When the recent photo of a drowned Syrian toddler woke up the world to the Syrian refugee crisis more viscerally than ever before, multiple nations announced plans to take in more refugees. According to the U.S. State Department, approximately 10,000 Syrian refugees are already in processing, eventually headed to cities that may include Atlanta, San Diego, Houston, Dallas, Chicago, Boston, Boise, Nashville, Tucson, Buffalo, and Erie.
To pediatricians, that boy on the beach represents a child who might have ended up in their practice with diverse, complex needs greatly exceeding the typical needs of a U.S. child coming in for a well-child visit.
“Families are coming from a country that has been ravaged by civil war for over 4 years,” Dr. Susan S. Reines , a pediatrician with the Southeast Kaiser Permanente Medical Group and lead pediatrician for the Refugee Pediatric Clinic at DeKalb County Board of Health in Decatur, Georgia, said in an interview. “Cities have been destroyed, and millions have been forced to leave their homes and are displaced either within Syria or in neighboring countries.”
About a third of the more than 58,000 refugees admitted to the United States in 2012 were under 18 years old. Although the majority that year hailed from Bhutan, Burma, and Iraq, an increasing number of children have been coming from war-torn Syria since June 2014. The proposed ceiling for all refugees in the United States 2015 fiscal year is 70,000, a “significant number” of whom will be children with their families, according to a State Department spokesperson.
These children come with “unique medical, developmental and psychosocial needs,” noted Dr. Thomas J. Seery and fellow authors of “Caring for Refugee Children,” a Pediatrics in Review article recommended by Dr. Reines for pediatricians who may be caring for refugee children.
“The health care infrastructure of Syria is broken and many hospitals have closed, medications are difficult to obtain, and numerous doctors have fled the violence,” Dr. Reines said. She compared the anticipated health care problems of these children with those seen among Iraqi refugee children:
• Undernutrition and micronutrient deficiencies.
• Infectious diseases such as vaccine-preventable diseases like measles, but also typhoid, tuberculosis, and parasitic infections.
• Dental disease.
• Surgically amenable congenital anomalies such as congenital heart disease, myelomeningocele, and others that have not been repaired.
• Neurologic problems, such as cerebral palsy, intellectual disability, and autism.
• Hearing loss.
• Posttraumatic stress disorder (PTSD),depression, and anxiety.
• Trauma such as gunshot wounds, shrapnel injuries, and genital trauma secondary to sexual violence.
• Sequelae from illnesses that previously were easily treated, such as hearing loss and ear complications from otitis media, and rheumatic fever from inadequately treated strep throat.
Various resources listed below, including Dr. Seery’s paper, can help guide providers in assessing and meeting these needs, and navigating paperwork and the U.S. refugee system. These resources also can help practitioners address the mental health concerns these patients and their families may face.
Mental health needs
Even children in the best physical shape will have experienced significant upheaval that could lead to depression, anxiety, and PTSD – conditions more common among refugee children than in the general population, research has shown.
“Mental health conditions will be especially present in these children uprooted from their homes and families, and exposed to the violence of war,” Dr. Francis E. Rushton Jr. of the department of pediatrics at the University of South Carolina, Columbia, and a member of the American Academy of Pediatrics Committee on Community Health Services, said in an interview. Of the four major areas of health care need he described for these children, two relate to mental health: toxic mental stress and fractured families and the lack of nurture.
One challenge pediatricians face, however, is recognizing these conditions despite cultural differences that could obscure them.
“It is not uncommon for teens and adults to deny symptoms of depression, stress, and anxiety in early encounters,” Dr. Reines said. “Many cultures stigmatize psychiatric or mental health problems, and refugees may be reluctant to admit they are having difficulties.”
One way around this obstacle is to ask patients and their parents about sleep, energy level, appetite, weight changes, and thoughts of harming one’s self, she said. Mental stress also manifests as somatic symptoms, such as headaches, stomach aches, and back pain, particularly in teens.
“Infants and toddlers are generally most adaptable as long as parents are coping well, and can provide a buffer for stress with a safe and nurturing environment,” Dr. Reines said. Children of parents with depression or PTSD, or who have lost a parent, may feel abandoned and experience depression or developmental delays.
Although school-age children may have nightmares, show anxiety, and cling to their parents, they usually transition well to their new homes. Adolescents face the biggest difficulties, especially if they have lost a parent, must care for their siblings, or have experienced sexual trauma. “They may have more vivid memories of disturbing events and a greater understanding of what their family has endured,” Dr. Reines said. Further, language and educational deficits can lead to alienation and embarrassment, yet families may rebuff behavioral health referrals.
“In these cases, it’s best to keep communication open, encourage dialogue with family, and try to find an activity or sport the refugee can participate in to improve self-esteem,” Dr. Reines said.
Avoiding cultural confusion
While cultural challenges are obvious – language barriers may necessitate translators or bicultural caseworkers – others may be more subtle. Developmental screening questions that rely on blocks, certain pictures, or other culturally specific bases, for example, may not adequately capture a child’s development.
Dr. Reines stresses a strategy for managing cultural differences that is recommended in Dr. Seery’s article: striving for cultural humility rather than cultural competence.
“It is impossible for U.S. physicians who have never practiced outside of our culture and are not bicultural or bilingual to become truly culturally competent in health care delivery for so many refugee populations,” Dr. Reines said. Instead then, cultural humility emphasizes showing respect, interest, and a willingness to learn from patients, she explained.
Cultural humility is a “lifelong process” that also demands flexibility and “allows the practitioner to release the false sense of security associated with stereotyping,” Dr. Seery and his colleagues wrote.
At the same time, pediatricians are guarding against inadvertent stereotyping; however, they can be aware of some cultural generalities that may apply to their Syrian refugee patients.
“Arab communities stress the importance of family rather than the individual and are often more modest than Westerners,” Dr. Rushton said. Further, “Arab families frequently experience discrimination on the basis of their religion in the United States, and pediatricians should be aware of ongoing traumatization even after arrival in America,” he said.
Teens may become embarrassed with discussions about sex or alcohol because few teens from the Middle East drink or become sexually active before marriage, Dr. Reines added. She noted that a Muslim male may not shake hands with females outside his family – a practice providers should respect – and that important religious holidays such as Ramadan may influence a family’s compliance with a treatment plan.
Perhaps the most important commonality, however, is one universal to most refugee families, regardless of their home country.
“The vast majority of families that we meet show incredible courage and resilience, and caring for their children is their highest priority,” Dr. Reines said. “We can learn a great deal from these families, and caring for their children is a tremendously rewarding experience.”
Other cultural resources:
“ The Middle of Everywhere: Helping Refugees Enter the American Community, ” by Mary Pipher (Orlando: Mariner Books, 2003)
“ Immigrant Medicine, ” a textbook by Patricia Walker, M.D., and Elizabeth Barnett, M.D. (New York, N.Y.: Elsevier, 2007)
“Opening cultural doors: Providing culturally sensitive healthcare to Arab American and American Muslim patients” ( Am J Obstet Gynecol. 2005 Oct;193]:1307-11 ).