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Abstract
Objective (1) To describe a novel integrated pathway for unaccompanied asylum-seeking children (UASC).
(2) To evaluate a population engaged with this service.
Design Description of the integrated pathway (objective 1) and retrospective evaluation, using data from community paediatrics, infectious diseases (IDs) screening and a sexual health (SH) service (objective 2).
Setting Unlinked data were collected from three services across three National Health Service (NHS) trusts in London.
Patients All Camden UASC engaged with the service from 01 January 2016 to 30 March 2019.
Interventions A multidisciplinary approach prioritising the health needs of UASC including a childre and adolescent mental health service (CAMHS) clinican and a health improvement practitioner. There are low thresholds for onward referral and universal asymptomatic screening of UASC for ID.
Main outcome measures Data on demographics, unmet health needs and known outcomes.
Results Data were available for 101 UASC, 16% female, median age 16 years (range 14–17). Physical assault/abuse was reported in 67% and 13% disclosed sexual assault/abuse, including 38% of female UASC. Mental health symptoms were documented in 77%. IDs warranting treatment were identified in 41% including latent tuberculosis (25%) and schistosomiasis (13%). Interpreters were required for 97% and initial non-attendance rates at follow-up were 40% (ID) and 49% (SH).
Conclusions These data demonstrate high rates of historical physical and sexual assault/abuse, unmet physical, mental and emotional health needs among UASC and significant barriers to engaging with services. An integrated pathway has been successfully implemented and shown to deliver appropriate, joined-up care for UASC, consistent with current recommendations, with the potential to improve outcomes.
- adolescent health
- child abuse
- health services research
Data availability statement
No data are available. Data were collected by staff members with honorary contracts at the respective trusts. The small numbers and unique characteristics of patients involved mean there is a risk of being able to identify the patients from the raw data. We are therefore unable to share the collected data due to risk of identification.
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What is already known on this topic?
Migration status is a key determinant of health.
Unaccompanied asylum-seeking children (UASC) are a vulnerable population with significant social, educational, mental and physical health needs.
The lack of healthcare data on refugee or asylum-seeking child health is an identified unmet research need, and a rights of the child concern.
What this study adds?
To the best of our knowledge, we present the most comprehensive and largest empirical UK data on UASC health needs.
London UASC have high rates of physical and sexual abuse/assault, and infectious diseases warranting treatment.
An integrated pathway has been successfully implemented in Camden (London) and has been shown to deliver appropriate, joined-up care for UASC, consistent with current recommendations.
Introduction
There were 5000 unaccompanied asylum-seeking children (UASC) in England at the end of March 2020,1 the majority of whom were male (90%) and aged 16 or 17 years (86%).1 UASC have frequently suffered trauma, including rape and torture, in their country of origin or during their journey,2 as well as poverty, deprivation and reduced access to healthcare.3 They represent a vulnerable and diverse population with significant social, educational, mental and physical health needs.4
There is a lack of guidance and education on management of UASC, and no standardised guidance for how their initial health assessments (IHAs) should be carried out.5 The medical staff undertaking assessments, time for appointments, translation facilities, thresholds for onward referrals and multidisciplinary involvement vary.6 Infectious diseases (IDs) and mental health problems are prevalent among UASC,7 8 and management including screening, diagnosis and referral for these conditions is inconsistent. The allocated social worker (SW) bears much of the responsibility for the healthcare plan resulting from the IHA, but often has limited training on UASC needs and a high caseload limiting their available time and input.
There is a lack of empirical data available on UASC, particularly more recent evidence from the UK.9 The lack of healthcare data on refugee or asylum-seeking children has been identified as an unmet research need,10 and a rights-of-the-child concern.11
We aim to describe a novel ‘integrated pathway’ for UASC developed in a London borough, and to present data from a population of UASC engaging with this service over a 3-year period. We aim to describe the baseline and clinical characteristics, and known outcomes of a population of London UASC.
Methods
Description of the integrated pathway
The integrated pathway (see figure 1) for UASC involves a multidisciplinary approach and prioritises three key areas: physical, sexual and emotional health. All UASC are referred for ID screening and signposted (provided with contact details and empowered to initiate contact with the service) to sexual health (SH) services, regardless of clinical presentation or risk factors. There is a low threshold for child and adolescent mental health service (CAMHS) referral, with a clinical psychologist from CAMHS working as part of the team. Mental health symptoms including post-traumatic stress disorder (PTSD), anxiety and depression as well as risk of self-harm and suicide are considered,12 and the Strengths and Difficulties Questionnaire (SDQ)13 is used. Risks including sexual assault or abuse, phsical assault or abuse and female genital mutilation (FGM) are considered. Standardised referrals are made for vision screening, hearing screening, dental care and catch-up immunisations. A looked after child (LAC) health improvement practitioner (HIP) works with the team liaising with UASC and the professionals around them (including the SW) to optimise engagement with medical services and reduce the 'Did not attend' (DNA) rate (i.e. when appointments are missed). Face-to-face interpreters are used whenever possible and appointments are rebooked if necessary to facilitate this.
The integrated pathway for UASC. Original image created by authors. CAMHS, child and adolescent mental health service; IHA, initial health assessment; UASC, unaccompanied asylum-seeking children.
Study population and period
The study period was 1 January 2016 until 30 April 2019. Data were collected retrospectively for all UASC in the borough of Camden seen at three services across three National Health Service (NHS) trusts: community paediatrics where IHAs took place, the ID clinic to which UASC were referred and an SH clinic within the same borough. The data were unlinked (no patient identifiable information was shared between trusts) and therefore there may be small differences in the group described due to time delays between appointments.
Community paediatrics data included IHA reports and any additional available documentation available, including letters and social care records. Access was via an electronic health record system, SystmOne. A data extraction tool used in a previous audit14 was revised to include additional detail, and data were entered into an Excel spreadsheet in anonymised form. ID and SH screening data were collected from clinic letters and entered into an Excel spreadsheet.
Outcomes, demographic and clinical variables
The following demographic data were collected where documented: age, gender, country of origin, use of interpreter and language, type of accommodation, reasons for leaving country of origin, arrival in UK, circumstances of transit (including refugee camps) and contact with family.
The following clinical data were collected where documented: medical history, physical symptoms, mental health symptoms, history of sexual abuse or assault, history of physical abuse or assault, known vaccination history. Clinical variables include weight and height, examination findings include scars and any signs of infection.
Onward referrals were recorded as were attendance rates at scheduled appointments. Data on outcomes were recorded where available such as results of a review health assessment (RHA) if present, results and completeness of ID screening, results and completeness of SH screening and SH education given.
Statistical analysis (calculations of percentages) was performed using Microsoft Excel V.2016.
Results
Data from IHAs were available for 101 UASC; one IHA was completed in absentia. Data were also available from 41 and 69 UASC from the same borough and study period seen at a local SH service and an ID screening service, respectively.
Community paediatrics data
Table 1 shows the demographic characteristics from the IHA data.
Clinical and demographic features reported at IHA
Reasons for migration included fear of persecution (23 of 101, 23%), fearing for their lives following the death of family members (17 of 101, 17%), fleeing forced military service (17 of 101, 17%) and fleeing forced marriage (4 of 101, 4%). It was documented that 43 of 101 (43%) of the young people spent time in a refugee camp, most commonly the so-called ‘Calais jungle’. Where information was available, 63 of 81 (78%) of UASC reported any duration of formal schooling in their country of origin, and 14 of 73 (19%) were currently in contact with their family back home. When the Red Cross tracing service was offered, 5 of 101 (5%) of UASC refused explaining that it would put their family in danger.
Mental and physical health symptoms
Many UASC reported current physical and mental health symptoms at IHA. Common physical symptoms were body or limb pain (28 of 101, 28%), abdominal pain or gastrointestinal symptoms (24 of 101, 24%), headache or dizziness (23 of 101, 23%), chest pain or palpitations (9 of 101, 9%) and symptoms of current or previous scabies infestation (11 of 101, 11%).
Mental health symptoms including symptoms of trauma are recorded where they were documented by the assessing paediatrician. Three-quarters (78 of 101, 77%) of UASC had any mental health symptom documented, mostly commonly sleep problems (50 of 101, 50%), signs of trauma or PTSD (43 of 101, 43%) and deliberate self-harm or suicide attempts (8 of 101, 8%).
Rates of physical and sexual assault and abuse, and examination findings are shown in table 2.
History of assault/abuse and examination findings
CAMHS input was offered to 88 of 101 (87%) of UASC, of whom 20 initially declined, though some later consented to referral. Fifty-two of 101 (51%) of UASC were directly referred to CAMHS, and a further 20 were signposted to services. Referral for ID screening is documented for 93 of 101 (92%) of UASC and 52 of 101 (52%) were referred to SH screening while a further 36 of 101 (36%) were signposted. Nine of 101 (9%) of UASC were referred to specialised services for sexual abuse or assault.
Recorded outcomes
An RHA 1 year after IHA was available for 26 of 101 (26%). Other relevant documentation from social care or other health services was only available from a minority of young people. There were recorded examples of mental health admissions (two cases), substance misuse (three cases), police involvement (three cases), breakdown of placements (three cases) and pregnancies among female UASC (two cases). Commonly cited causes for psychological distress were pending asylum claims (three cases) and the national transfer scheme (eight cases), whereby UASC are moved to different boroughs.
ID screening results
The ID service received 84 referrals for Camden UASC and data are available for 69 appointments (see table 3).
Infectious diseases (IDs) referrals, DNA rates and screening outcome
Only 60% of UASC attended for their initial appointment, but following attempts to optimise engagement, a total of 71 of 84 (85%) of UASC underwent ID screening in the service.
SH screening results
Data were available for 41 UASC who attended a local SH service (table 4), these data comprise scheduled appointments and walk-ins. There were no positive results for chlamydia or gonorrhoea in this cohort. No new diagnoses of blood-borne viruses were made from SH screening (though four cases of hepatitis B were diagnosed in ID clinic).
Sexual health screening outcome
Discussion
Key findings
These UASC demonstrated high rates of physical health problems and mental health symptoms warranting CAMHS referral. Barriers to accessing services and delivering care were demonstrated including inconsistency around names and dates of birth, high DNA rates and requirement for translators. An integrated pathway for UASC has been successfully implemented as a clinical management approach for this complex and vulnerable population.
Strengths and limitations
Data from three different services provide a comprehensive picture of the emotional, physical and SH needs of this population who are not flagged in routinely collected NHS data sets. We demonstrated that the integrated pathway model, in place since 2016, can be successfully implemented in a London local authority. However, the study size was small and limited to a single local area. It was not possible to access data from the NHS trust where the CAMHS service was based, limiting the completeness of this data set. As a retrospective evaluation, there was reliance on comprehensive documentation, and data were incomplete for some demographic and outcome measures. In the absence of comparative data (for example before-and-after or between boroughs), we are unable to prove that integrated pathway improves outcomes.
Findings in context
These comprehensive data from 101 UASC including demographics and health needs are some of the largest contemporary data available on UASC in England. The proportion of female UASC here is higher than the England average (16% vs 10%).1 Otherwise, the age and demographic characteristics are broadly representative of UASC across England.
Our findings are consistent with data on the health of UASC internationally.2–4 15–17 Systematic review evidence on screening of refugee children showed intestinal infections in 31%, latent tuberculosis (TB) 11%, and hepatitis B 3%.18 In comparison, Camden UASC had almost double the rates of latent TB (25%) and hepatitis B (6%), but lower rates of intestinal infection (10%, not including schistosomiasis). A study of UASC in Kent in 2016 reported modelled estimates for IDs based on country of origin19 (latent TB 19%, parasitic infection 28%, hepatitis B 5%), which are similar to the observed rates in Camden.
Kent UASC 2016 data reported 41% of UASC having psychological symptoms,19 substantially lower than the 77% in Camden UASC. Mental health needs in this study were subjectively assessed at the IHA with input from a CAMHS clinician. SDQ screening alone has been criticised for failing to identify the level of mental health need in this group,17 the Camden CAMHS team has recently replaced the SDQ with the RHS-15 Refugee Health Screener.20 Eighty-seven percent of Camden UASC were felt to meet the threshold for CAMHS involvement, a decision made with CAMHS input, suggesting that the close liaison with mental health services is justified.
The rates of reported physical assault/abuse are high in this study and half of young people had scars on examination consistent with these disclosures. The description of torture was used by one in six UASC, but there is an argument that all physical abuse or assault is a form of torture. Considering the known barriers to making a disclosure of sexual abuse/assault,21 the number in this cohort (13% UASC, 38% female UASC) is strikingly high. A further 6% denied personal sexual assault or abuse but described having witnessed or known of this happening to someone else. There is significant vicarious trauma of witnessing assault, but it is also recognised that children who feel unable to disclose their own abuse may describe this happening to another child.22 FGM is acknowledged to be a human rights violation; the horn of Africa, where many of the UASC come from, has some of the highest rates in the world. Documentation of physical evidence of torture or abuse, history of sexual assault/abuse and FGM may all have a significant impact on a young person’s asylum claim. The IHA report should be made available to the young person in all cases, and they may choose to share this with their solicitors.
The barriers to engaging with services, including inconsistent names and dates of birth, and high DNA rates are consistent with other studies.4 16 Face-to-face interpreters were used when possible, however, the interpreters had not received specific training and were not matched for gender of UASC. It is recognised that use of interpreters can be a barrier to UASC communicating their story,23 and that interpreters should be carefully selected if possible.24 Mistrust of health professionals is a significant barrier to understanding UASC health needs16 and UASC may be wary of disclosing information, for example, whether they are in contact with family at home, for fear that this might adversely affect their asylum claim. Many UASC also turn 18 soon after arrival, when they are discharged to primary care. A more flexible and individualised approach to transition to adult services could be very beneficial in this group. Unmet health need in adolescence is associated with poor health outcomes in adult life,25 and long-term outcomes are improved by early intervention and coordination of services. The study data demonstrate that consistent and coordinated attempts to re-engage can address some of these barriers and improve the attendance rate (from 60% to 85%).
Next steps and policy recommendations
Funding has been secured to implement a similar integrated pathway for UASC in a second borough and a prospective evaluation is underway. A qualitative study with UASC is also planned, aiming to explore their perceptions of existing services, what health needs are meaningful to them and the barriers to engaging with services.
An integrated pathway is in keeping with the proposed framework for best practice in management of newly arrived refugee children (comprehensive health screening, coordination of care, integration of physical, psychological and emotional needs, data collection and advocacy26). We demonstrated that the integrated pathway successfully addressed some of the barriers to engaging with services and demonstrates the potential to improve outcomes. Based on these data, this is an appropriate clinical approach for UASC in the UK. Given the high rates of IDs diagnosed (41%), we recommend universal asymptomatic screening of UASC arriving in the UK.
Conclusion
These results demonstrate that UASC are an extremely vulnerable population with identified high rates of IDs, physical abuse/assault including torture, historical sexual abuse/assault and ongoing trafficking concerns. The majority of UASC require mental health support. Significant barriers were identified to engaging with services and initial follow-up attendance rates were low. As many of these young people were close to turning 18, there is a lack of data on longer term outcomes or other follow-up recorded.
An integrated pathway has been successfully implemented and shown to deliver appropriate, joined-up care for UASC, consistent with current recommendations, and further evaluation of the model is planned. If demonstrated to be successful, the integrated pathway for UASC could be adopted more widely and could change outcomes for this vulnerable population.
Data availability statement
No data are available. Data were collected by staff members with honorary contracts at the respective trusts. The small numbers and unique characteristics of patients involved mean there is a risk of being able to identify the patients from the raw data. We are therefore unable to share the collected data due to risk of identification.
Ethics statements
Patient consent for publication
Ethics approval
This service evaluation is exempt from formal ethics review under HRA guidance.
Acknowledgments
The authors would like to thank all of the young people whose data are presented here.
References
Footnotes
Twitter @m_heys
Presented at Material from this article has been presented at the RCPCH online conference 2020 in two oral presentations, as well as several local presentations. Two abstracts have been published in Archives of Disease in Childhood.
Contributors All authors contributed to the article design. AJA carried out the data collection and analyses, with input from JC, MH, PH, AW and SE. All authors contributed to the interpretation of the results. AJA wrote the article. All authors commented on drafts of the article and have approved the final version.
Funding AJA is employed by UCL. Research at the UCL Great Ormond Street Institute of Child Health benefits from funding from the Great Ormond Street Hospital Biomedical Research Centre.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.