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Primary Care for Refugee Children: What Providers Need to Know

November 2, 2018
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The growing number of refugee children across the United States means that more pediatricians need to be aware of the unique health needs of this population.

The world’s estimated refugee population has surged to 24.5 million individuals – more than half of whom are children – at United Nations High Commissioner for Refugees (UNHCR) last count. Many refugees, including children, have experienced one or more traumatic events that affect their health and well-being for years to come.

UNHCR defines a refugee as “someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion.” Faced with war, violence and political unrest, refugees are forced to flee their homes, often with little or no warning, and seek safety in another country. For many, it is a long process, and they may endure the hardships of living in a refugee camp for more than a decade prior to coming to another country.

Nationwide Children’s Hospital, one of the largest and most comprehensive pediatric hospitals and research institutes in the United States and Columbus, Ohio’s safety-net provider for low-income children, provides care to refugee children who have resettled and now call Columbus, Ohio home. Since the early 1980s, tens of thousands of refugees have settled in the Columbus metropolitan area. It is now home to the largest Bhutanese-Nepali population and the second largest Somali population in the United States.

Columbus Mayor Andrew Ginther has noted, “our immigrant population is part of the fabric of what makes Columbus so vibrant.” An article from the area’s visitors’ bureau, Experience Columbus, explains how the city has benefitted from a diverse population. “According to recent data, foreign-born residents make up 9.3% of the city’s population and contribute $258 million in local and state income, property and sales taxes. The local refugee community supports an estimated 21,000 jobs in Columbus.”

Migrating to a new country is complex and the amount of time it takes is highly variable and in some cases can take decades.  During this time, many refugees experience or witness traumatic events, including displacement and loss of home and family, imprisonment, forced labor, acts of violence, rape, torture or long periods without adequate nutrition, housing and education.

“Though many refugee children are incredibly resilient, the traumatic events they experience can have profound effects on their health and well-being,” says Alex Rakowsky, MD, a pediatrician at Nationwide Children’s Hospital who treats a large number of refugee families.

Post-traumatic stress disorder (PTSD) can occur when a child experiences or witnesses a shocking, unexpected, or catastrophic event. A child’s risk of developing PTSD is related to the seriousness of the trauma, whether the trauma is repeated, the child’s proximity to the trauma, and his or her relationship to the victim.

The overall prevalence of PTSD among child refugees is approximately 11 percent. However, the rate varies significantly based on the type and duration of trauma, and can be as high as nearly 90 percent.

Dr. Rakowsky says the impact of trauma “does not just go away” once the refugee child is settled in their new country.

“The stress of the acculturation process can contribute to – and sometimes worsen – the trauma refugee children experienced in their homeland,” he says. Research suggests that post-migration stress significantly influences the emotional well-being of refugees, often resulting in a risk of poor mental-health that is similar to war-related trauma.

Emily Decker, MD, a pediatrician at Nationwide Children’s who also treats a large number of Nepali and Somali refugee families, says many refugee children experience culture shock when they get to the United States.

“Refugee children are confronted with a completely different way of life when they arrive in the United States – they often don’t speak the language or understand the customs,” she says. “This can feel very isolating, particularly if the child is also grieving the loss of their friends, family and community.”

Although trauma is an experience shared by many refugee children, “it’s important to remember that trauma manifests differently in each child,” says Dr. Decker. Many factors, such as age, family culture and the types of trauma experienced can affect how refugee children are impacted by trauma.

Preschool children, for example, may wet the bed, complain of stomachaches or throw temper tantrums. Elementary school age children may appear irritable or withdrawn or be scared of being separated from their parents. Middle and high school aged children may have relationship difficulties with their peers, family and teachers and may feel shame, embarrassment or a sense of responsibility or guilt for what they or their family went through.

Unexplained somatic symptoms, such as headaches or stomach pain, and sleep difficulties may all be signs of trauma-related distress in the resettled refugee child.

“There have been many times I’ve run every possible test, had them come back normal, only to then find out that their symptoms were related to depression or anxiety,” says Dr. Decker. “It can be very difficult to diagnose PTSD and mental health disorders in refugee children, because the stigma associated with a mental health diagnosis prevents children and families from talking about their symptoms and accessing services.”

She adds, “Many refugees don’t think about depression the same way Americans do.” She has had to find other ways to assess refugee patients’ mental health struggles, such as asking about activities of daily living and levels of fatigue.

Dr. Rakowsky notes that unexplained symptoms may also signal chronic health conditions and disabilities that were not identified before refugee children arrive in the United States. For example, while lead and anemia screening is done for all patients at their one and two year well-child visits, he will do this screening on all recent refugees regardless of age. Common lead exposures include ammunition manufacturing and use, as is common in war-torn countries. The lead absorption can be worsened by micronutrient deficiencies, such as iron, which are frequently observed in malnourished children.

Because he knows refugee children have unique health care needs, Dr. Rakowsky says he makes sure to screen them for health conditions he does not usually screen for in children born and raised in the United States. For example, he screens all children for lead and anemia and more commonly screens refugee children for parasitic infections. “I’m looking out for any red flags,” he says.

Both Drs. Decker and Rakowsky say building relationships with refugee children and their families is an important part of providing care.

“Many families are very distrusting of the health care system. We need to first build trust before they are comfortable letting us help their children,” says Dr. Decker.

While there’s no one way to do so, Dr. Rakowsky says learning about the refugees’ culture can go a long way. He has a map of the world on the wall to let the children show him where they are from and makes sure to do some research on the each child’s country or origin so he can talk about it with them if they choose.

“Once the family trusts you, you can also begin to help them in other ways,” says Dr. Decker. “There are many local resources that can help families stay physically and emotionally healthy. It’s important to be familiar with them so we can help connect them. They need access to community resources as much as they do health care.”

Symptoms of Trauma

Physical

  • Stomach aches
  • Headaches
  • Pain without a physical cause
  • Trouble falling asleep/sleeping too much

Emotional

  • Crying a lot
  • Fear or anxiety
  • Sadness or irritability
  • Thoughts about the traumatic event that won’t go away
  • Avoiding thinking or talking about anything that reminds him or her of the traumatic event
  • Acting as if the event is happening right now
  • Feelings of hopelessness
  • Nightmares
  • Trouble paying attention
  • Getting upset when things happen that remind him or her of the traumatic event

Behavioral

  • Lack of desire to play with others
  • Lack of interest in activities that were previously enjoyed