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Immigrant Health Service

Developmental assessment

  • Background

    Developmental assessment in refugee/asylum seeker children can be complex, requiring an understanding of child development, additional language acquisition, language transitions in relation to development, the impact of forced migration, trauma, and settlement, family and community constellations, 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 skilled interpreting. Also see Educational assessment (school-aged children) and Disability guideline. 

    Developmental assessment is a common reason for referral, and there is increased risk of autism and intellectual disability in children of immigrant and refugee backgrounds (Abdullahi et al, 2017).  Recent audits from our service have shown high prevalence of neurodevelopmental concerns in Syrian and Iraqi (2019), asylum seeker (2024), and Afghan cohorts (2025, submitted for publication). 

    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 may not be raised in initial visits, health and settlement issues often 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 years may be late in a child from Myanmar but would be considered relatively early in Australia.
      • Ask specifically about vision, hearing and balance and plan for early audiology and visual screening if there is any concern, or if there is developmental delay.
      • 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. Check specifically for developmental regression.
    • Antenatal and perinatal history - consider pre-, peri- and post-natal contributors to development.
    • Early medical history - also consider additional risk factors for developmental problems related to the refugee experience. Ask specifically about hospital admissions, any severe illnesses or coma, accidents/trauma, seizures, cerebral malaria and nutritional status. It is surprising how frequently these issues are not raised.
      • In recent years, an increasing proportion of new arrival children have complex developmental presentations, with a range of neurodevelopmental and genetic conditions.
      • 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.
      • Consider iron deficiency, low B12, lead exposure and hypothyoidism (neurodevelopmental impacts), and vitamin D deficient rickets (gross motor delay) as contributors.
    • Family history and consanguinity - 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 - in our experience it is (still) 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 come from direct conflict zones, and families who had babies in detention are 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. A healthy diet and family mealtimes are important supports for all children/families and should be encouraged and celebrated.

    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.
    • Education (more for school age children) - explore any any early childhood education or playgroup experience overseas.

    Post arrival settlement and early childhood service access

    Examination

    • Assess growth and head circumference - plot height, weight and head circumference percentiles and correlate with parent measurements.
    • General examination, look for pallor, goitre, nutritional status, syndromal features, neuro-cutaneous stigmata, full physical examination including ENT, and assessment of language, social skills, play, self regulation, and interaction with parents/siblings.

    Screening

    Investigations

    • Early investigations (some are part of refugee screening)
      • General - thyroid function, FBE, iron studies, B12/folate, vitamin D (risk factors/rickets/gross motor delay), consider blood lead levels, CK (gross motor delay).
      • Genetic tests - SNP microarray, Fragile X screening, exome sequencing can usually be performed later (now much easier with saliva testing) and rarely change initial management.
      • Consider metabolic disorders in children with regression, or where there is history/exam suggesting metabolic disease (lethargy/coma with intercurrent illness, food aversion, seizures, family history including unexplained deaths, syndromal features, hepatosplenomegaly) - venous blood gas, lactate, ammonia, LFT, plasma amino acids, urine amino/organic acids, MPS screening, others pending advice from metabolic team.
    • Vision and hearing 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. 

    Developmental screening and 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 a comprehensive developmental 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 wait, 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

    Additional supports for children with developmental delays/disability.

      Immigrant health resources. Author: Georgie Paxton, Shidan Tosif. Updated July 2025. Contact: georgia.paxton@rch.org.au