Caring for Kids New to Canada

An apparently hyperactive 10-year-old boy who had moved to Canada with his family from Eastern Europe as refugees came to your office for an assessment. Although they had been in Canada for more than six months, they spoke little French or English. He was reported to be disruptive in class and a diagnosis of attention deficit disorder was suggested. A routine examination revealed very poor vision in his left eye. A funduscopic examination revealed severe chorioretinitis. Further questioning of the parents revealed that he had been treated for toxoplasmosis when he was two years of age. Follow-up investigations confirmed the congenital toxoplasmosis diagnosis and the severe developmental delay, even when he was tested in his native language (1). Where do you start? How will severe developmental delay be interpreted in their culture? With the language barrier, how will the family navigate the foreign and complex medical system? Will they understand the importance of advocacy or will they remain quiet and seek alternative therapies? How will they afford the specialized therapy and eye glasses? With the increasing migration of children and youth to Canada, this illustrative case is all too common for the Canadian health care practitioner. The health of migrant children depends greatly on factors intrinsic to the migration process (Box 1) as well as social determinants of health such as housing and education (2). Country of origin Personal genetics/health characteristics Economic/political/social environment Reason for migration Ability to choose accepting country Process/experience of migration itself Policy differences Migrant status Presence or absence of ‘community of support’ Racial discrimination It is crucial for health professionals to understand the backgrounds of children who are new to Canada. Although each story of migration is unique, there are many experiences of loss that can negatively affect an immigrant child or family's migration process and adaptation, which can ultimately affect physical and mental health. These potential losses include social status, friends or family, and familiar societal systems. Equally important for health professionals is the understanding of how culture influences health. Not only does culture influence an individual's perceptions of health and disease, but it underlies his/her beliefs regarding the causes of disease, how illness and pain are experienced and expressed, from whom they may seek help, and the types of treatment or health promotion acceptable to them. Broadly, children who are new to Canada can be classified as permanent residents (family class, economic immigrants, refugees), temporary residents (foreign workers, students, refugee claimants) and those without official status. For official definitions, the reader is directed to the Citizenship and Immigration Canada reference (3). Children and youth younger than 15 years of age comprise a significant component of Canada's immigrants. Approximately 20% (50,000) of the immigrants to Canada each year are children and youth younger than 15 years of age. Approximately 15% of all immigrant children and youth new to Canada are refugees, and approximately 1500 to 2000 are children brought in through international adoption (4). Furthermore, an additional 98,383 international students came to Canada to study in 2011 (5). Although the immigration medical examination is required for permanent residents, it only assesses “…danger to public health, danger to public safety, and excessive demand on health or social services” (6), and not the health of the child. A urinalysis is performed in children five years of age and older, a chest x-ray for children 11 years of age and older, and HIV testing for children 15 years of age and older. Many studies have replicated the observation of the healthy immigrant effect, in which immigrants on arrival are healthier than native-born citizens (7). This effect diminishes over time with settlement (8,9). Even within the same family, health is dynamic and is affected by acculturation and to what extent people travel abroad to visit friends and relatives (10). Furthermore, health in populations new to Canada is not homogeneous. Consider the following contrasting stories: A brother and sister come to Canada from a cosmopolitan city in Eastern Europe. Their mother is a doctor, and their father a lawyer. The parents organized and self-financed the entire immigration process and emigrated solely to provide a better life to their children (11). Two newcomer siblings, a boy and a girl, come to Canada from the mountains of Burma, where they spoke Chin. Their mother is illiterate. Forced into hiding with their mother, the children had to watch their father being beaten to death before they were able to flee to a refugee camp on the Thai border. They did not attend school in the refugee camp (11). These two different sibling pairs demonstrate the diverse intrinsic migration factors that will affect their health and experience of life in Canada. Viewing all migrants to Canada with the same lens, disregarding their history and trajectory, is simplistic. One size does not fit all. Income and its distribution, early child development and health care services are disproportionally affected in some subgroups of migrants to Canada (12). According to one expert: The social exclusion of recent immigrants to Canada is well documented. Their unemployment rates are higher (6.7% for Canadian-born workers, 7.9% for all immigrants, and 12.1% for recent immigrants) and their labour force participation is lower (80.3% for Canadian-born workers, 75.6% for all immigrants, and 65.8% for recent immigrants). Social exclusion creates the living conditions and personal experiences (eg. segregation, lack of affordable housing, food and income insecurity etc.) that endanger health. Social exclusion also creates a myriad of educational and social problems. It creates a sense of powerlessness, hopelessness and depression that further diminish the possibilities of inclusion in society (13). A 10-year-old Sudanese girl lived for three years as the less-cared-for child of an aunt who had four other children. Her mother was a Sudanese journalist who had been persecuted and jailed after having written politically sensitive articles in a national newspaper. One night her mother suddenly reappeared and took the child under the cover of night. They walked all night and slipped across the border. Once across the border, they lived in a refugee camp for two years, facing some difficulties because they had no male family member to protect them. Eventually, with the assistance of the United Nations High Commissioner for Refugees and the Canadian government, they successfully made their way to Canada as government-assisted refugees. The mother has since been diagnosed with post-traumatic stress disorder, and although she is being treated, she has difficulty functioning and adapting to life in Canada. The girl quickly became the mother's interpreter and caregiver. She appeared well-adapted, did well in school, was motivated to help her mother, smiled and spoke easily, and was very intent on learning English. However, no one thought to ask how she had dealt with her own story (14). This vignette highlights the range of barriers – including individual health care provider behaviour and system characteristics – that can change the health care trajectory of a child in Canada. The many factors that can compromise the quality of care include: Assumptions/biases of health care providers Lack of knowledge of diseases and cultural interpretation of diseases Differing roles and responsibilities of family members Ethnocultural differences Fear/mistrust of authority Health care rationing (complex health insurance eligibility/ entitlement) Lack of familiarity with the health care system Financial barriers Language barriers Literacy and education Magnified effect of social determinants of health (15). The evidence-based clinical guidelines for immigrants and refugees recently published by the Canadian Collaboration for Immigrant and Refugee Health (16) are an exhaustive, evidence-based synthesis of the guidelines for clinical preventive manoeuvers in 20 different health care areas affecting immigrants and refugees. The literature used in determining the high-quality evidence synthesis was predominantly adult-based, leading to the concern that the recommendations may not be as applicable to children and youth. The Canadian Paediatric Society recognized this limitation and undertook a large-scale project, funded by Citizenship and Immigration Canada, to revise its book Children and Youth New to Canada: A health care guide, published in 1999 (17). In a future issue of Paediatrics & Child Health, we will introduce a new resource, which will be an open access, bilingual website for health professionals called Caring for Kids New to Canada. Transparent guidelines with practical recommendations and resources will enable health care providers to optimize care to newcomers with regard to culture and health, health promotion, mental health and development, assessment and screening, medical conditions and issues beyond the clinic. Although many migrant health situations are challenging, with the required knowledge, skills, understanding and advocacy opportunities, the interaction can become rewarding for both the patient and the health care practitioner.

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