Background
Developmental assessment in refugee/asylum seeker children can be complex, requiring an understanding of second (or later) language acquisition, language transitions in relation to development, the impact of forced migration, trauma, and settlement, and support services available. The aetiology of developmental issues may be complex in refugee/asylum seeker children, and routine neonatal, vision and hearing screening is unlikely to have been completed. There are specific challenges with formal language or cognitive assessments for children with English as an Additional Language (EAL). Development assessments take time and require close liaison with families and the help of a skilled interpreter.
Developmental assessment is a common reason for referral, although there are limited prevalence data on developmental issues in refugee/asylum seeker children. Also see
Educational assessment (school-aged children).
Key points
- Developmental assessment should include careful medical assessment, and consider the refugee/asylum seeker experience.
- Early audiology and visual screening.
- Early tests - thyroid function and iron studies (and consider blood lead levels) if developmental delay. Other tests (SNP microarray, Fragile X screening, metabolic screening) can usually be performed later and rarely change initial management.
- Link families with Maternal and Child Health Nursing and consider supported playgroups (also noting some families prefer unselected local playgroups)
- Kindergarten - refugee and asylum seeker children (including those in community detention) have been eligible for free 3 and 4-year old kindergarten through the
Kindergarten fee subsidy providing 15 hours weekly.
Early start kindergarten programs are an additional resource for 3 yr old children who meet eligibility criteria, although we advise against placing 3 years olds in 4-year old programs. See kinder finder (by postcode). Additional support and linkages are available through preschool field officers (PSFO) and kindergarten inclusion support.
- Raising Children provides useful parenting resources and a
directory of health and other services.
- Additional supports for children with developmental delay/disability.
- Childcare - families can be linked with local childcare through AEL (Access to Early Learning) in local councils, with additional support through
Inclusion support facilitators.
- Kindergarten - PSFO, Kindergarten inclusion support, the
Free Kindergarten Association provides support for bilingual children in childcare, kindergarten, out of school hours care and holiday programs.
- Community health services, early intervention services, (also note different
referral pathway for asylum seeker children - see Disability guideline).
- NDIS, autism funding where relevant - asylum seekers and people on temporary protection visas (TPV)/safe haven enterprise visas (SHEV) are not eligible for NDIS, although asylum seekers children are eligible for non resident pathways to disability support in Victoria (see Disability guideline).
- Permanent residents, including Humanitarian entrants are eligible for the Carer's allowance and payment if they meet the usual criteria . Centrelink have multicultural liaison officers to help families complete forms (
multilingual service phone 13 12 02).
Treating doctor reports are available. Asylum seekers and people on TPV/SHEV are not eligible for the Carer allowance; people on a TPV/SHEV are eligible for a health care card.
Assessment
Background and current function
- Parent concern about development issues - this is specific, but not necessarily sensitive in the early stages of resettlement. Developmental concerns are often not raised in the initial visits, health and settlement issues seem to take priority.
- Early development and current developmental level - gross motor milestones and major language milestones (e.g. speaking in sentences) appear to be remarkably constant across languages. and cultures. Children may not have had access to books/pens/paper/zips/buttons - these are culturally bound markers. Cultural expectations of adaptive function differ; toilet training at 2 may be late in a child from Burma but would be considered relatively early in Australia. Ask the family if they feel the child's skills were late or early, and whether they obtained skills at the same time as their siblings or other children in their community.
- Early medical history - consider additional risk factors for developmental problems related to the refugee experience. Ask about hospital admissions, any severe illnesses or coma, accidents/trauma, cerebral malaria and nutritional status. It is surprising how frequently these issues are not raised.
- Cerebral (Pl. falciparum) malaria is associated with long term cognitive impairment and problems with attention.1,2
- Severe early malnutrition is associated with lower IQ and problems with behaviour and school performance in school-aged children.3 Ask about weight/nutrition in the first 2 years, chronic diarrhoea, and any time in camp hospitals/feeing centres.
- Family history - be sensitive in asking about family demographics, family members may be missing or deceased. It is usually easier to ask 'Who is in your family in Australia?' and 'Do you have family overseas?' rather than enquire about specific family members. Ask about consanguinity.
- Trauma/mental health history and parent mental health - previously it was uncommon to get a history of significant trauma in refugee families during the initial health assessment, whereas trauma and mental health problems are often immediate concerns in asylum seeker children/families, and may be overwhelming. Families who have had babies in detention appear to be at extreme risk.
- Current behavioural, emotional or mental health concerns. Also consider attachment issues.
- Sleep, screen time, dietary history - sleep problems are common, and often multifactorial, and affected by household arrangements, and mental health issues, especially for asylum seeker children.
Pre-arrival education and language history
- Parent education and profession - people of all backgrounds flee situations of Humanitarian conflict, and people may work within refugee camps. Asking someone's background is informative and respectful - we see a relatively high proportion of families where a parent worked in a professional capacity overseas.
- Languages spoken, preferred language and timing of acquisition of language(s) - consider language acquisition in the context of major developmental transitions.
Post arrival settlement and early childhood service access
- Families' settlement or asylum experience and moves post arrival. Clarify detention duration and pathway for asylum seeker families.
- Home and family environment Families may be living in crowded or unstable conditions which affect routines, sleep and access to space for homework.
- Access to:
Examination
- Assess growth and head circumference - plot height, weight and head circumference percentiles and correlate with parent measurements.
- General examination, also looking for goitre, neurocutaneous stigmata, dysmorphism/syndromal features, and organic conditions.
Screening
- Developmental screening - there is a lack of validated developmental screening tools, and in practice we rely on the clinical history. Possibilties include:
- Vision, hearing and additional screening - refugee/asylum seeker infants have often missed screening for visual or hearing problems (even in Australia). If there is any concern about vision, hearing, or development complete screening early (see below).
- Thyroid function tests (TFT) are a priority if there is any suggestion of development delay/disability, as TFT may not have been screened previously.
- Iron deficiency is extremely common in children of a refugee background and is associated with irritability and effects on development.
- Consider additional causes of motor delay related to nutrition, such as B12 deficiency (reported in cohorts from Afghanistan, Bhutan and Iran) and thiamine deficiency (cases where history suggestive in Burmese children) and lead toxicity (reported in Karen children).
- Other tests (SNP microarray, Fragile X screening, metabolic screening, whole exome sequencing) can usually be performed later and rarely change initial management.
Formal assessments
Formal assessment (e.g. language testing, cognitive testing) is often only completed prior to school entry, and should be accompanied by a comprehensive paediatric assessment. These tests may be required in order to access supports in school, and they can provide useful information when considered in the context of the comprehensive assessment.
- There is no prescribed timing for completing testing; we recommend that children with a clear history of developmental delay are assessed at school entry to maximise support (after appropriate counselling) and that they are reassessed at a later date.
- In children with normal early development, it is nearly always appropriate to watch and liaise with the school - provided a paediatric assessment and initial investigations have been completed.
Cognitive and formal language testing is generally not validated for use in non-English speaking children, or for use with an interpreter. Any test result needs to be interpreted with extreme caution, families need appropriate pre-test and post test counselling. If cognitive assessment has already occurred - check families understanding of testing, and whether an interpreter (and which language) was available for testing and feedback sessions. This resource on
IQ test scores can be helpful to explain results.
Management
All refugee and asylum seeker children
- Ensure adequate sleep, and encourage a healthy diet - see
nutrition resources.
- Provide advice on appropriately limited screen time.
- Encourage first language development at home and expressing respect for the language skills within the family.
- Local libraries will have multilingual books.
- Talking about books and telling the story in the first language (i.e. by describing pictures) is likely to be of benefit.
- National Literacy Trust (UK) - Support for multilingual families - includes resources to support early literacy and school readiness (Arabic, Kurdish, Somali, Urdu, others).
- Encourage play, including outside play, and children's involvement in daily family activities.
- Supported playgroups.
- Toy libraries can be a useful resource.
- Link families with Maternal and Child Health services - MCH provide advice on playgroups and community programs, some MCH services provide immunisation. Routine checks are due at birth, 2w, 4w, 8w, 4m, 8m, 12m, 18m, 2y and 3.5yrs.
- Ensure children are enrolled in kindergarten - refugee and asylum seeker children are eligible for free 3-year old and 4-year old kindergarten - see above (now applies to all children in Victoria
- The
Free Kindergarten Association (FKA) provides support for bilingual children in childcare, kindergarten, out of school hours care and holiday programs.
- The BSL Refugee Child Outreach Program can link refugee families who live in the Western region and Hume (check eligibility criteria) with early childhood services, provide guidance on issues around parenting and child development, and help access activities in the local community.
Children with delay/disability
Immigrant health resources. Author: Georgie Paxton, Shidan Tosif. Updated Apr 2023. Contact: georgia.paxton@rch.org.au