Adolescents

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Key points

  • During adolescence, healthcare visits may be limited; the consultation goal should be to complete a thorough physical and psychosocial evaluation, with an emphasis on preventative care.
  • Adolescents should be seen alone at some point during (or soon after) the initial refugee health screening assessment.
  • Define confidentiality for the medical consultation and (separately) for working with interpreters.
  • Adolescents may have an incorrect date of birth recorded; this can have significant implications for assessing growth, development, learning or school/vocational placement.
  • Mental health problems may present in adolescence. Adolescents may make new meaning from past trauma, and present with mental health concerns in relation to early childhood trauma.

Consider sexual health, sexually transmitted infections (STIs, including hepatitis B), sexual violence, and female circumcision. A sensitive history is required, allowing adequate time. 

Overview

The World Health Organization defines adolescent as 10–19 years, youth as 15–24 years and young people as 10–24 years. Humanitarian populations include a high proportion of children and young people. In 2016, 28% of the Australian humanitarian intake was aged less than 12 years, and 23% were aged 12–24 years. Some refugee adolescents arrive as unaccompanied humanitarian minors; other adolescents of refugee-like background arrive under alternative visas (e.g. orphan relative) or as asylum seekers.  

Adolescent developmental issues include physical and cognitive transitions, emergent autonomy and independence, personal identity and body image, peer relationships and recreational goals, educational and vocational goals, and sexuality. Adolescence can be divided into three general stages of psychosocial development:

Early adolescence (10–14 years)  Late adolescence (15–19 years) Young adulthood (19–24 years)

Rapid growth and physical change, secondary sexual characteristics develop

Gender roles consolidate

Low resistance to peer influences

Low future orientation

Poor self regulation and increases in risk taking behaviour

Identity formation and new interests, including sexual relationships

Pubertal maturation

Growth rate decreases

Progression of intimate relationships

Development of executive and self-regulation skills

Greater future orientation and ability to assess consequences

Increasing autonomy and independence from family

Peak physical fitness and bone density

Further development of reasoning and self-regulation

Education and vocational goals important

Adoption of adult roles and responsibilities

Establishing the social, cultural, emotional, educational and economic resources to maintain health and wellbeing across the life course.

Rapid adoption and use of technology

Risks of injuries/transport injuries, communicable diseases, non-communicable diseases, mental health disorders, substance use, and maternal disorders, with variation between countries in risks and burden.

Adolescents of refugee-like background experience all these transitions in addition those of resettlement. They face balancing the values/expectations of their parents/cultural background with those of their new peers, while developing their own identity and learning a new language, in a new schooling system, in a new country. 

Approach to care

During adolescence, healthcare visits may be limited, and adolescents may seek care from a variety of providers. The goal should be to complete a thorough physical and psychosocial evaluation with an emphasis on preventative care. The initial refugee health assessment provides a starting point to introduce longer-term, developmentally appropriate care in the areas of physical, mental and sexual health.

When consulting with adolescents, helpful strategies include:

  • Seeing the adolescent alone at some point during (or soon after) the initial screening. assessment. This may be more acceptable to parents and adolescents if the health provider sees the family initially, and they are aware this will occur in the future.
  • Establishing confidentiality for the medical consultation (and also for the interpreter).
  • Taking a direct history from the adolescent.
  • Using clear language, open-ended questions, and a non-judgmental approach.
  • Allowing enough time.

HEADSSS screening can be used to assess adolescent psychosocial health:

H – home

E – education/employment (and eating)

A – activities

D – drug and alcohol use

S – sexual activity

S – suicide, depression, self-harm

S – safety from injury and violence

Considerations include:

  • Immigration Medical Examination (IME) for adolescents includes urinalysis (5 years and older), chest x-ray (11 years and older), HIV screening (15 years and older), and syphilis screening (15 years and older). Unaccompanied minors (all ages) also have screening for HIV and HBsAg; onshore protection visa applicants (15 years and older) also have screening for HBsAg and HCV.
  • IGRA testing is more reliable in adolescents for tuberculosis screening.
  • Catch-up vaccination and vaccine licensing varies with age. Adolescents will generally not need pneumococcal or Hib vaccines, they will need HPV vaccine, and the varicella vaccine schedule changes at 14 years.
  • Mental illness may present in adolescence. Adolescents may also make new meaning from past trauma, and present with mental health concerns arising from early childhood trauma.
  • Sexual health is an important area that is often neglected. Many refugee-background young people have low sexual health literacy, and limited opportunities to learn about sexual health. Consider STIs (including hepatitis B), sexual violence, and female circumcision.
  • Family structures and parenting roles may change with migration, affecting settlement and leading to ‘role reversal’, with adolescents having increased responsibility, or taking on parenting roles.
  • Prior schooling may have been limited or interrupted, with implications for educational placement in Australia. Evidence shows refugee young people have similar education outcomes to their native-born peers – ensure a proactive approach and early paediatric review for learning problems.
  • Adolescents may have an incorrect birthdate recorded; this is important to consider when assessing growth, development, learning, or school/vocational placement.
  • It takes many years to learn English as an additional language for academic purposes – explaining this is important, and a way to explore schooling and risk/resilience factors.
  • Seek early paediatric review for complex adolescent health issues, including physical health, learning/behavioural concerns, disability, and age assessment. Paediatric review may also help facilitate access to (and acceptance of) mental health services.

Links

ASID/RHeANA guidelines: Recommendations for Comprehensive Post-Arrival Health Assessment for people from Refugee-like backgrounds (2016 edition)  

The Lancet – adolescent health   

Raising Children Network (focus is 0-15 years) 

Better Health Channel  

Headspace 

RCH Immigrant Health Service website

Produced by

in consultation with

                  Refugee Health Network of Australia

Endorsed by

Funded by

The Australian Refugee Health Practice Guide was produced with funds from the Australian Government Department of Health.

Disclaimer

The information set out in the Australian Refugee Health Practice Guide (“the Guide”) is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is the Guide exhaustive of the subject matter. Persons implementing any recommendations contained in the Guide must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. The statements or opinions that are expressed in the Guide reflect the views of the contributing authors and do not necessarily represent the views of the editors or Foundation House. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

Whilst the information is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices.

Accordingly, Foundation House and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in the Guide for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in the Guide and whether caused by reason of any error, negligent act, omission or misrepresentation in the information. Although every effort has been made to ensure that drug doses and other information are presented accurately in the Guide, the ultimate responsibility rests with the prescribing clinician. For detailed prescribing information or instructions on the use of any product described herein, please consult the prescribing information issued by the manufacturer.