What about migrant/refugee children? What part do we play in improving their health outcomes?

Dr. Stacy John-Legere, Consultant Paediatrician, Designated Dr. for Looked after Children

In October 2015, the front page of several global media showed the stark reality of death encountered by many migrants as they make their perilous journey to safety. This image served to raise our consciousness regarding the hardships, danger and life threatening journeys those seeking a safe haven make. It caused us to reflect on the death of children; globally and in the UK.

In the many months that have followed, we have learnt of countries closing borders , of people making innovative journeys  by bicycle or boat, and closer to home - the efforts to make sense / improve conditions at “the Jungle” in Calais. Additionally, we learnt of the children starving as their villages are bombarded by fighter jets. Furthermore, those who are able to travel are subject to grievous demands from traffickers; with some forced to pay ransoms once in a safe country – with attendant threats to their families.

The plight of the displaced child in Europe remains in our public consciousness via the popular press such as the free publication Metro as well as established peer –reviewed publications such as The Lancet   and specially commissioned global reports including that by Unicef which highlights “5 steps to protect a vital generation.”

And so, what about the children who make it across the borders of Europe and arrive in the UK - in greater numbers on their own: unaccompanied by family or a responsible adult? It is recognised that as individuals and as a vulnerable client group- they may require additional considerations in order to ensure that they settle well and achieve their developmental potential.

Children ( for the purpose of this blog child refers to any person under the age of 18) who arrive in the UK without a responsible adult or family member is considered UASC ( unaccompanied asylum seeking child) and are accommodated by the local authority under section 20 of the children act - meaning that they become "looked after by the local authority " In 2015, the Home Office reported  that the countries with the highest number of UASC applications in the UK were Eritrea (694), followed by Afghanistan (656) and Albania (456). –thus indicating the diversity present; therefore whilst there are shared vulnerabilities; this client group should not be considered a homogenous whole.

For those local areas with relatively large numbers, the planning and delivery of services necessary for these children should be embedded within local health strategies.  A joint strategic needs assessment is a powerful tool for assessing and highlighting the needs of this vulnerable group and commissioning of appropriate services. In areas that have traditionally cared for large numbers of UASC, they have been included in this analysis as an important subgroup. The needs assessment for this client group should include an assessment of educational and employment opportunities, leisure facilities, and access to appropriate housing. 

Key themes regarding physical and mental health should also be explored. Access to religious and culturally appropriate settings should also be considered as many children have reported relying on their faith as a coping mechanism. It is important that interventions and strategies are delivered in a non-stigmatising and supportive manner; as well as adopt a holistic life-course approach.  This need is illustrated in studies such as by Walsh et al.   where it was shown that environments with more classmate support of immigrant youth experienced fewer episodes of violence in schools.

Understanding the key themes and challenges related to this client group can lead to the development of innovative services – such as commissioned joint working with third sector organisations; to the development of specialist GP services offered by the NHS.

Individual health practitioners working with this client group may find provision of care daunting – often the children may present with a myriad of unmet physical health needs – sometimes predating their journey. They may give a history or have physical stigmata of torture and abuse. Signs and symptoms of mental health problems such as post-traumatic stress disorder, depression and self-harm may also be apparent. In order to ensure the best care possible, the clinician must therefore actively consider all these possibilities, diagnosing, referring and signposting as appropriate. 

There are many available sources of advice. This includes advice on ways paediatricians can support this client group and further advice for paediatricians working with UASC as part of the statutory looked-after child process. The RCPCH has also provided a freely available online resource PHE has provided a suite of online resources freely available regarding migrant health issues. Statutory advice on safeguarding children who are unaccompanied and trafficked was published in 2014.

For those children who arrive as part of a family, the advice given to safeguard the health and wellbeing of children who are unaccompanied can be applied to children residing within their birth family. However, great care needs to be taken to ensure that the health and wellbeing needs of the entire family are taken into account. It is not uncommon that children may assume the position of young carers for their parents or their younger siblings. Parents may also require assistance to meet the psychological needs of their children who have experienced trauma. Services must thus be able to cope with needs of a family that has experienced great difficulties and tragedy; and must now settle in a strange country.

Those who seek asylum are frequently regarded as resourceful and resilient, however, owing to the complexities of the UK immigration system and the interplay with other statutory services, refugee children and their families often face further challenges on their arrival (and may continue to experience them for some time after). We should thus work toward the adoption of a co-ordinated multi-agency approach to the configuration of services made available to this group; utilising the strengths present in the refugee community and the benefits of an approach co-developed with local agencies and organisations.

1. Brhane, M; Trafficking in Persons for Ransom and the Need to Expand the Interpretation of Article 3 of the UN Trafficking Protocol; Anti-trafficking Review (2015) http://www.antitraffickingreview.org/index.php/atrjournal/article/view/93/113

2. Syria 5 years on: Special report; Metro UK  http://e-edition.metro.co.uk/2016/03/15/

3. Devi, S. Syria's health crisis: 5 years on, The Lancet , Volume 387 , Issue 10023 , 1042 - 1043

4. https://www.unicef.de/blob/106970/ef5ba0af8e768eacb0baefe0ca13d3ae/unicef-bericht-no-place-for-children-2016-03-14-data.pdf

5. https://www.gov.uk/government/publications/immigration-statistics-october-to-december-2015/asylum#nationalities-applying-for-asylum

6. Walsh, S et al; The Relationship Between Immigrant School Composition, Classmate Support and Involvement in Physical Fighting and Bullying among Adolescent Immigrants and Non-immigrants in 11 Countries, Journal of Youth and Adolescence;2016 Volume 45, Issue 1 , pp 1-16

7. Nyiri P, Eling J. A specialist clinic for destitute asylum seekers and refugees in London. The British Journal of General Practice. 2012;62(604):599-600. doi:10.3399/bjgp12X658386.

8. Hands, C et al. 1.Refugee children in the UK,Paediatrics and Child Health , 2016 ,Volume 26 , Issue 1 , 37 - 41

9. Lorek, A. (2015). Unaccompanied Asylum Seeking Children. In F. M. (Eds), Promoting Health of Children in Public Care (p. Chapter 11).

10. http://www.rcpch.ac.uk/improving-child-health/child-protection/refugee-and-unaccompanied-asylum-seeking-cyp/refugee-and-una

11. https://www.gov.uk/topic/health-protection/migrant-health-guide

12. https://www.gov.uk/government/publications/care-of-unaccompanied-and-trafficked-children

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