Providing Evidence-Based Medical Care to Immigrant Children

Transcription

1 Providing Evidence-Based Medical Care to Immigrant Children Janine Young, MD, FAAP Associate Professor of Pediatrics University of Colorado School of Medicine Julie M. Linton, MD, FAAP Assistant Professor of Pediatrics Wake Forest School of Medicine Chair, AAP Immigrant Health Special Interest Group

2 Disclaimer Statements and opinions expressed are those of the presenters and not necessarily those of the American Academy of Pediatrics. The presenters have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this presentation. The presenters do not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation. Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenters have complete and independent control over the planning and content of the presentation, and are not receiving any compensation from Mead Johnson for this presentation. The presenters comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.

3 Objectives Review pertinent background regarding care of immigrant children, including changing demographics, the impact of diverse legal statuses on the provision of healthcare, and the current refugee resettlement program. Review recommendations regarding comprehensive medical evaluation of newly arriving immigrant children and consider common scenarios regarding history, physical examination, laboratory evaluation, development, mental health, and social determinants of health. Identify strategies to integrate care of immigrant children into a family-centered medical home.

4 Who Are Children in Immigrant Families?

5 Background: Demographics Children in immigrant families will represent 1/3 of US children over the next 40 years. * Kids Count Data Center. datacenter.kidscount.org *Mendoza FS, Festa NK. New American children: supporting the health and well-being of immigrant populations. JAMA Pediatr. 2013;167(1):12 13.

6 US Arrival of Refugees by State, FY US Department of State.

7 Unaccompanied Children and Family Units Migration Policy Institute.

8 Key Clinical Domains 1. Medical screening 2. Developmental screening 3. Mental health and trauma 4. Social determinants of health Health literacy: Families must enter and navigate the system to address these domains.

9 Case 1 Adera is a 14-year-old girl who is seeing you for a refugee screening exam one month after arriving in the United States. She is from rural Somalia but has lived in Hagadera, a refugee camp in Kenya, for the past 6 years.

10 Story Maps. storymaps.esri.com/stories/2013/refugee-camps/?wt.mc_id= campaignh15201

11 Case 2 José is a 30-month-old Guatemalan boy who comes to your office with his mother because he has had diarrhea for one week. He looks small for his age, is well-hydrated, and his mother tells you (when asked) that they arrived in the United States 6 months ago. She reveals that her family paid a coyote $6,000 to traffic her and her child to your city.

12 Case 1 Adera

13 Centers for Disease Control and Prevention. Refugee Health Profiles.

14 Panel Physician Overseas Exam Tuberculin skin tests (TSTs) or interferon-gamma release assays (IGRAs) 2 14 years Chest X-ray only if >15 years History of: o Syphilis (venereal disease research laboratory [VDRL] test if >15 years) o Gonorrhea o Chancroid o Hansen s disease o Substance use o Mental illness o HIV testing no longer required and not done Past medical history checklist Physical exam Minimal vaccines given

15 Treat with confidence. Trusted answers from the American Academy of Pediatrics. Overseas Treatment

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17 Case 2 José

18 American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6hr1d; and Centers for Disease Control and Prevention. Guidelines for the US domestic medical examination for newly arriving refugees.

19 Photo credit: Stacene Maroushek Photo credit: Bill Stauffer, MD American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6hr1d; and Centers for Disease Control and Prevention. Guidelines for the US domestic medical examination for newly arriving refugees.

20

21 Hearst AA, Molnar AM. Female genital cutting: an evidence-based approach to clinical management for the primary care physician. Mayo Clin Proc. 2013;88(6):

22 Reproduced with permission from UW Medicine/Harborview Medical Center for Sexual Assault & Traumatic Stress.

23 Female Genital Mutilation/Cutting Complications Infection, bleeding, sepsis, death immediate complications Recurrent urinary tract infections/pyelonephritis Cysts Keloids Abscesses Hematocolpos/dysmenorrhea Dysfunctional voiding Dyspareunia Complications during/post childbirth increased C-section rate, post-partum hemorrhage, increased infant resuscitation rates Infertility?HIV, hepatitis B, C? World Health Organization Department of Reproductive Health and Research. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. 2016:1 7; and Nour NM. Female genital cutting: a persisting practice. Rev Obstet Gynecol. 2008;1(3):

24 Tiered Approach to Laboratory Screening American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6hr1d; and Centers for Disease Control and Prevention. Guidelines for the US domestic medical examination for newly arriving refugees.

25 American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6hr1d

26 If No Pre-treatment Exists

27 Opportunities for Practice Change Screen shot from the electronic medical record, Wake Forest Baptist Health.

28 Case 3 A 4-year-old Burmese boy, born in a Thai refugee camp, arrives in your clinic as a new patient. His parents report that others have difficulty understanding what he says, and that he does not speak as well as the other children in the refugee camp. What developmental screening evaluation is appropriate for refugee children?

29 What is Recommended for ALL Children? Developmental surveillance at all well child care visits with screening at selective intervals or in response to concerns noted with surveillance Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118(1):

30 Sample Screening Tools Parents Evaluation of Developmental Status (PEDS). Ages and Stages Questionnaire (ASQ). agesandstages.com Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F). Survey of Wellbeing of Young Children (SWYC). Birth to 5: Watch Me Thrive!

31 Opportunities for Practice Change Screen universally bilingualism does not cause language delay. Conduct developmental assessments in the child s primary language. Enlist assistance of interpreters or patient navigators to complete forms. Engage developmental specialists for follow-up screening and coordinated referral (integrated services are ideal Imprints Cares). Incorporate literacy promotion into routine care (i.e. Reach Out and Read).

32 Case 4 A mother is concerned that her 2-year-old daughter is reluctant to separate from her. The girl and her mother arrived in Winston-Salem 2 months ago after fleeing El Salvador. How may you explain this child s behavior?

33 Trauma-Related RED FLAGS American Academy of Pediatrics. Trauma Toolbox for Primary Care.

34 Case 5 An 18-year-old refugee girl from Syria presents for her comprehensive medical evaluation. She denies concerns, but review of symptoms reveals difficulty with sleep, appetite, and feeling badly about herself. Upon further questioning, you learn that her family came to the United States as refugees, but her fiancé remained in Syria. What mental health screening is warranted for immigrant children?

35 Mental Health Risk and Protective Factors American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6hr1d; and Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012; 379(9812):

36 The adverse events that necessitated their flight are often only the beginning of a long period of turbulence and uncertainty. Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in highincome countries: risk and protective factors. Lancet. 2012; 379(9812):

37 Common Mental Health Problems Post-traumatic stress disorder Depression Anxiety Conduct disorders Somatic complaints American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6hr1d; and Fazel M, Stein A. The mental health of refugee children. Arch Dis Child. 2002;87(5):

38 Sample Mental Health Screening Tools Pediatric Symptom Checklist (PSQ). Refugee Health Screener (RHS-15). refugeehealthta.org/2012/07/31/refugee-health-screener-15-rhs-15-packet Patient Health Questionnaire (PHQ) Screeners. American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6hr1d

39 Treatment and Referral Treatment o Cognitive-behavioral therapy (CBT) o Trauma-informed care (including trauma-focused CBT) o Medications if necessary Referral o Co-located/integrated behavioral health services o Community-based mental health care o School-based interventions Trained mental health professionals Supportive, caring environment for prevention and treatment American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. bit.ly/1y6hr1d; and Tyrer RA, Fazel M. School and community-based interventions for refugee and asylum seeking children: a systematic review. PLoS One. 2014;9(2):e89359.

40 Let s return to José.

41 Screen for Social Determinants of Health American Academy of Pediatrics Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4)e ; Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model. Pediatrics. 2009;123(3): ; Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child visits: a cluster RCT. Pediatrics. 2015;135(2):e296 e304; Kenyon C, Sandel M, Silverstein M, Shakir A, Zuckerman B. Revisiting the social history for child health. Pediatrics. 2007;120(3):e734 e738; Fazalullasha F, Taras J, Morinis J, et al. From office tools to community supports: the need for infrastructure to address the social determinants of health in paediatric practice. Paediatr Child Health. 2014;19(4): ; and Sheldrick RC, Perrin EC. Evidence-based milestones for surveillance of cognitive, language, and motor development. Acad Pediatr. 2013;13(6):

42 Legal Referrals No child should ever have to represent himself or herself in immigration court. o Many places have LIMITED no cost or low cost legal resources for undocumented immigrants. KIND Kids in Need of Defense National network American Immigration Lawyers Association (AILA) Some firms may help American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. Section 3: Immigration Status and Related Concerns. bit.ly/1y6hr1d

43 Medical Care for Uninsured Immigrants Federally qualified health centers Health departments Free clinics Public hospitals (charity care) School-based health centers Foster care Title X 340b drug pricing: Vaccines for Children:

44 National Immigration Law Center.

45 Opportunities for Practice Change Create a medical home for immigrant children: Provide comprehensive, coordinated, culturally and linguistically effective care, and continuous health services. Offer interpreter services for families with limited English proficiency. Develop protocols for screening newly arrived children. Offer co-located/integrated services. Support school readiness and academic success. Maintain a list of current, relevant community resources and incorporate warm hand-offs into your system. Weave in health literacy initiatives throughout clinical care. You may need to redesign your systems consider quality improvement methodology.

46 Treat with confidence. Trusted answers from the American Academy of Pediatrics. Understanding Their Journey

47 Conclusions When evaluating refugee and other newly arrived immigrant children, put the unique circumstances of each child and family into context. Recognize strengths and resilience as assets among immigrant children and families. Incorporate tools for screening newly arrived children regarding development, mental health, and social determinants of health. Engage available local and national resources to optimize access and services for immigrant families. Partner with pediatricians and relevant organizations to advocate on behalf of immigrant children.

48 Acknowledgements American Academy of Pediatrics Council on Community Pediatrics Immigrant Health Special Interest Group join us! Benard Dreyer, MD, FAAP Wake Forest Department of Pediatrics Denver Health and Hospitals

49 References 1. American Academy of Pediatrics Council on Community Pediatrics. Immigrant Child Health Toolkit. Available at bit.ly/1y6hr1d 2. American Academy of Pediatrics Council on Community Pediatrics. Community pediatrics: navigating the intersection of medicine, public health, and social determinants Treat with of children s confidence. health. Trusted Pediatrics. answers 2013;131(3): from the American Academy of Pediatrics. 3. American Academy of Pediatrics Council on Community Pediatrics. Providing care for immigrant, migrant, and border children. Pediatrics. 2013;131(6):e2028 e American Academy of Pediatrics. Trauma Toolbox for Primary Care. Dowd MD, ed. Available at 5. Ages and Stages Questionnaire (ASQ). Available at agesandstages.com 6. Caring for Kids New To Canada. Available at 7. Centers for Disease Control and Prevention. Guidelines for the US domestic medical examination for newly arriving refugees. Available at 8. Center on the Developing Child. Harvard University. Available at developingchild.harvard.edu/science/key-concepts/toxic-stress 9. Fazalullasha F, Taras J, Morinis J, et al. From office tools to community supports: the need for infrastructure to address the social determinants of health in paediatric practice. Paediatr Child Health. 2014;19(4): Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012; 379(9812): Fazel M, Stein A. The mental health of refugee children. Arch Dis Child. 2002;87(5): Festa N, Loftus PD, Cullen MR, et al. Disparities in early exposure to book sharing within immigrant families. Pediatrics. 2014;134(1):e162 e Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child visits: a cluster RCT. Pediatrics. 2015;135(2):e296 e Hearst AA, Molnar AM. Female genital cutting: an evidence-based approach to clinical management for the primary care physician. Mayo Clin Proc. 2013;88(6): Kenyon C, Sandel M, Silverstein M, Shakir A, Zuckerman B. Revisiting the social history for child health. Pediatrics. 2007;120(3):e734 e Kids Count Data Center. Available at datacenter.kidscount.org 17. Mendoza FS, Festa NK. New American children: supporting the health and well-being of immigrant populations. JAMA Pediatr. 2013;167(1): Migration Policy Institute. Available at Modified Checklist for Autism in Toddlers (M-CHAT). Available at National Child Traumatic Stress Network. Refugee Services Toolkit (RST) Core Stressors Overview. Available at learn.nctsn.org/mod/book/view.php?id=4518&chapterid= National Immigration Law Center. Available at North Caroline Pediatric Society. Fostering Health NC. Available at Nour NM. Female genital cutting: a persisting practice. Rev Obstet Gynecol. 2008;1(3): Parents Evaluation of Developmental Status (PEDS). Available at Patient Health Questionnaire (PHQ) Screeners. Pfizer. Available at Pediatric symptom checklist (PSC). Massachusetts General Hospital. Available at Refugee Health Screener (RHS-15). Available at refugeehealthta.org/2012/07/31/refugee-health-screener-15-rhs-15-packet 28. Survey of Wellbeing of Young Children (SWYC). Floating Hospital for Children at Tufts Medical Center. Available at Trehan I, Meinzen-Derr JK, Jamison L, Staat MA. Tuberculosis screening in internationally adopted children: the need for initial and repeat testing. Pediatrics. 2008;122(1):e7 e Tyrer RA, Fazel M. School and community-based interventions for refugee and asylum seeking children: a systematic review. PLoS One. 2014;9(2):e Birth to 5: Watch Me Thrive! US Department of Health and Human Services. Available at

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