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Psychosocial needs of refugee children 'unique'.

When the recent photo of a drowned Syrian toddler woke up the world to the Syrian refugee crisis more viscerally than ever before, multiple nations announced plans to take in more refugees. According to the U.S. State Department, about 10,000 Syrian refugees already are in processing, eventually headed to cities that might include Atlanta; San Diego; Houston; Dallas; Chicago; Boston; Boise, Idaho; Nashville, Tenn.; Tucson, Ariz.; Buffalo, N.Y.; and Erie, Pa.

To physicians, that boy on the beach represents a child who might have ended up in their practice with diverse, complex needs greatly exceeding the typical needs of a U.S. child coming in for a well-child visit.

Families are coming from a country that has been ravaged by civil war for more than 4 years, Dr. Susan S. Reines, a pediatrician with the Southeast Kaiser Permanente Medical Group and lead pediatrician for the Refugee Pediatric Clinic at DeKalb County Board of Health in Decatur, Ga., said in an interview.

"Cities have been destroyed, and millions have been forced to leave their homes and are displaced either within Syria or in neighboring countries."

About one-third of the more than 58,000 refugees admitted to the United States in 2012 were under 18 years old. Although most that year hailed from Bhutan, Burma, and Iraq, an increasing number of children have been coming from wartorn Syria since June 2014. The proposed ceiling for all refugees in the United States 2015 fiscal year is 70,000, a "significant number" of whom will be children with their families, according to a State Department spokesperson.

These children come with "unique medical, developmental and psychosocial needs," noted Dr. Thomas J. Seery and fellow authors of "Caring for Refugee Children," a Pediatrics in Review article recommended by Dr. Reines for physicians who might be caring for refugee children.

"The health care infrastructure of Syria is broken and many hospitals have closed, medications are difficult to obtain, and numerous doctors have fled the violence," Dr. Reines said. She compared the anticipated health care problems of these children with those seen among Iraqi refugee children, and the problems include posttraumatic stress disorder (PTSD); depression; anxiety; neurologic problems, such as intellectual disability and autism; and trauma, such as gunshot wounds, shrapnel injuries, and genital trauma secondary to sexual violence.

Dr. Aradhana Bela Sood said catastropic stress can be experienced by displaced children, particularly those without parents and caretakers.

Generally, there needs to be an awareness of two broad issues, Dr. Sood, professor of psychiatry and pediatrics at Virginia Commonwealth University in Richmond, said in an interview. "Issues related to events that occurred during the period of transition that would be based on extraordinary experiences such as physical, emotional or sexual assault, loss of parents or siblings, and the manner in which the loss occurred" must be considered, Dr. Sood said. Some children are forced into labor or become involved in war efforts as child soldiers.

In addition, psychiatrists must be aware of issues related to the mere act of being "uprooted and replanted into a new culture," said Dr. Sood, also senior professor of child mental health policy at the university. Those issues include "language barriers, rejection by peers as being different, identity dissolution (who am I?), academic lag because of language barriers, too quick of an assimilation (posing problems for the parents who emphasize retaining ethnic culture for home and assimilating into the majority culture in school). This can lead to confusion and irritability in the child."

Dr. Reines stresses a strategy for managing cultural differences that is recommended in Dr. Seery's article: striving for cultural humility rather than cultural competence.

"It is impossible for U.S. physicians who have never practiced outside of our culture and are not bicultural or bilingual to become truly culturally competent in health care delivery for so many refugee populations," Dr. Reines said. Instead then, cultural humility emphasizes showing respect, interest, and a willingness to learn from patients, she explained.

Cultural humility is a "lifelong process" that also demands flexibility and "allows the practitioner to release the false sense of security associated with stereotyping," Dr. Seery and his colleagues wrote.

Generally, younger infants and toddlers are more adaptable as long as their parents are doing well, Dr. Reines said. Adolescents, however, face biggest difficulties.

"They may have more vivid memories of disturbing events and a greater understanding of what their family has endured," Dr. Reines said.

Dr. Sood said recognizing resilience, and helping children and families optimize and enhance their innate abilities are key to helping them adjust to their new lives.

"Clinicians working with refugee families and children must familiarize themselves with local services that help them in accessing these resources," she said.

"Basic needs should be met, otherwise therapy is minimally successful. This type of concrete help is useful, practical, and sets a foundation for good adjustment."


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Author:Haelle, Tara
Publication:Clinical Psychiatry News
Date:Oct 1, 2015
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