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ObjectiveProtracted international conflict has seen escalating numbers of displaced and resettled Syrian and Iraqi refugees, raising concerns for their health and well-being. This paper describes the demographic and clinical profiles of recently resettled Syrian and Iraqi refugee children and adolescents across physical, psychosocial, developmental and educational domains using standardised multidisciplinary assessments.DesignA cross-sectional observational study was undertaken of initial specialist paediatric multidisciplinary Refugee Health Service assessments completed at the tertiary paediatric hospital (Western Australia) between June 2015 and September 2019.ResultsThree hundred and twenty-seven children and adolescents (264 Syrian, 63 Iraqi) were assessed following resettlement. Witnessed trauma (86%) and disclosed adversity (median Refugee Adverse Childhood Experiences score 3, range 1–14) were universally high. Almost all patients had health issues identified across physical (99%), psychosocial (76%) and developmental/educational (75%) domains. Interrupted education (65%) and death of a family member (16%) were significantly associated with psychological morbidities. Common comorbidities included dental caries (78%), non-infectious disease (76%), vitamin D deficiency (72%), malnutrition (46%; overweight/obesity 23%), and psychological (32%; post-traumatic stress disorder 4.3%) and developmental (9.5%) concerns. Emerging and alarming child protection concerns were prevalent (17%), with females demonstrating especially high risks.ConclusionThis is the largest comprehensive study demonstrating the complex and cross-dimensional health needs and specific vulnerabilities of resettled Syrian and Iraqi refugee children and adolescents. Early comprehensive standardised multidisciplinary paediatric assessments, and culturally safe, trauma-informed interventions and follow-up are required to optimise resettlement outcomes and promote well-being.

Since the 2016 release of the Australian Guide to the Diagnosis of Fetal Alcohol Spectrum Disorder (FASD), considerable progress has been made in the identification and diagnosis of the disorder. As part of a larger process to review and update the Guide, the aim of this study was to identify review priorities from a broad range of stakeholders involved in the assessment and diagnosis of FASD. Sixty-two stakeholders, including healthcare practitioners, researchers, other specialists, individuals with cultural expertise, lived experience and consumer representatives completed an online survey asking them to describe up to five priorities for the review of the Australian Guide to the Diagnosis of FASD. A total of 267 priorities were described. Content analysis of responses revealed priority areas relating to diagnostic criteria (n = 82, 30.7%), guideline content (n = 91, 34.1%), guideline dissemination (n = 15, 5.6%) and guideline implementation (n = 63, 23.6%). Other considerations included prevention and screening of FASD (n = 16, 6%). Engaging stakeholders in setting priorities will ensure the revised Australian Guide can be as relevant and meaningful as possible for the primary end-users and that it meets the needs of individuals with lived experience who will be most affected by the diagnosis.

The first study to investigate the prevalence of fetal alcohol spectrum disorder (FASD) within an Australian juvenile detention centre has identified the highest known prevalence of FASD among a justice-involved population worldwide. However, there has been limited investigation into the capacity of the custodial workforce to identify and manage young people in Australian detention centres with FASD or other neurodevelopmental impairment (NDI), and no published interventions aiming to develop environments appropriate for those with FASD in justice settings. Using the Template for Intervention Description and Replication checklist, this study describes the conception, implementation and evaluation of a training intervention aiming to upskill the custodial workforce in the management of youth with FASD and NDI; 117 staff participated in the intervention, and 109 completed pre- and post-intervention surveys. Improvements were seen across almost all knowledge and attitude items, and the intervention was considered highly necessary, appropriate and valuable by the workforce.

Aboriginal and Torres Strait Islander young people are over-represented in Australian youth detention centres and the justice system. In contrast to deficit-focused approaches to health and justice research, this article engages with the hopes, relationships and educational experiences of 38 detained youth in Western Australia who participated in a study of screening and diagnosis for fetal alcohol spectrum disorder. We report on a qualitative study that used a 'social yarning' approach. While the participants reported lives marred by substance use, crime, trauma and neurodevelopmental disability, they also spoke of strong connections to country and community, their education experiences and their future goals. In line with new efforts for a 'positive youth justice' and extending on models of recovery capital, we argue that we must celebrate success and hope through a process of mapping and building recovery capital in the justice context at an individual and institutional level. Refereed/Peer-reviewed

Aim To compare hospital admission patterns after the first year of life in Australian children with developmental disabilities and children with no known disability, according to maternal country of birth and Indigenous status. Method This was a retrospective cohort study using linked data across health, disability, and hospital admission databases. The study investigated 656 174 children born in Western Australia between 1983 and 2008 with a total of 1 091 834 records of hospital admissions. Results Children with no known disability born to Indigenous mothers had the highest rate of hospital admissions compared to children of non-Indigenous mothers. Children of foreign-born mothers from low-income countries had the highest rate of hospital admissions if disability was present. Children with cerebral palsy (CP) with or without associated intellectual disability had the highest rate of hospital admissions among children with developmental disability, especially if mothers were foreign-born. Interpretation Children with CP and intellectual disability, particularly from minority backgrounds (Indigenous Australian and foreign-born mothers), were at higher risk of being admitted to hospital after the first year of life. What this paper adds Hospital admissions in Australian children with and without disabilities differ according to maternal country of birth. Hospital admission rates in children without a developmental disability were greatest for Australian-born Indigenous children. Disabled Australian-born children of foreign-born mothers from low-income countries had the highest hospital admission rates. Hospital admission risk was greatest for Australian-born children with cerebral palsy, especially if mothers were foreign-born.

Little is known about the challenges non-custodial youth detention centre staff face supporting young people with foetal alcohol spectrum disorder (FASD). We undertook qualitative inquiry to identify and describe the perspectives of non-custodial staff detention staff regarding the value of an FASD prevalence study. Data were collected using semi-structured interviews and focus groups and analysed using thematic network analysis. Staff held few concerns about the prevalence study and its impact on participating young people; however, they identified barriers related to study processes, and practices and culture within their workplace, which hindered gaining maximum benefit from the research and its findings. Refereed/Peer-reviewed

Materials and Methods: Participants completed the Movement Assessment Battery for Children-2 (MABC-2), Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI) including its associated subtests, and a handwriting screen. Results: Ninety-nine young people (n=47 PAE; n= 36 FASD) with a mean age of 16 years were assessed. There was an association between a FASD diagnosis and lower scores on the VMI (p=0.005). Participants with FASD and PAE had higher impairment levels on the VMI compared to the No-PAE group. Mean MABC-2 scores were within age expected levels across all groups. More fine motor skill difficulties were observed compared to gross motor skill difficulties. Handwriting skills were below age expected levels in 84% of participants. Those in the PAE and FASD groups had more difficulty with letter formations and spatial awareness. Conclusions: Visual motor integration and handwriting skills were often impaired in this population. Lower VMI scores were more prevalent in participants diagnosed with FASD, and therefore should be routinely assessed as part of a diagnostic assessment. Assessment of fine and gross motor skills enabled recommendations for intervention support that address deficits and build upon strengths. Further research is needed to confirm these results using larger populations, and to investigate possible confounding factors associated with high VMI and handwriting difficulties in this population.

Background Prenatal alcohol exposure (PAE) can result in permanent disability, including physical, neurodevelopmental, and cognitive impairments, known as fetal alcohol spectrum disorder (FASD). Individuals with FASD are more likely to engage with the law, including being placed in detention, than individuals without FASD. Young people who were sentenced to detention participated in a FASD prevalence study in Western Australia. The diagnosis of FASD requires a multidisciplinary assessment and confirmation of maternal alcohol consumption during pregnancy. Obtaining accurate assessment of PAE for young people participating in the study was challenging. Methods An interview with the birth mother or other responsible adult for young people sentenced to detention in Western Australia was conducted as part of the FASD assessment. The Alcohol Use Disorders Identification Test consumption subset (AUDIT‐C), other relevant questions, and documentary evidence were used to assess PAE. PAE was categorized according to the Australian Guide to the Diagnosis of FASD: no PAE reported, confirmed or confirmed high‐risk, or unknown. Results Among the 101 participants, information on PAE was unable to be obtained for 13 (13%) young people. Of the remaining 88 participants with information of PAE, 41 reported no PAE and 47 had confirmed PAE. Conclusions Accurately assessing prenatal alcohol consumption is challenging in any setting, but it is exceptionally challenging when assessed 13 to 17 years retrospectively as part of a FASD assessment for a young person sentenced to detention. Recording and recoding detailed qualitative responses was required to provide an accurate assessment of PAE using the AUDIT‐C. Standardized recording of PAE in antenatal and birth records would facilitate later assessments for FASD and provide opportunities for advice and support for women who continue to drink during pregnancy., This study discusses the challenges of assessing prenatal alcohol exposure (PAE) as part of a fetal alcohol spectrum disorder assessment for young people sentenced to detention in Western Australia. PAE was assessed using the AUDIT‐C with the birth mother or another responsible adult who was present during the mother's pregnancy. Recording and recoding detailed qualitative responses was required to provide an accurate assessment of PAE, as recalling prenatal alcohol consumption retrospectively, 13 to 17 years post‐pregnancy, is challenging.

Nutritional deprivation, inadequate diet and food insecurity are common refugee experiences. The growth and nutritional status of paediatric refugees following resettlement in developed countries and the related interplay with socio-economic factors remain less defined; this study aims to describe these features.Standardised dietary, medical and socio-demographic health assessments of new refugee patients attending a multidisciplinary paediatric Refugee Health Service (RHS) in Western Australia between 2010 and 2015 were analysed.Demographic data from 1131 paediatric refugees are described (age 2 months to 17.8 years). The majority experienced socio-economic disadvantage, had limited parental education and required interpreters. Nutritional deficiencies were common but varied across ethnicities: iron deficiency (ID) (12.3%), anaemia (7.3%) and inadequate dairy intake (41.0%). A third of children (32.6%) did not consume meat. Infant breastfeeding was sustained (77.8%) in infants12 months. Prolonged breastfeeding (44.9% aged 12-24 months) was associated with an increased risk of ID (odds ratio 4.0, 95% confidence interval 1.4-11.6). Median body mass index increased significantly for those24 months between referral and RHS assessment (median period 1.8 months). Overall, 27.1% required additional formal dietetic follow-up, with higher nutritional concerns in refugee children24 months compared to older patients.Identification of frequent post-settlement nutritional concerns has been captured through structured multidisciplinary paediatric health screening. Specific screening for socio-economic influencing factors, including education, poverty and food insecurity, during refugee clinical assessments is recommended. Development of targeted, culturally appropriate parental education resources and interventions may improve management following resettlement. Longitudinal research assessing resettlement growth trajectories is required.

Little is known about the significance of cultural differences to how caregivers receive a diagnosis of neurodevelopmental disability. As part of a Fetal Alcohol Spectrum Disorder prevalence study among sentenced, detained youth, our qualitative study explored the experiences of diagnostic assessment among detained young people and their caregivers. We present findings from the perspectives of caregivers. In conversation with the sociology of diagnosis literature, we present vignettes of three Aboriginal and two non-Aboriginal caregivers' experiences of the diagnostic assessment process. We found that Aboriginal caregivers conceptualised their children's diagnosis and ongoing management in the context of their family networks and community. In contrast, non-Aboriginal caregivers focused on how the diagnosis would affect their child and interactions with various institutions including healthcare systems and schools. Caregivers' engagement with diagnostic reports and resources also followed cultural lines. Reflections on intergenerational drinking were voiced by Aboriginal caregivers, who expressed shame at receiving diagnosis. These findings advance our appreciation of cultural difference in receiving a diagnosis, the examination of which is in its nascent stages. We also suggest ways to mitigate harm from a stigmatising diagnosis and soften the well-established effects of medical dominance over the process of defining a person's capacity and status.

Undertaking research with young people presents an array of methodological challenges. We report the findings from a qualitative study that took place alongside a fetal alcohol spectrum disorder (FASD) prevalence study among detainees in Australia. Of 38 participants, 27 were Aboriginal youth. Interviews were conducted using “social yarning” and “research topic yarning,” an Indigenous research method which allows for data collection in an exploratory, culturally safe way. A complex interplay emerged between social yarning and research topic yarning which provided a space to explore responsively with participants their experiences of FASD assessments. Flexibility, including language adaptation and visual descriptions about assessments, was utilized to assist participants recall and retell their experiences. There were, however, challenges in gathering data on the assessment experiences of some participants. We describe how employing a “yarning” method for collecting data could benefit children and young people undergoing neurodevelopmental assessments in the future. Refereed/Peer-reviewed

ObjectiveTo investigate the medical needs and socioeconomic determinants of health among adolescent refugees resettling in Western Australia.DesignComprehensive medical and socioeconomic health data of resettling adolescent refugees aged 12 years and above attending a Refugee Health Service over a 1-year period were analysed.ResultsMedical records of 122 adolescents, median (range) age of 14 (12–17) years, were reviewed. Socioeconomic vulnerabilities included dependence on government financial support (50%), housing issues (27%) and child protection service involvement (11%). Medical concerns included non-communicable disorders (85%), infectious diseases (81%), nutrition/growth (71%) and physical symptoms of non-organic origin (43%). One quarter (27%) of female adolescents had sexual/reproductive health issues. A median (range) of 5 (2–12) health concerns were identified for each adolescent with 49% requiring referral to subspecialty services.ConclusionResettling adolescent refugees are socioeconomically vulnerable with a range of medical issues that frequently require additional subspecialty health referrals.

Background Fetal Alcohol Spectrum Disorder (FASD) is a condition caused by prenatal alcohol exposure and characterised by lifelong physical, behavioural and cognitive abnormalities. Primary disabilities, such as impairment in memory, attention, cognition, language, executive function, and adaptive function, can lead to young people with FASD becoming engaged with the justice system. Little is known about the extent of FASD in youth detention in Australia, or of the capacity custodial staff have to manage and support young people with FASD. In tandem with a study assessing the prevalence of FASD among youth in detention in Western Australia (WA), this study aims to establish the current knowledge, attitudes, experiences and practices regarding FASD and other neurodevelopmental impairments among youth custodial officers in order to develop training resources for this workforce. Methods We invited youth custodial officers in the only youth detention centre in WA to participate in an online or hardcopy survey. The survey was developed following extensive consultation with the workforce and investigated their knowledge, attitudes, experiences and practices relating to FASD and other neurodevelopmental impairments. This included experience working with young people with FASD and other impairments, and attitudes towards relevant training. Results 112 youth custodial officers (51% of the youth custodial workforce) completed the survey. While many respondents had heard of FASD (77%) and understood it is relevant to the justice system (74%), limited in-depth FASD knowledge existed. Many respondents were unsure or unaware that FASD is permanent brain damage (53%) and cannot be outgrown (57%). Respondents were infrequently informed if a young person in detention had a diagnosis of FASD. Almost all custodial officers indicated motivation to complete training to further understand FASD (92%) and other neurodevelopmental impairments (94%), with particular interest in the application of management strategies appropriate for affected young people. Conclusions A lack of specific knowledge, inadequate training to recognise and manage young people with neurodevelopmental impairments, and inconsistent information-sharing processes reduce the ability of the custodial workforce to care for young people with FASD and other neurodevelopmental impairments. These findings have supported the development and evaluation of training resources targeting the specific needs and requests of the WA youth custodial workforce, and this is now underway.

This paper systematically reviewed the literature from 2002 to 2016 describing the risks of autism spectrum disorder, intellectual disability and attention deficit hyperactivity disorder in children of immigrant and refugee backgrounds. Compared to children of non-immigrant mothers, 10 studies found increased risk of autism and intellectual disability and four studies found increased risk of autism without identifying concomitant intellectual disability. Very high risks were observed if the mother’s country of birth was a developing country or region. One study found higher risk of attention deficit hyperactivity disorder in a sample of children who were refugees. Children of immigrant and refugee backgrounds from developing countries had greater risks of a neurodevelopmental disorder compared to their peers whose mother was locally born.

ObjectiveAdolescent refugees encounter traumatic stressors and are at risk of developing psychosocial health problems; limited research data exist internationally. This study aims to identify health risk behaviours among adolescent refugees resettling in Western Australia and assess the feasibility of using a standardised adolescent health questionnaire for this purpose.DesignRefugees aged 12 years and above attending a tertiary Refugee Health Service (RHS) were recruited over 12 months. Sociodemographic data were collected. Psychosocial assessments based on the ‘Home, Education/Eating, Activities, Drugs, Sexuality, Suicide/mental health’ (HEADSS) framework were undertaken utilising interpreters where required. Health concerns identified were managed through the RHS.ResultsA total of 122 adolescents (20 ethnicities) participated; 65% required interpreters. Median age (range) was 14 (12–17) years. Most (80%) had nuclear family separation. Almost half (49%) had a deceased/missing family member. A third (37%) had lived in refugee camps and 20% had experienced closed detention. The median time (range) since arrival in Australia was 11 (2–86) months. Every adolescent had at least one health concern identified during the psychosocial assessment. Frequency of health concerns identified in each domain were 87% for home, 66% for education, 23% for eating, 93% for activities, 5% for drugs, 88% for sexuality and 61% for suicide/mental health. Most adolescents (75%) required intervention, consisting of counselling for health risk behaviours and/or referral to health or community services.ConclusionIt is feasible to use a standardised adolescent health questionnaire to identify health risk behaviours among a cohort of ethnically diverse adolescent refugees. Use of the questionnaire identified a large burden of psychosocial health issues requiring multidisciplinary intervention.

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 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.

An increased prevalence of autism spectrum disorder (ASD) among children of immigrant backgrounds has been observed but clinical profiles are rarely compared. Diagnostic data from children with ASD notified to the Western Australian Register for Autism Spectrum Disorders were analysed according to maternal-race ethnicity and country of birth. A total of 4776 children aged between 0 and 18 years diagnosed with ASD from 1999 to 2017 were included. Those born to immigrant mothers from lower income countries were younger at the time of diagnosis, had an increased risk of intellectual disability and poorer presentations in the social and communication domains. Further work is required to understand environmental influences that may affect children born to immigrant mothers and to improve monitoring and assessments.

Adolescent refugees resettling in Australia are a vulnerable and marginalised population. Dedicated research to help better understand their health-care needs remains scarce. There are multiple complexities which may deter health professionals from conducting research with this population. Health-care system barriers, such as lack of adolescent- and refugee-specific health-care services, complicate comprehensive data collection. Limited investigator knowledge pertaining to culturally appropriate research in a population with limited English proficiency or a history of trauma can have an impact on adolescent participation and retention in research studies. Additional ethical and legal issues relating to adolescent consent and confidentiality, which include suicidality and physical or sexual abuse, can arise during research and cause potential harm to adolescents if not managed appropriately. This article highlights current knowledge and understanding relating to these issues along with recommendations to address barriers and safeguard adolescents, with the aim of promoting high-quality research that will benefit resettling adolescent refugees.

Supplemental material, QHR_SUPPLEMENTAL_FILE for Disability “In-Justice”: The Benefits and Challenges of “Yarning” With Young People Undergoing Diagnostic Assessment for Fetal Alcohol Spectrum Disorder in a Youth Detention Center by Sharynne Hamilton, Tracy Reibel, Sarah Maslen, Rochelle Watkins, Freeman Jacinta, Hayley Passmore, Raewyn Mutch, Melissa O’Donnell, Valerie Braithwaite and Carol Bower in Qualitative Health Research

Table S2. High income countries. (PDF 243 kb)

Asylum seekers (ASs) report high rates of trauma and difficulty accessing health and educational services. This study aims to ascertain the needs of paediatric ASs managed by the tertiary Western Australian paediatric Refugee Health Service (RHS), including demographic features, the range of health and psychosocial issues and ongoing management challenges.An audit of multidisciplinary RHS assessments, health records and hospital admissions for new AS patients (16 years) between July 2012 and June 2016 was undertaken.Records for 110 ASs were reviewed (mean age 6 years, standard deviation 4.72 years). Multiple issues (medical, psychological, developmental, educational) were identified after the first tertiary assessment (median 4, interquartile range (IQR) 3-6) compared to referral sources (median 1, IQR 0-2, P 0.001). The median number of issues per child at audit completion was 6 (IQR 4-7, P 0.001). Multiple refugee adverse childhood experiences were identified, with all experiencing3 (median 4, IQR 4-5). Most had detention experience (107/110, 97.2%), family separation (91/108, 84%) and interrupted education (41/46, 89.2%). The median duration of detention was 7 months (IQR 3-12.5 months) at time of initial review across multiple sites (median 2, IQR 1-3 locations). High rates of hospital interaction were evident, with 45.4% requiring hospital admission and 36% presenting to the emergency department. The median number of outpatient appointments attended per child was 5 (IQR 2-8). Parental and child mental health concerns were identified in 53.6 and 46.3%, respectively.Paediatric ASs have complex trauma backgrounds with exposure to multiple adverse events within disrupted family units. The majority of Western Australian ASs assessed demonstrated negative health or education sequelae compounded by detention not previously identified prior to comprehensive paediatric review. Our data support the urgent removal of ASs from held detention. Ongoing holistic assessment and management engaging multidisciplinary trauma-informed paediatric refugee services to optimise health and well-being is recommended.

Adolescent refugees are a vulnerable population with complex healthcare needs that are distinct from younger and older age groups. Physical health problems are common in this cohort with communicable diseases being the focus of attention followed by an emphasis on nutritional deficiencies and other chronic disorders. Adolescent refugees have also often experienced multiple traumatic stressors and are at a heightened risk of developing mental health problems. Navigating these problems at the time of pubertal development adds further challenges and can exacerbate or lead to the emergence of health risk behaviours. Educational difficulties and acculturation issues further compound these issues. Adolescents who have had experiences in detention or are unaccompanied by parents are particularly at risk. Despite a constantly growing number of adolescent refugees resettling in high-income countries, knowledge regarding their specific healthcare needs is limited. Research data are largely extrapolated from studies conducted within paediatric and adult cohorts. Holistic management of the medical and psychological issues faced by this group is challenging and requires an awareness of the socioeconomic factors that can have an impact on effective healthcare delivery. Legal and ethical issues can further complicate their management and addressing these in a culturally appropriate manner is essential. Early identification and management of the healthcare issues faced by adolescent refugees resettling in high-income countries are key to improving long-term health outcomes and future healthcare burden. This review article aims to increase knowledge and awareness of these issues among paediatricians and other health professionals.

IntroductionImmigration detention has a profound and negative impact on the physical health, mental health, development and social-emotional well-being of children, adolescents and their families. Australian clinicians will report results from detailed health and well-being assessments of asylum seeking children and adolescents who have experienced prolonged immigration detention.Methods and analysisThis is a national, multicentre study with a longitudinal cohort design that will document health and well-being outcomes of the children and adolescents who have been detained in offshore detention on the remote island of Nauru. Outcome measures will be reported from the time arrival in Australia and repeated over a 5-year follow-up period. Measures include demographics, residency history and refugee status, physical health and well-being outcomes (including mental health, development and social-emotional well-being), clinical service utilisation and psychosocial risk and protective factors for health and well-being (eg, adverse childhood experiences). Longitudinal follow-up will capture outcomes over a 5-year period after arrival in Australia. Analysis will be undertaken to explore baseline risk and protective factors, with regression analyses to assess their impact on health and well-being outcomes. To understand how children’s outcomes change over time, multilevel regression analysis will be utilised. Structural equation modelling will be conducted to explore the correlation between baseline factors, mediational factors and outcomes to assess trajectories over time.Ethics and disseminationThis research project was approved by the Sydney Children’s Hospitals Network Human Research Ethics Committee. Subsequent site-specific approvals have been approved in 5 of the 11 governing bodies where the clinical consultations took place. In order to ensure this research is relevant and sensitive to the needs of the cohort, our research team includes an asylum seeker who has spent time in Australian immigration detention. Results will be presented at conferences and published in peer-reviewed Medline-indexed journals.

Background While studies confirm high prevalence of language disorder among justice-involved young people, little is known about the impact of Fetal Alcohol Spectrum Disorder (FASD) on language among this population. It is also not clear how language skills vary according to language diversity in Australian youth justice settings, where a disproportionate number of justice-involved youth are Aboriginal and may not speak Standard Australian English (SAE) as their first language. Language skills are important to understand, as language disorder and language difference can lead to a mismatch between the communication skills of a young person and the communication skills of the justice workforce with whom they are communicating. In the highly verbal environments that are common to justice systems, language disorder and language difference may result in a young person misunderstanding legal information and expectations placed on them and not being adequately understood by the justice workforce. Methods This study examined the language skills of 98 young people sentenced to detention in Western Australia (WA), who participated in a cross-sectional study examining the prevalence of FASD. Language skills assessed using standardised and non-standardised tasks were analysed by the three major language groups identified: speakers of SAE, Aboriginal English and English as an additional language. Results We identified rich diversity of languages, and multilingualism was common. Most young people for whom English was not their first language demonstrated difficulties in SAE competence. Further, nearly one in two young people were identified with language disorder – over half of whom had language disorder associated with FASD. Conclusions This study has documented language diversity and the prevalence of language disorder associated with FASD among a representative sample of youth sentenced to detention in WA. Results underscore the need for the justice workforce to consider language difference when working with justice-involved youth, as well as language disorder and FASD. The findings also demonstrate the need for speech pathology to be embedded as core service in youth justice systems, working in collaboration with local cultural and language advisors and accredited interpreters. This can better enable appropriate identification of and response to communication and associated rehabilitation needs of young people navigating youth justice systems.

Objectives To evaluate the prevalence and risks of developmental disability (autism spectrum disorder, intellectual disability, and cerebral palsy) in Western Australian children of different groups of foreign-born women. Study design Western Australian population-based linked data of 764 749 singleton live births from 1980 to 2010 were used to compare disability outcomes among children of foreign-born, Australian-born non-Indigenous, and Indigenous women. The risk of disability was assessed using multinomial logistic regression. Results Overall, the prevalence of any disability was lowest for the children of foreign-born mothers. From 1980 to 1996 but not from 1997 to 2010, children born to mothers from foreign-born low-income countries had an increased relative risk of autism spectrum disorder with intellectual disability, and children born to foreign-born mothers from upper-middle-income countries had an increased risk of cerebral palsy with intellectual disability. After adjusting for smoking, the relative risks of intellectual disability and cerebral palsy with intellectual disability were markedly decreased in children of Australian-born Indigenous mothers. Conclusions Although we did not find among children born to foreign-born women an increased prevalence across all the measured developmental outcomes, we did observe an increased risk of autism spectrum disorder with intellectual disability and cerebral palsy with intellectual disability for mothers of some foreign-born groups. Our findings related to smoking in the Indigenous population underscore its possible role on the causal pathway to intellectual disability. Maternal migration is considered a factor on the causal pathway to intellectual disability. Maternal migration may be either a risk or a protective factor on the causal pathway to developmental disabilities and the direct role of migration is inconclusive in our study.

Aim Play is vital to children's development, health and resilience. Play modulates cognitive, emotional and social well-being. Children constitute approximately half of all humanitarian refugee entrants resettled in Australia. Refugee children are commonly victims and witnesses of war and persecution, living across resource-poor environs during transit. Little is known about the effects of refugee migration on play. This study explores how refugee children engaged in play pre-migration (in their home country) and post-migration (Australia). Methods Refugee children attending the Refugee Health Clinic of a tertiary children's hospital were invited to complete a qualitative descriptive study of play. The children were asked to draw how they played pre- and post-migration. Drawings were analysed for (i) the presence of play; (ii) location of play; and (iii) drawing detail. Results Nineteen refugee children were recruited (mean age 8.5 years ± standard deviation 6.4 months). Significantly fewer children drew play pre- versus post-migration (11/19, 58% vs. 18/19, 95% P < 0.03). Girls had greater comparative changes in play with migration (pre: 2/8, 25% vs. post: 7/8, 87%, P = 0.06), trending to significance. Of those children who drew play, almost all drew playing outside (pre-migration: 10/11, 90.9%; post-migration: 17/18, 94.4%). Drawings showed equivalent detail pre- and post-migration. Conclusion Resettled refugee children, especially girls, demonstrated limited play pre-migration, with higher levels of engagement post-resettlement. Facilitating opportunities for variety of play may strengthen positive resettlement outcomes for children and parents. Larger longitudinal studies examining play in refugee children and associations with physical, development and psychological well-being are warranted.

Aim There is increasing attention on fetal alcohol spectrum disorders (FASD) in Australia, but there are limited data on their birth prevalence. Our aim was to report on the birth prevalence of FASD in Western Australia. Methods Data on notified cases of FASD born in Western Australia 1980–2010 were identified from the Western Australian Register of Developmental Anomalies. Tabulated denominator data were obtained from the Midwives Notification System. Prevalence rates per 1000 births were calculated by demographic variables. Prevalence ratios (PRs) and 95% confidence intervals (CIs) of Aboriginal compared with non-Aboriginal prevalence rates were calculated. PRs were also calculated to compare rates for births 2000–2010 with 1980–1989. Results Two hundred ten cases of FASDs were identified: a birth prevalence of 0.26/1000 births (95% CI 0.23–0.30). The majority of cases reported were Aboriginal (89.5%), a rate of 4.08/1000, compared with 0.03/1000 in notified non-Aboriginal cases, giving a PR of 139 (95% CI 89–215). The prevalence of FASD in 2000–2010 was over twice that in 1980–1989 for both Aboriginal (PR 2.37; CI 1.60–3.51) and non-Aboriginal (PR 2.13; CI 0.68–6.69) children. Conclusions There has been a twofold increase in FASD notifications in Western Australia over the last 30 years. Population surveillance data such as these are valuable in advocating for and monitoring the effectiveness of preventive activities and diagnostic and management services.

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 children16 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.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.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, age10 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.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.

Aim: Children account for approximately half of the humanitarian refugees currently resettled in Australia. A multidisciplinary refugee health clinic (RHC) was established at the tertiary paediatric hospital in Western Australia to address burgeoning referrals of refugee children following voluntary post-resettlement health assessment. The aim of this study is to describe the epidemiology of common conditions in resettled paediatric refugees attending a tertiary multidisciplinary RHC. Methods: Standardised clinical and demographic data were routinely collected during first visit clinical assessment at the RHC. Descriptive analyses of the first 1026 children are presented. Results: One thousand twenty-six refugee children from 475 families and over 30 different ethnicities were described. Nine hundred twenty-seven (90.4%) children were referred following post-resettlement health assessment. Median age was 7.8 years. Common reasons for referral were: vitamin D deficiency (400, 39%), iron deficiency (226, 22%), positive Helicobacter pylori serology (206, 21%), poor appetite (175, 17.1%), and schistosomiasis (170, 16.6%). Comorbidities identified by the RHC included tinea capitis and corporis (297, 28.9%), and dental disease (228, 22.2%). Two-thirds of children (680, 66.3%) had at least one abnormal finding on clinical examination that identified pathologies that were not evident from the history. Three hundred eighty children (37%) were referred to sub-specialty services. Conclusions: A multidisciplinary paediatric RHC facilitated and strengthened the management of refugee children with multiple and complex health needs. Evidenced–based culturally appropriate methods to identify developmental delay, psychological morbidity and quantify social needs of this vulnerable population remain uncertain. These findings are relevant to the continuing evolution of paediatric refugee health care in Australia and other high income countries.

Background Prenatal alcohol exposure is an important modifiable cause of adverse fetal outcomes during and following pregnancy. Midwives are key providers of antenatal care, and it is important to understand the factors which influence their ability to provide appropriate advice and support to women about alcohol use in pregnancy. The main aim of this study was to develop a psychometrically valid scale to evaluate midwives’ beliefs about assessing alcohol use during pregnancy. Method A self-administered questionnaire was developed to evaluate midwives’ beliefs about assessing alcohol use during pregnancy, including beliefs about positive and negative consequences of asking about alcohol use, and beliefs about capacity to assess alcohol use. The questionnaire was sent to 245 midwives working for a state-wide country health service in Western Australia. Exploratory factor analysis was used to identify the latent constructs assessed by the 36 belief items and provide initial construct validation of the Asking About Alcohol (AAA) Scale. Results Of the 166 (67.8 %) midwives who responded to the survey, 160 (96.4 %) completed one or more of the belief items and were included in this analysis. Factor analysis identified six subscales which assessed beliefs about discomfort, capacity, effectiveness, role, trust and knowledge. Midwives held the most positive beliefs about their capacity to ask and the effectiveness of asking about alcohol use, and the least positive beliefs about women’s knowledge about alcohol use and discomfort associated with asking about alcohol use in pregnancy. Midwives’ beliefs about their role and the effectiveness of asking were most strongly associated with the intention to ask all pregnant women about alcohol use during pregnancy (r = −0.59, p

ObjectivesTo estimate the prevalence of fetal alcohol spectrum disorder (FASD) among young people in youth detention in Australia. Neurodevelopmental impairments due to FASD can predispose young people to engagement with the law. Canadian studies identified FASD in 11%–23% of young people in corrective services, but there are no data for Australia.DesignMultidisciplinary assessment of all young people aged 10–17 years 11 months and sentenced to detention in the only youth detention centre in Western Australia, from May 2015 to December 2016. FASD was diagnosed according to the Australian Guide to the Diagnosis of FASD.Participants99 young people completed a full assessment (88% of those consented; 60% of the 166 approached to participate); 93% were male and 74% were Aboriginal.Findings88 young people (89%) had at least one domain of severe neurodevelopmental impairment, and 36 were diagnosed with FASD, a prevalence of 36% (95% CI 27% to 46%).ConclusionsThis study, in a representative sample of young people in detention in Western Australia, has documented a high prevalence of FASD and severe neurodevelopmental impairment, the majority of which had not been previously identified. These findings highlight the vulnerability of young people, particularly Aboriginal youth, within the justice system and their significant need for improved diagnosis to identify their strengths and difficulties, and to guide and improve their rehabilitation.

Exhaled nitric oxide (FENO) may provide a tool for identifying infants at risk of developing allergic disease in childhood. In infants there is no standardized collection technique; however, the easiest method is to measure FENO during tidal breathing. In this study we investigated various methodological issues for tidal breathing (TB) FENO in infants. These included the effect of ambient NO, oral or nasal breathing, sedation, and tidal expiratory flow. Furthermore, we compared TB FENO in 88 infants with and without wheeze. Ambient NO greater than 5 ppb significantly affected FENO. There was no significant difference between NO levels measured during either oral or nasal breathing; however, there was a significant difference between levels collected from infants before and after sedation (P

Background There is little reliable information on the prevalence of fetal alcohol spectrum disorders (FASD) in Australia and no coordinated national approach to facilitate case detection. The aim of this study was to identify health professionals’ perceptions about screening for FASD in Australia. Method A modified Delphi process was used to assess perceptions of the need for, and the process of, screening for FASD in Australia. We recruited a panel of 130 Australian health professionals with experience or expertise in FASD screening or diagnosis. A systematic review of the literature was used to develop Likert statements on screening coverage, components and assessment methods which were administered using an online survey over two survey rounds. Results Of the panel members surveyed, 95 (73%) responded to the questions on screening in the first survey round and, of these, 81 (85%) responded to the second round. Following two rounds there was consensus agreement on the need for targeted screening at birth (76%) and in childhood (84%). Participants did not reach consensus agreement on the need for universal screening at birth (55%) or in childhood (40%). Support for targeted screening was linked to perceived constraints on service provision and the need to examine the performance, costs and benefits of screening. For targeted screening of high risk groups, we found highest agreement for siblings of known cases of FASD (96%) and children of mothers attending alcohol treatment services (93%). Participants agreed that screening for FASD primarily requires assessment of prenatal alcohol exposure at birth (86%) and in childhood (88%), and that a checklist is needed to identify the components of screening and criteria for referral at birth (84%) and in childhood (90%). Conclusions There is an agreed need for targeted but not universal screening for FASD in Australia, and sufficient consensus among health professionals to warrant development and evaluation of standardised methods for targeted screening and referral in the Australian context. Participants emphasised the need for locally-appropriate, evidence-based approaches to facilitate case detection, and the importance of ensuring that screening and referral programs are supported by adequate diagnostic and management capacity.

To assess the effectiveness of alcohol documentation, examining medical correspondence and medical files of patients referred to the State Child Development Service (SCDS) and (ii) To measure the knowledge, attitudes and clinical practice of health practitioners working at the child development service (CDS) in relation to asking about alcohol use in pregnancy.Written documentation for children attending the State Child Development Centre (SCDC) in Western Australia were examined for documentation of alcohol use during pregnancy; a random sample of 40 medical records were examined and all correspondence authored by every paediatrician for the calendar year 2006 (n=210) were reviewed. (ii) A survey was completed of staff at the CDS, to assess their knowledge, attitudes, and clinical practice and their perceived importance of asking about alcohol and other drug use.Review of all written documentation, of both files and paediatric correspondence, found only three letters recording alcohol use in pregnancy; two of the letters recorded the index child displaying stigmata consistent with prenatal alcohol exposure, yet Fetal Alcohol Spectrum Disorders (FASD) were not considered within the concluding differential diagnoses. 56% of responding CDS staff (73% response) agreed it was important to ask about alcohol use when taking a pregnancy history, 20% indicated they routinely asked about alcohol exposure and 35% of staff said they never asked about alcohol use. 60% of the CDS staff completing the survey would welcome a proven technique to ask about alcohol use.There is a gap in clinical practice within this CDS in asking and/or recording information about alcohol use in pregnancy. The majority of CDS staff who completed the survey agreed that asking about alcohol use in pregnancy was important and welcomed a proven technique to do so.

Alcohol exposure in pregnancy can induce a broad range of physical and developmental defects in the child, collectively known as foetal alcohol spectrum disorders (FASD). In Australia, there are proven gaps in our knowledge and practice for recognising and diagnosing FASD. The challenge for the Australian health professional is agreeing on a model for diagnosing and treating FASD. The diagnostic method must be evidence based, sensitive and specific, and account for other exposures during pregnancy and early life events. Training in application of the diagnostic method needs to be readily available in metropolitan and regional Australia. The University of Washington FASD 4-digit diagnostic code fulfils all of these best practice criteria, recommending itself as the method of choice.

The present study investigated the association between reported parental smoking and exhaled nitric oxide fraction ( F eNO ) in young children. In total, 78 children (24 females, mean age 51.3 weeks) were recruited. Fourteen lived with one smoking parent and eight with two smoking parents. F eNO was measured using the modified single-breath technique. Mean±sd F eNO levels were 33.0±18.9, 38.3±15.0 and 48.3±14.7 ppb for children with no, one and two smoking parents, respectively. There was a significant linear trend across the groups and, after controlling for other relevant factors, a significant difference between the groups. In the present study, exposure to environmental tobacco smoke was associated with increased exhaled nitric oxide fraction in young children. Furthermore, there was evidence of a dose–response relationship between childhood exhaled nitric oxide fraction and the number of smoking parents.

The aim of this study was to compare two different methods, tidal breathing (TB) and single-breath (SB), for measuring fractional exhaled nitric oxide (FE NO ) in infants. FE NO was measured in 71 infants with either recurrent wheeze (n=32), recurrent cough (n=16) or no symptoms (healthy, n=23) using both methods. For TB measurements five breaths were collected into a gas sampling bag (off-line reservoir sampling). The SB method was modified from the raised volume rapid thoraco-abdominal technique. Agreement between the two methods was investigated and both methods were used to compare FE NO in infants with and without symptoms. Flow dependence of SB FE NO was demonstrated using two expiratory flows (11 and 40 mL·s −1 ). There was a moderate correlation (r=0.60) but poor agreement between levels using the TB and SB methods. A significant difference in FE NO between healthy children and children with wheeze was found using the SB but not the TB method. Due to lower expiratory flow and reduced nasal nitric oxide contamination the single-breath technique may be more sensitive than the tidal breathing method for detecting differences in exhaled nitric oxide between infants with and without respiratory symptoms.