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, approximately 10,000 Syrian refugees are already in processing, eventually headed to cities that may include Atlanta, San Diego, Houston, Dallas, Chicago, Boston, Boise, Nashville, Tucson, Buffalo, and Erie.
To pediatricians, 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.
Rachel Unkovic/International Rescue Committee/CC BY 2.0
Some of the 12,000 Iraqi Yazidi refugees that have arrived at Newroz camp in Al-Hassakah province, Northeastern Syria, after fleeing Islamic State militants.
“Families are coming from a country that has been ravaged by civil war for over 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, Georgia, 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 a third of the more than 58,000 refugees admitted to the United States in 2012 were under 18 years old. Although the majority that year hailed from Bhutan, Burma, and Iraq, an increasing number of children have been coming from war-torn 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 pediatricians who may 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:
• Undernutrition and micronutrient deficiencies.
• Infectious diseases such as vaccine-preventable diseases like measles, but also typhoid, tuberculosis, and parasitic infections.
• Dental disease.
• Surgically amenable congenital anomalies such as congenital heart disease, myelomeningocele, and others that have not been repaired.
• Neurologic problems, such as cerebral palsy, intellectual disability, and autism.
• Hearing loss.
• Posttraumatic stress disorder (PTSD),depression, and anxiety.
• Trauma such as gunshot wounds, shrapnel injuries, and genital trauma secondary to sexual violence.
• Sequelae from illnesses that previously were easily treated, such as hearing loss and ear complications from otitis media, and rheumatic fever from inadequately treated strep throat.
• Underimmunization.
Various resources listed below, including Dr. Seery’s paper, can help guide providers in assessing and meeting these needs, and navigating paperwork and the U.S. refugee system. These resources also can help practitioners address the mental health concerns these patients and their families may face.
Mental health needs
Even children in the best physical shape will have experienced significant upheaval that could lead to depression, anxiety, and PTSD – conditions more common among refugee children than in the general population, research has shown.
“Mental health conditions will be especially present in these children uprooted from their homes and families, and exposed to the violence of war,” Dr. Francis E. Rushton Jr. of the department of pediatrics at the University of South Carolina, Columbia, and a member of the American Academy of Pediatrics Committee on Community Health Services, said in an interview. Of the four major areas of health care need he described for these children, two relate to mental health: toxic mental stress and fractured families and the lack of nurture.
One challenge pediatricians face, however, is recognizing these conditions despite cultural differences that could obscure them.
“It is not uncommon for teens and adults to deny symptoms of depression, stress, and anxiety in early encounters,” Dr. Reines said. “Many cultures stigmatize psychiatric or mental health problems, and refugees may be reluctant to admit they are having difficulties.”
One way around this obstacle is to ask patients and their parents about sleep, energy level, appetite, weight changes, and thoughts of harming one’s self, she said. Mental stress also manifests as somatic symptoms, such as headaches, stomach aches, and back pain, particularly in teens.
“Infants and toddlers are generally most adaptable as long as parents are coping well, and can provide a buffer for stress with a safe and nurturing environment,” Dr. Reines said. Children of parents with depression or PTSD, or who have lost a parent, may feel abandoned and experience depression or developmental delays.
