Although school-age children may have nightmares, show anxiety, and cling to their parents, they usually transition well to their new homes. Adolescents face the biggest difficulties, especially if they have lost a parent, must care for their siblings, or have experienced sexual trauma. “They may have more vivid memories of disturbing events and a greater understanding of what their family has endured,” Dr. Reines said. Further, language and educational deficits can lead to alienation and embarrassment, yet families may rebuff behavioral health referrals.
“In these cases, it’s best to keep communication open, encourage dialogue with family, and try to find an activity or sport the refugee can participate in to improve self-esteem,” Dr. Reines said.
Avoiding cultural confusion
While cultural challenges are obvious – language barriers may necessitate translators or bicultural caseworkers – others may be more subtle. Developmental screening questions that rely on blocks, certain pictures, or other culturally specific bases, for example, may not adequately capture a child’s development.
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.
At the same time, pediatricians are guarding against inadvertent stereotyping; however, they can be aware of some cultural generalities that may apply to their Syrian refugee patients.
“Arab communities stress the importance of family rather than the individual and are often more modest than Westerners,” Dr. Rushton said. Further, “Arab families frequently experience discrimination on the basis of their religion in the United States, and pediatricians should be aware of ongoing traumatization even after arrival in America,” he said.
Teens may become embarrassed with discussions about sex or alcohol because few teens from the Middle East drink or become sexually active before marriage, Dr. Reines added. She noted that a Muslim male may not shake hands with females outside his family – a practice providers should respect – and that important religious holidays such as Ramadan may influence a family’s compliance with a treatment plan.
Perhaps the most important commonality, however, is one universal to most refugee families, regardless of their home country.
“The vast majority of families that we meet show incredible courage and resilience, and caring for their children is their highest priority,” Dr. Reines said. “We can learn a great deal from these families, and caring for their children is a tremendously rewarding experience.”
Other cultural resources:
Bridging Refugee Youth and Children’s Services
“The Middle of Everywhere: Helping Refugees Enter the American Community,” by Mary Pipher (Orlando: Mariner Books, 2003)
“Immigrant Medicine,” a textbook by Patricia Walker, M.D., and Elizabeth Barnett, M.D. (New York, N.Y.: Elsevier, 2007)
“Opening cultural doors: Providing culturally sensitive healthcare to Arab American and American Muslim patients” (Am J Obstet Gynecol. 2005 Oct;193]:1307-11).
