An issue of access: delivering equitable health care for newly arrived refugee children in Australia

Newly arrived refugees and asylum seekers are faced with many difficulties in accessing effective health care when settling in Australia. Cultural, language and financial constraints, lack of awareness of available services, and lack of health provider understanding of the complex health concerns of refugees can all contribute to limiting access to health care. Understanding the complexities of a new health care system under these circumstances and finding a regular health provider may be difficult. In some cases there may be a fundamental distrust of government services. The different levels of health entitlements by visa category and (for some) detention on arrival in Australia may further complicate the provision and use of health services for providers and patients. Children are particularly at risk of suboptimal health care due to the impact of these factors combined with the effect of resettlement stresses on parents' ability to care for their children. Unaccompanied and separated children, and those in detention experience additional challenges in accessing care. This article aims to increase awareness among health professionals caring for refugee children of the challenges faced by this group in accessing and receiving effective health care in Australia. Particular consideration is given to the issues of equity, rights of asylum seekers, communication and cultural sensitivities in health care provision, and addressing barriers to health care. The aim of the paper is to alert practitioners to the complex issues surrounding the delivery of health care to refugee children and provide realistic recommendations to guide practice.     

Pädiatrische Gesundheitsversorgung von minderjährigen Flüchtlingen und Asylbewerbern

The huge influx of refugees is a challenge to our society. Paediatricians in hospitals and in primary care are able to provide comprehensive medical care to children and adolescents of refugees and asylum seekers. Cultural-sensitive training for nurses, doctor’s assistants and physicians can further improve their competency. One needs time and motivation for voluntary services and first-aid health education for families in refugee camps. Sustainable health care for migrants can only be achieved by integrating them with equal rights into the regular national health system. Therefore primary care paediatricians have to open their doors to the newcomers. The DAKJ, BVKJ, DGKJ and DGSPJ societies should give priority to the health needs of children and adolescents of refugees and asylum seekers. The core messages of this statement are: 1. Paediatricians have to examine children and adolescents thoroughly and as soon as possible after arrival. 2. Vaccinations should be given as soon as possible. 3. Post-traumatic disorders should be recognized early and treated adequately. 4. Unaccompanied minors need special protection.     

Vietnamese child health in a Hong Kong closed camp

Vietnamese refugees arriving in Hong Kong since 1982 have been confined to restricted areas. In this study, 241 children in one of these areas were screened to identify their health status. Using NCHS standards, 48% were found to be below the fifth percentile for both weight-for-age and height-for-age. Anaemia was found in 8% and hepatitis B antigenaemia in 25%. Intestinal parasites were identified in 62% of faecal specimens and 26% of these contained more than one parasite. Although all children had received BCG, 41% had a negative PPD skin test. Chronic bacterial skin infections, lice and otitis media with perforation were identified as other common problems. Screening of this population revealed a high prevalence of health problems, some of which would respond to appropriate public health measures.     

Personal viewpoint: eclecticism in health services for developmental disorders

The term 'eclectic', as applied to health care for children with developmental disorders, portrays an individualized, adaptive service response to local constraints and pressures. While this may appear appropriate for the local setting, the end result is a broad diversity of health care approaches. This paper discusses three separate processes that interact at a local level, increasing the likelihood of an eclectic local model of health care for this population of children. The first process draws from the direct clinical work. Variable training, knowledge and skills among health care providers, in combination with differing beliefs around the nature of the problems and their management leads to health care which directly reflects the attributes of the local clinicians. A separate, second process fuelling variability is the differing models of departmental responsibility across Australia - which Government departments fund which aspect of care for children with disabilities. The final process relates to funding streams for health care. State public health, federal Medicare and private insurance all support health services for children with disabilities, with the financial incentives (budgets compared to fee-for-service) driving a divergence of practice. This paper concludes that the external political, administrative and financial frameworks within which health care is constructed will continue to promote clinical eclecticism to a degree that would probably be considered unacceptable in other areas of child health care. The solution can only arise from within the clinical work itself, with greater clarity of understanding around the nature of the disorders, the outcomes for which health care takes responsibility, and an increasing focus on an evidence based set of approaches towards achieving these.     

Refugee children—a concern for European paediatricians

Many refugees, about 33% of them children, come to Europe from several different countries. Their somatic state of health is sometimes impaired and they have often been exposed to persecution, war and atrocities with consequences for their psychological health status. The period of application for asylum is often long and strenuous, both socially and psychologically. Their needs are often disregarded. Acccording to the United Nations Convention on the Rights of the Child, Europan paediatricians should take it as their responsibility to provide health care for them at the same level as that for children of the host country.Prepared for the Ethics Working Group of the Confederation of European Specialists in Paediatrics (CESP). This paper was prepared in co-operation with the following members of the CESP Ethics Working Group: Ronald Kurz, Dennis Gill, Francis Crawford, and Milena Lo Giudice.     

New faces from faraway places: Immigrant child health in Canada

For the past several years, more than 50,000 children have immigrated to Canada annually. These children are particularly vulnerable in terms of their health. Although the Immigration Medical Examination provides the required medical screening, a number of additional recommendations for the medical evaluation of immigrant children can optimize their health care as they transition to life in Canada. Furthermore, a number of other issues must be specifically addressed in the care of immigrant children, such as consideration of their culture, nutritional issues and growth, psychosocial issues and immunizations. Certain groups of immigrant children, such as internationally adopted children and refugees, may be even more vulnerable and have special needs. However, despite the numerous challenges in addressing the health issues of immigrant children, there are many resources available to help paediatricians provide these children with optimal care.     

War trauma experience and behavioral screening of Bosnian refugee children resettled in Massachusetts

The authors assessed war violence exposure and behavioral symptoms in Bosnian refugee children in Massachusetts and the utility of behavioral screening of refugees during the Refugee Health Assessment (RHA), required of newly arrived refugees. The study was a survey of 31 Bosnian refugee children in 1996 at the International Clinic of Boston Medical Center, the state's largest contracted provider of the RHA. Subjects were also offered referrals to appropriate mental health services. Sixty-eight percent experienced long-term separation from a parent. Eighty-one percent were directly exposed to armed combat. Seventy-one percent experienced the death of a close friend or relative. Fifty-two percent experienced economic deprivation. Families reported behavioral symptoms for 77% of children. Only one family expressed interest in psychosocial services of any kind. Large numbers of Bosnian refugees are likely to have experienced traumatic war violence and are at risk of behavioral symptoms. The RHA affords opportunities to screen for behavioral problems but not to intervene. Primary care providers and other clinicians should be aware of likely recurrences of symptoms in high-risk children such as these.     

Health of Australian children in out-of-home care: needs and carer recognition

Aim: Following research highlighting high levels of health need in New South Wales children in out‐of‐home care, this study aimed to quantify health need in a sample of Queensland children in care based on multidisciplinary child health assessments. The study also sought to examine the concordance between foster carers' health concerns for children for whom they are providing care and health need as established through referrals made as a result of health assessment. Methods: Children entering out‐of‐home care in the north Brisbane area within the previous month were referred for baseline child health assessment. Child health was assessed by paediatricians and clinical nurses utilising a pro forma‐based methodology. Analysis of initial carer concerns, health referrals and immunisation status in the sample was undertaken. Results: Of the 63 children assessed, 70% were found to require multiple referrals to various health services. The most frequently made referrals included paediatrician follow‐up (41% of children), counselling services (30%) and audiology (26%). Only 68% of the sample was found to be fully immunised. A discrepancy was noted between foster carers' child health concerns and level of referral need established during assessment. Conclusions: Queensland children in care have high health needs similar to those evidenced by children in care in other areas of Australia. Foster carers appear to underestimate the health needs of children in their care, demonstrating the necessity of multidisciplinary health screens and foster carer training in order to detect child health problems in this population.     

Complexities of conducting research in adolescent refugees resettling in Australia

Adolescent refugees resettling in Australia are a vulnerable and marginalised population. Dedicated research to help better understand their health‐care needs remains scarce. There are multiple complexities which may deter health professionals from conducting research with this population. Health‐care system barriers, such as lack of adolescent‐ and refugee‐specific health‐care services, complicate comprehensive data collection. Limited investigator knowledge pertaining to culturally appropriate research in a population with limited English proficiency or a history of trauma can have an impact on adolescent participation and retention in research studies. Additional ethical and legal issues relating to adolescent consent and confidentiality, which include suicidality and physical or sexual abuse, can arise during research and cause potential harm to adolescents if not managed appropriately. This article highlights current knowledge and understanding relating to these issues along with recommendations to address barriers and safeguard adolescents, with the aim of promoting high‐quality research that will benefit resettling adolescent refugees.     

Community Outreach: An expanding role for hospitals

Abstract Pressures for paediatric institutions to expand their traditional roles have come from changes in morbidity patterns, training requirements and community needs. Planning for new models of health care delivery has led to the development of the Community Outreach Program (COP), a hospital-based model which utilizes existing community resources to provide early intervention services, training in community paediatrics and integtration of hospital and community based health care.
A process evaluation of the COP was performed after 18 months operation. Eighty-eight children were seen in a 7 week period, 20% with complex problems requiring further assessment and community consultation. Staff at the community agencies serviced considered the COP to be a major contributor to health care in their areas. Medical trainees developed new assessment techniques and management strategies for children with problems not previously encountered. It appears that the COP is a useful model for the delivery of health care, in particular to disadvantaged communities.     

儿童发育监测和筛查在儿童保健中的应用

早期识别儿童发育迟缓、障碍或行为异常是儿童保健的重要任务之一,有利于儿童发育障碍及相关疾病的早期发现和早期干预、治疗,促进儿童早期发展并减少残疾率。发育监测和发育筛查是早期识别儿童发育迟缓或障碍的有效途径。发育监测是发现、鉴认具有发育迟缓风险儿童的过程;发育筛查是采用简单、标准化筛查工具帮助识别可能有发育迟缓、障碍或需要进行复杂、综合评估的儿童。定期的标准化发育筛查可提高儿童发育迟缓、障碍的早期识别率。重视基层儿童保健医生发育监测和筛查技能的培训,将发育监测和筛查纳入儿童保健常规工作,推动其在实践中的应用,对儿童发育迟缓或障碍的早干预、早治疗有重要意义。     

Paediatric growth charts: How do we use them and can we use them better?

Aim: Measurement of growth parameters is a key aspect of paediatric care. The aim of this retrospective study was to ascertain rates of growth assessment in children in an acute paediatric setting and to define the frequency of placement of growth data on appropriate growth charts. The accuracy of plotting of growth data and role of potential factors were also examined. Methods: The charts of children attending the Children's Acute Assessment (CAA) unit at Christchurch Public Hospital, New Zealand, were reviewed. The frequency of documentation of height, weight and head circumference in the notes and on the appropriate growth chart was ascertained, along with review of the accuracy of the plotted data. Results: Weight was documented in the charts of 95% and height in 5% of 103 children. None of the children had measurement of their head circumference. A growth chart was present in the notes of 27% of children, but just 7% of the group had a growth chart with the current measurements plotted. Conclusions: This study identifies a missed opportunity for assessment of the nutritional status of children in the hospital setting in New Zealand. The results highlight a need for optimising child growth assessment, particularly at a time of growing awareness of health inequalities and childhood obesity.     

Children and the Patient Protection and Affordable Care Act: Opportunities and Challenges in an Evolving System

The Patient Protection and Affordable Care Act (ACA), passed in 2010, focused primarily on the problems of adults, but the changes in payment for and delivery of care it fosters will likely impact the health care of children. The evolving epidemiology of pediatric illness in the United States has resulted in a relatively small population of medically fragile children dispersed through the country and a large population of children with developmental and behavioral health issues who experience wide degrees of health disparities. Review of previous efforts to change the health care system reveals specific innovations in child health delivery that have been designed to address issues of child health. The ACA is complex and contains some language that improves access to care, quality of care, and the particular needs of the pediatric workforce. Most of the payment models and delivery systems proposed in the ACA, however, were not designed with the needs of children in mind and will need to be adapted to address their needs. To assure that the needs of children are met as systems evolve, child health professionals within and outside academe will need to focus their efforts in clinical care, research, education, and advocacy to incorporate child health programs into changing systems and to prevent unintended harm to systems designed to care for children.     

A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder

There remain large discrepancies between pediatricians' practice patterns and the American Academy of Pediatrics (AAP) guidelines for the assessment and treatment of children with attention-deficit/hyperactivity disorder (ADHD). Several studies raise additional concerns about access to ADHD treatment for girls, blacks, and poorer individuals. Barriers may occur at multiple levels, including identification and referral by school personnel, parents' help-seeking behavior, diagnosis by the medical provider, treatment decisions, and acceptance of treatment. Such findings confirm the importance of establishing appropriate mechanisms to ensure that children of both genders and all socioeconomic, racial, and ethnic groups receive appropriate assessment and treatment. Publication of the AAP ADHD toolkit provides resources to assist with implementing the ADHD guidelines in clinical practice. These resources address a number of the barriers to office implementation, including unfamiliarity with Diagnostic and Statistical Manual of Mental Disorders criteria, difficulty identifying comorbidities, and inadequate knowledge of effective coding practices. Also crucial to the success of improved processes within clinical practice is community collaboration in care, particularly collaboration with the educational system. Such collaboration addresses other barriers to good care, such as pressures from parents and schools to prescribe stimulants, cultural biases that may prevent schools from assessing children for ADHD or may prevent families from seeking health care, and inconsistencies in recognition and referral among schools in the same system. Collaboration may also create efficiencies in collection of data and school-physician communications, thereby decreasing physicians' non-face-to-face (and thus nonreimbursable) elements of care. This article describes a process used in Guilford County, North Carolina, to develop a consensus among health care providers, educators, and child advocates regarding the assessment and treatment of children with symptoms of ADHD. The outcome, ie, a community protocol followed by school personnel and community physicians for >10 years, ensures communication and collaboration between educators and physicians in the assessment and treatment of children with symptoms of ADHD. This protocol has the potential to increase practice efficiency, improve practice standards for children with ADHD, and enhance identification of children in schools. Perhaps most importantly, the community process through which the protocol was developed and implemented has an educational component that increases the knowledge of school personnel about ADHD and its treatment, increasing the likelihood that referrals will be appropriate and increasing the likelihood that children will benefit from coordination of interventions among school personnel, physicians, and parents. The protocol reflects a consensus of school personnel and community health care providers regarding the following: (1) ideal ADHD assessment and management principles; (2) a common entry point (a team) at schools for children needing assessment because of inattention and classroom behavior problems, whether the problems present first to a medical provider, the behavioral health system, or the school; (3) a protocol followed by the school system, recognizing the schools' resource limitations but meeting the needs of community health care providers for classroom observations, psychoeducational testing, parent and teacher behavior rating scales, and functional assessment; (4) a packet of information about each child who is determined to need medical assessment; (5) a contact person or team at each physician's office to receive the packet from the school and direct it to the appropriate clinician; (6) an assessment process that investigates comorbidities and applies appropriate diagnostic criteria; (7) evidence-based interventions; (8) processes for follow-up monitoring of children after establishment of a treatment plan; (9) roles for central participants (school personnel, physicians, school nurses, and mental health professionals) in assessment, management, and follow-up monitoring of children with attention problems; (10) forms for collecting and exchanging information at every step; (11) processes and key contacts for flow of communication at every step; and (12) a plan for educating school and health care professionals about the new processes. A replication of the community process, initiated in Forsyth County, North Carolina, in 2001, offers insights into the role of the AAP ADHD guidelines in facilitating development of a community consensus protocol. This replication also draws attention to identification and referral barriers at the school level. The following recommendations, drawn from the 2 community processes, describe a role for physicians in the collaborative community care of children with symptoms of ADHD. (1) Achieve consensus with the school system regarding the role of school personnel in collecting data for children with learning and behavior problems; components to consider include (a) vision and hearing screening, (b) school/academic histories, (c) classroom observation by a counselor, (d) parent and teacher behavior rating scales (eg, Vanderbilt, Conner, or Achenbach scales), (e) consideration of speech/language evaluation, (f) screening intelligence testing, (g) screening achievement testing, (h) full intelligence and achievement testing if discrepancies are apparent in abbreviated tests, and (i) trials of classroom interventions. (2) Use pediatric office visits to identify children with academic or behavior problems and symptoms of inattention (history or questionnaire). (3) Refer identified children to the contact person at each child's school, requesting information in accordance with community consensus. (4) Designate a contact person to receive school materials for the practice. (5) Review the packet from the school and incorporate school data into the clinical assessment. (6) Reinforce with the parents and the school the need for multimodal intervention, including academic and study strategies for the classroom and home, in-depth psychologic testing of children whose discrepancies between cognitive level and achievement suggest learning or language disabilities and the need for an individualized educational plan (special education), consideration of the "other health impaired" designation as an alternate route to an individualized educational plan or 504 plan (classroom accommodations), behavior-modification techniques for targeted behavior problems, and medication trials, as indicated. (7) Refer the patient to a mental health professional if the assessment suggests coexisting conditions. (8) Use communication forms to share diagnostic and medication information, recommended interventions, and follow-up plans with the school and the family. (9) Receive requested teacher and parent follow-up reports and make adjustments in therapy as indicated by the child's functioning in targeted areas. (10) Maintain communication with the school and the parents, especially at times of transition (eg, beginning and end of the school year, change of schools, times of family stress, times of change in management, adolescence, and entry into college or the workforce).     

Paediatric emergency and acute care in resource poor settings

Acute care of seriously ill children is a global public health issue, and there is much scope for improving quality of care in hospitals at all levels in many developing countries. We describe the current state of paediatric emergency and acute care in the least developed regions of low and middle income countries and identify gaps and requirements for improving quality. Approaches are needed which span the continuum of care: from triage and emergency treatment, the diagnostic process, identification of co‐morbidities, treatment, monitoring and supportive care, discharge planning and follow‐up. Improvements require support and training for health workers and quality processes. Effective training is that which is ongoing, combining good technical training in under‐graduate courses and continuing professional development. Quality processes combine evidence‐based guidelines, essential medicines, appropriate technology, appropriate financing of services, standards and assessment tools and training resources. While initial emergency treatment is based on common clinical syndromes, early differentiation is required for specific treatment, and this can usually be carried out clinically without expensive tests. While global strategies are important, it is what happens locally that makes a difference and is too often neglected. In rural areas in the poorest countries in the world, public doctors and nurses who provide emergency and acute care for children are revered by their communities and demonstrate daily that much can be carried out with little.     

Nutrition in children with neurodisability

Children with neurodisability are at risk of nutritional impairment due to a number of factors including feeding and swallowing difficulties, gastrointestinal disorders, disorders of movement and posture, immobility, medication, adverse food related sensory experience and behavioural feeding difficulties. Undernutrition has a negative impact on growth, general health indices, bone health, muscle strength, immunity and wound healing and brain and cognitive development. Regular multidisciplinary assessment including the routine measurement of body composition and micronutrient status are recommended to inform appropriate nutritional support and intervention. Intervention may include management of tone, posture and positioning for feeding, comorbid gastrointestinal disease, seizure management, alteration to medications or use of a sensory diet as well as changes to protein and energy intake, dietary fluid and fibre content, micronutrient supplementation, or establishment of an appropriate enteral feeding route in children unable to safely maintain nutritional needs orally. Children having nutritional support should have regular multidisciplinary follow up as clinically indicated, and when the clinical situation changes. This article aims to briefly review the most important aspects of nutrition in children with neurodisability and offer practical advice to health care practitioners involved in their care.     

Caring for the health and medical and emotional needs of children of migrants and asylum seekers

Political turmoil, military conflicts and other international sociological upheavals are causing significant immigration of large numbers of people, including infants and children, in Europe. Many of these young migrants are refugees. These youngsters have significant health needs, and medical conditions (such as infectious diseases) and mental health problems due to their previous stressful situations and the difficulties that they often experience while settling, even temporarily, into their new environments. Government authorities must screen for transmissible diseases and ensure that vaccine-preventable infections are adequately covered. Paediatricians must give the best possible care for these children and act as their advocates. This can be enhanced by collaborating with national and international paediatric societies and with international non-government agencies. This problem is not confined to Europe; world-wide, it occurs on a massive scale and causes huge burdens for poorer countries that have serious difficulties in coping with the extra financial, personnel and infrastructure needs imposed by massive, uncontrolled migration of populations that are often unhealthy and inadequately nourished. However, this should not be used as a pretext to deny safe refuge to children and their families who need it.

Conclusion: Massive movements of infant and child immigrants and refugees across European borders over recent years have brought challenges to paediatricians because of the needs for the health and medical and mental health care of these young people. Paediatricians have an important role in their care and by acting, wherever possible, as their advocates. This is a massive problem, world-wide, in which paediatricians can have a potentially significant positive impact.     

A 'chronic disorder' health-care model for children with complex developmental disorders

OBJECTIVES: To conceptualize, develop and evaluate a 'chronic disorder' clinical model of health services for children with 'low-severity' developmental disorders assessed and treated within a public Child Development Unit. METHODOLOGY: Concepts of family empowerment, child resiliency and the management of clinical complexity were explicitly incorporated into the service model and the clinical strategies in order to address long-term goals of prevention and health promotion. To explore the efficacy of this model, a telephone audit survey was conducted of parents of 42 children seen sequentially through this modified service. RESULTS: Parent data indicate a high level of satisfaction with the integrated, individualized assessment processes and effective transmission of information through both written reports and dedicated discussion visits. A treatment methodology based on parent chosen treatment goals for short and long time-frames was experienced as achievable and successful. CONCLUSIONS: These data suggest that the service goals of an integrated team process, parent empowerment and effective clinical collaborations may be achievable from a health care setting. A change in emphasis from remedial treatment to adaptation, health promotion and tertiary prevention is integral to these strategies. The concepts, clinical model and evaluation are presented to stimulate discussion around the question of what child health services are attempting to achieve for children with complex developmental disorders.