Strongyloides stercoralis, an intestinal parasitic nematode, is estimated to infect at least 370 million people worldwide, although prevalence studies are heterogeneous both within and between countries.¹²⁹ Strongyloidiasis can occur without any symptoms, but may also present as a potentially fatal hyper-infection or disseminated infection. The most common risk factors for these complications are immunosuppression caused by corticosteroids, and infection with human T-lymphotropic virus (HTLV) or HIV. A definitive diagnosis of strongyloidiasis can be made by microscopic identification of larvae in stool, but multiple fresh samples and concentration techniques are required to achieve reasonable sensitivity. Given the ease of screening with serological testing, the availability of effective short course treatment, and the long-term risk of morbidity and mortality from disseminated infection, active post-arrival screening of high-risk groups has been previously recommended.^93,124,130

Strongyloidiasis is endemic in many countries, with high prevalence particularly noted in Africa, Asia and South America.¹³¹ In refugees settling in Western countries in the last decade, the highest prevalence has been documented in those from South East Asia and Africa. Prevalence in refugee-like populations depends on country of origin and the migration journey, and recently high rates have been reported in Latin American refugees (61%) with eosinophilia in Madrid¹³² and in Iraqi children (13%) settling in New York.¹³³ Strongyloidiasis is endemic in some parts of Australia¹³⁴ and is common in refugee and immigrant populations from high-prevalence areas.¹³⁵ Published Australian surveys have reported prevalence estimates ranging from 1–33%.^39,43,48,108 In Hazara refugees settling in rural Australia, the prevalence has been <5% (personal communication M. Sanati-Pour). See prevalence tables for more information.

Transmission of strongyloides occurs through contact with soil or surface water containing infectious (filariform) larvae. Larvae enter through the skin, travel to the lungs via the blood stream, and penetrate the alveolar spaces. They then move to the pharynx, are swallowed, and mature to adult worms in the small intestine. Eggs hatch and the resulting early larval stage (rhabditiform) pass out in the faeces and either moult twice to become filariform larvae, or become free-living adult males and females that mate and produce rhabditiform larvae. The latter normally develop into infective filariform larvae in the environment. In some patients rhabditiform larvae mature to the infectious filariform stage within the intestine and invade colonic mucosa or perianal skin to cause ‘autoinfection’. In an individual with a normal immune system the numbers of circulating larvae are controlled, but the infection may persist for decades. Those with depressed cell-mediated immunity are at risk of disseminated infection with large numbers of circulating larvae (hyper- infection syndrome).¹³⁶ 

Most infected individuals are asymptomatic, or, have minimal symptoms and are therefore unlikely to seek treatment.

Recent infection may be associated with ‘ground itch’ or pruritic rash at the site of larval penetration. A slowly moving cutaneous linear eruption (larva currens) associated with migration of larvae under the skin is also characteristic of recent infection. Urticarial skin rashes may occur around the buttocks and hips, and purpuric skin lesions, angioedema and erythroderma have also been reported.

Intestinal symptoms include intermittent watery diarrhoea, nausea, vomiting, abdominal pain and weight loss.¹³⁰ Pulmonary symptoms with dry cough, dyspnoea, and wheezing, with or without eosinophilia (similar to Loeffler’s syndrome) may be associated with larval penetration of alveolar spaces. Asthma and repeated episodes of fever, cough and/or dyspnoea (pneumonitis) may occur in some patients. A history of larva currens, the rash associated with strongyloidiasis, is rarely volunteered, but may emerge with specific questioning (See Skin Infections).

Chronic strongyloidiasis may be complicated by secondary gram-negative septicaemia and/or meningitis. In patients with impaired cell-mediated immunity (after corticosteroids, cytotoxic agents, malignancy, malnutrition etc.), the combination of immunosuppression and autoinfection may lead to massive larval invasion of the lungs and intestinal tract (‘hyper-infection syndrome’ or ‘disseminated strongyloidiasis’). HTLV-1 and, to a lesser extent, HIV are also risk factors for disseminated infection because of immunosuppression. Patients with disseminated disease may present with abdominal pain and distension, intestinal obstruction, shock, pulmonary and neurologic complications and septicaemia. Eosinophilia may be absent due to immunosuppression.¹³⁷ Disseminated strongyloidiasis and the rapidly progressive hyper-infection syndrome have a poor prognosis with a mortality rates of >60%.^138,139 Hyper-infection may occur many years after resettlement in Australia.

Strongyloidiasis is usually asymptomatic. Therefore screening with serology should be offered to all people from refugee-like backgrounds. In addition, the diagnosis of strongyloidiasis should be considered if there are clinical signs and symptoms, or unexplained eosinophilia. The sensitivity and specificity of Strongyloides stercoralis serology is reported to be up to 94.6% and 99.6% respectively, depending on the assay used.¹⁴⁰ However, as there is no gold standard test for comparison, these are estimations only.

Limitation of tests

Serology may overestimate the prevalence of disease due to cross-reactivity with other nematode infections. Therefore a single stool examination is recommended following a positive serological result to investigate further for other infections.

Eosinophilia has a poor predictive value for detecting strongyloides infection ranging from 25% to 83% in different series.^141–143

Stool microscopy is insensitive for detecting strongyloides infection unless multiple fresh, warm samples are examined.^144,145 The sensitivity is higher in patients with hyper-infection syndrome because of the large number of larvae present. Harada-Mori and agar plate methods increase detection rates significantly. The main value of stool microscopy is that it can be used to monitor response in the first few months after treatment and to exclude co-existing enteric pathogens.

Caution

Hyper-infection syndrome is a medical emergency and admission to hospital, management of sepsis and treatment with ivermectin should be initiated as soon as possible.¹³⁷

If serology is positive or strongyloides larvae are identified on stool microscopy, treat with ivermectin 200 μg/kg (≥15kg) at day 1 and 14 (two doses total).

Four studies have compared the efficacy of a single oral dose of 200 μg/kg of Ivermectin with two oral doses of 200 μg/kg given either on consecutive days or two weeks apart. In one study, two doses of ivermectin was more efficacious than a single dose (100% v 77% cure, respectively) whereas in the other three studies the efficacy was similar (>93%) for both regimens.¹³⁰ However, as the efficacy of ivermectin against extra intestinal larvae is uncertain, we advise two doses of ivermectin two weeks apart to increase the number of larvae exposed to the drug in the gastrointestinal tract during the autoinfection cycle. This approach is supported in other recommendations.^93,130 Albendazole has been shown to have inferior efficacy in comparison to ivermectin in numerous studies, although longer duration of therapy (400mg twice daily for 7 days) has increased efficacy (63%¹⁴⁶) and may be used in patients in whom ivermectin is contraindicated, including in younger children.

Table 7.1: Conversion of ivermectin tablet quantities corresponding to 200mcg/kg bodyweight dose123
Stromectol® blister pack
Dosage in strongyloidiasis
Bodyweight (kg)	Dose (number of 3mg tablets)
15-24	1
25-35	2
36-50	3
51-65	4
66-79	5
≥ 80	Approx. 200mcg/kg

In persons from West or Central Africa co-infected with Loa loa, ivermectin can also cause encephalopathy and other severe adverse reactions. Those with neurocysticercosis or a history of seizures may be at risk of acute encephalopathy as a result of ivermectin treatment.⁹³ Consider referral to a specialist prior to ivermectin treatment if Loa loa or neurocysticercosis are suspected (a history of migratory subcutaneous swellings; ‘eye-worm’, or seizures; unexplained lymphadenopathy; unexplained eosinophilia).

Follow up

Serology is currently the best measure of treatment efficacy available as there is a decline in antibody titre after treatment. Decline in serological titres after effective treatment may be seen in many cases but can take 12 months or longer with current tests available in Australia. Therefore, serological testing should be repeated at 6 months and repeated at 12 months after treatment.^144,147 Follow up serology should preferably be done in the same laboratory and in parallel with previous specimen where available. Seroreversion can be considered proof of cure.

Full blood counts for eosinophilia and stool microscopy for larvae are too insensitive for assessment of treatment efficacy. Patients who remain seropositive despite adequate treatment should be referred for specialist management.

Ivermectin has an excellent safety record, but safety data is too limited to support its use in pregnancy or in children <15kg.

Avoid albendazole in children <6 months and adjust dosing for children <10kg.

Ivermectin is a category B3 drug in pregnancy. It is considered safe in breastfeeding.

Albendazole is teratogenic in the 1st trimester of pregnancy (category D drug). In the 2nd and 3rd trimesters, it has not been shown to be associated with congenital abnormalities. Albendazole appears safe during breastfeeding,⁷⁶ it passes into breast milk however systemic concentrations in the mother are low, except when used for hydatid disease or neurocysticercosis.

http://www.cmaj.ca/content/suppl/2010/06/07/cmaj.090313.DC1/imm-para-8-at.pdf

ttp://www.health.state.mn.us/divs/idepc/refugee/guide/index.html

ttp://www.cdc.gov/parasites/strongyloides/ 

Female adolescents and women from refugee-like backgrounds may have had limited access to women’s healthcare services prior to arrival in Australia, either due to lack of availability in their countries of origin and transit or because of prolonged periods spent in transit camps. Depending on their country of origin, the concept of women’s health screening and perinatal care may be unfamiliar, and the rationale, benefits and processes thus may need to be explained with a professional interpreter to enable informed consent.

A comprehensive women’s health assessment should be offered respectfully and sensitively. This is an opportunity to build trust and to create a safe environment. Similar to other communities, sensitive aspects of history may not be volunteered by patients until rapport is established, and may not be raised in the presence of other family members. Interpreter rapport is a further factor in building trust in the consultation. It is essential to clearly define the routine role of confidentiality in consultations, including defining interpreter confidentiality. Female adolescents should be seen alone for part of their health consultations once rapport is established. Explaining this is routine in the Australian healthcare system and seeking permission from both the adolescent and her parent/carers is helpful to facilitate this aspect of adolescent healthcare.

It is rarely necessary to perform a breast or pelvic examination at the first visit, unless there is an issue of immediate concern to the patient. It may be appropriate to see the patient over several visits in order to establish trust, to adequately explain the reason for women’s health screening and to ensure understanding and informed consent. Practitioners should always offer and provide a female interpreter, or, if requested by the individual, a chaperone for these consultations.

Cultural pressures and expectations as well as additional vulnerabilities related to migration status may influence the health consultation. As an example, women who are seeking asylum who are victims of IPV, as well as facing the many barriers common to all women who are victims of family violence, may struggle to disclose their traumatic experiences because of concerns about potential impacts on their asylum claim.

Confidentiality within the consultation should be emphasised as well as the fact that resources and support are available if violence is disclosed.³⁵⁵ Re-establishing trust is essential to emotional recovery for women who have experienced pre and/or post-migration trauma. Development of a quality therapeutic relationship with a primary care provider can be an important part of this recovery process.

Preventive health

Many women from refugee-like backgrounds are unfamiliar with pap smears and mammography, as well as other aspects of preventive health. Women with a first language other than English in Australia have been found to have lower health screening access rates and poorer quality of health outcomes compared to English speakers.^358,359

Explain the benefit and mechanism of these investigations to ensure an informed choice. Use health promotion material such as multilingual patient information sheets, flip charts, anatomical models and diagrams to explain screening tests, basic anatomy and physical functions such as menstruation.³⁶⁰

Women from refugee-like backgrounds may be at increased risk of osteoporosis due to prolonged poor nutrition and/or low vitamin D levels. Standard national guidelines apply for chronic disease (such as type 2 diabetes, ischaemic heart disease and osteoporosis), cervical, breast and bowel cancer screening.³⁴⁰

Screening for STIs also needs to be considered for women at risk, particularly for women who have come from a high-risk environment for, or disclosed exposure to sexual violence or unprotected sex (See Sexually Transmissible Infections).

Fertility and contraceptive choices

A comprehensive contraceptive and obstetric history is essential. Avoid making assumptions when providing sexual and reproductive healthcare. Some women may have limited knowledge and experience of contraception and are consequently at greater risk of unplanned pregnancy.³⁶¹

Contraceptive choices may be a responsibility shared by both partners. Offer information sensitively and clarify and enhance existing knowledge of emergency, reversible and irreversible contraception. Multilingual resources are available.³⁶²

Avoidance of assumptions is particularly pertinent to the management of unplanned pregnancy. Some women may decline a termination of pregnancy for religious and/or cultural reasons, others will make use of the opportunity; in any case, information regarding referral and clinical options, including medical abortion, should be provided so women can make an informed choice.

Female genital mutilation/cutting

Female genital mutilation/cutting³⁶³ is practised in many humanitarian source countries, although there are no prevalence data on how many women have undergone the procedure prior to arrival in Australia. It is estimated that over 125 million women worldwide have been affected by FGM/C,³⁶⁴ and in some countries the prevalence in women is up to 90%.

FGM/C involves removing normal, healthy genital tissue. The procedure is typically performed in young girls, from infancy to 15 years of age. It is medically unnecessary and has many potential physical and psychological consequences. The risks are related to the type of FGM/C that a woman has undergone. It is important that all primary care providers who see women from countries where this practice is performed are aware of the facts on the procedure, and potential consequences for women and girls.

It is important to be aware that use of the term FGM/C can be offensive to women. This issue should be explored respectfully, ascertaining what term the patient prefers. Other suggested terms such as ‘female circumcision’, ‘traditional cutting’ or ‘female ritual surgery’ may be perceived as being more respectful.³⁶³ For many women, FGM/C is a normal part of their life experience and thus they may be surprised when concerns are raised. Adolescent girls may not be aware that they have undergone the procedure.

There are four different types of FGM/C, ranging from excision of the prepuce to removal of the majority of the external genitalia and narrowing of the introitus (infibulation).³⁶³ Potential consequences depend on the type of FGM/C performed. Many women do not experience difficulties; however some may suffer from difficulty voiding, frequent UTIs, obstructed urinary flow, incontinence, sexual difficulties, urinary and/or faecal fistulae, obstruction during miscarriage and childbirth, intra-partum vaginal and perineal damage, chronic pain and psychological sequelae. Refer to an experienced female GP or sexual health nurse for gynaecological examination, including for pap smears. If women request de-infibulation (surgical opening of a narrowed introitus), facilitate expert gynaecological review – this is considered an urgent rather than routine referral.

Respectful, non-judgemental explanation of medical concerns about risks of FGM/C is important, particularly during pregnancy. Women and their families need to be aware of Australian law concerning FGM/C. It is particularly important that women understand that it is illegal in Australia for their daughters or other female relatives or friends to have this procedure, either in Australia or while overseas. Some families may want their daughters to undergo FGM/C and may wish to take them out of Australia to facilitate the procedure, this is an issue to consider when families seek travel advice for other reasons. Mandatory child protection reporting is required if there is any concern that girls aged less than 18 years of age are at risk of undergoing FGM/C.³⁶⁵ Education programmes to inform and support communities about the negative health consequences of FGM/C are available in several states in Australia.³⁶⁶

Pregnancy care

Women who have a positive pregnancy test or who are planning pregnancy should be offered screening consistent with Australian antenatal care guidelines.³⁵²

Pregnancy planning, preferably in the prenatal period, is very important in women who have had FGM/C, to ensure that health outcomes of both mother and baby are optimised. Assess the type of FGM/C and refer appropriately to ascertain if de-infibulation is required. The external appearance of genitalia is not necessarily an accurate representation of internal narrowing due to the procedure, which may complicate labour. Understanding and managing expectations, which may be divergent from obstetric practice in Australia, such as expectation of re-infibulation following delivery, is important; these concerns should be recognised and addressed as soon as they arise.

Many women from refugee-like backgrounds come from countries where there are high fertility rates and poor access to antenatal and prenatal care. Consequently, pregnancy complications and fetal loss are not uncommon.³⁶⁷ The sense of loss experienced by women from refugee-like backgrounds may increase during pregnancy. Many women are distressed at not being able to follow their traditional cultural practices at this time, where supporting women through pregnancy and childbirth, and raising children is a shared responsibility. Women often feel the absence of relatives acutely and some studies suggest a higher risk of postnatal depression.³⁶⁸

Menopause

Menopause should be considered when taking a history from women aged over 40 years. Menopausal symptoms may be masked by, or attributed to the difficulties of resettlement. Prolonged periods of amenorrhoea due to malnutrition or stress may be mistaken for premature menopause, or mask a slowly returning and/or unexpected fertility. This presentation provides a good opportunity to talk about contraception and preventive health, including the importance of weight-bearing exercise.

Intimate partner violence³⁵⁵

Refugee women often lack knowledge of laws about IPV in Australia, particularly knowledge of what constitutes family violence, and how to access help for this issue. Women can face multiple barriers to disclosing their experience of violence.

Family violence in Australia is not confined to particular socioeconomic or cultural groups – it is pervasive.³⁶⁹ Recognised correlating factors for risk of violence in women include exposure to child abuse or violence as a child, alcohol or drug dependency issues, financial or personal stress and lack of social support. IPV is more common in countries experiencing war, conflict or social upheaval. Some women are more vulnerable to violence, or less able to leave violent relationships, based on factors such as age, rural and remote location, disability, ethnicity, English language ability and being pregnant.

As is the case with any women presenting for healthcare in Australia, the possibility of IPV should always be considered in women from refugee-like backgrounds, sensitively explored, level of safety assessed and managed empathically.^354,355

It is useful to screen discreetly for family wellbeing and to interview the woman separately from her partner where possible, giving her an opportunity to raise concerns. Useful questions include: ‘Is there a lot of tension in your relationship at the moment?’, ‘How do you solve arguments if they happen?’, ‘Do arguments ever get physical at home?’, ‘Do you feel safe at home?’. Assessing safety is important, as is providing support to develop a safety plan for women and children at risk.

The majority of women who are victims of IPV do not readily disclose their traumatic experiences due to a number of factors including:

• fear of reprisal/worsening violence
• social isolation and financial dependence
• poor self-esteem as a consequence of the violence
• emotional dependence
• being unable to recognise the cycle of abuse/self-blame
• fear of loss of custody of children.

For women from refugee-like backgrounds, disclosure rates are believed to be lower than the rest of the population, and they may face additional complexities such as concerns about potential impact on immigration status, and cultural and religious factors, including risk of social ostracism if disclosure occurs.^370,371

Healthcare providers need to be aware of these issues, to approach concerns about IPV sensitively and to review regularly and invest time in the therapeutic relationship as the development of trust is imperative. When a woman is ready, referral to culturally appropriate advocacy, support and legal services can be facilitated.

RACGP White book Abuse and violence – working with our patients in general practice Feb 2014.

Australian antenatal guidelines (contains information on culturally sensitive care and on specific needs of women from refugee-like backgrounds)

The National Education Toolkit for FGM/C awareness

Female genital mutilation Information for health professionals booklet 1997.

Hach M. Multicultural centre for womens health. Common threads, common practice. Working with immigrant and refugee communities in sexual and reproductive health.

Family planning NSW multilingual audiovisual resource for patients explaining importance of cervical screening

Cohealth. Helping health professionals to start conversations about female circumcision website.

Jean Hailes Multilingual womens health resources including menopause and PCOS.

Women from culturally and linguistically diverse backgrounds
https://www.beyondblue.org.au/resources/for-me/multicultural-people

http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~population-groups~diverse-backgrounds

https://www.beyondblue.org.au/resources/health-professionals/perinatal-mental-health 

Many adults and children from refugee-like backgrounds have experienced trauma, conflict, family separation and significant human rights violations, including torture and physical and sexual violence. A meta-analysis found the population prevalence of reported torture was 21% in refugee adults,³⁷² and available Australian data suggest a high proportion of asylum seekers in detention disclose a history of trauma and torture.³⁷³ Unaccompanied and separated children are recognised as having specific risks and vulnerabilities.^374–378

While pre-arrival trauma is well recognised in refugee populations, settlement may also contribute to mental illness, and is often associated with multiple stressors. Navigating life in a new country, language barriers, housing and financial instability, difficulty accessing employment, changes in family roles, and loss of community, country and cultural connections can have additive impacts in terms of risk for mental health. A meta-analysis of risk factors affecting mental health outcomes in refugee groups³⁷⁹ found poorer outcomes were associated with institutional or temporary housing after settlement, restricted economic opportunity after settlement, ongoing conflict in the country of origin, higher education level and higher socioeconomic status pre-arrival, and coming from a rural area. Child and adolescent refugees had relatively better mental health outcomes than adults in this analysis, although parent mental health has a strong influence on child wellbeing.

Asylum seekers may face additional stressors related to their asylum experience – through perilous journeys, time in immigration detention, and living in a state of prolonged uncertainty. There is clear evidence that Australian immigration detention, especially long-term detention, is detrimental to health and mental health at all ages, in the short and long term.^380–400 Additionally, Australian temporary protection visas have been shown to be associated with worse mental health status when compared to permanent protection visas,^{387,392,401–404} due to restrictions on family reunion, access to employment and/or Medicare, and exposure to ongoing uncertainty.⁴⁰⁴

Widely variable rates of mental health issues are reported in refugee children (reviewed in,⁴⁰⁵ also^406,407 and adults,^{372,391,408–412}) although there is more information available on the prevalence of Post Traumatic Stress Disorder (PTSD), depression, and anxiety than other mental health diagnoses, and findings are typically specific to cohorts, conflicts and countries of settlement. Like any population, people from refugee-like backgrounds may have conditions such as schizophrenia or bipolar disorder; although, there is little evidence to suggest that these diagnoses are more frequent in refugee-like populations.

The validity of mental health screening in refugee groups has been questioned.⁴¹³ Existing assessment tools, diagnostic approaches and psychological interventions may have limited applicability to refugees and asylum seekers, and caution is required with mental health diagnoses; however, evidence suggests that therapy is beneficial in these groups.^414–416

We advise clinical screening for emotional wellbeing and mental disorders as part of the post-arrival screening, and ongoing review for stressors related to the refugee and resettlement experience over time.

Available evidence suggests that both refugees^{405,417–423} and asylum seekers^424–427 face significant barriers to accessing health and mental health services. A comprehensive post-arrival health assessment offers an opportunity to build trust and rapport, consider risk and resilience, and raise awareness of mental health and supports in Australia. Understanding mental health is also essential to address other health problems, and support adherence to medication and management.

A complete history and examination is outlined in Promoting Refugee Health.²¹

Health consultations and discussion about mental health may be a source of significant anxiety for some individuals. Past experiences influence people’s understanding and access to healthcare, and it is important to recognise that people may not had prior experience of mental health care. Furthermore, in some source countries, authority figures, including health professionals, may have been complicit in torture or other form/s of persecution. It is also important to consider the presence of family members in the room, and issues specific to working with interpreters.

The following areas are useful to explore during initial consultations:

• Migration history. Some useful general (and sensitive) questions include:
  • When did you leave your country?
  • Were you forced to leave?
  • What was the situation that led you to leave?
  • What countries were you in before you came to Australia?
  • What were conditions like in those countries?
  • Have you spent time in a refugee camp or a detention centre?
• Migration status (asylum seekers). Asylum seekers in Australia experience prolonged delays (i.e. years) in processing their claims for refugee status, which includes frequent changes to immigration policies that directly impact on their day-to-day lives. An insecure and temporary visa status is associated with feelings of powerlessness and inability to plan for the future,^401,403 with the additional burden of stringent code of conduct requirements,⁴²⁸ denial of work rights⁴²⁹ and/or Medicare, and restrictions on family reunion.⁴³⁰
• Family composition. Useful questions include: ‘Who is in your family in Australia?’ and ‘Who is in your family overseas?’ rather than trying to construct a genogram. Concern for remaining family overseas may be overwhelming, with significant effects on settlement and wellbeing.
• Settlement experience, social connections, resources and support.
• Current functioning. It is often useful to ask about appetite, energy, daily activities, memory and concentration, sleep and plans for the future as an entry to more specific mental health symptoms. Asking about approaches to stress management, and coping strategies can also be useful, as it can indicate the extent of the person’s (internal and external) resources, and utilisation of these resources.
• Trauma screening. It is rarely necessary to ask in detail about a client’s trauma and torture history, and it is important to consider the potential for triggering a trauma response. Useful screening questions include:
  • Terrible things have often happened to people who have been forced to leave their countries. I do not need to know the details about what you have been through, but is there anything that has happened that might be affecting you now?
  • Do you think a lot about these things that you’ve been through?
  • Is it hard to concentrate on other things in your life, or is it hard to get to sleep because of these memories or thoughts, or because of bad dreams or nightmares?
  • Do you worry about going crazy or ‘losing your mind’?
• More specific mental health symptoms. Enquire about symptoms such as current mood, irritability or anger, sadness, hopelessness, guilt and worthlessness, loss of interest in (previously) enjoyable activities, social withdrawal, anxiety symptoms, panic symptoms/panic attacks, rumination, and intrusive thoughts.
• Self-harm/suicide risk assessment. Suicidality can occur independently of mental illness,⁴³¹ and hopelessness has been found to be a stronger predictor of suicidal ideation than a diagnosis of depression.^432–434 Furthermore, suicidality may present differently in those from diverse refugee-like backgrounds.^435,436 Religious beliefs and a strong sense of responsibility to one’s family can be particularly potent protective factors, which often precludes intentional and planned acts of self-harm. It is worth noting that asylum seekers are likely to be at greater risk of suicide after a negative refugee determination decision.^437,438 Therefore in addition to the usual risk assessment questions (i.e., Does the individual have thoughts of harming themselves? Do they have intent, a plan and means to do so?), the following questions may also be useful: ‘Do you ever wish you were dead?’; ‘How often do you have these thoughts… and how long have you been having them? Have they increased or lessened over time?’; ‘Do you worry that you might hurt yourself impulsively, without planning to (e.g. walking in front of a car or train)?’ ‘Do you sometimes find yourself doing things that put you at risk without realising, such as walking across the road without checking to see if there is traffic?’.

Other common presentations in adults include:

• Somatization of psychological symptoms including chronic and regional pain syndromes. Pain syndromes, particularly neuropathic pain, can also be the consequence of previous torture and thus should be comprehensively assessed.
• Concerns about memory and concentration.
• Complicated grief,^439–441 prolonged grief/bereavement,^439,442 and traumatic grief.⁴⁴³ Common – even adaptive – traumatic/complicated grief reactions in this population may be mistaken for psychotic symptoms, such as visual or auditory hallucinations,^444,445 and must be considered and assessed carefully within this context.
• Relationship difficulties (including family violence, parenting issues). Refer to Women’s health for further exploration of family violence identification and management.
• Disorders of addiction, including gambling or substance abuse.

Culture, mental health literacy, education, language proficiency, education and perceptions of stigma also have profound effects on presentation and access to mental health services.

The Cultural Assessment Tool⁴⁴⁶ is a useful framework that encourages a narrative approach to exploring people’s beliefs and cultural interpretation of illness. Questions from this tool include:

• Why do you think the problem started when it did?
• What do you think your illness does to you?
• What are the main problems it has caused for you?
• How severe is your illness?
• What do you most fear about it?
• What kind of treatment/help do you think you should receive?
• Within your own culture how would your illness be treated?
• How is your community helping you?
• What have you been doing so far?
• What are the most important results you hope to get from treatment?

Patients with mental health issues related to torture and trauma should be referred to a specialised torture and trauma service.

Where there is no torture or trauma history, referral to mainstream mental health services may be more appropriate. There are a number of ways to provide assistance while people await review. These include:

• Regular review and providing support to reduce feelings of isolation.
• Exploring and identifying strengths and evidence of resilience.
• Advice regarding regular exercise and good nutrition.
• Advice on sleep hygiene and relaxation strategies.
• Psycho-education about common mental health symptoms and conditions (e.g. social withdrawal, anhedonia, and disturbance of mood, sleep, appetite for depression; intrusive symptoms, avoidance and hyper-arousal for PTSD; physiological responses during panic attacks; transient cognitive difficulties due to anxiety/depression/chronic stress). Normalising symptoms can help to de-stigmatise perceptions of mental illness, and individuals may prefer to manage symptoms themselves unless, or, until, significant psychosocial functional impairment and/or subjective suffering is encountered.
• Explaining what is meant by counselling, which may increase the likelihood of the individual accepting a referral in the future. Counselling may be normalised by framing it as a way to help problem-solving processes and increase coping strategies, in addition to it being a confidential space to release ‘emotional pressure’ independent of family and community relationships.
• Introducing the concept of talking with others – e.g. friends, religious figures, or a counsellor as a way to releasing pent up emotions and stress. Useful analogies can be to get things ‘off one’s chest’ or a pressure cooker valve ‘letting off steam’, rather than ‘bottling things up’. Explaining that counselling may not suit everyone, but that it may help provide strategies to reduce further build up of emotional stress, strengthen emotion regulation, and increase social connectivity, can be a useful strategy.
• Teaching structured problem-solving, and identifying and challenging negative core beliefs using simple cognitive behavioural therapy strategies. Technology such as mobile phone applications may be useful. Whilst most applications are in English, there is at least one (‘New Roots’) that has been translated. (Refer to Links at the end of this chapter).
• Excluding possible medical contributors to mental health symptoms where relevant (e.g. low B12, thyroid dysfunction).

A list of services for each state and territory is available in the Foundation House Promoting Refugee Health Guideline.²¹

The methods of documenting (and managing) physical and psychological findings of torture and trauma are outside the scope of these guidelines. Please refer to the Istanbul protocol for further details.

The sense of disconnection and loss relating to separation from key family members, supports and culture can be exacerbated during pregnancy and the perinatal period. It is common for women to be distressed by differences between mainstream ante and perinatal care and their traditional cultural practices during this time. Many women of refugee-like background are from cultures where supporting a new mother and raising children is a shared responsibility. Pregnancy and the post-partum period are often times where the sense of loss related to absence of friends and relatives is heightened and thus there is a higher risk of anxiety and postnatal depression.³⁶⁸ This risk appears to be extreme for women who are pregnant and give birth while they are in immigration detention.

Women who have experienced FGM/C face specific physical and psychological risks in pregnancy, which need to be recognised early and addressed (see Women’s Health).

Pregnancy is a time where women at risk of family violence may be particularly vulnerable to harm. Women of refugee-like background are not immune to these risks and thus this needs to be considered and sensitively managed^355,369 (see Women’s Health).

Recognition of the risks which women of a refugee like background face during this vulnerable time is important, to enable appropriate screening, to facilitate access to care with early referral to culturally and linguistically appropriate services, to enhance social supports and enable access to appropriate health promotion and education resources to optimise outcomes.³⁵² 

Children and young people of refugee-like background are likely to have been exposed to significant trauma prior to their arrival in Australia, and may have additive risk for mental health and developmental concerns through parent mental illness, disrupted family functioning, periods of separation, and the timing of trauma in relation to developmental milestones. Unaccompanied and separated minors have specific vulnerabilities, including increased risk of experiencing violence, sexual abuse or sexual violence, and they may have cumulative risk for mental illness. Children and adolescents experience a similar range of psychological reactions to trauma to adults; however, their clinical presentation reflects their age and development.

Parent mental health influences child mental health, and the impacts of parental distress and/or mental illness on children are significant. For asylum seeker children and adolescents, Australian immigration detention has been found to have profound negative impact on parenting and family functioning,^{209,390,391,395,447,448} and children frequently witness adult distress, mental illness and self-harm in detention.⁴⁴⁹ Children and adolescents in detention are at high risk of mental health problems, including PTSD, anxiety and depression, sleep and behavioural disturbances, and enuresis. Infants born in detention may have severe attachment issues in association with maternal postnatal depression.

Parental well-being is also identified as a key factor in optimising a child’s ability to recover from adversity.⁴⁵⁰ Children and adolescents experience settlement through their family circumstances, but also through their interaction with peers, community and education in their new country, and there is increasing recognition of the role of education and schools in supporting child wellbeing.^451–454
In addition to the areas of history suggested in the earlier section, other points to consider in children and adolescents include:⁴⁵⁵

• Attachment to parents/caregivers.
• Behavioural difficulties, including irritability or aggression.
• Play and peer relationships, including emergent themes in games or drawing, any difficulties making friends, engaging in play, or joining group activities.
• Difficulties with attention or concentration, hyperactive behaviour, learning difficulties.
• Withdrawal or lack of interest in normal activities; retreating into screen-based play is common.
• Separation issues, including school refusal, watchfulness, and co-sleeping.
• Sleep-related symptoms, including nightmares, intrusive worries or thoughts, disordered sleep routine and fatigue.
• Enuresis and encopresis.
• Difficulties with self-esteem.
• Developmental delay, lack of expected developmental progress or regression.
• Sexualised behaviour, which may indicate that a child or young person has witnessed or been exposed to sexual abuse. Seek advice on child protection concerns and consider reporting requirements.
• Risk taking behaviour in adolescents.

Self-harm or suicidality are extremely rare in younger children, but require urgent review if present at any age.

Consider use of a screening tool for children such as the Strengths and Difficulties Questionnaire (SDQ). HEADSSS screening is useful to elicit key aspects of psychosocial history in adolescents. See below for links.

Management and referral (children and adolescents)

Management and referral of children with mental health concerns follows similar principles to adults. Where mental health difficulties relate to torture/trauma experience, a torture trauma service is an appropriate referral, and in most states and territories these services will provide services for children. Seek specialist paediatric advice early; referral to generalist mental health services may also be appropriate. Also consider (and screen where relevant) for treatable conditions that may cause or exacerbate mental health or behavioural problems, including hypothyroidism, vitamin B12 deficiency and iron deficiency.

General principles of managing children/adolescents experiencing trauma reactions and/or other mental concerns include:

• Addressing mental health issues in the whole family.
• Supporting primary attachments with significant people.
• Maintaining routine and preparing for changes, reassuring children about the future.
• Addressing sleep issues, and maintaining a healthy age-appropriate sleep routine, and limiting screen time.
• Encouraging play in younger children (between children, and between parents and children) and enjoyable activities in older children/adolescents, including sport and exercise.
• Encouraging them to express emotions and asking what they are thinking/feeling.
• Setting realistic goals for behaviour and avoiding overreacting to difficult behaviour during transition periods.
• Promoting engagement with school and community, and also promoting maintenance of first language alongside English language learning.

A brief assessment of developmental milestones should be included as part of a comprehensive assessment in children of refugee-like background, specifically eliciting parent concern, excluding sensory impairment (vision and hearing), and ensuring children are linked with age-appropriate services such as Maternal and Child Health Nursing and kindergartens early in the settlement period. Assessment of children with developmental delays or disability will usually require specialist child health input, by paediatricians or through paediatric allied health professionals.

There are limited prevalence data on developmental issues or disability in children of refugee- like background, although they may have multiple risk factors for developmental concerns, and the aetiology of developmental issues is typically multifactorial. Routine neonatal, early childhood, vision and hearing screening are unlikely to have been completed, and children may arrive with significant developmental delays or disability.

Psychological and developmental assessment can be complex, requiring an understanding of second (or later) language acquisition, language transitions in relation to development, relevant medical conditions, the impact of forced migration, trauma, and settlement, and support services available. There are specific challenges with the use of developmental screening tools, language assessments and cognitive assessments for children with English as an Additional Language (EAL). Developmental assessments take time and require close liaison with families and the help of a skilled interpreter. They are usually completed in the specialist child health setting, after referral from primary care. Service guidelines are available.⁴⁵⁶

Adolescence is a developmental stage, for which milestones include emergent autonomy and independence, personal identity and body image, peer relationships and recreational goals, educational and vocational goals, and sexuality. Adolescents of a refugee background face all these transitions in addition to the transitions of resettlement. They are faced with 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 and social system. Adolescents may also make new meaning from past trauma, and present with mental health concerns in relation to trauma in early childhood.

Promoting refugee health: a guide for doctors, nurses and other health care providers caring for people from refugee backgrounds.

Mental health in multicultural Australia

Forum of Australian Services for the Survivors of Torture and trauma services (listed by state and territory)

http://www.healthtranslations.vic.gov.au/bhcv2/bhcht.nsf/PresentEnglishResource?Open&x=&s=Mental_Health/Illness

http://www.beyondblue.org.au/resources/health-professionals/clinical-practice-guidelines/asd-ptsd-clinical-practice-guidelines

http://refugeehealthnetwork.org.au/mental-health-resources-weblinks/ http://refugeehealthnetwork.org.au/refer/mental-health-services/
New Roots smartphone app

Children and young people

ANU Australian child and adolescent trauma, loss and grief network – refugee children and families information

Royal Children’s Hospital Melbourne. Immigrant Health service. Developmental assessment page.

Transcultural Mental Health Centre & NSW Centre for the Advancement of Adolescent Health. Adolescent Health: Enhancing the skills in caring for young people from culturally diverse backgrounds. 2nd edn. 2008 

Strengths and Difficulties Questionnaire

HEADSSS screening