Key points:

• Consider functional impairment, behavioural difficulties and developmental progress as well as mental health symptoms when assessing children/adolescents
• Mental health concerns may not come up in the first visits
• Supportive management can commence within general paediatric care, while awaiting specialist mental health input.

Background

Children and young people of refugee-like background are likely to have been exposed to significant adversity, before and after arrival in Australia. Many have experienced past trauma, conflict, and family separation, and they may have additive risks for mental health and developmental concerns through parent mental illness, disrupted family functioning, and interrupted schooling. Consider the timing of trauma exposure(s) in relation to development milestones.

• Children and adolescents experience similar psychological reactions to trauma as adults, however the clinical presentation reflects their age and development.
• Presentations may include behavioural issues, sleep concerns, attention difficulties, enuresis, and developmental/education concerns, as well as symptoms of anxiety, depression and post-traumatic stress disorder (PTSD).
• Unaccompanied and separated minors have specific vulnerabilities and increased risk of experiencing violence (including sexual violence).^1-5 Orphan relative visa holders are a high-risk group, who do not receive the supports available to Humanitarian entrants.
• Parent distress and mental illness influence child mental health.
• Asylum seeker children and adolescents who have experienced immigration detention are at high risk of mental health problems. Australian immigration detention has a negative impact on parenting and family functioning.^6-13 Infants born in detention may have severe attachment issues associated with parent depression.^{7, 9,12,13}
• While pre-arrival trauma is well recognised in refugee populations, settlement is also associated with multiple stressors.^14-16
• Consider cultural aspects to the presentation, and the child/adolescent and family’s perspectives.
• People of refugee-like background face significant barriers to accessing mental health services in Australia.^17-22

Prevalence

Widely variable rates of mental health issues are reported in refugee children/adolescents, although there is more information available on the prevalence of PTSD, depression, and anxiety than other diagnoses. Prevalence is specific to cohorts, conflicts and countries of settlement.^23-25 

Assessment

All ages

Consider the presence of family members (especially with adolescents) and issues specific to working with interpreters. Briefing and debriefing interpreting colleagues (checking in with their experience of trauma disclosures) is especially important for consultations exploring mental health. Define confidentiality, and (separately) define interpreter confidentiality.

The following areas are useful to explore during initial consultations:

• Migration history - countries of origin/transit, reasons for migration, circumstances around the journey
• Migration status - seeking asylum (and stage in the protection process), humanitarian entry
• Family composition - concern for remaining family overseas may be overwhelming, with effects on settlement and wellbeing
• Settlement experience - housing, social connections, resources and supports
• Trauma screening - it is rarely necessary to ask in detail about trauma history, and it is important to consider the potential for triggering a trauma response. Indirect questioning may be useful e.g. 'Sometimes terrible things have happened to people who have been forced to leave their countries. I do not need to know the details, but is there anything that has happened that might be affecting you now?' Where traumatic events are disclosed, consider intensity, proximity, familiarity, chronicity and age/developmental status.²⁶

Mental health issues can present as difficulties with²⁷

• Attachment to parents/caregivers 
• Behaviour, including irritability or aggression 
• Play and peer relationships, including emergent themes in games or drawing, difficulties making friends, engaging in play, or joining group activities 
• Attention or concentration, hyperactive behaviour, learning difficulties 
• Withdrawal or lack of interest in normal activities; retreating into screen-based activities is common 
  
• Avoidance behaviour, including school refusal
• Separation issues, watchfulness, and co-sleeping 
• Sleep-related symptoms, including nightmares, intrusive worries or thoughts, disordered sleep routine and fatigue 
• Enuresis or encopresis 
• Self-esteem 
• Developmental delay, lack of expected developmental progress, worsening of pre-existing developmental concerns or regression
• More overt presentations of anxiety, depression, intrusive thoughts/images, a 'frozen' appearance, mutism, or perceptual abnormalities (e.g. hearing voices)
• Sexualised behaviour, which may indicate that a child or young person has witnessed or been exposed to sexual abuse. Seek advice on child protection concerns and consider reporting requirements 
• Self-harm or suicidality - these presentations are extremely rare in younger children, but require urgent review if present at any age 
• Family function and parenting, including presentations related to family violence.

For younger children: (in addition to above)

• Many of these presentations are general paediatric issues, and working through an issue can empower the child and family
• Sleep management is always a good place to start
• Exploring the impact of migration on parenting is often a useful entry into exploring attachment and risk/resilience factors for the child and family
• Consider use of a screening tool for children such as the Strengths and Difficulties Questionnaire (available in more than 80 languages)

For adolescents

• Current functioning: ask about appetite, energy, daily activities, memory/concentration, sleep and plans for the future as an entry to more specific mental health symptoms 
• Mental health symptoms:  mood, irritability or anger, sadness, hopelessness, guilt/worthlessness, self-esteem, loss of interest in (previously) enjoyable activities, social withdrawal, anxiety symptoms, panic symptoms/attacks, rumination, and intrusive thoughts 
• Risk-taking behaviour
• Self-harm/suicide risk assessment: hopelessness is a stronger predictor of suicidal ideation than diagnosed depression²⁸ and suicidality may present differently in those from diverse backgrounds.^29,30
• Ask about approaches to stress management and coping strategies, and assess internal and external resources
• Adolescents may reflect on past childhood trauma and have a new understanding of events
• HEADSS screening is useful to elicit psychosocial history in adolescents.               
  

Management and referral

• Seek specialist paediatric mental health advice early; referral to torture-trauma counselling may also be appropriate
• Where relevant, consider and screen for treatable conditions that may cause/exacerbate mental health or behavioural problems, including hypothyroidism, vitamin B12 deficiency and iron deficiency. 

General principles of managing children/adolescents experiencing trauma reactions and/or mental health concerns include:

• Making sure children are informed about their own situation - using developmentally appropriate language, and offering them the opportunity to ask questions.
• Addressing mental health issues in the whole family. 
• Supporting primary attachments. 
• Ensuring predictability - through maintaining routine, including school attendance, and preparing for changes; reassuring children about the future. 
• Addressing sleep issues - maintaining a healthy age-appropriate sleep routine and limiting screen time (and addressing screen content/safety).
• Encouraging play in younger children, enjoyable activities or sports in older children/adolescents, and peer connections and experiences of success at all ages.
• Encouraging expression of emotions and asking what children/young people are thinking/feeling.
• Setting realistic goals for behaviour and avoiding overreacting to difficult behaviour during transition periods. 
• Promoting engagement with school and community, and maintenance of first language alongside English language learning.

Many of these strategies can be implemented while waiting for specialist mental health input.

Mental health resources & further information

• Mental health services - refugee or CALD specific
• Mental health services - general
• Mental health services - perinatal and early infancy
• Other resources including translated materials
  

Mental health services – Refugee or CALD specific

• Foundation House (Victorian Foundation for Survivors of Torture, VFST) provides counselling, advocacy, family support, group work, psycho-education, school support, information sessions and complementary therapies for refugee and asylum seeker clients. VFST has offices in Brunswick, Dandenong and Sunshine and an outpost in Ringwood. Services are also provided in a number of rural and regional centres. Interpreters available. Details on  referrals (including translated information),  make a referral, intake 9388 0022. 

• Centre for Multicultural Youth (CMY) undertake a range of programs, projects and policy initiatives to enhance life opportunities for young people from CALD backgrounds. They provide a variety of  Youth Support Programs (interpreters available), including:
  • Reconnect - young people in Australia  <5 years at risk of homelessness in Hume, Brimbank, Greater Dandenong or Casey (see Referral)
    

Mental health services - general

• Child and Adolescent Mental Health Services (CAMHS) see children <18 years. Young people 16-18 years of age may receive services from either CAMHS or youth/adult area mental health services depending on needs/services available. Refugee or asylum seeker children are not currently part of the priority access service response (PASR). Referral occurs through an intake process, and can be initiated by any concerned adult, although parent consent is needed for work to progress. The intake worker will contact the family with an interpreter to triage the referral.
  
  CAMHS see children and adolescents with serious emotional disturbance (e.g. impaired reality testing, hallucinations, depression, suicidal behaviour, hyperactivity, nightmares, fearfulness, bed-wetting, language problems, school refusal and stealing. Services include:
  • Outpatient assessment and ongoing counselling services
    
  • Acute inpatient services: short-term assessment and/or inpatient treatment for children/adolescents who cannot be assessed or treated within the community. Refer via CAMHS
  • Specialised Programs vary by region; e.g.  Children and Schools Early Action (CASEA) program.  
  • Orygen  see young people 15-24y in the West/North-West areas. Multiple programs available, including outreach services; intake through  central triage
  • Travancore school provides education support for children/young people (prep - year 12) engaged with the RCH Mental Health Service.

• RCH Department of Psychology - Referrals to the  Department of Psychology are accepted for children attending regular outpatient appointments with complex developmental, cognitive, academic, language, behavioural or social-emotional difficulties, who require specialised assessment, e.g.
  • Children who present a diagnostic dilemma after appropriate primary and secondary level assessment
  • When an understanding of cognitive/emotional state is critical to plan medical treatment or manage ongoing treatment
  • Where early intervention is required to prevent psychological disorders.

• Referrals to Neuropsychology are accepted for children who have:
  • An identified or suspected neurological disorder (e.g. epilepsy)
  • An acquired brain injury (e.g. head injury, cerebral infection, anoxia)
  • An illness that may affect brain function (e.g. diabetes, leukaemia, heart disease)
  • A need for a rehabilitation program.
  Referrals can be made by letter or by completing a  referral form (for either Psychology or Neuropsychology). Interpreters are available.
  
  
• Other RCH mental health services 
  • The  Academic Child Psychiatry Unit  provides a comprehensive assessment, key assessment clinics are also available for medical conditions with a psychiatric component, and for disruptive behaviour disorder, anxiety disorders, depressive disorders and autism spectrum disorder. This service also includes the  Developmental Neuropsychiatry Program (DNP)  
  • Infant mental health - RCH has an active infant mental health program, although there is no service website - phone 1800 445 511
  • The RCH Psychiatry Clinic is available for RCH patients <18 years with co-morbid mental and physical health problems, including those who may not meet entry criteria for public mental health services. Phone 9345 6180 and fax 9345 5034. 

• Private psychologists and relevant directories  - private psychologists may provide bulk-billed or low cost services.
  • Australian Psychological Society Find a Psychologist (search by language available, also includes search for ASD services)
  • Australian Clinical Psychologist Association directory (search by language available)
  • VTMH directory of bilingual providers (includes links to GPs, psychiatrists, pharmacists, psychologists)

• Better Access Scheme  provides up to 10 individual or group, therapy services per calendar year, which are partially  funded via Medicare. Out-of-pocket expenses vary; many clinicians charge around $180, the Medicare rebate is $123.50 for a clinical psychologist or $84.80 for a general psychologist. Interpreters are usually not available. Requirements include:
  • Referral to psychologist by a GP with a Mental Health Care Plan, or a specialist psychiatrist (after billing items 104-109), consultant physician psychiatrist (after billing items 293-370), specialist paediatrician (after billing items 104-109) or consultant physician paediatrician (after billing item numbers 110-132).
  • The psychologist must have a Medicare Provider Number. See register, then filter by Medicare status.

• Primary Health Networks (PHN) Mental health service pathways - PHN manage approximately 10% of federal expenditure in mental health, 60% of PHN mental health care funding is a flexible funding pool. Following the National Mental Health Commission’s recommendations PHNs around Australia have developed Mental Health Care Models which replace previous schemes  (e.g. ATAPS – Access to Allied Psychological Services).
  • Find your PHN
  • North-Western Melbourne PHN - NWMPHN -  Targeted Psychological Support (TPS) service is part of the CAREinMIND programs (this site includes referral forms)
  • Eastern Melbourne PHN - EMPHN - see good summary of recent changes to mental health services, and Mental Health Stepped Care Model - no age restrictions and clinicians experienced in working with children available, not session or time limited, and interpreters available. Youth Mental Health and Alcohol and other Drugs (AoD) also available.  (great work EMPHN!)
  • South Eastern Melbourne PHN - SEMPHN - has two primary mental health services and a central mental health intake:
    • SEMPHN access and referral - support for people with severe or complex mental illness - central phone and fax line (including GP priority line), that links people with primary mental health services, including referrals into the API and MHICC services below
    • Accessible psychological interventions (API)  - for 12yrs and older - eligibility criteria – people who live or work in SEMPHN catchment, have Health care card or can’t afford or access similar services, and have an assessment and diagnosis of mild-moderate mental illness such as mild depression or anxiety. Priority groups include age <12y, CALD background, experience of family violence and risk of suicide. 
    • Mental health integrated complex care (MHICC)
      

• University psychology clinics - patients are seen by senior Psychology trainees, under the supervision of clinical psychologists. Costs vary, largely based on family income (from $10-$60 per session, with different costs for psychological assessments/testing); clinics do not have access to interpreters.
  • Latrobe University, Bundoora, also has a Child Behaviour Clinic. 
  • Monash University, Clayton also has neuropsychology
  • RMIT, Melbourne  
  • Victoria University, Footscray . 
  • Australian Catholic University, Fitzroy . 
  • Swinburne Psychology Clinic, Hawthorn . 

• Frontyard Youth Services is a multidisciplinary service for young people <25 years who spend time in the Melbourne CBD and who are homeless or at risk of homelessness. Specific counselling services are (appointments needed):
  • Melbourne Gateway Reconnect (12-21 years if refugee background and in Australia <5 years, homeless/at risk homelessness, Mon-Fri 9am-5pm)
  • Young Person's Health Service (12-24 years, homeless/at risk homelessness, Mon-Fri 11:30am-5pm)
    
  • Young Women's Crisis Service (12-24 years, if homeless/at risk of homelessness, north-west Melbourne, young parents, and young women who are pregnant, focus is on housing)

• Forensic mental health services - in summary - are very difficult to access. Community Forensic Youth Mental Health Services (CFYMHS) are based at Orygen Youth Health, and provide secondary consultation and support to CAMHS/CYMHS case managers (other providers are not able to refer to this service, and they do not see patients directly. 
  
  
• Orygen Specialist Program (Orygen Youth Health) - provides mental health services for young people aged 15-25 years in the west and north western regions. 
  • How to refer and clinical services
  • Ask for the Refugee Access Program (workers only available Mon, Wed, Thurs (and not clear from OYH website). 
    
    
• Headspace  is a youth-friendly health service for age 12-25 years, operating a bulk-billing Medicare service with clinicians including GPs, psychiatrists, psychologists, occupational therapists, drug and alcohol workers and counsellors. No referral needed; medical clinicians within Headspace should be able to access TIS interpreting, allied health clinicians may not be able to access interpreting. Centres are located throughout Australia (link to postcode search).   

• Community health centres - The following centres provide counselling for CALD clients. Interpreters are available.
  • CoHealth Footscray
  • IPC Health: multiple sites - Deer Park, St Albans, Sunshine, Altona Meadows, Hoppers Crossing, Wyndham Vale. 
  • Your Community Health sites: East Reservoir, Northcote, Preston (PANCH). Priority groups include refugees and asylum seekers. 
  • DPV Health (child and youth psychology) sites: Broadmeadows, Craigieburn
  • Barwon Health CAMHS
  • Goulburn Valley Community Health

Mental health services - perinatal

• Information resources: 
  • Beyondblue has published a guide for primary care health professionals on perinatal mental health of women from CALD backgrounds. The Beyondblue resources page also has a number of information resources for health professionals, women and their families.

• Telephone counseling and helplines: 
  • PANDA (Perinatal Anxiety & Depression Australia). Run a national helpline (telephone counseling service): 1300 726 306 (Mon-Fri, 10am-5pm AEST). Patients can call directly, or can be referred. Interpreters available – leave a message with your phone number and the language you need.
  • Maternal and Child Health Line. Ph: 13 22 29. Interpreters available. A 24-hour telephone service staffed by maternal and child health nurses for families of children aged from birth to school age. 
  • Beyondblue helpline. Ph: 1300 22 46 36. Interpreters available through TIS national –  call 131 450, state the language you require, and you can ask to contact Beyondblue. 
    
    
• Clinical services: 
  • Perinatal Emotional Health Programs (PEHPs) provide mental health support for families during pregnancy and up to 12 months after birth. Located at: 
    • South West Healthcare. Ph: 03 5564 6010. Accepts self-referrals. 
    • Latrobe Regional Hospital. Ph: 1300 363 322 (mental health triage service). Accepts self-referrals.
    • Goulburn Valley Health. Ph: 03 5823 6000. Accepts self-referrals. 
    • Albury-Wodonga Base Hospital. Ph: 02 6051 7950. 
  • Mother baby units offer specialist residential support for parents with a mental illness (e.g. psychosis, bipolar disorder, severe depression, complex personality disorders) in the postnatal period (usually up to 12 months post-birth). Located at: 
    • Austin Health (Parent Infant Inpatient Program). 
    • Monash Medical Centre(Mother & Baby Unit).
    • Werribee Mercy Hospital (Mother Baby Unit).
    • Latrobe Regional Hospital (Agnes Parent and Infant Unit).
    • Ballarat Health Service (Mother and Family Unit).
  • Other parent-infant mental health services
    • PIMHI (Parent Infant Mental Health Initiative) at Austin Health supports parents with major mental illness with an infant <12 months - for families in NE Melbourne.
    • PIRI (Parent Infant Research Institute) at Austin Health provides outpatient perinatal services for mothers with infants <2 years, including group programs such as Baby HUGS.
    • Centre for Women’s Mental Health at RWH provides services for women who have delivered at RWH. The team includes psychiatrists, psychologists and psychiatric registrars.
      
  • Early parenting centres offer a range of different services addressing infant care, including sleep/settling, and assisting parents to develop skills. Both QEC and Teddle also do PASDA assessments (formal assessment of parental skills organised via DHHS or Children's Court). 
    • TweddleChild and Family Health Service (Footscray). Ph: 03 9689 1577.
    • O’Connell Family Centre (Cantebury). Ph: 03 8416 7600.
    • Queen Elizabeth Centre (Noble Park). Ph: 03 9549 2777, also see referral form. 

Other resources

• Schools - are a central point of contact for refugee children and young people. All schools will have a designated person who is a point of contact for student welfare. VFST may be able to provide individual counselling in the school setting, and support and professional development for schools. Many schools have homework support clubs, which can be useful for this population. Schools may provide counselling, and they are mandated to provide educational assessment.  
  
• Helplines - Kidshelpline, Lifeline.
  
• Your Health in Mind (RANZCP) has a number of useful resources, including fact sheets and a directory of psychiatrists.
  
• Victorian Transcultural Mental Health  (VTMH) is a state-wide unit supporting mental health and psychiatric disability support services in working CALD consumers and carers. VTMH does not work directly with clients, but has a role in service, policy, community development, research and education. A  directory of bilingual mental health professionals is available, and the site also includes links to  translated mental health information. 
  
• Mental health in Multicultural Australia (MHMA)  provides a wide variety of resources, including  translated fact sheets and assessment tools.   
  
• Australian Child & Adolescent Trauma, Loss & Grief Network through Australian National University (ANU) provides evidence-based resources and research on trauma/loss/grief for providers working with children and young people and families. Resources include a  fact sheet about refugee and asylum seeker children experiencing trauma and working with young people of CALD background.
  
• Victorian Refugee Health Network  
  • Mental Health Resources web links.
  • Mental Health Services.

• Translated mental health information
  • MHMA  translated fact sheets and  assessment tools.
  • NSW Transcultural Mental Health Centre - includes some  specific resources for children and  consumer medication brochures.
  • Royal College of Psychiatrists translated fact sheets on a range of mental health issues, in Arabic, Farsi, Tamil, Pashto, Somali and Urdu (and others).
    
  • Easidose can be used to provide picture based prescribing for any medications.
    
    

References

See References

_{Immigrant health clinic resources. Authors Karen Kiang, Rachel Heenan and Georgie Paxton. Last revision June 2020. Contact georgia.paxton@rch.org.au}