Providing health care for refugee children and unaccompanied minors
The health of refugee children, as with any young person, must be considered within a wider context, recognising issues, which impact upon health, such as housing, education, economic and family stress. Providing health care for these children must extend beyond ensuring access. To respond adequately, health professionals must appreciate the wide range of problems faced by asylum seeking and refugee families and the multiply disadvantages experienced by unaccompanied minors. They also need to understand the significance and difference between terms such as asylum seeker and refugee, have some knowledge of entitlements, be interested in learning about different cultures and be prepared when necessary to advocate on their patients behalf.
Experience has shown us that it is unreasonable to expect refugees to slot neatly into existing styles of health care; they require support in accessing and using services and health professionals require guidance on how to respond effectively. Many refugee children come from cultural and religious backgrounds, with which staff in local the statutory services are unfamiliar. They and their parents usually speak little or no English and will often have witnessed and suffered events outside the experience of most health professionals in this country. This can leave health workers feeling dis-empowered and unsure of how they should interact with parent and child. Currently as with other professionals e.g. teachers, there is a need to develop training and to make ongoing support available to all health service staff working with asylum seeking and refugee children. This should include working with interpreters and link workers, who also require training, supervision and support.
Planning of health service provision for children from asylum seeking families is not helped by the way, in which Asylum applications are recorded, making it difficult to know the numbers of children involved. Dispersal means that some families are now finding themselves in areas unfamiliar with the provision of services to asylum seekers and refugees and where health service staff may have had no advance warning of their arrival.
Children who are asylum seekers or refugees have the same rights to health, and access to services as all other children in this country. Charges for NHS prescriptions, dental or optical care do not apply to any child under 16 years, but there does not appear to be any clear provision for 16-18 year olds. Under the new provisions asylum seekers are not eligible for welfare foods and vitamins for their babies. This has implications for the childs nutrition and is causing a particular problem for HIV positive mothers who are advised not to breast-feed.
All children are entitled to routine child health surveillance, health promotion and immunisations, including a primary course if this has not previously been completed. However it must be remembered that, until permanently registered with a GP, routine appointments will not be sent.
There should not be any delay in referring children what ever their status to specialist child health services including multidisciplinary Child Development Teams. Even when there is good access to such provision there is evidence of severe delays occurring before disabled children are able to access appropriate educational placements. Asylum seekers are not eligible to claim Disability Living Allowance either for themselves or for their children. Therefore once refugee status is approved it is important to ensure the appropriate applications are rapidly made.
Unaccompanied under -18 year olds have the right to be "looked after", to have somewhere to live, to education and health care. Current initiatives in this country, under the government Quality Protects programme, are seeking to improve the health and educational outcomes for children in public care. It is essential to ensure unaccompanied young asylum seekers are specifically included in such local provision. The reality is that currently many 15 to 18 year olds are placed in adult accommodation and many authorities do not offer this age group full needs assessments leading on to individual care plans.
In working with both children of asylum seekers and unaccompanied children it should be remember that they can still be considered "children in need" under the Children Act and indeed both groups are mentioned in the new Department of Health guidance (Framework for the Assessment of Children in Need and their Families (2000).
Physical Health Considerations
While most illnesses experienced by children will be those common to all children it is important to know where to access specialist advice for unfamiliar diseases. Children may have had no previous child health surveillance or neonatal screening for congenital abnormalities or inborn errors of metabolism. Immunisation status should be reviewed and appropriate primary, catch up and booster immunisations organised. Culturally sensitive advice on diet and support for breast-feeding must be available. Children may arrive malnourished, but are also at risk of suffering from an inadequate diet in this country.
Paediatricians have been advised to use caution in making any medical assessment of a young persons age. It is worth knowing that the Home Office Asylum Casework Instructions acknowledge that anthropometric measurements can be misleading and consider the use of X-rays merely to assist in age determination inappropriate
Young people who are asylum seekers and refugees like all young people need access to sexual health and drugs education. Programmes will need to be developed in partnership with refugee communities and the young people themselves.
Emotional Health and Wellbeing.
While refugee parents and children may be psychologically distressed it is important that resilience and resourcefulness are recognised and respected. Some families come from cultures with perceptions of mental illness that are very different to ours and for whom the suggestion of "referral for counselling" is meaningless and therefore unhelpful. This is not to say distress should not be acknowledged or support not offered. Some children may exhibit signs of post-traumatic stress, but the majority witnessing violence and conflict do not experience long-term behavioural problems It should also be remembered that response to stress might manifest itself with physical signs.
Children can also be affected by their parents psychological state. Parents suffering from the effects of their own traumatic experiences and preoccupied with making sense of life as an asylum seeker will find it difficult to provide their children with a self confident and strong role model. Nor are they likely to be as emotionally available to support and encourage their children as they might wish.
Young people themselves have identified a number of issues that affect their wellbeing. When groups of young asylum seekers (aged 12 to 16) were consulted in South London they included loss of family members, loneliness, feeling cold, being depressed and lack of money and language barriers. Bullying emerged as a major concern as did difficulty in accessing services (not just health). More than a half felt their health had deteriorated since coming here! Another issue also identified by the young people and which needs to be urgently denounced as unacceptable is the use of children as interpreters for the parents at medical appointments.
Our present Government is committed to reducing both child poverty and social exclusion and has funded a range of innovative initiatives. By ensuring such projects are always made accessible to asylum seekers and refugees some of the multiple disadvantages faced by the children would be addressed. As dispersal gathers pace health professionals throughout the country must share good practice. Sixteen to 18 year olds deserve special attention. Present arrangements and provision risk making them one of the most excluded groups of young people in the country. Both professional and public attitudes to these young people need to be challenged and changed. Working with families from diverse cultures should to be viewed as a privilege not a chore. As a country with an ageing indigenous population we should be welcoming these young newcomers and providing them with education and training. In the future they could be in a position to solve the staffing crisis that will surely face our Health and Social Services.
· Levenson R, Sharma A. Health of refugee children: guidelines for paediatricians. London: RCPCH, 1999.
· Lynch MA , Cuninghame C. Understanding the needs of young Asylum Seekers. Archives Diseases of childhood. 2000; 83, 384-387.
· Gosling R. HAZ National Innovation Fund: Young Refugee Project. 2000. (firstname.lastname@example.org)