Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Child and Adolescent Health Service, Perth, Western Australia, Australia
School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
Correspondence: Dr Sarah Cherian, School of Paediatrics and Child Health, University of Western Australia, GPO Box D184, Perth WA 6840, Australia. Fax: +61 8 9340 7652; email: Sarah.Cherian@health.wa.gov.au
There are limited data regarding the educational backgrounds and associated psychological and developmental outcomes of refugee children resettling in Western Australia (WA). The WA paediatric Refugee Health Service (RHS) revised its first consult questionnaire (August 2011) to increase educational and psychosocial documentation, concurrent with engagement of a School of Special Educational Needs: Medical and Mental Health (SSEN: MMH) liaison teacher. This study aims to utilise these data to increase understanding of this cohort's educational, developmental and psychological needs and to describe SSEN: MMH's role within the RHS.
Retrospective audit and analyses were performed on all initial standardised questionnaires for school-aged refugee children (4–18 years) and SSEN: MMH referrals between August 2011 and December 2012.
Demographic data from 332 refugees are described (mean age 9.58 ± standard deviation 3.43 years). Detailed educational information was available for 205 children. Prior education was limited (median 2 years), 64.9% experienced likely schooling interruption and 55.8% received education in their primary language. Language development concerns were significantly associated with previous education in a second language (odds ratio (OR) 4.55, P < 0.05). Other severe developmental and schooling issues were uncommon at presentation, with few correlations to prior education. In contrast, several migration factors, including family separation and mandatory detention, were significantly associated with psychological comorbidities such as post-traumatic stress disorder (OR 5.60, P < 0.001 and OR 14.57, P < 0.001, respectively). SSEN: MMH reviewed 59 complex cases. Referral was significantly associated with multiple educational, developmental and psychological concerns.
Refugee children have varied migration, trauma and educational backgrounds, impacting on health and psychological outcomes. In-depth multidisciplinary history including prior education and psychosocial issues is recommended. Partnering with education services appears to play an effective, multifaceted role in aiding resettlement; however, longitudinal studies are required.
Refugee children have complex migration histories and past experiences that can negatively impact on their current physical and mental health status.
School involvement has the ability to contribute to the improvement of physical and mental well-being for children and adolescents, including refugee children.
Documentation regarding educational and developmental backgrounds of newly arrived refugee children is often poor on first clinical assessment.
What this paper adds
This paper provides further evidence of the limited background educational experiences of many refugee children resettling in Western Australia.
Specific education and migration features demonstrated correlations with current developmental and psychological outcomes. This information can be utilised by those working with refugee children to guide earlier identification and intervention for these issues.
The many diverse roles that the School of Special Educational Needs: Medical and Mental Health can play in enhancing the resettlement process for refugee children were identified, providing further understanding of school service involvement in the Refugee Health multidisciplinary team.
Refugee children belong to a vulnerable cohort that has often experienced deprivation, poverty, complicated physical, mental and nutritional health issues, and exposure to significant violent and traumatic events.[1-6] These experiences occur during a critical developmental period, placing these children at risk of physical health problems, cognitive impairment, developmental delay and psychological and behavioural issues.[2-4, 6-12] There is increasing recognition of the fundamental role that education provides in protecting health outcomes for refugee children in the early resettlement period.[1, 3, 13] Schools are often the first external social environments encountered in Australia. They provide a unique opportunity to deliver significant social support,[1, 4, 13, 14] with evidence of improved physical health, academic performance, self-esteem, psychological outcomes[5, 6, 15, 16] and reduced incidences of post-traumatic stress disorder (PTSD) and depression. Theoretically, therefore, improving educational experiences may assist in these children's resettlement and recovery from trauma.[3, 4, 6, 7, 17, 18]
The Princess Margaret Hospital (PMH) Refugee Health Service (RHS) reviews almost 90% of refugee children resettled in Western Australia (WA). Knowledge pertaining to previous educational experiences would help guide clinical practice and health resourcing, yet there are currently limited data available. Based on previous research, the PMH RHS amended its standard health-screening questionnaire in August 2011 to increase developmental and educational documentation, coinciding with the appointment of a refugee health liaison teacher from the School of Special Educational Needs: Medical and Mental Health (SSEN: MMH). This current study was undertaken to utilise these data to (i) improve understanding of the educational, developmental and psychological needs of this group; and (ii) examine the role of educational services within the RHS multidisciplinary team.
Retrospective descriptive data analyses were performed on data from the revised health-screening questionnaire used for all new patients reviewed by PMH RHS between 1 August 2011 and 31 December 2012. The cohort studied was comprised of school-aged children (4–18 years old) with a completed pro forma. Children <4 years and >18 years old, patients seen outside of the study period, asylum-seeking children in active/guarded detention and children without completed questionnaires were excluded. Parentally reported demographic and transit information, detention details, developmental history, educational background, psychological health and referral data were extracted. Formal developmental screening was not undertaken at the first visit because of concerns about cultural sensitivity based on previous local research in this cohort (J Geddes et al., unpublished data, 2006). Formal PTSD screens were not used; instead pro forma questions were based on literature and clinical experience of the RHS staff. For those referred to the liaison teacher during this period, the SSEN: MMH student database and PMH medical notes were interrogated to identify information regarding liaison teacher–student contact, ongoing interactions and onward referrals. As formal overseas documentation was limited, ‘likely interruption in education’ was calculated based on the age at which WA children begin compulsory formal education (pre-primary beginning the year in which the child reaches 5 years and 6 months) as a comparator. Thus, if the patient's age minus the documented years of prior schooling was greater than six, past education was considered interrupted.
Data from each child was de-identified, recorded and entered into a secure database. Quantified data were analysed using SPSS version 21.0 (SPSS Inc., Chicago, IL, USA), providing descriptive statistics of frequencies, cross-tabulations and binary logistic regression analyses of the above covariates, adjusted for age and gender.
This study received PMH Governance, Evidence, Knowledge, Outcomes approval (Quality Activity #4878). SSEN: MMH referral was undertaken with written parental consent. SSEN: MMH partnered with the RHS to commission this retrospective analysis, providing access to the SSEN: MMH student database for audit purposes.
Four hundred and sixty-four new patients were seen by the RHS during the study period, with 332 (71.6%) included as per the study criteria (mean age 9.58 years, standard deviation (SD) ± 3.43, range 4–17.25). Patients originated from 24 countries and spoke 26 primary languages (L1), with 76.2% requiring interpreter services (Table 1). Half (51.6%) had documented transit times greater than 5 years, 49.5% experienced nuclear family separation during their migration and one quarter (26.6%) remained separated at first medical review. The majority of children lived with both parents (70.3%), while 27 children (including unaccompanied minors) were under the care of alternative guardians. Mean time from arrival in Australia to review by the RHS was 6.63 months (SD ± 5.09 months). Further demographic and migration information is displayed in Table 1.
Table 1. Demographic and migration backgrounds of all patients and the SSEN: MMH patient subgroup
All patients (n = 332) (%)
SSEN: MMH subgroup (n = 55) (%)
Odds ratio for referral to SSEN: MMH
**P = < 0.01; ***P = < 0.001. †Sibling/grandparent/other relative/allocated unrelated guardian. N/A, not assessed; NS, non-significant; SSEN: MMH, School of Special Educational Needs: Medical and Mental Health.
Detailed educational information was available for 205 (61.7%) children (Table 2), with a median of 2 years of prior education undertaken (0–9 years). Only 55.8% received prior education in their primary spoken language and 64.9% were calculated to have experienced interrupted education. The majority (66.9%) of patients were enrolled in an intensive English centre (IEC) (mean age 8.05 years, SD ± 3.16), while 20.5% attended mainstream schooling (mean age 10.37 years, SD ± 3.32). The level of English as an additional language/dialect input for children in mainstream schooling was not documented.
Table 2. Educational backgrounds of all patients and the SSEN: MMH patient subgroup, with associated odds ratio of referral to SSEN: MMH
All patients (n = 332) (%)
SSEN: MMH subgroup (n = 55) (%)
Odds ratio for referral to SSEN: MMH
*P = < 0.05; ***P = < 0.001. NS, non-significant; NA, not applicable; SSEN: MMH, School of Special Educational Needs: Medical and Mental Health.
Table 3 outlines developmental and psychological comorbidities at first paediatric presentation. Language concerns were the most common developmental issue identified at first encounter (5.7%). Schooling, learning and bullying/interpersonal issues were infrequent, with a cumulative prevalence of 4.5%. Over one quarter of patients demonstrated psychological comorbidities or PTSD symptoms, 41 patients (12.3%) were identified as being at risk of PTSD and 19 (5.7%) met diagnostic criteria. Major depression or anxiety disorders were uncommon (<4%). Almost two thirds (59%) of all patients were referred to additional services, including allied health, subspecialists, psychological medicine and the Association for Services to Torture and Trauma Survivors (ASeTTs) (Table 3).
Table 3. Educational, developmental, psychological backgrounds and onward referrals for all patients and the SSEN: MMH patient subgroup, with associated odds ratio of referral to SSEN: MMH
All patients (n = 332) (%)
SSEN: MMH subgroup (n = 55) (%)
Odds ratio of referral to SSEN: MMH
*P = < 0.05; **P = < 0.01; ***P = < 0.001. †Subspecialties: audiology, cardiology, dermatology, endocrinology, enuresis clinic, gastroenterology, genetics, general paediatrics, general surgery, gynaecology, haematology, immunology, metabolic medicine, neurology, nephrology, ophthalmology, orthopaedics, otolaryngology, plastic surgery, rehabilitation medicine, rheumatology, TB clinic and urology. ASeTTs, Association for Services to Torture and Trauma Survivors; NA, not applicable; NS, non-significant; PTSD, post-traumatic stress disorder; SSEN: MMH, School of Special Educational Needs: Medical and Mental Health.
SSEN: MMH received 59 new referrals during the designated study period. The mean age at SSEN: MMH review was 8.7 years (range 3.4–17.6). Two thirds (39/59, 66.1%) were referred from the initial medical consultations. Other referral sources included informal waiting-room discussions between the liaison teacher and families, community health nurses and case workers. The median length of contact with SSEN: MMH was 4 weeks (0.00–57.7 weeks) with a median of two interactions (range 1–7). School enrolment issues were the most common reason for review (17 patients, 28.8%), followed by academic/developmental concerns (15.3%). Other referral indications included psychological issues/PTSD, truancy/behavioural issues, financial assistance, bullying and transport issues (Fig. 1). The most frequent liaison teacher role was to communicate with schools for information regarding academic performance or behaviour (71.2%). Other interventions included initiating communication between the school and family, student or family advocacy and liaison with school psychologists.
Fifty-five of the 59 patients seen by SSEN: MMH were analysed for their general demographic data, with four children excluded because of age <4 years at first medical consult (Tables 1-3). Compared with the complete cohort, this subset had a significantly greater proportion of patients living in single-parent households (32.7% vs. 21.7%) and with persisting nuclear family separation (40.0% vs. 26.6%) at first medical review. Transit times >5 years (54.8%), rates of educational interruption (68.3%) and previous education in their L1 (59.5%) were comparable with the whole study population, although the SSEN: MMH subgroup had a median of only 1 year (range 0–6) of prior schooling compared with 2 years. Higher rates of reported scholastic issues and developmental and psychological concerns were observed across all domains, including almost double the prevalence of psychological comorbidities (45.5% vs. 23.8%) and PTSD (12.7% vs. 5.7%). Allied health referrals were fourfold higher (43.6% vs. 11.7%) and subspecialist referrals were more frequent compared with the overall cohort.
Regression analyses of available data were undertaken (Tables 2,3), demonstrating similar baseline demographics among the general cohort and the SSEN: MMH subgroup. Language development concerns were significantly associated with previous education in a second language (odds ratio (OR) 4.55, P < 0.05). Scholastic and several developmental issues, in particular gross motor (OR 12.3, P < 0.05) and language (OR 4.79, P < 0.001), were significantly correlated with liaison teacher referral (Tables 2,3). Increased SSEN: MMH referrals were also associated with current family separation (OR 2.84, P < 0.01), children with mothers as sole guardian (OR 2.57, P < 0.01) and those with an incorrectly documented date of birth (DOB) (OR 7.05, P < 0.001), which was more likely in refugees with longer transit times (OR 5.35, P < 0.05). There were numerous significant associations observed between SSEN: MMH referral and the presence of psychological issues or symptoms, including PTSD, depression, oppositional behaviour, primary nocturnal enuresis and poor appetite (Table 3).
Multiple migration experiences were significantly correlated with psychological comorbidities. Those with a history of mandatory detention demonstrated an increased likelihood of a PTSD diagnosis (OR 5.60, P < 0.001) and symptoms of nightmares (OR 3.97, P < 0.001), separation anxiety (OR 7.57, P < 0.001) and aggressive behaviour (OR 6.48, P < 0.05). Children currently residing in community detention displayed an increased likelihood of depression (OR 14.92, P < 0.05), poor appetite (OR 5.51, P < 0.05) and positive PTSD symptoms (OR 3.85, P < 0.05). A diagnosis of PTSD was also significantly associated with both current and previous nuclear family separation, despite adjustment for ‘ever being in detention’ (OR 8.46, P < 0.01 and OR 14.57, P < 0.001, respectively). Children with current family separation showed an increased likelihood of referral to allied health services (OR 2.48, P < 0.001) and ASeTTs (OR 2.61, P < 0.01). Those with histories of mandatory detention were more likely to receive psychology and ASeTTs referrals (OR 5.46 P < 0.05 and OR 3.17 P < 0.01, respectively).
Our data support previous studies demonstrating that refugee children have heterogeneous backgrounds with differing complexities in their migration histories, which can impact variably on their health status.[18, 22] Long transit times and family separation were common and previous findings of minimal or disrupted prior schooling, lack of access to education in refugee camps and detention centres, and frequent education in non-primary languages were confirmed.[4, 23-25] The prevalence of diagnosed mental health and developmental issues at initial RHS review was lower than comparative data;[3, 6, 26] however, the high incidence of somatic symptoms indicates that their true prevalence is likely underestimated. There is currently a lack of validated culturally appropriate developmental and psychological screening tools for use with culturally and linguistically diverse populations,[27, 28] which is reflected by local experience and subsequent modification of the RHS screening pro forma.
There were no significant correlations between length of transit and psychological issues, suggesting that transit time per se is not a major influence on experiences of trauma and psychological disturbance in early resettlement. However, the effect of forced detention on psychological well-being, education and health of these children was apparent. This reinforces previous findings regarding the adverse effects of detention and family separation on psychological outcomes, most notably PTSD, depression and developmental issues.[5, 8, 29-31]
Positively, despite frequently interrupted schooling, substantial cognitive and developmental problems were not widespread among parental concerns at first medical contact. Delay in language development (primary dialect) was the most frequently identified developmental issue. L1 delay is an important consideration as many refugee children are learning English concurrently in an IEC following resettlement, and proficiency and prior schooling in one's first language can affect additional language acquisition and schooling success. Targeted RHS questioning regarding failure to progress in L1 provides an important indicator of future educational and language concerns. Additionally, although evidence suggests that children with specific language impairment will follow a similar developmental path and achieve comparable proficiency in their second language after significant language exposure, those with backgrounds of restrictive detention, interrupted prior schooling, trauma, social isolation and socio-economic disadvantage may have increased difficulties acquiring a second language.[5, 32, 33]
The apparently limited influence of educational interruption on developmental or psychological outcomes may be misleading. Educational difficulties may manifest with time and the children described in this paper were reviewed during the resettlement ‘honeymoon’ period. Most children are supported in IEC's during the first 12–18 months after resettlement, with subsequent educational problems commonly manifesting upon transition to mainstream schooling with loss of intensive support.[23, 32] Coupled with limited or interrupted prior schooling, low first language literacy, prior traumatic experiences and the lack of time to develop second language competency, these factors may cumulatively affect educational trajectories. The Good Starts Study of Melbourne adolescent refugees demonstrated high levels of well-being 3 years following resettlement; however, the longitudinal educational outcomes (8 years on) are yet to be published. For this reason, SSEN: MMH reviews are initiated for any school child presenting with educational and developmental concerns at RHS follow-up to capture longitudinal problems.
Many migration features were significantly associated with SSEN: MMH review, demonstrating the diverse ways this service assists these children and their families. Long transit times, for example, were associated with an increased likelihood of incorrectly documented DOBs. Incorrect DOB was independently significantly correlated with liaison teacher referral. As age has the potential to adversely affect schooling placement, developmental expectations and peer relationships if the patient's chronological age is markedly different from predicted, liaison teacher assistance in appropriate school placement was essential. SSEN: MMH advocacy was also required to ensure those in community detention gained access to appropriate school services, as WA remains the only state without educational funding agreements between federal and state governments, rendering asylum seekers ineligible to enroll in public schools as local students.
The observed association between reported scholastic and developmental issues and SSEN: MMH referral was anticipated. However, the demonstrated correlation with concerns such as family separation and mental health was unexpected. The diverse range of issues associated with SSEN: MMH referral may allow for school service application beyond traditional cognitive and academic roles, including improving access to mental health services with school-based psychology appointments. Many refugee children and their families do not accept traditional mental health services because of stigma, financial constraints, fear of missing school, language barriers and the low priority of mental and developmental health compared with other physical issues.[9, 22, 35, 36] This SSEN: MMH link to the school environment may enable children to receive psychological assistance in a timely and culturally appropriate way.
Importantly, our data demonstrate that despite frequent narratives of prior hardship, in early resettlement most refugee children are generally resilient, develop appropriately and do not display significantly increased problems in the interpersonal sphere. Despite a multitude of risk factors for adversity and psychopathology, major educational concerns raised were identified only in a small subset, but these required follow-up and intervention. Augmenting resources for successful resettlement, such as improving school liaison roles and providing stable school supports, may enhance resilient behavior, empower families and allow refugee children to experience academic and social achievement, thus fostering development into well-adjusted adults.[1, 3, 6, 11, 22, 35]
This study has a number of limitations. As a retrospective audit of only initial RHS visits, with variably completed educational histories, the true prevalence of the educational and/or psychological difficulties may be underestimated. Formal screening for developmental or psychological issues was not performed as part of the initial patient consult: identification of issues in this study relied on parental disclosure at first RHS presentation. Identification may also therefore have been affected by (i) other resettlement stressors taking priority; (ii) the fear of losing visa status or jeopardising family reunification; (iii) reluctance to disclose sensitive information without prior rapport with their treating doctor/teacher; and (iv) the absence of available past medical/educational documentation. Lastly, because of the relatively short follow-up period, subsequent presentation of developmental, educational or psychological complications and/or manifestation of other adverse outcomes (including impaired attainment of secondary language proficiency), was not fully captured.
This study demonstrates that resettled refugee school children have diverse migration and educational backgrounds, which impact on health outcomes and educational and psychological requirements. Despite frequent interruptions and adversities in these children's lives, many displayed marked resilience in early resettlement. However, several migration experiences, such as mandatory detention, produced substantial adverse effects on health and well-being.
A clear understanding of the effects of refugee experiences is necessary to successfully identify issues, so as to improve the health and educational outcomes for this growing population of Australian children. Multidisciplinary paediatric screening questionnaires containing increased educational, developmental and psychosocial documentation appear to assist in identification of both parental and staff concerns. SSEN: MMH intervention was multifaceted, demonstrating the capacity to flexibly assist these children and promote the potential benefits of belonging to a school environment. RHS collaboration with educational services appears to facilitate earlier intervention, advocacy and family support in early resettlement. Longitudinal and/or linkage studies of refugee children specifically looking at educational and health/psychosocial and intervention outcomes are required in order to confirm these findings.
We wish to thank the staff of the PMH Refugee Health Service and the School of Special Educational Needs: Medical and Mental Health for their time and input into the clinics and database. We also wish to acknowledge Professor Peter Jacoby for his assistance with statistical analyses, Dr Aesen Thambiran for clarifying visa subclass information and especially thank the children and families of the RHS.