Immigrant Health Service

Mental health

  • Key points:

    • Consider functional impairment, behavioural difficulties and developmental progress as well as mental health symptoms when assessing children/adolescents
    • Mental health concerns may not come up in the first visits
    • Supportive management can commence within general paediatric care, while awaiting specialist mental health input.

    Background

    Children and young people of refugee-like background are likely to have been exposed to significant adversity, before and after arrival in Australia. Many have experienced past trauma, conflict, and family separation, and they may have additive risks for mental health and developmental concerns through parent mental illness, disrupted family functioning, and interrupted schooling. Consider the timing of trauma exposure(s) in relation to development milestones. 

    • Children and adolescents experience similar psychological reactions to trauma as adults, however the clinical presentation reflects their age and development.
    • Presentations may include behavioural issues, sleep concerns, attention difficulties, enuresis, and developmental/education concerns, as well as symptoms of anxiety, depression and post-traumatic stress disorder (PTSD).
    • Unaccompanied and separated minors have specific vulnerabilities and increased risk of experiencing violence (including sexual violence) [1-5]. Orphan relative visa holders are a high-risk group, who do not receive the supports available to Humanitarian entrants.
    • Parent distress and mental illness influence child mental health.
    • Asylum seeker children and adolescents who have experienced immigration detention are at high risk of mental health problems. Australian immigration detention has a negative impact on parenting and family functioning [9,10,13,14,16]. Infants born in detention may have severe attachment issues associated with parent depression [9-15].
    • While pre-arrival trauma is well recognised in refugee populations, settlement is also associated with multiple stressors.
    • Consider cultural aspects to the presentation, and the child/adolescent and family’s perspectives.
    • People of refugee-like background face significant barriers to accessing mental health services in Australia [6,25]. 

    Prevalence

    Widely variable rates of mental health issues are reported in refugee children/adolescents, although there is more information available on the prevalence of PTSD, depression, and anxiety than other diagnoses. Prevalence is specific to cohorts, conflicts and countries of settlement [6-9].

    Assessment

    All ages

    Consider the presence of family members (especially with adolescents) and issues specific to working with interpreters. Briefing and debriefing interpreting colleagues (checking in with their experience of trauma disclosures) is especially important for consultations exploring mental health. Define confidentiality, and (separately) define interpreter confidentiality.

    The following areas are useful to explore during initial consultations:

    • Migration history - countries of origin/transit, reasons for migration, circumstances around the journey
    • Migration status - seeking asylum (and stage in the protection process), humanitarian entry
    • Family composition - concern for remaining family overseas may be overwhelming, with effects on settlement and wellbeing
    • Settlement experience - housing, social connections, resources and supports
    • Trauma screening - it is rarely necessary to ask in detail about trauma history, and it is important to consider the potential for triggering a trauma response. Indirect questioning may be useful e.g. “Sometimes terrible things have happened to people who have been forced to leave their countries. I do not need to know the details, but is there anything that has happened that might be affecting you now?" Where traumatic events are disclosed, consider intensity, proximity, familiarity, chronicity and age/developmental status [30].

    Mental health issues can present as difficulties with [24]

    • Attachment to parents/caregivers 
    • Behaviour, including irritability or aggression 
    • Play and peer relationships, including emergent themes in games or drawing, difficulties making friends, engaging in play, or joining group activities 
    • Attention or concentration, hyperactive behaviour, learning difficulties 
    • Withdrawal or lack of interest in normal activities; retreating into screen-based activities is common 
    • Avoidance behaviour, including school refusal
    • Separation issues, watchfulness, and co-sleeping 
    • Sleep-related symptoms, including nightmares, intrusive worries or thoughts, disordered sleep routine and fatigue 
    • Enuresis or encopresis 
    • Self-esteem 
    • Developmental delay, lack of expected developmental progress, worsening of pre-existing developmental concerns or regression
    • More overt presentations of anxiety, depression, intrusive thoughts/images, a 'frozen' appearance, mutism, or perceptual abnormalities (e.g. hearing voices)
    • Sexualised behaviour, which may indicate that a child or young person has witnessed or been exposed to sexual abuse. Seek advice on child protection concerns and consider reporting requirements 
    • Self-harm or suicidality - these presentations are extremely rare in younger children, but require urgent review if present at any age 
    • Family function and parenting, including presentations related to family violence.

    For younger children: (in addition to above)

    • Many of these presentations are general paediatric issues, and working through an issue can empower the child and family
    • Sleep management is always a good place to start
    • Exploring the impact of migration on parenting is often a useful entry into exploring attachment and risk/resilience factors for the child and family
    • Consider use of a screening tool for children such as the Strengths and Difficulties Questionnaire (available in more than 80 languages)

    For adolescents:

    • Current functioning: ask about appetite, energy, daily activities, memory/concentration, sleep and plans for the future as an entry to more specific mental health symptoms 
    • Mental health symptoms:  mood, irritability or anger, sadness, hopelessness, guilt/worthlessness, self-esteem, loss of interest in (previously) enjoyable activities, social withdrawal, anxiety symptoms, panic symptoms/attacks, rumination, and intrusive thoughts 
    • Risk-taking behaviour
    • Self-harm/suicide risk assessment: hopelessness is a stronger predictor of suicidal ideation than diagnosed depression [21] and suicidality may present differently in those from diverse backgrounds [22,23] 
    • Ask about approaches to stress management and coping strategies, and assess internal and external resources
    • Adolescents may reflect on past childhood trauma and have a new understanding of events
    • HEADSS screening is useful to elicit psychosocial history in adolescents.               

    Management and referral

    • Seek specialist paediatric mental health advice early; referral to torture-trauma counselling may also be appropriate
    • Where relevant, consider and screen for treatable conditions that may cause/exacerbate mental health or behavioural problems, including hypothyroidism, vitamin B12 deficiency and iron deficiency. 

    General principles of managing children/adolescents experiencing trauma reactions and/or mental health concerns include:

    • Making sure children are informed about their own situation - using developmentally appropriate language, and offering them the opportunity to ask questions
    • Addressing mental health issues in the whole family 
    • Supporting primary attachments 
    • Ensuring predictability - through maintaining routine, including school attendance, and preparing for changes; reassuring children about the future 
    • Addressing sleep issues - maintaining a healthy age-appropriate sleep routine and limiting screen time (and addressing screen content/safety)
    • Encouraging play in younger children, enjoyable activities or sports in older children/adolescents, and peer connections and experiences of success at all ages
    • Encouraging expression of emotions and asking what children/young people are thinking/feeling
    • Setting realistic goals for behaviour and avoiding overreacting to difficult behaviour during transition periods 
    • Promoting engagement with school and community, and maintenance of first language alongside English language learning.

    Many of these strategies can be implemented while waiting for specialist mental health input.

    Mental health resources & further information

    Mental health services – Refugee or CALD specific:

    • Foundation House (Victorian Foundation for Survivors of Torture, VFST) provides counselling, advocacy, family support, group work, psycho-education, school support, information sessions and complementary therapies for refugee and asylum seeker clients. VFST has offices in Brunswick, Dandenong and Sunshine and an outpost in Ringwood. Services are also provided in a number of rural and regional centres. Interpreters available. Details on referrals and referral forms are available, or intake is 03 9388 0022. 
    • Centre for Multicultural Youth (CMY) undertake a range of programs, projects and policy initiatives to enhance life opportunities for young people from CALD backgrounds. They provide a variety of Youth Support Programs (interpreters available), including:
      • Reconnect - young people in Australia <5 years at risk of homelessness in Hume, Brimbank, Greater Dandenong or Casey (see Referral)

    Mental health services - general:

    • Child and Adolescent Mental Health Services (CAMHS) see children <18 years. Young people 16-18 years of age may receive services from either CAMHS or youth/adult area mental health services depending on needs/services available. Refugee or asylum seeker children are not currently part of the priority access service response (PASR). Referral occurs through an intake process, and can be initiated by any concerned adult, although parent consent is needed for work to progress. The intake worker will contact the family with an interpreter to triage the referral.

      CAMHS see children and adolescents with serious emotional disturbance (e.g. impaired reality testing, hallucinations, depression, suicidal behaviour, hyperactivity, nightmares, fearfulness, bed-wetting, language problems, school refusal and stealing. Services include:
      • Outpatient assessment and ongoing counselling services
      • Acute inpatient services: short-term assessment and/or inpatient treatment for children/adolescents who cannot be assessed or treated within the community. Refer via CAMHS
      • Specialised Programs vary by region; e.g. Children and Schools Early Action (CASEA) program.  
      • Orygen see young people 15-24y in the West/North-West areas. Multiple programs available, including outreach services; intake through central triage
      • Travancore school provides education support for children/young people (prep - year 12) engaged with the RCH Mental Health Service.
    • RCH Department of Psychology - Referrals to the Department of Psychology are accepted for children attending regular outpatient appointments with complex developmental, cognitive, academic, language, behavioural or social-emotional difficulties, who require specialised assessment, e.g.
      • Children who present a diagnostic dilemma after appropriate primary and secondary level assessment
      • When an understanding of cognitive/emotional state is critical to plan medical treatment or manage ongoing treatment
      • Where early intervention is required to prevent psychological disorders.
    • Referrals to Neuropsychology are accepted for children who have:
      • An identified or suspected neurological disorder (e.g. epilepsy)
      • An acquired brain injury (e.g. head injury, cerebral infection, anoxia)
      • An illness that may affect brain function (e.g. diabetes, leukaemia, heart disease)
      • A need for a rehabilitation program.
      Referrals can be made by letter or by completing a referral form (for either Psychology or Neuropsychology). Interpreters are available.

    • Other RCH mental health services 
    • Better Access Scheme provides up to 10 individual or group, therapy services per calendar year, which are partially funded via Medicare. Out-of-pocket expenses vary; many clinicians charge around $180, the Medicare rebate is $123.50 for a clinical psychologist or $84.80 for a general psychologist. Interpreters are usually not available. Requirements include:
      • Referral to psychologist by a GP with a Mental Health Care Plan, or a specialist psychiatrist (after billing items 104-109), consultant physician psychiatrist (after billing items 293-370), specialist paediatrician (after billing items 104-109) or consultant physician paediatrician (after billing item numbers 110-132).
      • The psychologist must have a Medicare Provider Number. See register, then filter by Medicare status.
    • Frontyard Youth Services  is a multidisciplinary service for young people <25 years who spend time in the Melbourne CBD and who are homeless or at risk of homelessness. Specific counselling services are (appointments needed):
    • Headspace is a youth-friendly health service for age 12-25 years, operating a bulk-billing Medicare service with clinicians including GPs, psychiatrists, psychologists, occupational therapists, drug and alcohol workers and counsellors. No referral needed; medical clinicians within Headspace should be able to access TIS interpreting, allied health clinicians may not be able to access interpreting. Centres are located throughout Australia (link to postcode search).   

    Mental health services - perinatal:

    • Telephone counseling and helplines: 
      • PANDA (Perinatal Anxiety & Depression Australia). Run a national helpline (telephone counseling service): 1300 726 306 (Mon-Fri, 10am-5pm AEST). Patients can call directly, or can be referred. Interpreters available – leave a message with your phone number and the language you need.
      • Maternal and Child Health Line. Ph: 13 22 29. Interpreters available. A 24-hour telephone service staffed by maternal and child health nurses for families of children aged from birth to school age. 
      • Beyondblue helpline. Ph: 1300 22 46 36. Interpreters available through TIS national –  call 131 450, state the language you require, and you can ask to contact Beyondblue. 
    • Clinical services: 

    Other resources:

    References

    See References

    Immigrant health clinic resources. Authors Karen Kiang, Rachel Heenan and Georgie Paxton. May 2017. Contact georgia.paxton@rch.org.au