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Abstract
Objective Protracted international conflict has seen escalating numbers of displaced and resettled Syrian and Iraqi refugees, raising concerns for their health and well-being. This paper describes the demographic and clinical profiles of recently resettled Syrian and Iraqi refugee children and adolescents across physical, psychosocial, developmental and educational domains using standardised multidisciplinary assessments.
Design A cross-sectional observational study was undertaken of initial specialist paediatric multidisciplinary Refugee Health Service assessments completed at the tertiary paediatric hospital (Western Australia) between June 2015 and September 2019.
Results Three hundred and twenty-seven children and adolescents (264 Syrian, 63 Iraqi) were assessed following resettlement. Witnessed trauma (86%) and disclosed adversity (median Refugee Adverse Childhood Experiences score 3, range 1–14) were universally high. Almost all patients had health issues identified across physical (99%), psychosocial (76%) and developmental/educational (75%) domains. Interrupted education (65%) and death of a family member (16%) were significantly associated with psychological morbidities. Common comorbidities included dental caries (78%), non-infectious disease (76%), vitamin D deficiency (72%), malnutrition (46%; overweight/obesity 23%), and psychological (32%; post-traumatic stress disorder 4.3%) and developmental (9.5%) concerns. Emerging and alarming child protection concerns were prevalent (17%), with females demonstrating especially high risks.
Conclusion This is the largest comprehensive study demonstrating the complex and cross-dimensional health needs and specific vulnerabilities of resettled Syrian and Iraqi refugee children and adolescents. Early comprehensive standardised multidisciplinary paediatric assessments, and culturally safe, trauma-informed interventions and follow-up are required to optimise resettlement outcomes and promote well-being.
- paediatrics
- adolescent health
- global health
- child development
- child protective services
Data availability statement
Data may be obtained from a third party and are not publicly available. These data are not in a repository (eg, deidentified hospital data) within the Child and Adolescent Health Service (CAHS), Perth, Western Australia.
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What is already known on this topic?
Syrian and Iraqi refugee children and adolescents represent the largest cohort of displaced children globally.
Access to healthcare, education and other basic needs prior to displacement and during transit has been severely limited.
Lived and vicarious trauma is universal with high rates of psychological sequelae.
What this study adds?
Resettled Syrian and Iraqi refugee children and adolescents demonstrate multiple complex health concerns across physical, psychosocial and developmental/educational domains.
Syrian and Iraqi refugees experienced substantial adversity including interrupted schooling and family deaths, which significantly correlated with early and complex psychological morbidities.
Chronic paediatric disease; malnutrition; psychological, developmental and child protection concerns were frequently unrecognised, reinforcing benefits of comprehensive standardised paediatric multidisciplinary assessments postsettlement, looking beyond infection.
Introduction
Syrian and Iraqi refugees have protracted lived experience of war involving the disregard for international humanitarian law.1 Many refugees transit via Turkey, Lebanon and Jordan where access to healthcare, food and education remains limited.2 Child marriage and labour are also reported.3 4 In 2015, in response to the Syrian crisis, the Australian government increased humanitarian resettlement quotas with escalating referrals to the Refugee Health Service (RHS) in Western Australia (WA).5
The RHS is a paediatric multidisciplinary team that manages the complex care needs of recently resettled refugee and asylum-seeker children and adolescents.6 Anecdotally, compared with earlier cohorts,6 Syrian and Iraqi refugee children and adolescents appeared more traumatised at presentation, with unaddressed and complex health concerns. This paper describes the comprehensive health profile of recently resettled WA Syrian and Iraqi refugee children and adolescents across physical, psychosocial, developmental and educational domains.
Methods
A retrospective study of the initial standardised multidisciplinary RHS assessments was undertaken. Humanitarian entrants aged up to 17 years and of Syrian and/or Iraqi backgrounds assessed at the RHS between June 2015 and September 2019 were included. Refugees who fled Syria or Iraq prior to 2011, those assessed after 1 year of Australian resettlement and asylum seekers were excluded.
Standardised assessments were performed by RHS staff (medical, nursing, social work, dental, education, clinical psychology and dietetic) using professional interpreters. Demographics, transit details, medical history, physical examination findings, screening investigations, diagnoses and management were captured, with practice aligned to national guidelines and previously identified clinical requirements.6–11 Refugee Adverse Childhood Experience (R-ACE) scores were calculated based on patient/parental disclosures at first review.12 13 The Australian Bureau of Statistics Index of Relative Socio-economic Advantage and Disadvantage deciles (2016) were calculated from resettlement postcodes.14
Data were entered into SPSS Statistics V.25 (SPSS). Fisher and Mann-Whitney tests were used for family characteristics analyses across subgroups; a generalised estimation equation framework incorporating robust SEs was used for analyses of patient-specific characteristics.
Results
Demographics
Overall, 327 children and adolescents (264 Syrian; 63 Iraqi) comprising 106 families (78 Syrian; 28 Iraqi; no unaccompanied minors) were analysed (table 1). The median age was 8.0 years (range 0–17 years); 43% were female and 17% were born in transit. Arabic was the primary language; all families demonstrated limited English proficiency. The median time between resettlement and initial RHS visit was 4 months (IQR 3–5 months); 27 patients presented to the paediatric hospital earlier (11 emergency department presentations).
Syrian and Iraqi family demographics
The majority of Syrian families transited via Lebanon (62%) and Jordan (28%), and Iraqi families via Jordan (50%) and Turkey (43%) (p<0.0001). Transit residence was predominantly urban; 18% of Syrian families lived in camps with no camp exposure reported by Iraqi families (p=0.02).
Nearly one-third of Syrian and one-fifth of Iraqi mothers were married under the age of 18 years. Most Syrian parents had no formal or primary education only, contrasting with a significant proportion of tertiary educated Iraqi parents (fathers p<0.01; mothers p<0.0001). Three-quarters of families were resettled in areas of highest relative national socioeconomic disadvantage.14
Refugee Adverse Childhood Experiences
R-ACE scores ranged from 1 to 14, with a median of 3 (figure 1). Scores varied across country of transit (p=0.001), irrespective of country of origin. Lower R-ACE scores were observed in children who transited via Jordan (mean (SD) Lebanon 3.9 (2.3), Jordan 2.7 (1.2), Turkey 4.2 (2.1)).
Distribution of Refugee Adverse Childhood Experience (R-ACE) scores for Syrian and Iraqi children and adolescents. This figure is original and produced with the permission of the authors.
Nearly all patients had direct war trauma exposure (85% Syrian, 90.5% Iraqi) (table 2). Interrupted education (67% Syrian, 55% Iraqi), death of a nuclear family member (17% Syrian, 9.5% Iraqi), parental mental illness (14% Syrian, 19% Iraqi) and family separation were frequently disclosed. Rates of previous and current family separation were lower if transit was via Jordan (p=0.008 and p=0.01, respectively). Domestic violence, child abuse and parental separation were also identified. Prolonged transit (>5 years) was reported for 14% of Syrian families but no Iraqi families (p=0.04).
Syrian and Iraqi patient Refugee Adverse Childhood Experiences (R-ACE) disclosed at first Refugee Health Service assessment, comparison by country of origin and transit
Systemic review
Table 3 summarises health diagnoses analysed by country of origin and transit country. Almost all patients had physical diagnoses (99%) with nutritional, chronic and other non-infectious morbidities more common than infections. Reported physical (51.4%) and psychological (28.7%) symptoms were common (figure 2). Significant differences were noted with respect to frequency of vitamin D deficiency, psychological diagnosis and R-ACE scores >3 between transit countries; and R-ACE scores >3 between country of origin. Saliently, almost two-thirds (63%) had concerns across all three domains (figure 3). Unmanaged dental caries burden was also high in non-infants (>75%).
Proportions of Syrian and Iraqi patients who disclosed physical and psychological symptoms on history. This figure is original and produced with the permission of the authors.
Frequencies and overlap of Syrian and Iraqi patients with health concerns within physical, psychosocial and developmental/educational domains. This figure is original and produced with the permission of the authors.
Syrian and Iraqi patient health concerns after initial Refugee Health Service assessment by physical, psychosocial and developmental/educational domains, comparison by country of origin and transit*
One-third of children and adolescents had an unrecognised psychological diagnosis; 4.3% fulfilled post-traumatic stress disorder (PTSD) criteria, 17% presented with partial features. Almost one in five patients had child protection concerns identified; females at much greater risk (females 32%, males 5%; OR 16.02, 95% CI 4.1 to 62; p<0.0001). This included history of child labour, disclosed risk of under-age marriage or females with personal or maternal history of early child marriage. Nearly 10% had a developmental disorder and almost 5% had a physical disability requiring assistance with activities of daily living.
Formal psychological diagnosis following RHS assessment was significantly associated with a greater number of problems on initial referral (OR 1.3, 95% CI 1.0 to 1.5; p=0.04) and higher R-ACE score (OR 1.3, 95% CI 1.1 to 1.5; p=0.004) for all children. Interrupted schooling (OR 2.47, 95% CI 1.2 to 5.3; p=0.02), nuclear family member death in conflict (OR 5.92, 95% CI 1.1 to 32; p=0.04) and previous family separation (OR 2.27, 95% CI 1.0 to 5.0; p=0.04) were significant and independent risk factors among school-age children. Multiple psychological symptoms were strongly associated with years of interrupted schooling (independent of age and gender), but not years in transit nor overall R-ACE score (table 4).
Frequency of school-age Syrian and Iraqi patients with psychological symptoms and association with years of interrupted schooling, years in transit and R-ACE score (n=223)
The median number of problems that referrers identified was 2 (range 0–5). New health concerns identified after initial RHS assessment (median 4, range 0–9) frequently included multiple diagnoses within a single captured concern. While the RHS is multidisciplinary in nature, almost all (90.2%) required at least one onward referral (median referrals 2; highest 11). Small numbers required emergency department transfer (1.2%) and inpatient admission (1.5%) due to acuity.
Discussion
To our knowledge, this is the largest study comprehensively examining the health of resettled Syrian and Iraqi refugee children and adolescents in a high-income country. Our data demonstrated that almost 90% of patients had issues across physical, psychosocial, educational and developmental domains. This complexity was not fully recognised prior to RHS first review and reinforces the need for a holistic approach beyond screening for infection and public health concerns. Broader resettlement concerns included identification of chronic illness, high psychological burden, complex trauma and adversity, interrupted education, developmental delay and child protection concerns.
Infectious disease rates were low, contrasting with previously described cohorts.6 15 Sparse resettlement literature has demonstrated similar findings,16–18 including Heenan et al, an Australian study.19 Regardless, future outbreaks are concerning, particularly in the current COVID-19 pandemic.20 Our nutritional and chronic disease findings support small published reports.21–23 The dental caries burden was consistent with international literature describing poor access to dental treatment, fluorinated water, malnutrition and food insecurity.24 25 This is also influenced by postsettlement factors such as access to dental services, particularly for preschool children, and lower prioritisation of dental care among resettlement needs.26
Overnutrition was common, with only a small proportion being underweight/stunted consistent with previous WA nutritional analyses.9 Large cross-sectional studies of Syrian refugee children aged 6–59 months in host countries have demonstrated low prevalence of wasting (<5%) and stunting (<20%) and high prevalence of overnutrition (10.6%),27 28 according to WHO thresholds. Our rates of overnutrition are similar to the general population in Australia,29 but the risk factors preceded the short time since resettlement. We found no correlates with increased body mass index, though transit food insecurity was common. Evidence from other populations demonstrates association between adverse experiences and overnutrition.30
Our data highlight concerning psychological burden in early resettlement. Transit times were short and disproportionate to early cohorts,6 but burden was similar to asylum seekers who experienced held detention.31 Estimated lifetime prevalence of PTSD in refugee children resettled in western countries is 11%,32 and mental illness in war-exposed children around 47%.33 Heenan et al reported lower rates of witnessed trauma and psychological diagnosis, but higher rates of parental mental health concerns.19 International literature reports variable rates of anxiety and PTSD, but studies from neighbouring countries (Turkey, Lebanon and Jordan) consistently report rates of PTSD or other psychological diagnosis between 30% and 65%,34–41 reinforcing our findings. This variability likely reflects differences in patient age, education, origin, transit histories and clinician/team screening practices.
While the relationship between adverse events, war and mental illness is clear,35 37 42 the natural history, contributory risk and protective factors remain inconsistently reported. A limited systematic review found no strong evidence of longer term improvement in PTSD without intervention.43 Positive school experience has been demonstrated to be protective against psychological diagnosis.37 42 Previous WA research demonstrated improvements in Strengths and Difficulties Questionnaire responses over time in school-age refugee children, reinforcing education as a therapeutic tool.12 We demonstrated significantly increased risk of psychological diagnosis in patients who had experienced interrupted schooling, family member death in conflict, previous family separation and transit via Turkey. Other Syrian paediatric studies also suggest parental death is associated with increased risk of PTSD.36 38 Lack of education, poverty and resettlement in Lebanon (compared with Jordan) are possible risk factors for psychological diagnosis.36–38 41
Adversity, witnessed trauma and interrupted schooling were higher than in other refugee cohorts.11 12 The longitudinal risk of poorer health and social outcomes increases with each adversity score.13 Iraqi and Syrian children and adolescents who have survived and escaped war have experienced atrocities, loss of freedom and safety. Historically, Syrian children had almost universal school attendance and access to quality healthcare.34 44 Breakdown of basic infrastructure, education and healthcare systems due to ongoing conflict, and purposeful targeting of schools, and healthcare services have led to a major decline in the health status of the population and direct violence to children including chemical weapons.45–47
We demonstrated a strong and independent association between interrupted schooling and psychological symptoms. This reinforces the need for interdisciplinary support and strength of the RHS model of care. RHS parents routinely provide consent for the liaison teacher to support education engagement after resettlement.11 The RHS clinical psychologist is embedded up front, assisting in the formalisation of psychological diagnoses, lessening the stigma and providing mental health education. Earlier engagement with mental health, supported by education, community nursing, social work and medical staff, thus supported Syrian and Iraqi families from point of first RHS assessments and subsequent transition to mainstream services.
Additional child protection vulnerabilities were identified in almost one-fifth of patients, with increased risks evident in female adolescents. It is suspected that under-reporting has affected this figure due to family/community pressures, safety fears or fear of legal consequences of disclosure, particularly under-age marriage and mandatory reporting.48 Increased rates of child marriage among Syrian refugees have complex causality which is influenced by poverty, lack of education, safety and family honour concerns.3 49 Increased clinician awareness has led to a change in RHS screening practices and greater identification. Child labour was also reported and has known risks, including child sexual assault and other abuse, interrupted schooling and health consequences.4 These issues were all reported in this cohort, necessitating formal child protection engagement and reinforcing the value of embedded social work support.
During refugee transit, medical care, education and social services are constrained.50 51 The main priority is acute illness with limited capacity to detect and provide support for chronic illness, mental health or preventative care such as child development and nutrition.52 The developmental consequences of the Syrian and Iraqi war remain unknown. We identified developmental issues (9.5%) and physical disability (4.9%) on first presentation, which were slightly higher than previous cohorts studied.11 Only two other studies of Syrian and Iraqi refugee children identified developmental/behavioural/learning issues and reported higher rates (around 25%).19 53 Developmental concerns may be masked, or not evident to families during early resettlement stages due to alternative priorities, health literacy and language barriers. Increased educational and developmental concerns emerge over time. Many patients had missed critical intervention or preventative health input until engaged with the RHS.
This study has many strengths, including the large cohort, which accounted for almost all Syrian and Iraqi refugee children and were representative of national humanitarian entrants. The comprehensive and multidisciplinary nature of the resettlement assessments enabled broad health concerns to be identified and addressed. RHS assessments are based on Australasian refugee health guidelines, and international best practice, and adapted over time to reflect emerging knowledge and findings.10–12 The psychological burden has directly influenced the modification of assessment proformas to include the child trauma screening questionnaire.54 Additionally, identifying early child marriage trends and risks has informed the state interagency guidelines and knowledge.48
The true extent of the impact of war and mental health sequelae is likely underestimated as assessments are parental/patient disclosures at first assessment, and is a limitation. We know cumulative disclosures occur with the establishment of trust and rapport, but these data are not captured in this study. Cultural stigma related to mental illness also contributes to under-reporting.46 There were no unaccompanied children, which is not reflective of the broader Syrian and Iraqi displaced population. Older adolescents were also not represented due to the age cut-off of the health service. Not all Syrian and Iraqi refugee children in WA were seen in the early resettlement stage, and subsequent referral of patients has resulted in untreated and emerging problems.
Clinical practice recommendations
Recognition of individual complexity involving adversity, trauma and non-infectious morbidities is critical for the holistic management of Syrian and Iraqi refugee children and adolescents and identifying especially high-risk patients. Targeted multidisciplinary and trauma-informed intervention and follow-up for this growing population is required to optimise resettlement outcomes. This includes nutritional, psychological, neurodevelopmental and educational surveillance. Multisector cooperation and policy to address culturally appropriate and safe schooling in transit and on resettlement is time critical, as well as prevention, detection and early intervention for children at risk, particularly early and/or forced marriage of females. Importantly, the evolving humanitarian crisis in Afghanistan reinforces the need for national alignment as similar vulnerabilities exist in other international refugee cohorts. Longitudinal studies including pooled national and international data are needed to examine the trajectory of initial health problems identified, cumulative psychological burden and the impact of intervention and follow-up.
Conclusion
The health and well-being of Syrian and Iraqi refugee children and adolescents is of global significance with resettled populations experiencing cumulative childhood adversity and complex health concerns. The use of routine standardised comprehensive assessments in our service enables identification and capture of broad morbidity beyond infection and nutrition-focused screening. Furthermore, engagement of a multidisciplinary team in early resettlement has enabled timely management and culturally appropriate intervention of these complex health concerns as well as identification of emerging trends.
Data availability statement
Data may be obtained from a third party and are not publicly available. These data are not in a repository (eg, deidentified hospital data) within the Child and Adolescent Health Service (CAHS), Perth, Western Australia.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was granted through Child and Adolescent Health Service Ethics Committee, WA (1255/EP; RGS2338).
Acknowledgments
We would like to acknowledge our RHS patients and families. We also wish to thank our interpreters, volunteers and wider members of the RHS team, who have contributed to delivering clinical service and care over many years.
References
Footnotes
Twitter @kristenjlindsay
Contributors KL conceptualised and designed the study, collected data, conducted statistical analyses and interpretation, assisted with design and production of figures and tables, drafted the initial manuscript, and reviewed and revised the manuscript. SC aided in conceptualisation and study design, supervised the data collection, analyses and interpretation, and critically reviewed and revised the manuscript and is overall responsible for the content. GH and RM contributed to data acquisition and interpretation, and reviewed and revised the manuscript. EM undertook the statistical analyses and assisted with interpretation, preparation of tables and creation of figures, and revised the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.