Forensic age estimation at the University Center of Legal Medicine Lausanne-Geneva: a retrospective study over 12 years

With the undeniable increase in asylum requests from unaccompanied alleged minors, age estimation of living individuals has become an essential part of the routine work in European forensic centers. This study aims to review the forensic age estimations performed in our center since 2010, to evaluate the state-of-the-art of this practice in Switzerland with the evolution of the methodology according to upcoming recommendations. Our institute's expert reports performed between 2010 and 2022 were retrospectively analyzed. We gathered the following parameters: demographic data, morphological characteristics, alleged age compared with the assessed minimum age, sexual maturation, dental and bone age. When available, we collected personal and family history, medical history, records of torture-related/self-inflicted injuries, and information about eating habits that might affect skeletal development. Data collection amounted to 656 cases. Forensic age estimations ordered by the Swiss Secretariat for Migration (SEM) represented 76.4% of cases, with 23.6% of them ordered by the Court/Public Prosecutor. Most alleged minors were male (94.5%) and came from Afghanistan (53.4%). Adjunction of CT scans of the sternoclavicular joints was necessary in 86.4% of cases. Only 25.2% of our reports concluded on most probable minority, with 55.6% of definite majors; in 19.2% of our cases, minority could not be excluded. This study aspires to further broaden our expertise regarding forensic age estimations. Given the increasing migratory flows, we can expect a notable increase in the frequency of these requests. Consequently, this study aims to promote a multidisciplinary approach and the international standardization of the methodology of these estimations.

Age assessment in unaccompanied minors: assessing uniformity of protocols across Europe

Age assessment of migrants is crucial, particularly for unaccompanied foreign minors, a population facing legal, social, and humanitarian challenges. Despite existing guidelines, there is no unified protocol in Europe for age assessment.The Forensic Anthropology Society of Europe (FASE) conducted a comprehensive questionnaire to understand age estimation practices in Europe. The questionnaire had sections focusing on the professional background of respondents, annual assessment numbers, requesting parties and reasons, types of examinations conducted (e.g., physical, radiological), followed protocols, age estimation methods, and questions on how age estimates are reported.The questionnaire's findings reveal extensive engagement of the forensic community in age assessment in the living, emphasizing multidisciplinary approaches. However, there seems to be an incomplete appreciation of AGFAD guidelines. Commonalities exist in examination methodologies and imaging tests. However, discrepancies emerged among respondents regarding sexual maturity assessment and reporting assessment results. Given the increasing importance of age assessment, especially for migrant child protection, the study stresses the need for a unified protocol across European countries. This can only be achieved if EU Member States wholeheartedly embrace the fundamental principles outlined in EU Directives and conduct medical age assessments aligned with recognized standards such as the AGFAD guidelines.

Forensic age estimation in Barcelona: analysis of expert reports issued between 2011 and 2018

INTRODUCTION

In recent years, there has been a notable increase of migratory movements into Europe with the arrival of not (reliably) documented young individuals within EU-Member States. Accordingly, the need for forensic age assessments likewise increased in order to administratively differentiate along the legally relevant cut-off age of 18 completed years. The objective of our study was to analyse the expert reports of forensic age estimation issued in Barcelona between 2011 and 2018.

METHOD

In all cases, data on the medical history, physical examination, radiology of the left hand and orthopantomography were collected. In cases without third molars and a complete ossification of the hand, a CT scan of the clavicles was also performed.

RESULTS

A total of 2754 expert reports were evaluated; 96.7% were males, the majority were of North African origin, mainly from Morocco (63.6%), and 19.6% were sub-Saharan Africans; 65.4% had a level of bone maturation corresponding to the last three standards of Greulich and Pyle. Most cases had mineralization of the third molar corresponding to the F, G or H stages of Demirjian. In 85.9%, there was a correspondence between bone and dental age. A total of 28.8% of the subjects were evaluated as being aged over 18 years; 86.2% of North Africans were considered to be younger than 18, and 82% of sub-Saharan Africans were considered to be over 18 years old.

CONCLUSIONS

In Barcelona, most of the subjects evaluated were male and North African, and 71.2% of the cases were considered to be minors.

Attitudes of Employees in Unaccompanied Children's Shelters and Work-Related Stress During the COVID-19 Pandemic

Data related to the stress of employees in shelters for unaccompanied minors are scarce, especially when considering the escalation of the refugee issue. This study analyzed aspects of this issue as it was carried out in child protection organizations in Greece, which is a country where a huge number of immigrants and refugees pass through and thousands of professionals are employed in this field.More specifically, the aim of this study was to examine the stress (general, perceived, work-related) and burnout symptoms of a specific group of employees exposed to the COVID-19 quarantine restrictions, employees at the 'front line' of care in shelters that host unaccompanied minors and teenagers.The study was carried out from March 2020 to December 2021, when social restrictions and other preventive measures were imposed. The study sample was recruited from non-governmental organizations and shelters for unaccompanied minors, in the urban area of the center of Athens, i.e. the International Organization for Migration, The Home Project, Arsis, Iliachtida, and Zeuxis. The sample consisted of employees at the 'front line' of care in shelters that hosted unaccompanied minors and teenagers. Participants were professionals whose duty was to deal with and respond to the needs of children and adolescents within the shelters they lived in. Participants completed the following questionaires before and after the pandemic restrictions: the Job Stress Measure (JSM), the Maslach Burnout Inventory (MBI), the Perceived Stress Scale (PSS), the Stress in General Scale (SiGS) and a questionnaire of 11-items regarding COVID-19, focusing on the professionals' perceived stress, working conditions, working demands and the impact of COVID-19 on all the aforementioned.The study sample consisted of 50 employees (40 females, 10 males; mean age ± SD 31.46 ± 7.91 years) in hostels for unaccompanied minors. A statistically significant difference was found only in SiGS, with increased stress after COVID-19 (p = 0.001). In terms of sex, significant differences were found at baseline in PSS and Emotional Exhaustion (p = 0.036 and p = 0.028, respectively) (females revealed higher levels than males). Age and educational level were factors that interacted with the increased levels in SiGS after COVID-19 (p = 0.015 and p = 0.006, respectively). Moreover, significant differences were found at baseline in PSS (p = 0.004), with higher levels observed in employees with higher education. Workers who did not work remotely had lower levels in Personal Accomplishment after COVID-19 compared to employees who worked remotely (p = 0.050). Interestingly, the JSM showed a tendency for decreased stress levels after the implementation of the quarantine, suggesting that the employees' work-related stress remained approximately at the same levels. On the other hand, perceived stress increased as the job demands remained the same, while social and personal outlet was in appeasement.The necessity for more research to be held among health professionals is evident and is also imperative to carry out interventional studies to manage stress and thus, provide better mental health services to unaccompanied minors. There is also need for further research in similar populations of professionals outside the urban context of Athens, i.e. in the Greek islands near the sea borders, where the refugees' entries are higher in number and more frequent.

Screening for parasites in migrant children

BACKGROUND

Globalization has pushed population movements in the last decades, turning imported diseases into the focus. Due to behavioral habits, children are at higher risk of acquiring iparasitosis. This study aims to investigate the prevalence of parasites in migrant children and factors associated with parasitic diseases.

METHOD

Retrospective cross-sectional study (2014-2018) including children diagnosed with parasitosis. The diagnosis was based on serology and/or microscopic stool-sample evaluation. Epidemiological and clinical data were recorded.

RESULTS

Out of 813 migrant children screened, 241 (29.6%) presented at least one parasite, and 89 (10.9%) more than one. The median age was 6.6 years (IQR: 3.1-11.9) and 58.9% were males. Most cases were referred for a health exam; only 52.3% of children were symptomatic, but 43.6% had eosinophilia. The most common diagnosis were giardiasis (35.3%), schistosomiasis (19.1%), toxocariasis (15.4%), and strongyloidiasis (9.1%). After the multivariate analysis, African origin and presenting with eosinophilia were the main risk factors for parasitism.

CONCLUSIONS

parasitosis are frequent among migrant children. Children are often asymptomatic, and thus active screening for parasitosis should be considered among high-risk populations. Eosinophilia can be useful to guide complimentary tests, as well as geographical origin, but normal eosinophil count does not exclude parasitosis.

Toxocariasis in migrant children: A 6 years' experience in a reference pediatric unit in Spain

BACKGROUND

Toxocariasis is a worldwide distributed zoonosis that affects characteristically children. Clinical presentation is highly variable, often asymptomatic, and treatment duration is controversial.

METHODS

A retrospective descriptive study (January 2014-December 2019) was performed in a referral Unit for Pediatric Tropical Diseases. Patients younger than 18 years of age diagnosed with toxocariasis were included.

RESULTS

Out of 931 children screened for toxocariasis, 49 (5.3%) were seropositive. The median age was 11.0 years, 55.1% male and 30.6% referred contact with puppies. Overall, 34.7% were Latin-American, 24.5% Asiatic, 20.4% European, and 20.4% African. Only 34.7% presented symptoms, gastrointestinal the most common (52.9%). The 57.1% of children presented eosinophilia and 50% elevated total IgE. Most cases (95.9%) corresponded to covert toxocariasis. All children were treated with albendazole for 5-14-21 days, and 4 children required a second course. Follow-up data were available in 32 children (65.3%) for a median of 7 months, showing a progressive decline in eosinophils, IgE-titers and ELISA optical density.

CONCLUSION

Toxocariasis is mostly asymptomatic in children and eosinophilia is not always present. Serological tests should be included in migrant health screening and in the diagnostic assessment of eosinophilia. Eosinophil count, IgE-titers and ELISA optical-density could be useful during follow-up.

Survivors of Hell: Resilience Amongst Unaccompanied Minor Refugees and Implications for Treatment- a Narrative Review

Approximately half of the world's displaced population are children and a significant proportion of these are unaccompanied asylum-seeking children (UASC). UASC are the most vulnerable of all refugee populations. Up to 90% of UASC have been subjected to exploitation, including trafficking or being drafted into military groups. Having survived the perils of flight, UASC are confronted with continued challenges, including the uncertainties regarding their residential rights in host counties. Unsurprisingly, the prevalence of mental health problems is higher amongst UASC than in any other refugee group. Yet, Mental Health and Psychosocial Support (MHPSS) appears to neither reach nor engage UASC. This begs for re-examination of what and how MHPSS is offered. Despite high levels of adversity, UASC often have considerable resilience, and make remarkable recoveries. However, literature exploring their resources or their own views of what helps or hinders recovery is scarce. In this narrative review, we explore individual and systemic factors promoting recovery in UASC. We consider theoretical understanding of resilience, emerging data and user perspectives. From these we deduct four areas of resilience in UASC: Individual factors - prosocial behaviour, problem-solving skills; Lifetime relationships - positive early family relationships, connection with family and country of origin, positive peer and adult relationships in host country; Acculturation - integration of own and new culture, positive relationships with prosocial institutions; Care arrangements - supported but less restrictive living arrangements. We suggest, MHPSS may need to focus on enhancing social networks, including connectedness with positive relationships in the home-country, life-history work with a focus on resource-building experiences in addition to trauma, and promoting integration of old and new cultural values. We also conclude that despite growing data, there is a gap in both eliciting user perspectives and understanding adaptive resources, especially those emerging during early development and within their cultural setting.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40653-021-00385-7.

Medical check-up of newly arrived unaccompanied minors: A dedicated pediatric consultation service in a hospital

BACKGROUND AND AIMS

Healthcare for the increasing number of migrants in Europe, and particularly of unaccompanied minors (UMs) seeking asylum, has become a major challenge. We aimed to describe the health issues of UMs managed in a dedicated pediatric consultation service in a care center in Paris.

METHODS

All UMs attending a dedicated migrant medical consultation service in Robert Debré Hospital, Paris, France, were included in a single-center retrospective observational study from September 1, 2017, to September 30, 2018.

RESULTS

Out of the 107 UMs who were included, 87% had a health problem (n=93) and 52% had an infectious disease (n=56). The main infectious diagnoses were schistosomiasis (22%), latent tuberculosis (22%), intestinal parasitosis (16%), and chronic hepatitis B (8%). Posttraumatic stress disorder (PTSD) and overweight were common (35% and 20%, respectively). The median age was 15 years old (IQR, 14-16), the male/female ratio was 95/12. Most of the children were from sub-Saharan Africa (n=67), 46% had crossed Libya (n=49) and, when compared to the other migration routes, faced an increasing risk of violence (69%, p=0.04), imprisonment (53%, p=0.03), and forced labor (48%, p=0.02). The median duration of the trip before reaching France was 6 months (IQR, 2-13), the median time to consultation was 2 months (0-5) and was not associated with an increased risk of health problems. A total of 43 UMs were lost to follow-up.

CONCLUSION

Health problems, particularly infectious diseases and PTSD, are common among UMs and should prompt an early medical consultation with psychiatric evaluation. Follow-up is problematic and could be improved by an on-line health book.

Analysis of interrater reliability in age assessment of minors: how does expertise influence the evaluation?

Nowadays, the clinical forensic medical management of migration flows comprises the age assessment of unaccompanied minors. The process of age estimation is a fundamental pillar for legally ensuring the minors' rights and their protection needs. The procedure is complex and involves different phases and actors, from medical doctors to law enforcement officers. The present study aimed to investigate the performance of Greulich and Pyle, Demirjian, and Mincer methods when performed by raters both trained and without training. Also, the interrater reliability within groups of raters from different areas of expertise was evaluated. A total of 36 participants were enrolled for this study, divided in two groups according to their level of experience with age estimation methods. Each rater was asked to allocate stages and standards for age assessment, evaluating ten orthopantomograms and ten hand-wrist roentgenograms. The interrater reliability expressed through the Fleiss Kappa coefficient and the agreement with the reference standard were calculated. The results showed that none of the categories analyzed could reach a good interrater reliability (ĸ > 0.8) for both methods. The study results highlighted variation and disagreement in the interpretation of the sample among raters and in the subsequent stages and standards allocation. In conclusion, the results of this study highlight that expertise does influence the reliability of the most utilized methods of age estimation of living individuals and stress the importance of proper training and practice, which could greatly increase the accuracy of age assessments.

Study of the ethnicity's influence on the third molar maturity index (I3M) for estimating age of majority in living juveniles and young adults

Estimation of age of majority has important applications in the forensic daily practice because of the increasing demand for age estimates of unaccompanied minors. Diagnostic accuracy of I_3M to assess legal adult age of 18 years has been already tested in several specific population samples. The aim of this work was to compare the available data about sensitivity and specificity of the third molar maturity index (I_3M) from five different regional groups' radiographic samples to study possible ethnical difference. For this purpose, a sample of 6157 orthopantomograms (OPGs), coming from 15 countries, was analysed. Data about sensitivity and specificity were pooled using a bivariate modelling approach. The one-way MANOVA analysis was applied to assess the likelihood that sensitivity and specificity of the five regional groups are sampled from the same population. The result of the one-way MANOVA showed that both sensitivity and specificity did not depend from the regional groups. The obtained sensitivity was 84% (95% CI: 82% and 85%), and its specificity was 94% (95% CI: 93% and 95%). Based on these results, the I_3M was a useful statistical tool to identify whether a subject has reached the legal age of 18 years old, regardless of his or her ethnicity.

Male unaccompanied refugee minors' perceptions of relationships and information about sexual health in Sweden - 'it feels like you've been in prison and then set free'

Unaccompanied refugee minors represent a potentially vulnerable group regarding sexual and reproductive health and rights, particularly due to the circumstances surrounding their migration. Research is scarce about the sexual and reproductive health and rights needs of unaccompanied minors, many of whom come from countries with limited access to information about sexual and reproductive health and rights. This study aimed to gain a deeper understanding of how unaccompanied minors in Sweden experience romantic and/or sexual relationships and their need for sexual and reproductive health and rights information. In-depth interviews were conducted with eight young men who had sought asylum in Sweden as unaccompanied minors. Qualitative content analysis identified three themes: "being confronted with a different type of 'sexual' society", "becoming ready for information about sexual and reproductive health and rights" and "moving forward as a person 'in the know'". These themes illustrate the process of relating to a society with different norms and beliefs about relationships and sexual and reproductive health and rights information than in the country of origin. The Young men's difficulties in taking the initiative when talking about sexual and reproductive health and rights in combination with their perceived strong self-efficacy in finding sexual and reproductive health and rights information is noteworthy and should be considered by health professionals aiming to reach this group. The findings highlight the importance of access to formal sexual and reproductive health and rights information for unaccompanied minors and young migrants with similar needs.

Balancing autonomy and expediency within legal parameters: providing primary care to unaccompanied minors

The issue of how primary care clinicians manage unaccompanied minors is not well studied. This month’s article “Treatment of unaccompanied minors in primary care clinics- Caregivers practice and knowledge” begins to fill that gap. The study results reveal that Israeli primary care nurses and doctors often treat unaccompanied minors. Legal parameters offer significant latitude for urgent or simple and ordinary care. Communication to parents afterward is inconsistent. Clinicians also appear to be operating without full understanding of the law in this regard.

This contrasts somewhat with the American situation wherein state level laws more clearly proscribe what types of treatment may be offered to adolescents without the prior consent of a parent and also what may remain confidential. Also, in the US, the variability of what is permitted varies widely across the 50 states and territories.

The tensions between offering appropriate and timely care, maintaining the trust of patient and family, and doing what is expedient are all important considerations for primary care clinicians who treat unaccompanied minors. This exploratory study identifies current Israeli practice and should serve as an invitation to other national primary care groups to examine their own current state and work towards best practices.

Ethical aspects of medical age assessment in the asylum process: a Swedish perspective

According to European regulations and the legislations of individual member states, children who seek asylum have a different set of rights than adults in a similar position. To protect these rights and ensure rule of law, migration authorities are commonly required to assess the age of asylum seekers who lack reliable documentation, including through various medical methods. However, many healthcare professionals and other commentators consider medical age assessment to be ethically problematic. This paper presents a simplified and amended account of the main findings of a recent ethical analysis of medical age assessment in the asylum process commissioned by the Swedish National Board of Health and Welfare. A number of ethical challenges related to conflicting goals, equality and fairness, autonomy and informed consent, privacy and integrity, and professional values and roles are identified and analysed. It is concluded that most of these challenges can be met, but that this requires a system where the assessment is sufficiently accurate and where adequate safeguards are in place. Two important ethical questions are found to warrant further analysis. The first is whether asylum seekers' consent to the procedure can be considered genuinely voluntary. The second is whether and how medical age assessments could affect negative public attitudes towards asylum seekers or discriminatory societal views more generally.

Unaccompanied Children Migrating from Central America: Public Health Implications for Violence Prevention and Intervention

PURPOSE OF REVIEW

Unaccompanied children (UC) migrating to the USA from the Central American countries of El Salvador, Guatemala, and Honduras are an underserved population at high risk for health, academic, and social problems. These children experience trauma, violence, and other risk factors that are shared among several types of interpersonal violence.

RECENT FINDINGS

The trauma and violence experienced by many unaccompanied children, and the subsequent implications for their healthy development into adulthood, indicate the critical need for a public health approach to prevention and intervention.

SUMMARY

This paper provides an overview of the violence experienced by unaccompanied children along their migration journey, the implications of violence and trauma for the health and well-being of the children across their lifespan, prevention and intervention approaches for UC resettled in the USA, and suggestions for adapted interventions to best address the unique needs of this vulnerable population.

UK Government Policy and Unaccompanied Adolescents Seeking Asylum

A series of decisions made by successive UK governments with the aim of reducing the flow of immigration has impacted in countless ways on those seeking asylum. The recently published 5-year strategy for asylum and immigration (Home Office, 2005) has potentially very serious implications for unaccompanied asylum seeking children with the government making plans to commence routine detention and deportation of these children if their asylum claim is not accepted. This paper aims to lay out recent legislation in relation to the treatment of unaccompanied 16- and 17-year old young people seeking asylum and to outline the complex asylum process negotiated by these young people.