emma kinderziekenhuis amc

EMMA KINDERZIEKENHUIS AMC

Amsterdam

Paradigm shift in pediatrics

From:

Medical support for diseases in infancy and childhood

To:

Medical support to allow children with a disease or

handicap to develop in as normal as possible adults

The role of the

pediatrician in the

(administrative)

traumatization of the

young refugee

Hugo Heymans 2016

Refugees

Global 2015

• 65.3 milj Refugees

• 40.8 milj Internally displaced

• 16.1 milj In foreign countries

86% in developing countries

in the Netherlands 88.536

VluchtelingenWerk Nederland

2016

Refugees

Global 2015

3.219.941 Asylum Seekers waiting for a decision

Reception:

South Africa 1.096.063 ( 1/3 )

Germany 420.625

The Netherlands 28.051

The majority from: Syria

Afghanistan

Vluchtelingen Werk Nederland

2016

Minor (< 18) asylum seekers

Nederlands Jeugdinstituut 2016

Minor refugees in the Netherlands

Minor refugees in the Netherlands

In Central Reception of Asylum seekers (COA)

December 2015: 13.215

February 2016: 11.795

unaccompanied minor asylum seekers(UMA’s)

2015: 3.749

2016: 2.602

Syria 43%

Eritrea 25%

Nederlands Jeugdinstituut 2016

Unaccompanied minor asylum seekers (UMA)

AMA’s alleenstaande minderjarige azielzoekers

(AMVreemdelingen) <18 jaar

• Children without parents/ adult supervisor

• Children from outsite the European Union

• Children with a traumatic past

- in country of origin

- during the flight

- during the asylum procedure

UMA’s what do pediatricians contribute ??

A global problem !

Europa 2015 - 88.300 UMA’s

Sweden 40%

Gemany 16%

Males: 91%

Age 16 – 17y: 57%

Eurostat 2016

UMA’s

Problems depend on - age

- cause

- country of origin

• Afghanistan

• China

• Guinee

• Iraq

• Somalia

• Syria

• Eritrea

UMA’s

Medical problems increased

Growth disorder

Developmental disorder

Malnutrition ( 33% )

Nutritional deficiencies

Infectious diseases ( 50% )

Hematologic disorders

Hearing-problems

Visual-problems

Dental-problems

Van den Muijsenberg, UMC St Radboud 2011

UMA’s

Infectious diseases

• Malaria

• TB

• Hiv/Aids

• Hepatitis b

• Worm infections

Van den Muijsenberg, UMC St Radboutd 2011

UMA’s

Good physical examination

safe, reputable

Lab investigations

directed towards findings, epidemiology of the

country of origin

UMA’s

Mental health problems

due to trauma’s from past and present

• Country of origin

violence against parents

persecution, abuse, harassment

compulsion, detention

• Flight fear, tension, 60% via smugglers,(sexual)

abuse, 60% teenage-girls pregnant

• Asylum procedure

UMA’s

Asylum procedure

(traumatic for adults

and children)

Foreign language

Crowding

Detention

Isolation

Uncertainty

Mistrust

Hardship

Wiegersma et al. J Nervous and Ment Dis 2011

UMA’s


effected by

• Length of stay Asylum Seekers Centre (AZC)

• Number of relocations

• Possibility of being sent back

Wiegersma et al. J Nervous and Ment Dis 2011

UMA’s


Sleep-, feeding problems

Separation anxiety

Depression

Posttraumatic stress sydrome

Concentration disorder

Headache

Abdominal pain

Enuresis

Behavior problems (11 – 17%)


UMA’s

Behavior problems

Aggressive behavior

Regression

Hyperactivity

School absence

Drug-, alcohol abuse


UMA’s

Mental health problems 6-17 years

• Posttraumatic stress syndrome

• Depression

• Suicidal behavior

• Self-destructive behavior

• Anxiety disorders

Mares et al, Aust NZ j Public Health 2004

UMA’s


nature and severity related

• duration of stay (reception)centra

• duration asylum-procedure

Laban et al, J Nerv Ment Dis 2004

UMA’s duration procedure

Childrens-ombutsman

1400 children waiting > 4 year

700 children waiting > 8 year

UMA’s minors after major trauma

• Miss structure (family/education)

• Uncertainty about the future

More physical problems

More mental problems (50%)


UMA’s < 18 y

Right to care, protection and education

• Right to gardian

• No imprisonment (unless in self interest)

• No return if no guarantee for

-safe assistance

-acceptable environment

-possibilities for independent functioning

European Migration Network 2010

European com. 2011

UMA’s trends in detention

2009 1400 uma’s 300 locked up (20%)

2010 700 uma’s 300 locked up (40%)

Without detention: uma’s disappeared from reception centres

(AZC), trafficking in human beings, prostitution

2011 Policy change, majority UMA’s <15y foster home, >15y

provisional housing COA, with intensive supervision

2013 30 uma’s ±39 days locked up

F.Teeven, 2014

UMA’s consequences of detention

• Isolation

• Inhibits development

• Boredom

• Depression

• Anxiety

A bad climate for development, learning, faith, with big

consequences for behavior later in life

G. Smits- Baauw scriptie 2007

UMA’s, minors < 18 y

>30% no birth registration

Somalie, Afghanistan for many years

Many come without papers

Immigration and Naturalisation service (IND) for fear of registration of adults as UMA

asks medical support

“They all try to fool us”

UMA’s calendar age

Biologic variation in development implicates that any attempt

for the determination of the chronological age

X-ray – hand root , clavicula, teeth –

will always be inaccurate

Many factors: Etnic, Socioeconomic, Disease related,

will result in a 2 – 4 year variation

Hjern et al, Acta Paediatrica 2011

AMA’s calendar age

Royal College of Paediatrics and Child Health

Importance of an extensive social history !!!

Will that be possible ???

- trauma, psychic stress

- experience before / during / after flight

- strict approach during questioning

Royal college Paed Childh, Policy statement 2007

Pediatrics

Care for a child with a disorder

to provide a optimal chance to mature

as normal as possible

Rights of the child

Right to assistance and protection b.o.

physical and psychological vulnerability

Can these rights be limited by days, weeks, month or

years from birth ??

UMA’s role of the pediatician

Medical support in somatic problems

Trauma directed interventions

Cognitive therapy

Anxiety management

Personal support (mentorship, mediation)

UMA’s

Due to trauma, loss of confidence, lack of security,

etc, etc, etc,

Psychosocial development stays behind

To determine the size of that backlog is many times

more relevant than calendar age!!!!!

UMA’s

Due to trauma, loss of confidence, lack of security,

etc, etc, etc,

Psychosocial development stays behind

To determine the size of that backlog is many times

more relevant than calendar age!!!!!

Should not that be the role of the

pediatrician??

emma kinderziekenhuis amc

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