Immigrant Health Service

Education assessment

  • Also see Developmental assessment (younger children). 

    Assessing learning issues in refugee and asylum seeker students is often challenging. Like any other student, a developmental and family history is essential; however the assessment must also consider previous education and language transitions in relation to development, the impact of forced migration and trauma, second (or later) language acquisition, education pathways in Victorian schools, and support services available. There are different aetiologies to consider in developmental/learning problems in this group and basic screening for contributors, such as vision and hearing problems, is frequently missed. There are complex issues around the timing and validity of formalised language or intelligence testing in a child's second language. Finally, birthdates may be incorrect; creating additional complexity with assessment and year level placement. Ultimately an assessment takes time, and requires close liaison with the family and the help of a skilled interpreter.

    Key points

    • A refugee focussed medical and developmental assessment should be performed in conjunction with any psychology or educational assessment .
    • Early audiology and visual screening
    • Early thyroid function testing and iron studies (and consider serum active B12 and blood lead levels) if history of developmental delay. Other tests (SNP microarray, Fragile X screening, metabolic screening) can usually be performed later, and rarely change initial management
    • Permanent residents, including offshore Humanitarian entrants, are eligible for the Carer's allowance if they meet the usual criteria . Centrelink have multicltural liaison officers to help families complete forms (multilingual service phone 13 12 02).  Treating doctor reports can be downloaded. Asylum seeker students are not eligible for Carer allowance.
    • Additional supports for children with developmental delay/disability - through the Program for Students with Disabilities in government schools or Additional Needs program in Catholic education.
    • If there is a clear history of developmental delay/disability, try to access support early, after careful explanation and counseling of parents on the process and limitations of testing and a discussion on the harm/benefit of making a formal diagnosis. 

    Clinical assessment

    Background

    • Establish age (see guideline)
    • Parent concern about learning issues - this is specific, but not necessarily sensitive in the early stages of resettlement. Developmental and learning concerns are often not raised in the initial visits, health and settlement issues seem to take priority. Learning concerns may present some years after arrival
    • Early development - 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]
      • Take a careful history for seizures. There may be different aetiologies to consider (e.g. mass lesions from parasites).
    • 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. 
    • Trauma/mental health history  - previously it was uncommon to get a history of significant trauma in refugee families during the initial health assessment; trauma and mental health problems are often more immediate concerns in asylum seeker children/families.  Available data suggest extremely high rates of traumatic events for refugee and asylum seeker children/young people. Trauma histories may emerge over time.
    • Vision, hearing and additional screening - refugee children/adolescents have often missed screening for visual or hearing problems (even in Australia). Middle ear disease is common and may be severe, deafness due to extreme noise exposure is a possible aetiology, but not common in practice. Refractive errors and problems with visual acuity are common. Letter charts are not a good screen early after arrival, picture charts are a better option if available. If there is any concern about vision, hearing, or learning complete early formal audiology and/or formal visual screening (e.g. bulk billing community optometrist). The  Australian College of Optometry (in Carlton) provides an affordable range of glasses.
    • Other screening - thyroid function testing is a priority if there is any suggestion of development delay/disability, as it 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).

    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; for instance moving country and languages at age 2 - 3 (when children would typically start speaking in sentences) then again at the start of schooling (which then commences in another language) is likely to have more significant effects on education than attending continuous first language schooling in a stable school situation.
    • Schooling history overseas -  ask about access to school, quality of school (which varies widely), continuity of schooling, level achieved and the language the schooling was in (which may not be the child's language). Children with no/limited experience of school need to learn class rules/structures, as well as acquire a new language, establish friendships and start to learn academic content. 
    • Print literacy in other languages.

    Post-arrival education and settlement history

    • Families' settlement or asylum experience and moves post arrival. Clarify detention duration and pathway for asylum seeker students.
    • Previous access to kindergarten and school - clarify access and attendance, English language school/centre access/duration, the subsequent school pathway, amount of English as an Additional Language (EAL) support, and the demographics of the school they attend (other children or multicultural education aides speaking the same language). Asylum seeker students may have missed significant amounts of schooling during their time in Australian immigration detention.
    • 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 case management (AMESRed Cross or Life Without Barriers) and/or mental health/trauma services, including Foundation House
    • Sleep routine, diet and behaviour issues. 

    Formal assessment tools

    Like any other student group, a proportion of refugee children will have disabilities and additional learning needs compared to other children of similar background, however all refugee children have risk factors for educational disadvantage (language transitions, displacement) and many have additional, cumulative risk factors (trauma, lack of/interrupted prior schooling, mental health issues). This may lead to significant educational impairment in cognitively normal children.

    Cognitive testing is culturally bound and is usually 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.

    Funding guidelines (Program for Students with Disabilities (PSD) in government schools or Additional Needs program in Catholic education) prescribe pathways of testing with defined times when schools can apply for student funding.

    • Post round funding applications are possible in extenuating circumstances.
    • Specific PSD guidelines were available from 2009 for assessing intellectual disability in refugee students.These guidelines suggested a developmental assessment in addition to cognitive testing and the use of non verbal tests of intelligence (Wecshler Non Verbal, or the UNIT tests) in addition to the screen for adaptive function (Vineland).
    • There are no provisions for children with severe language disorders (who are likely to score in the intellectually disabled range in language based cognitive testing through an interpreter).

    There is no prescribed timing for completing testing; we recommend that children with a clear history of developmental delay are assessed early 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.

    Simple clinical suggestions

    • Encourage language school attendance in new arrivals
    • Sitting the child up the front of the class and checking they have understood instructions
    • Sitting children with others who speak the same language so they can discuss concepts in their first language
    • Encouraging first language development at home, explaining language acquisition, and expressing respect for the language skills within the family
      • Local libraries may 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
    • Informing parents of their rights to access interpreters in the school setting
    • Encouraging activities where students experience success and can enjoy peer relationships, without academic or language pressure, e.g. sport or art
    • Allowing time for play, rest and to adapt to life in Australia. Full time homework is not practical (or likely)
    • Ensuring adequate sleep, and encouraging a healthy diet in Australia.

    Formal supports for schools and other resources

    RCH Education Institute consent form (for interaction with schools) 

    Notes

    • Students of a refugee background are only exempt from benchmark testing for 12 months after arrival in both the Government and Catholic school systems in Victoria.
    • Children of a refugee background are underrepresented in the special school setting and at group level are not over represented in the PSD funding system (although there is variation by country of origin).

    References

    Immigrant health resources. Initial: Georgia Paxton, Last update May 2016. Contact georgia.paxton@rch.org.au