Children

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Table of contents

Key points

Around half of all humanitarian arrivals to Australia are aged less than 18 years, with a high proportion of young children.
Children who arrived as refugees or asylum seekers will have similar health problems to their Australian-born counterparts, but may also have health issues specific to their country of origin and migration experience.
Trauma affects development and family functioning, and interrupted schooling is common – children may need healthcare and support related to their developmental and learning needs.
Children may have an incorrect date of birth recorded on their migration paperwork, which is an important consideration when assessing growth, development, learning or school placement.
The initial refugee health assessment is a starting point to link children with other universal service systems, and introduce longer-term preventative healthcare.

Overview

The World Health Organization defines children as 0–17 years, 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. Families are often large, and there may be many children within a family group. Some refugee children arrive as unaccompanied humanitarian minors; other children of refugee-like background arrive under alternative visas (e.g. orphan relative) or as asylum seekers.

Considerations in working with children include their developmental stage and ability to express themselves, different types and presentations of medical conditions, and providing healthcare through parents/carers.

Approach to care

Early childhood is typically a period with multiple healthcare visits. The initial refugee health assessment provides a starting point to introduce longer-term preventative health care, for example, through catch-up immunisation, hearing and vision screening, dental referral, healthy eating advice and developmental surveillance. Additional supports for children are available through maternal and child health nursing, early childhood intervention, and the education system (through pre-schools and schools).

Children of refugee-like background will have similar health problems to their Australian counterparts (e.g. viral illnesses and injuries), but may also have health issues specific to their country of origin and migration experience.

Considerations

Immigration Medical Examination (IME) is limited for children less than 11 years compared to adolescents and adults. Screening includes urinalysis (5 years and older), interferon gamma release assay (IGRA) or tuberculin skin test (TST) (2–10 years), chest x-ray if clinically indicated, and HIV screening if risk factors are identified.   Unaccompanied minors (all ages) also have screening for HIV and HBsAg.
Screening tests differ – they may have lower sensitivity or may not be validated in younger age groups, and the interpretation of test results may vary with age.
Paediatric pathology specimen collection should be used to reduce the amount of blood drawn for screening tests.
Tuberculin skin test (TST) preferred for tuberculosis screening in children less than 5 years.
Catch-up vaccination and vaccine licensing varies with age. Children less than 5 years will need pneumococcal and Hib vaccines and additional doses of DTPa and IPV vaccines; hexavalent vaccine (DTPa-IPV-HBV-Hib) is licensed for use less than 10 years; MMR-V should not be used as the first dose less than 4 years.
Medication dosing varies with age and medications may not be licensed for use in children.
The impact of trauma and mental health problems may present differently in children. Consider functional impairment, developmental progress, attachment, behavioural and learning concerns, sleep issues and difficulties with attention/concentration, as well as mental health symptoms. Parent mental illness affects child wellbeing, and addressing both parent and child mental health is important.
Family structures and parenting roles may change with migration, affecting settlement and child development. Exploring these aspects offers an opportunity to assess risk and resilience factors for children and families.
Prior schooling may have been limited or interrupted, with implications for educational placement in Australia.
Children may have an incorrect birthdate recorded on their migration paperwork; this is important to consider when assessing growth, development, learning and school placement.
Link infants and children with the universal service system, which will also provide a safety net.
Seek early paediatric review for complex child health issues, including physical health, developmental/behavioural concerns, disability, and age assessment. Paediatric review may also help facilitate mental health services where needed.

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.