat decomposing food leading to gastrointestinal infections and parasites. They may also be forced to travel in close vicinity to people who are dying or deceased, increasing risk of infection and also severe traumatisation.
The phase of flight and cross-border movement for children can be very dangerous, particularly if unaccompanied. Damage risks are extensive and can include:
Children may be forced to use medical contraception unsuitable for their age with future risks to reproductive health.
Witchcraft practices may be used as a control mechanism for trafficking victims, leading to physical and psychological damage.
Some human traffickers tattoo their victims, a modern form of the slavery branding of the past. The most commonly reported images are money symbols (dollar signs, money bags), bar codes, crowns and trafficker’s initials. Hex (evil spell) symbols have also been detected. If your patient has a tattoo, remember to make a note of its shape as it could be relevant to modern slavery in your region.
Phase 3: Post Flight
You might assume that arriving in the UK and beginning the immigration process may offer some relief for weary migrants – however in reality this post-flight phase also has health challenges of its own.
Consider at what stage in this child’s development they have reached the UK. Have they been exploited or abused on arrival and if so, in what way? Do they have access to education and an environment that reduces stress enough to connect, concentrate, learn and sleep?
Asylum seekers are housed but usually not allowed to work and survive on £37.75 per week (that’s £5.39 a day) from the government. The extra money “to buy healthy food” if you are pregnant is £3 a week, £5 a week per child under 1 year and £3 a week per child aged 1-3 years . As you can see, when living on such a budget, toys and educational materials can be hard to justify. For more information explore the Refugee Council website.
Survival skills are not the same as daily life skills. Do not assume that because your apparently confident 17 year old patient has made it from Syria to the UK alone he also has the ability to cook healthy food for himself, manage money and negotiate the adult world.
For children who have been trafficked or exploited, risks of blood borne viruses and sexually transmitted disease may remain.
New migrants may also be poorly nourished and unvaccinated, leaving them at risk of infectious disease and new viral strains – including influenza. Poor or cramped living quarters can increase the risk of TB and infestation (lice, scabies etc).
It is important to recognise and treat communicable diseases in migrant children promptly. The list of Public Health England Notifiable Diseases can be found here. Remember to report when you suspect a notifiable disease, you do not need to wait for results.
Refugee and asylum- seeking children have risked much to enter UK but are sadly at risk of further traumatisation through racism, xenophobia, bigotry and social-integration issues.
Health & social care professionals and refugee advocate groups are increasingly concerned
that the current UK Immigration System itself has a detrimental impact on those seeking asylum in the UK. The immigration process is stressful and confusing, with many young people left ‘in limbo’ for months without a school place and awaiting decisions on their cases . The sense of powerlessness and fear that they might be returned to the country from which they fled can be overwhelming and very obstructive to successful language learning, friendship building and education.
A child’s immigration status – particularly asylum refusal – can trigger the child going missing, putting them at high risk of trafficking and exploitation . Children may be under pressure to provide financial support to family members or to repay smugglers or traffickers. Significant delay in their ability to perform family obligations can be highly stressful and guilt-ridden.
The depths of trauma in children can manifest in psycho-somatic symptoms and unusual presentations. In Sweden, hundreds of asylum-seeking children have entered a catatonia-like state termed Resignation Syndrome, apparently unconscious and requiring nasogastic feeds for months or years during lengthy and stressful immigration processes. There is still much to be explored regarding this seemingly culture-bound psychogenic disorder .
Ask about the immigration status of your patient as this may be very relevant to changes in health and risk of going missing.
After identifying the problems – what’s next?
Moving forward to health, healing and the ability to flourish…
Refugee, asylum-seeking and trafficked children have been exposed to high-level, multi-faceted risks of harm before, during and after migration. By using a structured approach to assess health impacts in the ‘3 Dimensions’ of Development, Disease exposure and Damage risk at each phase of migration we can develop a more comprehensive picture of the needs of our patient. Alongside risks of harm, we also need to factor in the resilience characteristics of the young person that will combat the impact of such trauma, and consider what interventions work best to support recovery and health. We will tackle this in the next article on refugee child health.
Laura.firstname.lastname@example.org Twitter: @DrLauraCN
ESRC PhD student at Lancaster University & Bradford Institute of Health Research
- Entzel PP, Fleming LE, Trepka MJ, Squicciarini D. The Health Status of Newly Arrived Refugee Children in Miami–Dade County, Florida. American Journal of Public Health. 2003;93(2):286-288.
- World Health Organisation (2017). Media Centre Fact Sheet – Antibiotic Resistance.
- UN Population Fund (2018). Female Genital Mutilation – frequently asked questions.
- Crafa D & Warfa N (2015) Maternal migration and autism risk: Systematic analysis, International Review of Psychiatry, 27:1, 64-71, DOI: 3109/09540261.2014.995601.
- UK Government (2018). Asylum Support.
- Chase, E. and Sigona, N. (2017) ‘Forced returns and protracted displacement’, Becoming Adult Research Brief no. 7, London: UCL http://www.becomingadult.net
- Sigona, N., Chase, E., Humphris, R. (2017) ‘Understanding causes and consequences of going ‘missing’, Becoming Adult Brief no. 6, London: UCL http://www.becomingadult.net
- Sallin K, Lagercrantz H, Evers K, Engström I, Hjern A, and Petrovic P (2016) Resignation Syndrome: Catatonia? Culture-Bound? Front. Behav. Neurosci. 10:7. doi: 10.3389/fnbeh.2016.00007
- Alayarian A (2017). Children of Refugees. Karnac Books Ltd, London.
- Annamalai A (Ed.)(2014). Refugee Health Care – An essential medical guide. Springer USA.
- UASC Health website
- Medicin sans Frontiers (2017). Report: Dying to reach Europe: Eritreans in search of safety