Learning Problems in Children of Refugee Background: A Systematic Review

Adaptative Skills and Global Functioning of Unaccompanied Migrant Minors in Europe: A Systematised Review

Objectives

This systematised review aimed to examine European literature reporting data about adaptative skills and global external functioning of unaccompanied minors (UAMs).

Methods

We conducted a systematised screening of four databases (APA PsycINFO Ovid, Medline Ovid ALL, Embase.com and Web Of Science Core Collection) using a research strategy including social, scholarly and behavioural abilities as well as externalising problems associated with the target population of UAMs. Thirty articles were included using pre-defined inclusion and exclusion criteria.

Results

Our review showed that despite high levels of internalising disorders, socio-behavioural and educational adjustment of UAMs remained positive. It demonstrated how this population displays a strong desire for academic success and prosocial behaviours instead of aggressivity in everyday life. Nevertheless, our review drew attention to the strong tendency of UAMs to internalise their disorders and display chronic distress and problematic behaviours which increased with time spent in the host country.

Conclusion

Our study draws attention to the risk of underestimating the real mental health needs of refugees, due to preserved external functioning combined with significant settlement pressures.

Resilience and Positive Wellbeing Experienced by 5-12-Year-Old Children with Refugee Backgrounds in Australia: The Childhood Resilience Study

Refugee research tends to be deficit based and focused on the risks threatening positive adaptation and wellbeing. High rates of mental (and physical) health issues have been reported for refugee adults and children, including intergenerational trauma. This study uses the new Child Resilience Questionnaire (CRQ), co-designed with refugee background communities, to describe resilience and positive wellbeing experienced by children of refugee-background. The Childhood Resilience Study (CRS) recruited 1132 families with children aged 5-12 years in Victoria and South Australia, Australia. This included the recruitment of 109 families from 4 refugee background communities: Assyrian Chaldean (Iraq, Syria), Hazara (Afghanistan), Karen (Burma, Thailand) and Sierra Leonean families. CRQ-parent/caregiver report (CRQ-P/C) scores were categorised into 'low', 'moderate' and 'high'. The child's emotional and behavioural wellbeing was assessed with the Strengths and Difficulties Questionnaire, with positive wellbeing defined as <17 on the total difficulties score. Tobit regression models adjusted for a child's age. The CRQ-P/C scores were not different for boys and girls of refugee background. Children of refugee-background (n = 109) had higher average CRQ-P/C scores than other CRS children (n = 1023) in the personal, school and community domains, but were lower in the family domain. Most children with 'high' resilience scores had positive wellbeing for both children of refugee-background (94.6%) and other CRS children (96.5%). Contrary to common stereotypes, children of refugee-background show specific individual, family, school and cultural strengths that can help them navigate cumulative and complex risks to sustain or develop their positive wellbeing. A better understanding as to how to build strengths at personal, family, peer, school and community levels where children are vulnerable is an important next step. Working in close collaboration with refugee communities, schools, policy makers and key service providers will ensure the optimal translation of these findings into sustainable practice and impactful public policy.

Cognitive, social, and mental health functions of refugee children - screening and supportive actions at school: a study protocol

BACKGROUND

Despite a world-leading educational system, an achievement gap in educational outcomes exists between children of refugee background and native-born peers in Finland. To offer targeted support for children at schools, we need to be able to reliably assess and understand the interplay of the aspects of children's cognitive, social, and mental health functions that may explain the underachievement of refugee children. This study tests a novel research-based, universally applicable screening battery for evaluating cognitive, social, and mental health functioning of children at schools and planning supportive actions. It aims to answer research questions about a) the cognitive, social, and mental health functioning of refugee children compared with non-refugee immigrant and native-born children, b) the interplay of these different functions among refugee and other children, c) whether implementing a screening battery can inform schools in planning supportive actions for (refugee) children, and d) whether such supportive actions result in improvements in cognitive, social, and mental health functioning.

METHODS

Four hundred fifty children aged 10-12 will be recruited from primary schools, including 150 children of refugee background, 150 of non-refugee immigrant background, and 150 native-born Finnish children. A screening battery including tasks and questionnaires on different aspects of cognitive, social, and mental health functioning will be used to assess the children in their classrooms at the start and end of a school year. Supporting information will also be collected from parents and teachers. The information gathered will be collated into class-level feedback reports for teachers and, with parental permission, individualized reports for multiprofessional student welfare bodies, for informing supportive actions. Correlational and latent profile analyses, ANOVAs, and linear regression will be used to answer the research questions.

DISCUSSION

This study will help clarify how the interplay of cognitive, social, and mental health factors may explain underachievement at school among refugee children. It will provide evidence about the extent to which a standardized screening battery could be helpful in informing and planning supportive actions for children at schools, and whether such supportive actions can lead to positive cognitive, social, or mental health outcomes.

TRIAL REGISTRATION

The study will be preregistered on the Open Science Framework.

Upholding the Human Rights and Well-Being of Refugee Children Through Effective Clinical Care

Refugee children are often exposed to adversities and traumatic experiences that can harm the mental health and well-being of refugee children. These include human trafficking and exploitation and dangers in detention centers and refugee camps. All these adverse events can be traumatic and contribute to poor mental health, including posttraumatic stress, anxiety, depression, and substance use disorders. Therefore, the assessment of refugee children and adolescents should include screening and identification for these experiences, provision of evidence-based trauma treatment, and social supports to promote their well-being and thriving.

Exploring the determinants of successful implementation of a preventive mental health and wellness intervention for Afghan refugee families: a qualitative analysis

Many refugee children experience trauma in early childhood. Effective, tailored interventions are needed to improve refugee children's access to preventive mental health. We interviewed refugee-serving stakeholders and parents participating in an evidence-based preventive mental health and wellness intervention adapted for Afghan refugee children and families who may have experienced trauma. Interview guide development was informed by two implementation science frameworks: the Consolidated Framework for Implementation Research and the Model for Adaptation Design and Impact. A three-person team coded transcripts via rapid qualitative analysis, and the study team reached consensus on themes. Six refugee-serving facilitators and five refugee parents discussed key determinants of successful implementation. Themes included: (i) modeling cultural humility to promote communication about emotions; (ii) needed linguistic support and referral networks to avoid miscommunications and missed communications; (iii) bridging connections between children, families and schools; (iv) different takeaways, or differing goals and expectations between facilitators and participants; and (v) timely, specific cultural considerations to overcome participation barriers. Overall, we found key determinants of successful implementation of a preventive mental health and wellness intervention for refugee children and families included adaptations to enhance cultural humility and sensitivity to cultural context while strengthening communication among facilitators, children and families.

Young children's development after forced displacement: a systematic review

OBJECTIVES

To examine the impact of displacement experiences on 0- to 6-year-old children's social-emotional and cognitive development, as well as influencing factors on reported outcomes.

STUDY DESIGN

We systematically searched MEDline, Psyndex, Cochrane Library, Web of Science, Elsevier, TandF, Oxford Journal of Refugee Studies, Journal of Immigrant & Refugee Studies, and Canada's Journal on Refugees for existing literature regarding social-emotional and cognitive outcomes in children directly exposed to forced displacement due to political violence. Results were synthesized in the discussion and displayed using harvest plots.

RESULTS

Our search generated 9,791 articles of which 32 were selected for review and evaluation according to NICE criteria. Included studies provided results for 6,878 forcibly displaced children. Measured outcomes were diverse and included areas such as peer relations, prosocial behavior, family functioning, play, intelligence, learning performance, and language development. Repeated exposure to adverse experiences, separation from parents, parental distress, as well as duration and quality of resettlement in the host country were reported as influencing factors in the reviewed studies.

CONCLUSION

As protective factors like secure and stable living conditions help to promote children's development, we call for policies that enhance participation in the welcoming society for refugee families. Early integration with low-threshold access to health and educational facilities can help to mitigate the wide-ranging negative consequences of forced displacement on young children's development.

Changing landscape of paediatric refugee health in South Western Sydney, Australia: a retrospective observational study

OBJECTIVES

To examine the changing health needs of refugee children and young people (CYP) entering Australia, in relation to key government policy changes.

STUDY DESIGN

Retrospective analysis of health service use data over 11 years.

SETTING

Paediatric refugee clinics in South Western Sydney (SWS), the Australian region with the largest annual resettlement of refugees.

PARTICIPANTS

Refugee CYP (≤25 years) attending the SWS paediatric refugee clinics for their first visit between 2009 and 2019.

MEASURES

Clinician defined health conditions categorised as communicable and non-communicable disease (NCD).

RESULTS

Data were analysed for 359 CYP, mean age 9.3 years; 212 male (59.1%). Most CYP (n=331, 92.2%) had health problems identified; 292 (81.3%) had ≥1 NCD and 24 (6.7%) had ≥1 communicable disease. The most frequent individual NCDs were dental disease (n=128, 35.7%) and vitamin D deficiency (n=72, 20.1%). Trend analysis showed increased odds of identifying an NCD from 2013 onwards (crude OR 1.77, 95% CI 1.06 to 2.96). Neurodevelopmental problems, especially Global Developmental Delay (n=31, 8.6%), emerged as more prevalent issues in the latter half of the decade. There were significantly increased odds of identifying a neurodevelopmental problem in 2016-2019, especially in 2016-2017 (adjusted OR 2.93, 95% CI 1.34 to 6.40). Key policy changes during this period included acceptance of refugees with disabilities from 2012, additional Australian Humanitarian Programme intake from the Eastern Mediterranean region and mandatory offshore processing for those seeking asylum by boat from 2013. In response to the changing needs, local health services adopted nurse-led primary healthcare screening, early childhood services, youth and disability clinics.

CONCLUSIONS

Refugee CYP in Australia are presenting with a growing burden of NCDs, with neurodevelopmental problems contributing. Government policy changes affect the sociodemographics of resettled populations, influencing health profiles. Paediatric refugee health services need to be responsive to the changing needs of these populations to optimise well-being.

Exploring Mental Health and Development in Refugee Children Through Systematic Play Assessment

To evaluate a standardized play observation as a measure of young children's mental health and development in a clinical and refugee population. We conducted individual play observations with 70 refugee children aged 3- to 6-years and compared them to a clinical group of 111 age-matched children regarding their level of play development, social interaction during play, traumatic re-enactments, and emotionless-cold play. Additionally, we assessed children's mental health, social-emotional development and markers of adversity by parent and educator report as well as their IQ-test scores and learning performance and related these factors to the play variables. Play variables were significantly correlated with IQ-test scores (r = 0.184, p = 0.037), learning performance (r = 0.208, p = 0.010) and vocabulary (r = 0.208, p = 0.021) in the comparison group and with social-emotional development in educator report (r = 0.368, p = 0.011), time spent in Germany (r = 0.342, p < 0.001) and parental distress (r = - 0.292, p = 0.034) in the refugee group. Children with more parent-reported adverse experiences showed less social-interactive play in the overall sample (r = - 0.178, p = 0.011). Our child-centered approach to standardized play observation augments information obtained from parent and educator reports and can provide valuable insights in subgroups where other commonly used tests are not available or applicable.

Barriers and facilitators to education access for marginalised non-citizen children in Malaysia: A qualitative study

In Malaysia, marginalised non-citizen children are excluded from formal education at public schools. Recognising education as a fundamental human right, the barriers and facilitators to educational access among refugee and asylum-seeker, migrant, stateless and undocumented children in Malaysia were explored. Qualitative data were collected via 32 in-depth interviews with multiple stakeholders. Data were thematically analysed and organised at three socio-ecological levels. At the 'legislative and policy' level, the requirement of citizenship documents only allows some stateless children to access public schools. Yet, many informal learning centres are not state-endorsed, as they are unable to fulfil licensing criteria. Importantly, denying the right to work for adult refugees and other undocumented people demotivates the pursuit of education among children. At the 'individual and family' level, financial constraints constitute a major reason for school dropouts, especially through expectations on boys to work. Cultural norms partly contribute to the lower enrolment of Rohingya refugee girls in secondary education, but gender parity is maintained for most in primary education. Another factor is proximity to learning centres, which links to safety concerns and transportation costs. Those who accessed public schools reported bullying by local children, which parallels institutional discrimination against marginalised non-citizens. At the 'community and educational institutions' level, inadequate funding for learning centres limits their ability to invest in physical facilities, teachers' salaries and others. Despite difficult operating conditions, learning centres address diverse school readiness, educational backgrounds, and language competencies among students by having sensitised teachers, placement tests and preparatory classes at school entry, and options for vocational training. We propose the gradual inclusion of all children in public schools and the immediate state recognition and support of learning centres. Correspondingly, realising the 'Right to Work' for refugees and stateless peoples will be synergistic in advancing universal education access for all children.

Offshore detention: cross-sectional analysis of the health of children and young people seeking asylum in Australia

OBJECTIVE

To describe the health and well-being of children and young people (CYP) seeking asylum subjected to Australia's immigration policy of indefinite mandatory detention on Nauru.

DESIGN

Cross-sectional analysis of a cohort of CYP seeking asylum.

SETTING

Australian paediatric clinicians from 10 health services completed detailed health assessments around the time of transfer from Nauru, mostly to Australia.

PARTICIPANTS

Sixty-two CYP who were ≤18 years on entry into offshore immigration detention on Nauru between 2013 and 2019. Mean age at health assessment was 9 years.

MAIN MEASURES

Health outcomes were categorised as physical, mental or neurodevelopmental concerns/conditions. Risk and protective factor data were collected using the adverse childhood experiences and refugee-specific adverse childhood experiences tools.

RESULTS

Over half of the CYP (n=32, 52%) were held on Nauru for ≥4 years. The vast majority of CYP had physical health (n=55, 89%) and mental health (n=49, 79%) concerns including self-harm or suicidal ideation/attempt (n=28, 45%). Mental health concerns were more likely in CYP who were school-aged (p=0.001), had been held on Nauru for ≥1 year (p=0.01); originated from the Eastern Mediterranean region (p<0.05); witnessed trauma (p<0.05) or had exposure to ≥4 refugee-specific adverse childhood experiences (p<0.05). Neurodevelopmental concerns were seen in eight children (13%).

CONCLUSIONS

This study highlights the almost universal physical and mental health difficulties in a sample of CYP who experienced forced migration and were subjected to Australia's offshore immigration detention policy. Immigration detention in recipient countries, a known adverse childhood experience, may contribute to or exacerbate harmful outcomes in CYP seeking asylum.

Maternal age at childbirth and the risk of attention-deficit/hyperactivity disorder and learning disability in offspring

Background

Studies have shown that young maternal age at childbirth can increase the risk of attention-deficit/hyperactivity disorder (ADHD) in offspring, but a study of the U.S. population has not been reported. Moreover, there is no reported research on young and advanced maternal age at childbirth and whether it can contribute to the risk of learning disability (LD) in offspring.

Methods

This study evaluated the association between young and advanced maternal age at childbirth and offspring risk of ADHD and LD in the U.S. population. Using data from 8,098 participants included in the National Health and Nutrition Examination Survey (NHANES) conducted in 1999-2004, we analyzed the association between maternal age at childbirth and ADHD and LD risk in offspring. Odds ratios (ORs) and 95% confidence intervals (CIs) for maternal age at childbirth in association with ADHD and LD risk in offspring were estimated using multivariate logistic regression models after adjustment for age, sex, race, body mass index (BMI), poverty income ratio, smoking status during pregnancy, and NHANES cycle. Restricted cubic spline (RCS) models were used to evaluate potential non-linear relationships. Sensitivity analyses were performed to ensure the reliability of the results.

Results

Among all participants, the offspring of subjects with a maternal age at childbirth of 18-24 years had an increased risk of ADHD (OR = 1.34, 95% CI: 1.01, 1.79) and LD (OR = 1.36, 95% CI: 1.06, 1.79) or either ADHD or LD (OR = 1.48, 95% CI: 1.20, 1.81). Additionally, compared with subjects with a maternal age at childbirth of 25-29 years, subjects with a maternal age at childbirth of 35-39 years had lower odds of having offspring with ADHD (OR = 0.60, 95% CI: 0.36, 1.00) and higher odds of having offspring with LD (OR = 1.34, 95% CI: 1.01, 1.78). The relationship between maternal age at childbirth and LD risk presented a U-shaped curve.

Conclusions

These results provide epidemiological evidence showing that young and advanced maternal age at childbirth are associated with ADHD and LD risk.

Mental health and adaptation among newcomer immigrant youth in United States educational settings

Schools play a vital role in the acculturation process of newly migrated youth. Social and academic factors within school settings predict a wide variety of adaptation outcomes. Age and grade also impact the ways that school experiences can shape the post-migration adjustment trajectories of migrant youth. Negative school experiences can exacerbate migration trauma, whereas positive school experiences play an important protective role in overcoming migration-related challenges and adjusting to a new cultural context. Emerging research also suggests that the school environment presents a valuable opportunity for service delivery, as students are readily accessible during the school day which reduces systemic barriers to engagement. Socio-emotional prevention and intervention can address migration trauma, foster resiliency, and help lead the way to acculturative and academic success. Teachers, counselors, coaches and mentors who engage with newcomer immigrant youth in schools can play a pivotal role in easing migration-related challenges by encouraging positive emotional attachments, linking to resources, and helping to navigate new systems. These professionals benefit from specialized training on the unique needs and best practices for supporting the learning, engagement, development, and adaptation of newcomer youth.

Migrant-Background Student Experiences of Facing and Overcoming Difficulties in Finnish Comprehensive Schools

This article considers what students with a migrant background in Finnish comprehensive schools report as difficult, and how they succeed in overcoming these difficulties. We draw on two sets of school wellbeing and learning surveys for migrant students, conducted in 2016 and 2021 in comprehensive schools (grades 1–9) in and around two major cities in Finland. We pay attention to student answers to three questions: What is difficult in school? How do you succeed in difficult tasks in school? and Who helps you in school? The datasets from the two points in time are compared to see whether changes in school demographic situation and the student length of stay in Finland had an impact on student experiences. Our findings show that theory-based school subjects that depend strongly on language, such as science subjects, maths, Finnish, Swedish and English, are considered difficult. Additionally, interaction with peers, which also relies on language, causes challenges. The students report turning to teachers, other professionals and peers for assistance and support, and also mention personal strategies they have developed to overcome school-related difficulties. Understanding what migrant students find difficult, as well as how, and with the help of whom, they overcome such difficulties is crucial for the development of effective and sensitive pedagogical practices.

The feasibility of implementing autism intervention methods in formal education settings welcoming refugee and asylum-seeking children: A systematic review of the literature

Given the significant amount of time that refugee and asylum-seeking children (RASC) spend in schools, these institutions play an important role in their lives and represent an ideal environment in which to help them to adapt to their host society. The present study aimed to draw attention to the possibility of transferring intervention methods designed for children with ASD to formal education settings welcoming newly arrived RASC to support their adaptation to their new school environment. For this purpose, a systematic review was undertaken to assess the feasibility of implementing three specific ASD intervention methods (i.e., TEACCH, PECS, and PMI) in schools welcoming RASC. While the review did not reveal previous attempts to implement and evaluate ASD intervention methods with newcomer RASC, 21 records were uncovered providing preliminary evidence in support of this idea. Hypothesized strengths and limitations, as well as considerations about implementation, are discussed.

Undiagnosed Phenylketonuria Can Exist Everywhere: Results From an International Survey

Many countries do not have a newborn screening (NBS) program, and immigrants from such countries are at risk for late diagnosis of phenylketonuria (PKU). In this international survey, 52 of 259 patients (20%) with late diagnosed PKU were immigrants, and 145 of the 259 (55%) were born before NBS or in a location without NBS.

Effects of COVID-19 on integration of women refugees into Turkish society

The objective of this research is to determine how the COVID-19 pandemic influenced integration of women refugees into Turkish society. The study was designed as a qualitative study between March 2020 and June 2020. The notion of integration is redefined as an eight-dimensional model composed of education, sociocultural, health, economy, legal, shelter, family and security. Semi-structured interviews were conducted by telephone, with 50 women refugees in Turkey, about the impact of COVID-19 on integration. The results of the research indicate that most women refugees had both positive and negative experiences in economic, education and sociocultural dimensions of integration. The COVID-19 outbreak affected their integration in an unprecedented way, especially in daily and work life as well as access to health services. Similarly, language barriers faced by refugee women create significant challenges and obstacles, making the integration process more complex. Refugee women stated that COVID-19 positively influenced the security dimension of integration.

Refugees at Work: The Preventative Role of Psychosocial Safety Climate against Workplace Harassment, Discrimination and Psychological Distress

It is widely recognised that employment is vital in assisting young refugees’ integration into a new society. Drawing on psychosocial safety climate (PSC) theory, this research investigated the effect of organisational climate on young refugee workers’ mental health (psychological distress) through stressful social relational aspects of work (e.g., harassment, discrimination). Drawing on data from 635 young refugees aged between 15 and 26 in South Australia, 116 refugees with paid work were compared with 519 refugee students without work, and a sample of young workers from Australian Workplace Barometer (AWB) data (n = 290). The results indicated that refugees with paid work had significantly lower psychological distress compared with refugees with no paid work, but more distress than other young Australian workers. With respect to workplace harassment and abuse, young refugee workers reported significantly more harassment due to their ongoing interaction and engagement with mainstream Australian workers compared with unemployed refugees. Harassment played a vital role in affecting psychological health in refugees (particularly) and other young workers. While refugee youth experienced harassment at work, overall, their experiences suggest that their younger age upon arrival enabled them to seek and find positive employment outcomes. Although PSC did not differ significantly between the employed groups, we found that it likely negatively influenced psychological distress through the mediating effects of harassment and abuse. Hence, fostering pathways to successful employment and creating safe work based on high PSC and less harassment are strongly recommended to improve refugees’ mental health and adaptation.

Morphosyntactic Development in First Generation Arabic—English Children: The Effect of Cognitive, Age, and Input Factors over Time and across Languages

This longitudinal study examined morphosyntactic development in the heritage Arabic-L1 and English-L2 of first-generation Syrian refugee children (mean age = 9.5; range = 6–13) within their first three years in Canada. Morphosyntactic abilities were measured using sentence repetition tasks (SRTs) in English and Syrian Arabic that included diverse morphosyntactic structures. Direct measures of verbal and non-verbal cognitive skills were obtained, and a parent questionnaire provided the age at L2 acquisition onset (AOA) and input variables. We found the following: Dominance in the L1 was evident at both time periods, regardless of AOA, and growth in bilingual abilities was found over time. Cognitive skills accounted for substantial variance in SRT scores in both languages and at both times. An older AOA was associated with superior SRT scores at Time−1 for both languages, but at Time-2, older AOA only contributed to superior SRT scores in Arabic. Using the L2 with siblings gave a boost to English at Time−1 but had a negative effect on Arabic at Time-2. We conclude that first-generation children show strong heritage-L1 maintenance early on, and individual differences in cognitive skills have stable effects on morphosyntax in both languages over time, but age and input factors have differential effects on each language and over time.

Teachers’ Perspectives: Challenges in the Integration of Refugee Children Deported from Israel to Uganda

In 2012, Israel deported 500 South-Sudanese refugee children and their families. A year later, a civil war broke out in the young South Sudan and the deportees, along with over one million South-Sudanese citizens, fled to the neighboring Uganda. Since then, many of these children have studied in boarding schools in Uganda. We explore, using qualitative methods, the perceptions and experiences of six Ugandan teachers all working with these children for at least 5 years. The research is unique in studying children who have previously lived and studied in a developed Western environment, and experienced, subsequently, a transition to the global south, with far more conservative social norms and an authoritarian, teacher-centered conception of education. The results show a clear progression in the teachers’ conception of the children, beginning with an impression of the children as rebellious, tending to initiate conflicts, and disrespectful. Gradually, they came to view them as being open and assertive, often very articulate and communicative. They observed changes in the children’s behavior: acquiring language skills, being cooperative with staff, integrating with the other children and caring. Working with the refugee children had a great impact on the teachers’ perceptions and on their personal and professional conduct: they substituted punishments—including physical caning—with other methods of discipline. They endorsed open academic methods based on dialogue in class and between teachers and students, and encouraged experiment-based learning methods. On the other hand, the teachers initial perception of children’s parents as ignorant and disruptive remained unchanged and little effort, if any, was made throughout the years of this educational encounter to include the parents in the educational process. The teachers’ recommendations focused mainly on three issues: preparing the children and the staff to the new experience in order to facilitate integration, enhancing the communication and mutual work with the children’s parents, and giving more attention to the children’s emotional state. The discussion section addresses the limitation of this study, directions for future research, and practical implications.

Academic Achievement and Psychosocial Adjustment in Child Refugees: A Systematic Review

Child refugees are at high risk for problems with academic achievement and psychosocial well-being. We aimed to review the literature concerning these outcomes in primary school-aged child refugees. This study was a systematic review and included studies that reported on outcomes of interest in child refugees between 5 and 12 years of age. Our search generated 3,172 articles; we selected 313 for review and included 45. Child refugees are diverse in their educational performance, and early deficits often resolve with time spent in the host country. These children are at an increased risk of emotional and behavioral difficulties, and multiple factors are associated with these outcomes. Although educational difficulties of primary school-aged child refugees in high-income countries tend to resolve, the risks for psychosocial problems persist. This review provides a deepened understanding of the diverse educational and psychosocial experiences of these children and highlights the need for developing health and educational programs to support this population.

Lifestyle habits and academy performance amongst forcibly displaced students: A cross-sectional survey in a school of dentistry

INTRODUCTION

There is no recognised investigation examining the influence of some lifestyle comportments on academic performance (AP) in forcibly displaced students in higher education. Thus, the frequency of physical inactivity (PI), insufficient sleep (IS), alcohol consumption (AC), drug consumption (DC) and cigarette smoking (CS) and the independent and combined consequences of these habits on AP in forcibly displaced dental students were investigated.

MATERIALS AND METHODS

A sample of 185 students was studied (thirty-seven forcibly displaced and 148 non-displaced students). This cross-sectional study used an institutional administrative database that included students' demographic features and lifestyle behaviours. Multivariate analyses were performed to evaluate the independent and combined effects of lifestyle behaviours on AP.

RESULTS

PI, IS, AC, DC and CS were observed in 51%, 43%, 83%, 27% and 16% of forcibly displaced students, respectively. Compared with non-displaced students, forcibly displaced students presented higher frequencies for all of these behaviours (P < .05), lower AP (P < .0001) and lower socio-economic status (P = .003). Unadjusted regression models showed independent and significant associations between forcibly displaced students and PI (P = .01), IS (P = .01), AC (P = .01), DC (P < .0001), CS (P = .02) and low AP (P = .006). The multivariate model for AP and forcibly displaced students increased odds by 4.6 times (1.5-11; 95% CI). Moreover, the lifestyle comportments studied were also statistically significant, showing combined effects. The variables of gender and age were not statistically significant in the adjusted model.

CONCLUSIONS

This research observed high frequencies of the behaviours analysed in forcibly displaced students. Furthermore, independent and combined effects of them on AP were detected.

Psychosocial and cultural needs of children with intellectual disability and their families among the Syrian refugee population in Turkey

BACKGROUND

Turkey is the country hosting the largest number of refugees from Syria, with currently 3 571 175 million persons. The general health needs of the refugees are being addressed; however, people with intellectual disabilities (IDs), particularly children, are relatively missed. The aim of this study was to identify medical, psychological and social needs of children with ID and their families, among the Syrian refugee population in Turkey, and to define psychosocial and cultural needs for planning of future services.

METHODS

One hundred forty-two children (67.6% men; mean age 90.5 months) diagnosed with intellectual disorders were included in the study. Family Needs Survey, with additional open-ended and close-ended questions, was used to evaluate family needs. Items from Developmental Disabilities Profile-2 were used to evaluate and screen cognitive, motor and language development as well as medical concerns and behavioural problems. Data on sociodemographic characteristics were also collected.

RESULTS

The highest needs were identified in information and financial needs domains. Other indicated needs were on child care and community services domains. The least indicated items were on family and social support and explaining to others domains. An average of 63.5% of the respondents definitely agreed with the Family Needs Survey items. The overall level of identification of need items was higher than that in some previous studies, indicating the level of unmet needs of the studied population. Family income, parents' employment and parents' education were not significantly associated with unmet family needs. Special education services were unreachable for most of the families in the study.

CONCLUSIONS

Families reported the highest needs in information and financial needs domains. The overall level of identification of needs was higher than that in some previous studies, indicating the level of unmet needs of the studied population. The majority of the parents reported that they had sufficient family and social support, which might be a protective factor for parental mental health. Parents' Turkish fluency was very significantly associated with every domain of unmet needs. Language barriers and translation problems had significant negative effects on families, as confirmed by the answers to open-ended questions. Another important factor identified was access to service professionals. Special education services, sorely needed for most of the families, could not always be reached. Although the progress of children who had received special education was not very encouraging, it was better than those who did not receive it. The first implication of the study is that increasing Turkish proficiency or providing high-quality and consistent translation services is vital for this category of children with ID. The second implication is that information and financial needs must be met with priority. Information must be tailored for each child's needs and developmental level. Special education and physical therapy must be more accessible and at higher quality.

Beyond Developmental Supports for a Child Refugee

Zahid is a 10-year-old boy who moved to the United States 18 months ago with his parents and 3 younger siblings. He and his family are refugees from Syria. Zahid was born in Syria after an uncomplicated pregnancy and delivery. Zahid's parents first became concerned about Zahid's development when he was 9 months old because he had not started cooing or babbling and did not respond to his name. At 3 years, a doctor in Syria expressed concern that Zahid may have autism spectrum disorder; however, his parents did not know what symptoms triggered the concern and believed his behavior was because of his ongoing exposure to trauma.Zahid underwent a full evaluation 1 year ago in the United States and was found to meet the criteria for autism spectrum disorder. Coaching was provided to his parents in obtaining appropriate educational support for their son, and a referral was placed for applied behavior analysis (ABA) to be provided by an organization in the community. After several meetings between the parents and school administration, an Individualized Education Program was initiated. Despite acceptance into a community-based ABA program, Zahid has not begun the intervention because of transportation difficulties. In-home ABA was offered but was refused by the family.The family is under significant stress. Zahid is nonverbal and has displayed behaviors affecting safety, including wandering/eloping and turning on kitchen appliances resulting in a kitchen fire. Zahid's mother completed high school, and his father completed sixth grade. Both parents speak limited English, and neither is employed. The family receives financial support through the government, but this will be ending soon. Zahid's father is concerned that employment outside of the home will further limit his ability to transport Zahid to necessary appointments. Zahid's mother does not drive. Zahid's father requests that the physician provide a letter requesting exemption from requirements to participate in work or training programs because of Zahid's needs. How would you respond to this overwhelmed father?

Which Measures Better Discriminate Language Minority Bilingual Children With and Without Developmental Language Disorder? A Study Testing a Combined Protocol of First and Second Language Assessment

Purpose This study aimed to assess a protocol for the evaluation of developmental language disorder (DLD) in language minority bilingual children (LMBC). The specific aims were (a) to test group differences, (b) to evaluate the discriminant validity of single measures included in the protocol, and (c) to define which model of combined variables had the best results in terms of efficacy and efficiency. Method Two groups of LMBC were involved, one with typical development (n = 35) selected from mainstream schools and one with DLD (n = 20). The study protocol included the collection of demographic information and linguistic history; a battery of standardized tests in their second language (Italian), including nonword repetition, morphosyntactic comprehension and production, and vocabulary and narrative skills; and direct (children's evaluation) and indirect (parents' questionnaire) assessment of linguistic skills in their first language. Results Results showed that the two groups differed in almost all linguistic measures. None of the single measures reached good specificity/sensitivity scores. A combined model that included direct and indirect assessment of first language skills, morphosyntactic comprehension and production, and nonword repetition reached good discriminant validity, with 94.5% of cases correctly classified. Discussion The study defines a complex picture of the linguistic profile in bilingual children with DLD, compared to typically developing bilingual peers. The results reinforce the idea that no single measure can be considered optimal in distinguishing children with DLD from typical peers. The study offers a concrete example of an effective and efficient protocol with which to discriminate LMBC with and without DLD.

Systematic Review and Meta-analysis: The Prevalence of Mental Illness in Child and Adolescent Refugees and Asylum Seekers

OBJECTIVE

Over half of the world's refugee population are under the age of 18 years. This systematic review aims to summarize the current body of evidence for the prevalence of mental illness in child and adolescent refugee populations.

METHOD

Eight electronic databases, gray literature, and Google Scholar were searched for articles from 1 January 2003 to 5 February 2018. Strict inclusion criteria regarding the diagnosis of mental illness were imposed. Study quality was assessed using a template according to study design, and study heterogeneity using the I² statistic. Random effects meta-analyses results were presented given heterogeneity among studies. The protocol for this systematic review was registered with PROSPERO (CRD42016046349).

RESULTS

Eight studies were eligible, involving 779 child and adolescent refugees and asylum seekers, with studies conducted in 5 countries. The overall prevalence of posttraumatic stress disorder (PTSD) was 22.71% (95% CI 12.79-32.64), depression 13.81% (95% CI 5.96-21.67), and anxiety disorders 15.77% (95% CI 8.04-23.50). Attention-deficit/hyperactivity disorder (ADHD) was 8.6% (1.08-16.12) and oppositional defiant disorder (ODD) was 1.69% (95% CI -0.78 to 4.16). Because of the high heterogeneity, further subgroup analyses were conducted.

CONCLUSION

Refugee and asylum seeker children have high rates of PTSD, depression, and anxiety. Without the serious commitment by health and resettlement services to provide early support to promote mental health, these findings suggest that a high proportion of refugee children are at risk for educational disadvantage and poor social integration in host communities, potentially affecting their life course.

Pre-school Teachers' Stereotypes and Self-Efficacy are Linked to Perceptions of Behavior Problems in Newly Arrived Refugee Children

Introduction: Since 2015, increased numbers of refugee families with pre-school-aged children have arrived in Germany. In pre-schools, teachers' professional competence for teaching those children and adapting to their socio-emotional needs has become increasingly important. Previous research linked teachers' stereotypes and cultural beliefs to their self-efficacy and enthusiasm when teaching immigrant children. This study investigated the links between domains of pre-school teachers' professional competence (i.e., negative stereotypes, multicultural beliefs, self-efficacy, and enthusiasm when teaching newly arrived refugee children), and examined whether teachers' professional competence was linked to their perceptions of newly arrived refugee children's behavior problems. Method: In a cross-sectional self-report survey, N = 147 German pre-school teachers reported on their professional competence and completed the Strengths and Difficulties Questionnaire (SDQ) for a selected refugee child from their pre-school group. We used regression modeling to link teachers' negative stereotypes and multicultural beliefs to their self-efficacy and enthusiasm for teaching refugee children. Next, we examined the links between teachers' beliefs, values, and motivational orientations to their ratings on the SDQ subscales. Last, we linked demographic data on teachers and children to teachers' professional competence and SDQ ratings. Results: Teachers with more negative stereotypes toward newly arrived refugee children and less agreement with multicultural beliefs reported lower self-efficacy and enthusiasm for teaching newly arrived refugee children. Teachers with more negative stereotypes perceived more hyperactivity/inattention and total difficulties. Teachers with higher self-efficacy perceived less hyperactivity/inattention, less total difficulties, and more prosocial behavior. Additionally, teachers who had more experience with refugee children reported more negative stereotypes and higher agreement with multicultural beliefs. Teachers having more overall work experience perceived more total difficulties. Boys were perceived to display more externalizing behavior problems, less prosocial behavior, and more total difficulties. Older children were perceived as displaying more prosocial behavior and children from African countries were perceived as displaying more conduct problems. Discussion: Our findings suggest that pre-school teachers' stereotypes and self-efficacy might be related to perception biases concerning newly arrived refugee children's externalizing behavior problems. Implications for the professional development of pre-school teachers and teacher-informant diagnostics of refugee children's socio-emotional needs are discussed.

School-based programs for Supporting the mental health and psychosocial wellbeing of adolescent forced migrants in high-income countries: A scoping review

As communities around the world continue to receive record-setting numbers of newcomers fleeing armed conflict, schools play a central role in supporting these families through the challenges of adjustment. Policymakers and educators in several high-income countries have begun to invest in efforts to support these young forced migrants not only academically, but also socially and emotionally. This study reviews the published and grey literature on 20 school-based programs aimed at improving the mental health and psychosocial wellbeing of adolescent forced migrants in high-income countries from 2000 to 2019. This review seeks to inform a more comprehensive and detailed understanding of the types of program options available to schools, while also identifying gaps in the current literature related to factors influencing program implementation. We find several common approaches and challenges to supporting adolescent forced migrants, as well as their families, communities, schools, and service providers. The reviewed programs faced recurring challenges related to intercultural exchange, gaining access to communities, promoting care-seeking, school capacity limitations, and sustainability. The lessons learned from these programs indicate that several steps can be taken to mitigate these challenges, including adapting services to individuals and their contexts, taking a multi-layered approach that addresses multiple levels of young people's social ecologies, and building trusting, collaborative partnerships with schools, communities, and students.

Providing Care for Children in Immigrant Families

Children in immigrant families (CIF), who represent 1 in 4 children in the United States, represent a growing and ever more diverse US demographic that pediatric medical providers nationwide will increasingly encounter in clinical care. Immigrant children are those born outside the United States to non-US citizen parents, and CIF are defined as those who are either foreign born or have at least 1 parent who is foreign born. Some families immigrate for economic or educational reasons, and others come fleeing persecution and seeking safe haven. Some US-born children with a foreign-born parent may share vulnerabilities with children who themselves are foreign born, particularly regarding access to care and other social determinants of health. Therefore, the larger umbrella term of CIF is used in this statement. CIF, like all children, have diverse experiences that interact with their biopsychosocial development. CIF may face inequities that can threaten their health and well-being, and CIF also offer strengths and embody resilience that can surpass challenges experienced before and during integration. This policy statement describes the evolving population of CIF in the United States, briefly introduces core competencies to enhance care within a framework of cultural humility and safety, and discusses barriers and opportunities at the practice and systems levels. Practice-level recommendations describe how pediatricians can promote health equity for CIF through careful attention to core competencies in clinical care, thoughtful community engagement, and system-level support. Advocacy and policy recommendations offer ways pediatricians can advocate for policies that promote health equity for CIF.

Practitioner Review: Mental health problems of refugee children and adolescents and their management

BACKGROUND

Since 2010, the numbers of refugees have increased and around half are under 18 years of age. It is known that experience of organised violence, displacement and resettlement increases the risk for psychiatric disorders and psychosocial impairment. This review integrates recent research into the risk and protective factors for psychopathology with service and treatment issues.

METHODS

We draw on and critically evaluate key systematic reviews in the selected areas, innovative robust studies and relevant government reports.

RESULTS

Many refugee children show resilience and function well, even in the face of substantial adversities. The most robust findings for psychopathology are that PTSD, and posttraumatic and depressive symptoms are found at higher prevalence in those who have been exposed to war experiences. Their severity may decrease over time with resettlement, but PTSD in the most exposed may show higher continuity. More severe psychiatric disorders including psychosis may also occur. Service delivery needs to take into account socioeconomic and cultural influences but, given the high level of unmet need even in high-income countries, stepped care delivery is required. The evaluation of psychological interventions, often delivered in group settings, suggests that they can be effective for many distressed children; however, for the more impaired, a greater range of disorder-specific therapies will be required.

CONCLUSIONS

Child and adolescent mental health clinicians and service providers need to be aware of the specific needs of this population and systems for service delivery. There are significant knowledge gaps in understanding risk and vulnerability, service delivery and treatment effectiveness.

The Effects of Armed Conflict on Children

More than 1 in 10 children worldwide are affected by armed conflict. The effects are both direct and indirect and are associated with immediate and long-term harm. The direct effects of conflict include death, physical and psychological trauma, and displacement. Indirect effects are related to a large number of factors, including inadequate and unsafe living conditions, environmental hazards, caregiver mental health, separation from family, displacement-related health risks, and the destruction of health, public health, education, and economic infrastructure. Children and health workers are targeted by combatants during attacks, and children are recruited or forced to take part in combat in a variety of ways. Armed conflict is both a toxic stress and a significant social determinant of child health. In this Technical Report, we review the available knowledge on the effects of armed conflict on children and support the recommendations in the accompanying Policy Statement on children and armed conflict.

Finnish-born children of immigrants are more likely to be diagnosed with developmental disorders related to speech and language, academic skills and coordination

AIM

We examined the association between having at least one parent born abroad and being diagnosed with a developmental disorder related to speech and language, academic skills or coordination.

METHODS

This nested case-control study was based on Finnish population records for 1996-2007. Cases from the Finnish Hospital Discharge Register were diagnosed with developmental disorders of speech and language, academic skills and coordination by the end of 2012. We identified 28 192 cases and 106 616 matched controls.

RESULTS

Children were more likely to be diagnosed with developmental disorders if they had an immigrant mother than children with two Finnish-born parents, with an adjusted odds ratio (aOR) of 1.3 and 95% confidence interval (95% CI) of 1.2-1.4, an immigrant father (aOR 1.2, 95% CI 1.1-1.3) or two immigrant parents (aOR 1.5, 95% CI 1.3-1.6). The level of development of the parental country of origin was not associated with receiving a diagnosis.

CONCLUSION

Children of immigrant parents were more likely to be diagnosed with developmental disorders and the association was strongest with regard to speech and language disorders. There were similar adjusted odds ratios for mothers, fathers and both parents. The development level of the country of origin was irrelevant.

Experiences of Inner-City Fathers of Children With Chronic Illness

We aim to explore the experiences of fathers from inner-city families caring for children affected by chronic health conditions or disabilities. A systematic scoping review was conducted using the Arskey and O'Malley framework. Fourteen of the 5114 articles were included in the full review and were qualitatively evaluated in terms of stressors, resources, perception, coping, and adaptation according to the Double ABCX model. Stressors included financial strain and health care access barriers. Resources ranging from immediate to extended family members depended on ethnicity. Fathers' perceptions of their primary caregiver roles depended on ethnicity in the context of cultural gender norms. While inner-city fathers desired information about their children's health, some were uncomfortable asking physicians. They had a higher risk for coping difficulties and maladaptation, including depression. We highlight a need for pediatricians to advocate for additional resources to provide comprehensive care for inner-city fathers caring for their children with chronic health conditions or disabilities.

Psychological and psychosocial interventions for refugee children resettled in high-income countries

Large numbers of refugee children are arriving in high-income countries. The evidence to date suggests that they have mental health needs that are higher than for the general population and that these are exacerbated by the numbers of traumatic events they have experienced and the post-migration stressors they continue to be exposed to. The importance of a thorough and thoughtful assessment is discussed. Treatments of note are described for post-traumatic stress disorder, family functioning, general mental health problems and school environments. Future opportunities to operationalise outcome measures, develop multimodal interventions and utilise implementation science methodology are considered.

Supporting the developmental health of refugee children and youth

The Canadian Government has announced that over 50,000 refugees from the Middle East will be resettled in Canada by 2018. More than one-third of these refugees are expected to be children. The Canadian Paediatric Society has called for the Canadian government to prepare for the influx of these children. This should include addressing developmental, behavioural, and mental health needs. The focus of this paper is the role of paediatricians and family physicians in caring for the developmental health of refugee children, as a means of supporting their developmental and learning potential. The authors suggest the use of EMPOWER (Education, Migration, Parents and Family, Outlook, Words, Experience of Trauma and Resources), a mnemonic checklist they developed for assessing developmental risk factors in refugee children. EMPOWER can be used along with online web resources such as Caring For Kids New to Canada in providing evidence-informed care to these children.

Refugee children and their health, development and well-being over the first year of settlement: A longitudinal study

AIM

This study aimed to describe refugee children, their families and settlement characteristics, and how their development and social-emotional well-being change over time.

METHODS

We conducted a longitudinal study of 61 refugee children (6 months to 15 years) in an Australian setting, over 2009-2013 and measured child, family and settlement factors as well as physical health, development and social-emotional well-being (Strengths and Difficulties Questionnaire, SDQ).

RESULTS

Questionnaires were completed with parents of 54 (89%) children at year 2 and 52 (100%) at year 3. Forty percent of parents had low levels of education, 30% of fathers were absent on arrival, 13% of children were born in refugee camps and 11% of parents self-disclosed previous trauma. Over time, there was increased parental employment (P = 0.001), improved English proficiency for partners (P = 0.02) and reduced stressful life events in the last 12 months (P = 0.003). At years 2 and 3, parents were studying English (96%; 76%), accessing government financial support (96%; 100%) and primary health care (98%; 87%), and feeling supported by their own (78%; 73%) or the general (69%; 63%) community. Fifteen percent of children had a chronic disease, and 13% were obese and overweight. In pre-school children, 27% had mild developmental problems in year 2; all were normal by year 3. Abnormal SDQ total difficulties scores reduced over time from 13 to 6% of children but this did not reach significance.

CONCLUSION

Most refugee children have developmental and well-being outcomes within the normal range by year 3. However, a minority of children have persistently poor social-emotional outcomes.

Adversity and resilience amongst resettling Western Australian paediatric refugees

AIM

Cumulative adverse childhood experiences have long-term consequences and may manifest within and influence health, educational and psychosocial domains. The Princess Margaret Hospital Refugee Health Service (RHS) undertakes multidisciplinary screening of refugee children <16 years, allowing standardised identification of negative childhood experiences. Addition of the extended Strengths and Difficulties Questionnaire (SDQ) in 2014 aimed to augment psychological assessment of this cohort.

METHODS

An audit of prospectively collected standardised RHS proformas, health records and initial and 6-month follow-up SDQs for new patients aged 2-16 years between August 2014 and January 2016 was undertaken. Wider refugee adverse childhood experiences (R-ACE) were also captured.

RESULTS

Initial SDQ data were obtained from 204 patients (mean age 9.2 ± SD 4.4 years) with 143 follow-up SDQs available. One third (37.3%) had at least one psychological symptom identified based on initial screening proforma. Multiple R-ACE were disclosed with 126 of 201 (62.7%) experiencing ≥3. African ethnicity, age >10 years, separation anxiety on initial proforma and no formal parental education were associated with higher R-ACE. Initial SDQ results varied with age/ethnicity; however, peer problem scores were consistently elevated. Total difficulty SDQ scores did not capture psychopathology at expected frequencies. Improvement in follow-up SDQ results were appreciated for children aged 4-10 years. Most patients (80.2%) disclosed improvement in health status following RHS involvement.

CONCLUSIONS

Refugee children have complex backgrounds with exposure to multiple traumatic events. Comprehensive standardised health and psychological screening is recommended to target intervention. Further validation of culturally age-appropriate mental health screening tools in this diverse population is required.

Addressing the Needs of Preschool Children in the Context of Disasters and Terrorism: Clinical Pictures and Moderating Factors

PURPOSE OF REVIEW

This paper surveys the existent theoretical and research literature regarding the needs of preschool children in the context of disasters and terrorism with the aim of understanding (a) the consequences of such events for young children and (b) the main moderating variables influencing the event-consequence association to learn how to enhance their resilience.

RECENT FINDINGS

Consequences include a variety of emotional, behavioral, and biological outcomes. Implications for refugee children are discussed. Main moderating variables were mother's sensitivity and mother's PTSD symptoms. Exposure to disasters and terrorism may have severe effects on the mental health and development among preschool children. Future research should explore the implications of different levels of exposure and the effects of moderating psychosocial and biological variables, including the parent-child triad, on the event-consequence relationship.

Addressing the Needs of Preschool Children in the Context of Disasters and Terrorism: Assessment, Prevention, and Intervention

PURPOSE OF REVIEW

The goal of this paper is to review the research literature regarding the needs of preschoolers in the context of disasters and terrorism with the aim of understanding the existing methods for assessment, prevention, and intervention to provide recommendations and point out required research and development.

RECENT FINDINGS

We differentiate between screening tools that provide initial evaluation and assessment tools for diagnosing preschooler children's pathology and review possible interventions that address the preschool child's needs before, during, and after the incident itself. We also emphasize the lack of dissemination and research of prevention programs and mass interventions for preschoolers. Programs for community mass prevention and intervention for preschoolers should be developed and evaluated and interventions should be adapted for individual and group delivery. Moreover, the increase in the number of children refugees requires cultural adaptations of assessment measures and interventions.

Screening and Primary Care Access for Newly Arrived Paediatric Refugees in Regional Australia: A 5 year Cross-sectional Analysis (2007-12)

This study aimed to determine the prevalence of health conditions in newly arrived refugee children and access to timely heath screening. Methods: Cross-sectional data from screening of refugee children in regional Australia (2007-12) were analysed for health conditions and timeliness of primary care access. The health of 376 newly arrived refugee children (0-15 years) was assessed. Refugee children came from African (45%), Southeast Asian (29%) and Eastern Mediterranean (10%) regions. Access to primary care screening was present in 367 children (97% of arrivals). Completion of all recommended screening tests was 72%. Of 188 children with arrival and screening dates recorded, 88% were screened within 1 month and 96% within 6 months of arrival. Timely access of remaining children could not be assessed. Conclusion: Primary care was highly accessible to almost all newly arrived refugee children. Health screening was timely in those children with complete medical records.

Medical and social issues of child refugees in Europe

In mid-2015, there were an estimated 20.2 million refugees in the world; over half of them are children. Globally, this is the highest number of refugees moving across borders in 20 years. The rights of refugee children to access healthcare and be free from arbitrary detention are enshrined in law. Unaccompanied asylum-seeking children have a statutory medical assessment, but refugee children arriving with their families do not. Paediatricians assessing both unaccompanied and accompanied refugee children must be alert to the possibilities of nutritional deficiencies, infectious diseases, dental caries and mental health disorders and be aware of the national and international health guidance available for support.