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.
• Kindergarten - refugee and asylum seeker children are eligible for free 4-year old kindergarten through the  Kindergarten fee subsidy providing 15 hours weekly. Children in community detention can also access 4-year old kindergarten.  Early start kindergarten programs are an additional resource for 3 yr old children who meet eligibility criteria.
• Raising Children  provides useful parenting resources and a directory of health and other services.
  
• Additional supports for children with developmental delay/disability.
  
  • Childcare - through  Inclusion support facilitators.
  • Kindergarten  -  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).
  • 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 seeker children are eligible for early intervention in Victoria.
  • 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:
  • Maternal and Child Health Services (see below). 
  • Childcare - adult Humanitarian entrants are eligible for 510 hours of free English language tuition under the Adult Migrant Education Program - free childcare is provided in association with these classes.
  • Kindergarten - 4-year old kinder has been free for refugee and asylum seeker children for several years, free 3-year old kindergarten for these cohorts was announced in the 2020-21 Victorian State Budget. 
  • Case management (AMES or Life Without Barriers) and/or mental health/trauma services, including Foundation House).

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:
  • Strengths and difficulties questionnaire (SDQ) which is translated into multiple languages (2-17 years). 
  • Ages and Stages Questionnaire (ASQ) - see ASQ calculator for which tests to use.
  • NICHQ Vanderbilt Assessment for ADHD, ODD and CD.Also see  Parent Arabic, Parent follow-up Arabic, Teacher Arabic, Teacher follow-up Arabic.
    
  • Spence Children's Anxiety Scale- also has translated versions and online scoring
  • Modified Checklist for Autism in Toddlers (M-CHAT).
    
• 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).
    • Arabic language - Talk to your baby in your language, Sharing books with your baby, Playing with your baby, Talking with your baby, Making the most of television.
• 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 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.
• The  Free Kindergarten Association  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

• Childcare - additional support is available through  Inclusion support facilitators
• Childcare subsidy calculator
  
• Kindergarten  -  additional support available through  Kindergarten inclusion support.
• Vision checks can be accessed at commercial bulk-billing optometrists for clients with Medicare, or at the  Australian College Optometry ( ACO associated clinics and  regional access), the ACO also has affordable glasses.
• Hearing checks can be accessed at  audiology services – see directory.  Hearing aids are available through  Australian Hearing.
  
• Community health services offer support for children with delays in one developmental area (age 0 - 6 years or until school entry).
  
• Autism MBS allied health sessions.
• NDIS - see operational guidelines on early intervention, BSL early intervention (also links to referral form). Asylum seekers aged 0-6 years are also eligible for ECEI through non-resident pathways (but not NDIS) (see  ECIS referral form for asylum seeker children - contacts on the form).
• Disability services.
• School finder (by postcode, including special education).
• Down syndrome  - translated resources from Down Syndrome Victoria.
  
• Chronic disease management plans  (through GPs) can provide access to 5 allied health sessions each calendar year.
• Humanitarian entrants are eligible for the Carer's allowance if they meet the usual criteria. Centrelink have multicultural liaison officers to help families complete forms ( multilingual service phone 131202). Treating doctor reports are available. Asylum seekers and people on TPV/SHEV are not eligible for Carer allowance.
  
• Bilingual health professional directories 
  
  • Clinical psychologists and  psychology
  • Psychiatry
  • Dietitians 
  • Speech pathologists
  • Pharmacists.

_{Immigrant health resources. Author: Georgie Paxton, Shidan Tosif. Updated Dec 2020. Contact: georgia.paxton@rch.org.au}