Adolescents

Written by on . Posted in Adolescents, Populations

Table of contents

Key points

During adolescence, healthcare visits may be limited; the consultation goal should be to complete a thorough physical and psychosocial evaluation, with an emphasis on preventative care.
Adolescents should be seen alone at some point during (or soon after) the initial refugee health screening assessment.
Define confidentiality for the medical consultation and (separately) for working with interpreters.
Adolescents may have an incorrect date of birth recorded; this can have significant implications for assessing growth, development, learning or school/vocational placement.
Mental health problems may present in adolescence. Adolescents may make new meaning from past trauma, and present with mental health concerns in relation to early childhood trauma.

Consider sexual health, sexually transmitted infections (STIs, including hepatitis B), sexual violence, and female circumcision. A sensitive history is required, allowing adequate time.

Overview

The World Health Organization defines adolescent as 10–19 years, youth as 15–24 years and young people as 10–24 years. Humanitarian populations include a high proportion of children and young people. In 2016, 28% of the Australian humanitarian intake was aged less than 12 years, and 23% were aged 12–24 years. Some refugee adolescents arrive as unaccompanied humanitarian minors; other adolescents of refugee-like background arrive under alternative visas (e.g. orphan relative) or as asylum seekers.

Adolescent developmental issues include physical and cognitive transitions, emergent autonomy and independence, personal identity and body image, peer relationships and recreational goals, educational and vocational goals, and sexuality. Adolescence can be divided into three general stages of psychosocial development:

Early adolescence (10–14 years)

Late adolescence (15–19 years)

Young adulthood (19–24 years)

Rapid growth and physical change, secondary sexual characteristics developGender roles consolidate

Low resistance to peer influences

Low future orientation

Poor self regulation and increases in risk taking behaviour

Identity formation and new interests, including sexual relationships

Pubertal maturationGrowth rate decreases

Progression of intimate relationships

Development of executive and self-regulation skills

Greater future orientation and ability to assess consequences

Increasing autonomy and independence from family

Peak physical fitness and bone densityFurther development of reasoning and self-regulation

Education and vocational goals important

Adoption of adult roles and responsibilities

Establishing the social, cultural, emotional, educational and economic resources to maintain health and wellbeing across the life course.Rapid adoption and use of technology

Risks of injuries/transport injuries, communicable diseases, non-communicable diseases, mental health disorders, substance use, and maternal disorders, with variation between countries in risks and burden.

Adolescents of refugee-like background experience all these transitions in addition those of resettlement. They face balancing the values/expectations of their parents/cultural background with those of their new peers, while developing their own identity and learning a new language, in a new schooling system, in a new country.

Approach to care

During adolescence, healthcare visits may be limited, and adolescents may seek care from a variety of providers. The goal should be to complete a thorough physical and psychosocial evaluation with an emphasis on preventative care. The initial refugee health assessment provides a starting point to introduce longer-term, developmentally appropriate care in the areas of physical, mental and sexual health.

When consulting with adolescents, helpful strategies include:

Seeing the adolescent alone at some point during (or soon after) the initial screening. assessment. This may be more acceptable to parents and adolescents if the health provider sees the family initially, and they are aware this will occur in the future.
Establishing confidentiality for the medical consultation (and also for the interpreter).
Taking a direct history from the adolescent.
Using clear language, open-ended questions, and a non-judgmental approach.
Allowing enough time.

HEADSSS screening can be used to assess adolescent psychosocial health:

H – home

E – education/employment (and eating)

A – activities

D – drug and alcohol use

S – sexual activity

S – suicide, depression, self-harm

S – safety from injury and violence

Considerations include:

Immigration Medical Examination (IME) for adolescents includes urinalysis (5 years and older), chest x-ray (11 years and older), HIV screening (15 years and older), and syphilis screening (15 years and older). Unaccompanied minors (all ages) also have screening for HIV and HBsAg; onshore protection visa applicants (15 years and older) also have screening for HBsAg and HCV.
IGRA testing is more reliable in adolescents for tuberculosis screening.
Catch-up vaccination and vaccine licensing varies with age. Adolescents will generally not need pneumococcal or Hib vaccines, they will need HPV vaccine, and the varicella vaccine schedule changes at 14 years.
Mental illness may present in adolescence. Adolescents may also make new meaning from past trauma, and present with mental health concerns arising from early childhood trauma.
Sexual health is an important area that is often neglected. Many refugee-background young people have low sexual health literacy, and limited opportunities to learn about sexual health. Consider STIs (including hepatitis B), sexual violence, and female circumcision.
Family structures and parenting roles may change with migration, affecting settlement and leading to ‘role reversal’, with adolescents having increased responsibility, or taking on parenting roles.
Prior schooling may have been limited or interrupted, with implications for educational placement in Australia. Evidence shows refugee young people have similar education outcomes to their native-born peers – ensure a proactive approach and early paediatric review for learning problems.
Adolescents may have an incorrect birthdate recorded; this is important to consider when assessing growth, development, learning, or school/vocational placement.
It takes many years to learn English as an additional language for academic purposes – explaining this is important, and a way to explore schooling and risk/resilience factors.
Seek early paediatric review for complex adolescent health issues, including physical health, learning/behavioural concerns, disability, and age assessment. Paediatric review may also help facilitate access to (and acceptance of) mental health services.

Incorrect birth date: children and adolescents

Refugee children/adolescents may have an incorrect birth date on their visa paperwork, which becomes the basis for all the official documentation in the country of settlement. This issue is not uncommon, especially for adolescents, and may have significant effects on school placement, developmental assessment (including formal assessments such as cognitive testing) and access to welfare, services, and case management support. The reasons for an incorrect birth date are often complex; it may be unknown, due to error, related to calendar discrepancies, or changed to due to family circumstances/conditions in country of origin. Any child with a birth date of 01/01/(year) is almost certainly younger. Families may be reluctant to raise this as an issue, and may be worried about the implications for their migration claim/visa/citizenship. Often this emerges as an issue some years after settlement.

Correcting a birth date requires an assessment of the family narrative (including contextual migration events, birth order/ages of siblings matched to any known local events or transitions in the migration pathways), reviewing and documenting any existing paperwork or known milestones, and an assessment of the child’s growth, dental eruption, pubertal stage and development with information from schools wherever possible (on peers, learning, maturity/function in the classroom). Our experience is that frequently, undisclosed trauma becomes apparent during age assessment, and it is essential to allow enough time and be prepared to work through this process at a pace that is acceptable to the family. A bone age X-ray or orthopantogram (OPG) is sometimes used as additional information in the specialist setting, but neither bone age nor OPG imaging defines the child/young person’s age. Bone age X-rays provide an estimate of bone age compared to chronological age. The Greulich and Pyle (GP) method[73] is used most commonly (evaluating a single frontal X-ray of the left wrist), however, it is essential to note:

The GP method is intended to assess skeletal age knowing the chronological age (not the reverse)
The GP method is based on data from white American children from the 1930s; and considerable racial variation is found.[74, 75]
The GP method is not precise, the margin of error is typically a 3–4 year range throughout childhood/adolescence
Skeletal maturity is affected by additional factors such as constitutional delay in maturation.

Bone age X-rays are most useful in a child who is clearly many years older or younger than their paperwork birth date. Similar principles apply to the use of the OPG.

Incorrect dates of birth can be formally changed using Form 424C under the Freedom of Information Act, through the Department of Immigration and Citizenship: www.border.gov.au/forms/Documents/424c.pdf.

Child protection

Like any other group of children/adolescents in Australia, child protection issues may be identified for children/adolescents of refugee-like background. Child maltreatment is broadly defined as any non-accidental behaviour by parents, caregivers, other adults or older adolescents that is outside the norms of conduct and entails a substantial risk of causing physical or emotional harm to a child or young person. Maltreatment may occur through acts of omission (such as neglect of care) or commission (such as inflicted harm). Subgroups of protective concerns include:[71]

Physical abuse – non-accidental use of physical force against a child that results in harm to the child.
Emotional maltreatment – Inappropriate verbal or symbolic acts toward a child and/or a pattern of failure over time to provide a child with adequate non-physical nurture and emotional availability.
Neglect – failure by a parent or caregiver to provide a child (where they are in a position to do so) with the conditions that are culturally accepted as being essential for their physical and emotional development and wellbeing.
Sexual abuse – the use of a child for sexual gratification by an adult or significantly older child/adolescent
Witnessing family violence – Child being present (hearing or seeing) while a parent or sibling is subjected to physical abuse, sexual abuse or psychological maltreatment, or is visually exposed to the damage caused to persons or property by a family member’s violent behaviour.

The National Framework for Protecting Australia’s Children 2009-2020[72] emphasises that protecting children is everyone’s business’. Priorities include early recognition and action, support for carers, responding to sexual abuse, and joining up service delivery. Reporting requirements (mandated reporting (including categories of reporting) and failure to disclose offences) vary with jurisdiction, and it is important to be aware of responsibilities and requirements (and seek advice if needed). Forced underage marriage and procurement of female circumcision are both urgent child protection matters, with mandated reporting requirements. For asylum seeker families, current immigration policy and prolonged uncertainty can be substantial drivers for mental illness and parenting issues, and may also act as a disincentive for disclosure of family violence and/or child protection matters. These situations are complex, and require a high index of concern, and a supportive response with specialist input.