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Treat with confidence. Trusted answers from the American Academy of Pediatrics.Treat with confidence. Trusted answers from the American Academy of Pediatrics.

Providing Evidence-Based Medical Care to

Immigrant Children

Janine Young, MD, FAAPAssociate Professor of PediatricsUniversity of Colorado School of Medicine

Julie M. Linton, MD, FAAPAssistant Professor of PediatricsWake Forest School of MedicineChair, AAP Immigrant Health Special Interest Group


Disclaimer Statements and opinions expressed are those of the presenters and not necessarily those

of the American Academy of Pediatrics.

The presenters have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this presentation.

The presenters do not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation.

Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenters have complete and independent control over the planning and content of the presentation, and are not receiving any compensation from Mead Johnson for this presentation. The presenters’ comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.


Objectives Review pertinent background regarding care of immigrant

children, including changing demographics, the impact of diverse legal statuses on the provision of healthcare, and the current refugee resettlement program.

Review recommendations regarding comprehensive medical evaluation of newly arriving immigrant children and consider common scenarios regarding history, physical examination, laboratory evaluation, development, mental health, and social determinants of health.

Identify strategies to integrate care of immigrant children into a family-centered medical home.


Who Are Children in Immigrant Families?


Background: Demographics

Kids Count Data Center. datacenter.kidscount.org*Mendoza FS, Festa NK. New American children: supporting the health and well-being of immigrant populations. JAMA Pediatr. 2013;167(1):12–13.

Children in immigrant

families will represent 1/3 of US children over the next

40 years.*


US Arrival of Refugees by State, FY 2006–2015

US Department of State. www.state.gov/r/pa/pl/249076.htm


Unaccompanied Children and Family Units

Migration Policy Institute. www.migrationpolicy.org


Key Clinical Domains

1. Medical screening

2. Developmental screening

3. Mental health and trauma

4. Social determinants of health

Health literacy:

Families must enter and navigate the system to address these domains.


Case 1

Adera is a 14-year-old girl who is seeing you for a refugee screening exam one month after arriving in the United States. She is from rural Somalia but has lived in Hagadera, a refugee camp in Kenya, for the past 6 years.


Story Maps. storymaps.esri.com/stories/2013/refugee-camps/?WT.mc_id=EmailCampaignh15201


Case 2

José is a 30-month-old Guatemalan boy who comes to your

office with his mother because he has had diarrhea for one

week. He looks small for his age, is well-hydrated, and his

mother tells you (when asked) that they arrived in the

United States 6 months ago. She reveals that her family

paid a coyote $6,000 to traffic her and her child to your city.


Case 1Adera


Centers for Disease Control and Prevention. Refugee Health Profiles. www.cdc.gov/immigrantrefugeehealth/profiles/bhutanese/medical-screening/index.html


Panel Physician Overseas Exam Tuberculin skin tests (TSTs) or interferon-gamma release assays (IGRAs)

2–14 years

Chest X-ray only if >15 years

History of:o Syphilis (venereal disease research laboratory [VDRL] test if >15 years)

o Gonorrhea

o Chancroid

o Hansen’s disease

o Substance use

o Mental illness

o HIV testing no longer required and not done

Past medical history checklist

Physical exam

Minimal vaccines given


Overseas Treatment


Case 2José


American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6HR1D; and Centers for Disease Control and Prevention. Guidelines for the US domestic medical examination for newly arriving refugees. www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html.


Photo credit: Stacene Maroushek

Photo credit: Bill Stauffer, MD

American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6HR1D; and Centers for Disease Control and Prevention. Guidelines for the US domestic medical examination for newly arriving refugees. www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html


Hearst AA, Molnar AM. Female genital cutting: an evidence-based approach to clinical management for the primary care physician. Mayo Clin Proc. 2013;88(6):618–629.


Reproduced with permission from UW Medicine/Harborview Medical Center for Sexual Assault & Traumatic Stress.


Female Genital Mutilation/Cutting Complications Infection, bleeding, sepsis, death—immediate complications Recurrent urinary tract infections/pyelonephritis Cysts Keloids Abscesses Hematocolpos/dysmenorrhea Dysfunctional voiding Dyspareunia Complications during/post childbirth—increased C-section rate,

post-partum hemorrhage, increased infant resuscitation rates Infertility ?HIV, hepatitis B, C?World Health Organization Department of Reproductive Health and Research. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. 2016:1–7; and Nour NM. Female genital cutting: a persisting practice. Rev Obstet Gynecol. 2008;1(3):135–139.


Tiered Approach to Laboratory Screening

American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6HR1D; and Centers for Disease Control and Prevention. Guidelines for the US domestic medical examination for newly arriving refugees. www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html.


American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6HR1D


If No Pre-treatment Exists


Opportunities for Practice Change

Screen shot from the electronic medical record, Wake Forest Baptist Health.


Case 3

A 4-year-old Burmese boy, born in a Thai refugee

camp, arrives in your clinic as a new patient.

His parents report that others have difficulty

understanding what he says, and that he does not

speak as well as the other children in the refugee

camp.

What developmental screening evaluation is

appropriate for refugee children?


What is Recommended for ALL Children?

Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118(1):405–420.

Developmental surveillance at all

well child care visits with

screening at selective intervals or in response to concerns noted

with surveillance


Sample Screening Tools

Parents’ Evaluation of Developmental Status (PEDS). www.pedstest.com/default.aspxAges and Stages Questionnaire (ASQ). agesandstages.com

Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F). www.m-chat.org/index.phpSurvey of Wellbeing of Young Children (SWYC). www.theswyc.org

Birth to 5: Watch Me Thrive! www.acf.hhs.gov/sites/default/files/ecd/screening_compendium_march2014.pdf


Opportunities for Practice Change

Screen universally—bilingualism does not cause language delay.

Conduct developmental assessments in the child’s primary language.

Enlist assistance of interpreters or patient navigators to complete forms.

Engage developmental specialists for follow-up screening and coordinated referral (integrated services are ideal—Imprints Cares).

Incorporate literacy promotion into routine care (i.e. Reach Out and Read).


Case 4

A mother is concerned that her 2-year-old daughter is reluctant to separate from her. The girl and her mother arrived in Winston-Salem 2 months ago after fleeing El Salvador.

How may you explain this child’s behavior?


Trauma-Related RED FLAGS

American Academy of Pediatrics. Trauma Toolbox for Primary Care. www.aap.org/traumaguide


Case 5

An 18-year-old refugee girl from Syria presents for her comprehensive medical evaluation. She denies concerns, but review of symptoms reveals difficulty with sleep, appetite, and feeling badly about herself. Upon further questioning, you learn that her family came to the United States as refugees, but her fiancé remained in Syria.

What mental health screening is warranted for immigrant children?


Mental Health Risk and Protective Factors

American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6HR1D; and Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012; 379(9812):266–282.


“The adverse events that necessitated their flight

are often only the beginning of a long period

of turbulence and uncertainty.”

Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012; 379(9812):266–282.


Common Mental Health Problems

Post-traumatic stress disorder

Depression

Anxiety

Conduct disorders

Somatic complaints

American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6HR1D; and Fazel M, Stein A. The mental health of refugee children. Arch Dis Child. 2002;87(5):366–370.


Sample Mental Health Screening Tools

Pediatric Symptom Checklist (PSQ). www.massgeneral.org/psychiatry/services/psc_forms.aspx Refugee Health Screener (RHS-15). refugeehealthta.org/2012/07/31/refugee-health-screener-15-rhs-15-packet

Patient Health Questionnaire (PHQ) Screeners. www.phqscreeners.com/overview.aspx?Screener=02_PHQ-9American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6HR1D


Treatment and Referral Treatment

o Cognitive-behavioral therapy (CBT)o Trauma-informed care (including trauma-focused CBT)o Medications if necessary

Referralo Co-located/integrated behavioral health services o Community-based mental health care o School-based interventions

• Trained mental health professionals • Supportive, caring environment for prevention and treatment

American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6HR1D; and Tyrer RA, Fazel M. School and community-based interventions for refugee and asylum seeking children: a systematic review. PLoS One. 2014;9(2):e89359.


Let’s return to José.


Screen for Social Determinants of Health

American Academy of Pediatrics Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4)e20160339; Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model. Pediatrics. 2009;123(3):858–864; Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child visits: a cluster RCT. Pediatrics.2015;135(2):e296–e304; Kenyon C, Sandel M, Silverstein M, Shakir A, Zuckerman B. Revisiting the social history for child health. Pediatrics. 2007;120(3):e734–e738; Fazalullasha F, Taras J, Morinis J, et al. From office tools to community supports: the need for infrastructure to address the social determinants of health in paediatric practice. Paediatr Child Health. 2014;19(4):195–199; and Sheldrick RC, Perrin EC. Evidence-based milestones for surveillance of cognitive, language, and motor development. Acad Pediatr. 2013;13(6):577–586.


Legal Referrals

No child should ever have to represent himself or herself in immigration court.

o Many places have LIMITED no cost or low cost legal resources for undocumented immigrants.• KIND—Kids in Need of Defense–National network

• American Immigration Lawyers Association (AILA)

• Some firms may help…

American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. Section 3: Immigration Status and Related Concerns. bit.ly/1y6HR1D


Medical Care for Uninsured Immigrants Federally qualified health centers

Health departments

Free clinics

Public hospitals (charity care)

School-based health centers

Foster care

Title X

340b drug pricing: www.hrsa.gov/opa

Vaccines for Children: www.cdc.gov/vaccines/programs/vfc/index.html


National Immigration Law Center. www.nilc.org/issues/health-care/healthcoveragemaps


Opportunities for Practice Change Create a medical home for immigrant children: Provide

comprehensive, coordinated, culturally and linguistically effective care, and continuous health services.

Offer interpreter services for families with limited English proficiency.

Develop protocols for screening newly arrived children.

Offer co-located/integrated services.

Support school readiness and academic success.

Maintain a list of current, relevant community resources and incorporate “warm hand-offs” into your system.

Weave in health literacy initiatives throughout clinical care.

You may need to redesign your systems–consider quality improvement methodology.


Understanding Their Journey


Conclusions When evaluating refugee and other newly arrived immigrant

children, put the unique circumstances of each child and family into context.

Recognize strengths and resilience as assets among immigrant children and families.

Incorporate tools for screening newly arrived children regarding development, mental health, and social determinants of health.

Engage available local and national resources to optimize access and services for immigrant families.

Partner with pediatricians and relevant organizations to advocate on behalf of immigrant children.


Acknowledgements

American Academy of Pediatrics Council on Community Pediatrics Immigrant Health Special Interest Group–join us!

Benard Dreyer, MD, FAAP

Wake Forest Department of Pediatrics

Denver Health and Hospitals


References1. American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. Available at bit.ly/1y6HR1D2. American Academy of Pediatrics Council on Community Pediatrics. Community pediatrics: navigating the intersection of medicine, public health, and social

determinants of children’s health. Pediatrics. 2013;131(3):623–628.3. American Academy of Pediatrics Council on Community Pediatrics. Providing care for immigrant, migrant, and border children. Pediatrics. 2013;131(6):e2028–

e2034.4. American Academy of Pediatrics. Trauma Toolbox for Primary Care. Dowd MD, ed. Available at www.aap.org/traumaguide5. Ages and Stages Questionnaire (ASQ). Available at agesandstages.com 6. Caring for Kids New To Canada. Available at www.kidsnewtocanada.ca7. Centers for Disease Control and Prevention. Guidelines for the US domestic medical examination for newly arriving refugees. Available at

www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html 8. Center on the Developing Child. Harvard University. Available at developingchild.harvard.edu/science/key-concepts/toxic-stress9. Fazalullasha F, Taras J, Morinis J, et al. From office tools to community supports: the need for infrastructure to address the social determinants of health in

paediatric practice. Paediatr Child Health. 2014;19(4):195–199.10. Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet.

2012; 379(9812):266–282. 11. Fazel M, Stein A. The mental health of refugee children. Arch Dis Child. 2002;87(5):366–370. 12. Festa N, Loftus PD, Cullen MR, et al. Disparities in early exposure to book sharing within immigrant families. Pediatrics. 2014;134(1):e162–e168.13. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child visits: a cluster RCT. Pediatrics. 2015;135(2):e296–e304.14. Hearst AA, Molnar AM. Female genital cutting: an evidence-based approach to clinical management for the primary care physician. Mayo Clin Proc.

2013;88(6):618–629.15. Kenyon C, Sandel M, Silverstein M, Shakir A, Zuckerman B. Revisiting the social history for child health. Pediatrics. 2007;120(3):e734–e738. 16. Kids Count Data Center. Available at datacenter.kidscount.org17. Mendoza FS, Festa NK. New American children: supporting the health and well-being of immigrant populations. JAMA Pediatr. 2013;167(1):12–13.18. Migration Policy Institute. Available at www.migrationpolicy.org19. Modified Checklist for Autism in Toddlers (M-CHAT). Available at www.m-chat.org/index.php20. National Child Traumatic Stress Network. Refugee Services Toolkit (RST) Core Stressors Overview. Available at

learn.nctsn.org/mod/book/view.php?id=4518&chapterid=3621. National Immigration Law Center. Available at www.nilc.org22. North Caroline Pediatric Society. Fostering Health NC. Available at www.ncpeds.org/?page=FHNC23. Nour NM. Female genital cutting: a persisting practice. Rev Obstet Gynecol. 2008;1(3):135–139.24. Parents’ Evaluation of Developmental Status (PEDS). Available at www.pedstest.com/default.aspx25. Patient Health Questionnaire (PHQ) Screeners. Pfizer. Available at www.phqscreeners.com/overview.aspx?Screener=02_PHQ-926. Pediatric symptom checklist (PSC). Massachusetts General Hospital. Available at www.massgeneral.org/psychiatry/services/psc_forms.aspx27. Refugee Health Screener (RHS-15). Available at refugeehealthta.org/2012/07/31/refugee-health-screener-15-rhs-15-packet28. Survey of Wellbeing of Young Children (SWYC). Floating Hospital for Children at Tufts Medical Center. Available at www.theswyc.org29. Trehan I, Meinzen-Derr JK, Jamison L, Staat MA. Tuberculosis screening in internationally adopted children: the need for initial and repeat testing. Pediatrics.

2008;122(1):e7–e14.30. Tyrer RA, Fazel M. School and community-based interventions for refugee and asylum seeking children: a systematic review. PLoS One. 2014;9(2):e89359. 31. Birth to 5: Watch Me Thrive! US Department of Health and Human Services. Available at

www.acf.hhs.gov/sites/default/files/ecd/screening_compendium_march2014.pdf


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