Refugee and asylum seeking children and young people - guidance for paediatricians

Definitions

Asylum seeker - adult, child, or young person whose request for sanctuary has yet to be processed by the Government. 

UASC (unaccompanied asylum seeking child) - young people who have journeyed to the UK unaccompanied by a parent or legal guardian. They are automatically a Looked After Child, under the care of the Local Authority. They have full entitlement to free NHS care and other public services. NHS charging regulations do not apply to them.

Refugee - adult, child, or young person whose application for asylum has been accepted by the UK government as meeting the definition of refugee in the Refugee Convention, resulting in refugee status documentation. In the UK, refugees are usually granted five years leave to remain as a refugee, after which they need to apply for further leave. 

‘Undocumented’ migrant - a term often used to refer to people who do not have any formal immigration status/leave to remain. People without leave to remain also do not have recourse to public funds.

Limited leave to remain - legal terminology referring to temporary visas. People with limited leave to remain are permitted to stay for up to 10 years, depending on the type of visa, and are required to re-apply for another period of limited leave or for indefinite leave to remain (permanent residency rights) at the end of the time limit. These families have the No Recourse to Public Funds condition applied automatically to their visa in most cases.

Please see the RCPCH position statement and guidance.

General information

The UK received 26,903 asylum applications in the year ending March 2021, of whom 2,044 were unaccompanied children and young people. Iran, Albania and Eritrea were the top three countries from which applications were received.

Further information can be found:

1. UN Refugee Agency (UNHCR UK) Asylum Seekers
2. Refugee Council Refugee and asylum facts
3. UK Government How many people do we grant asylum or protection to

Current processes for asylum seeking children and young people

A young person judged to be under 18 years of age (see below for age assessment), without an adult to care for them, is entitled to the same rights as other looked after children and young people. This includes accommodation, some financial support, education, statutory health assessments, support and regular professional review meetings.

This group of young people will most likely be given discretionary leave to remain until 17-1/2 years old, at which time they must apply for asylum following standard processes.

Children and young people are entitled to legal aid. As much information as possible should be gathered using an appropriate interpreter at an early stage as this will be relevant to their application.

Specific statutory guidance is provided for England, Scotland, and Wales.

A new law was passed on 28 April 2022 which will impact on asylum processes – the Nationality and Borders Bill.

Access to healthcare

Refugee and asylum seeking children and young people have the same rights to care as UK nationals.

The Refugee Council provides a factsheet in a variety of languages which contains information on healthcare eligibility and access for people seeking asylum in the UK. They have also developed an information pack for refugees, which provides information about accessing health services.

For babies, children and young people born outside the UK, the usual route for obtaining an NHS number is to have one allocated through GP registration. In England, there is no set length of time that a patient must reside in the country to become eligible to receive NHS primary care services. Therefore, everyone is eligible to register with a GP practice. NHS England provide further information for patient registration.

Health services in the UK can be difficult to access for refugee or asylum seeking families. They may have little knowledge and awareness of services, how they work and how they are accessed, compounded by language and financial barriers. Mental trauma and past experiences may further prevent them from seeking help.

Health services often have little awareness of these communities and their needs and may lack cultural awareness and understanding. Confusing information about charging regulations may cause further issues on both sides.

Specific guidance on accessing NHS services is available for Scotland and Wales. In 2015, new regulations were introduced in Northern Ireland, meaning that all refugees and asylum seekers (including refused asylum seekers) are not required to pay for their healthcare treatment, including primary and secondary care.

Key practice considerations

Language, communication and interpreters

For children and young people with a first language that is not English, any assessment should be undertaken with the support of a culturally appropriate, registered interpreter (considering ethnic and gender issues).

It is not appropriate for other children or young people, or family members, to act as interpreters, or for people not trained as interpreters to perform this role. An interpreter telephone service can be used where access to a face-to-face interpreter is not possible.

It is important to remember that a health assessment may be the first opportunity that a child or young person and their carer have had to talk about their health needs through a registered interpreter. High quality translation depends on how interpreters are guided and supported. The GMC (General Medical Council) offers support around maintaining patient relationships and managing consent when English is not the first language. Providers may have their own policies and guidance. Translators without Borders (1 ) also reviews the challenges around use of interpreters.

Consent

Paediatricians should refer to GMC guidance regarding information about obtaining consent and what to do if consent is refused. Further information is also provided by the BMA and the Child Protection Companion.

You must have consent or other authority e.g. emergency duty of care before examining, investigating, or treating a child or young person. Unaccompanied minors may be able to consent to their own treatment, however, it is always good practice to attempt to contact their parents / guardians for a history and to communicate follow-up management.

In the UK, children and young people (including unaccompanied minors) can consent to treatment if they are deemed Gillick Competent. This means that they can:

• Understand the nature, purpose, benefits, risks and consequences of not proceeding or proceeding
• Retain the information discussed
• Use and weigh this information
• Communicate their decisions to others.

A child or young person with capacity to consent, who refuses, should have their decision respected unless there are exceptional circumstances.

Young people 16 years and over should be assumed to have capacity unless there is reason to believe that they have an impairment of mind or brain that affects their capacity for the specific decision at the specific time. If there is doubt about capacity, an assessment of capacity should be undertaken.

Young people over 16 years of age who are assessed to lack mental capacity for a specific decision at a specific time should have an independent advocate, with the best interests decision-making process followed. More information on Mental Capacity, best interests decisions and Liberty Protection Standards can be found in the Disability Matters eLearning Package. The Mental Capacity Act applies in England and Wales with equivalent protections in law in Scotland and Northern Ireland.

Confidentiality

As for all children and young people, it should be explained that in the UK, health information is recorded on a computer health system and shared with other health professionals (e.g. GP and health visitor). Health information may also be shared with other agencies (e.g. education and social services). It should also be explained that details will not be shared with outside agencies (e.g. legal or immigration officials) unless the young person and their family consent to this.

For unaccompanied asylum seeking children and young people, the initial health assessment, as part of the looked after children statutory guidance, is not used as part of the age assessment process. Age will have already been determined by other professionals, not paediatricians.

More detailed information on confidentiality is provided by the GMC and within the Child Protection Companion. The Caldicott principles on recording, keeping and sharing information should be followed.

Specialist referrals should be made in the usual way. However, paediatricians should be aware of factors which may impact on a child or family being able to make appointments, such as language barriers and transport.

Where appropriate, a Personal Child Health Record (PCHR / 'red book') should be issued. These are available online, from the health visitor, local health clinics and from some local authorities.

Paediatric health assessment

The health assessment of refugee and asylum seeking children and young people may occur in different settings with professionals who have different levels of experience. A formal health assessment is part of the statutory duties for looked after children, but less formalised health assessments may occur opportunistically in primary care, as part of a referral into developmental clinics, general paediatric clinics or acute settings. The general health assessment should be thorough, holistic and carefully documented. 

This cohort of children may be particularly vulnerable and are likely to have complex physical and mental health, and social needs. They may have grown up in a low or middle income country, have been exposed to conflict and disruption of infrastructure, or experienced long, dangerous journeys and possible abuse, and often separation from family members. 

On arrival to the UK, they may face barriers of language, culture, finance, stigma and limitations of access to healthcare and education. 

For refugee families, there is good evidence that adverse physical and mental health of parents and grandparents impacts on the health of children. (2 , 3 ) 

There are resources, research and textbooks available to support professionals in delivering good care to asylum seeking and refugee children and families. (See References and Resources below)

We can consider health needs in four broad areas:

• Physical health
• Mental health
• Social or wider determinants of health
• Facilitation of access to health care

Physical health

Important history and assessment

Refugee and asylum seeking children and young people should be assessed using the same principles as any other child, though with an additional focus on their particular health needs, vulnerabilities and barriers. Particular attention should be paid to the below issues in the history and examination, as signs and symptoms may be easy to miss. Some areas may have specific models of care and specialist teams set up to meet health needs. (4 ) Where routine health assessments are happening regularly e.g. for UASC, the agreed process for routine screening and referrals will be followed. There are several resources offering support and proposed screening/management pathways (UASC health, children’s health: Migrant health guide).

It is important to note that, despite public perception to the contrary, it is well established in the literature that the risk of spreading infectious diseases from migrant people to the host population is low. (5 )

Physical health assessment needs to include consideration of:

• Malnutrition, including stunted growth, obesity and micronutrient deficiencies
• Unrecognised or unmanaged chronic health conditions
• Low vaccine uptake
• Trauma and injury, which includes FGM (female genital mutilation)
• Infections, e.g. tuberculosis, hepatitis B and C, HIV, malaria, leishmaniasis, filariasis, intestinal parasitosis, helminth infection, schistosomiasis and sexually transmitted infection. There needs to be discussion about routine screening of asymptomatic children and symptomatic children and referral to specialist services
• Development, with pre-school children referred for developmental assessment and further follow-up if there are any concerns. It may also be appropriate to refer school-aged children for further follow-up if there are any concerns. Consider evidence of regression
• Lack of health screening and health promotion (e.g. newborn screening, thyroid function, hearing and vision screening, dental care)
• Investigations will be specific to health needs but consider baseline bloods, nutrition screen, infectious diseases screen

Communicable diseases

A significant number of refugees and asylum seeking children and young people (accompanied and unaccompanied) arrive from countries where blood-borne and other infections, including TB, are highly prevalent, and / or they may have been exposed to diseases en route to the UK. (6 , 7 )

Please see the Migrant Health Guide for up to date information. (8 )

Symptomatic presentations

• Consider symptomatic presentations of communicable diseases (including but not exclusive to: TB, Covid-19, scarlet fever, malaria, enterovirus, scabies, typhus, helminth infections, leishmania, skin and soft tissue infections) and vaccine preventable diseases (e.g. typhoid, pneumococcal and meningococcal infections). Appropriate referrals to local paediatric infectious diseases services should be made.
• TB should be considered in any child or young person presenting with suggestive symptoms (including, but not exclusive to fever, persistent, non-remitting cough, weight loss, failure to thrive, lethargy, enlarged lymph nodes). An urgent referral to TB services should be made if symptomatic.

Screening for asymptomatic infections

• Screening is recommended for asymptomatic communicable diseases for which refugees and asylum seekers are at increased risk. This includes (but is not exclusive to) tuberculosis (TB), hepatitis, HIV, sexually transmitted infections, and parasitic infections. For unaccompanied asylum seeking children , consent for screening tests could be covered in the general consent for Initial Health Assessment (IHA). Appropriate referrals to local services should be made.
• Any child or young person presenting from a country with a TB incidence of 40/100,000 or greater – including (but not exclusive to) Ethiopia, Eritrea, Somalia, Sudan and Afghanistan - should be referred to paediatric TB or Infectious Diseases (ID) services for assessment (as per NICE guidance).
• Children from countries with lower rates of TB may have been brought into close contact with active pulmonary TB on their journeys (e.g. overcrowding and refugee camps in transit) and these children and young people should also be proactively referred for TB screening.
• Children and young people are at risk of sexually transmitted infections and blood-borne viruses (BBV) and may be entirely asymptomatic as young adults. Children fleeing regions of conflict may have been infected by vertical transmission, as their mother may not have benefited from ante-natal screening. They may be at risk of sexually transmitted infections through consensual or non-consensual sexual contact. Nosocomial transmission of BBV is also higher in areas of conflict. Young people, especially those who have been subject to sexual violence, may not feel able to accurately report past history at the first health assessment with an unfamiliar clinician. Targeted screening based on risk perceived by the clinician may risk stigmatisation, but age and circumstances should be considered. Suggested screening includes Chlamydia, Gonorrhoea, Syphilis, Hepatitis B and C, and HIV should be routinely offered (see supplementary table for specific screening tests). Appropriate referrals to local GUM (genitourinary medicine) and paediatric infectious diseases services should be made.
• These children and young people may be at risk from soil transmitted helminths (e.g. Ascaris and hookworm). Empiric treatment with albendazole should be considered.
• Paediatricians should be aware of the risk of strongyloidiasis and schistosomiasis, children coming from endemic regions and should consider serology testing.

Overview of at risk communicable diseases

The below is a brief overview of the communicable diseases from which refugee and asylum seeking children and young people are at risk. For up-to-date information regarding epidemiology and disease-specific guidance, please refer to the Migrant Health Guide.

Tuberculosis

High Prevalence Countries – TB incidence of over 40 per 100,000 population

Risk factors:

• Children <5years
  • Close TB contact
  • Concomitant HIV
  • Diabetes Mellitus
  • End-stage CKD
• Immunosuppressed
  • Malnutrition
  • Homelessness
  • Detention/imprisonment
  • Refugee camps

Signs and symptoms (non-exhaustive list):

• Cough>2 weeks
• Shortness of Breath
• Fever
• Night sweats
• Weight loss/Anorexia
• Loss of playfulness
• Organ-specific:
  • Lymphadenopathy
  • Bone/joint pain
  • Abdominal/pelvic pain
• Sterile pyuria
• Headache
• Vomiting
• Irritability
• Skin lesions
• Chest pain

Diagnostic methods:

• Diagnostic jigsaw including:
  • Suggestive history/exam
  • IGRA +/- TST/CXR (if high incidence country or positive IGRA TST); sputum culture
• Alternative:
  • IGRA
  • TST 
  • Sputum culture
  • Gastric culture 

Suggested actions:

• If symptomatic - urgent referral to TB services
• If asymptomatic - refer to TB services for screening 
• If IGRA/TST positive – refer to TB services to establish whether latent TB infection or TB disease 
• Offering opportunistic BCG to unvaccinated children >4 weeks and <16 years at increased risk of TB who would have qualified for neonatal BCG and are TST negative is good practice, but service not commissioned in many areas

Hepatitis B

High Prevalence Regions – Intermediate or high prevalence of chronic infections [5-10% of adult prevalence]

Risk factors: 

• Hep B positive mother
• Hep B positive partner
• Early sexual activities
• Concomitant HIV, HCV
• Hx sexual abuse
• Immunosuppressed
• IVDU
• Pregnancy
• Close contact
• Tattoos

Signs and symptoms (non-exhaustive list):

• Asymptomatic
• Prodromal illness followed by jaundice
• Non-specific malaise
• Fever
• Nausea
• Anorexia
• RUQ abdominal pain
• Jaundice

Diagnostic methods:

• HBV serology: HBsAg, anti-HBc, anti-HBs

Suggested actions:

• Refer to Paediatric Infectious Disease services
• Offer Hep B vaccination for all unimmunised children

Hepatitis C

Risk factors: 

• Hep C positive mother
• Hep C positive partner
• Early sexual activities
• Concomitant HIV, HCV
• Hx sexual abuse
• Immunosuppressed
• IVDU
• Pregnancy
• Close contact

Signs and symptoms (non-exhaustive list):

 

• Asymptomatic
• Prodromal illness followed by jaundice
• Non-specific malaise
• Fever
• Nausea
• Anorexia
• RUQ abdominal pain
• Jaundice

Diagnostic methods:

• anti-HCV Ab; if positive → RNA testing

Suggested actions:

• Refer to Paediatric Infectious Disease services 

HIV

High risk countries – countries with >1% prevalence

Risk factors:

• HIV positive mother
• HIV positive partner
• Early sexual activities
• Hx of sexual abuse
• Concomitant active TB
• Concomitant STI

Signs and symptoms (non-exhaustive list):

• Asymptomatic
• Recurrent infections
• Poor growth
• Weight loss
• Opportunistic infections
• Generalised lymphadenopathy
• Fever
• Rash (maculopapular) 
• Developmental delay

Diagnostic methods:

• HIV serology

Suggested actions:

• Refer to Paediatric Infectious Disease services

Strongyloides

High risk countries – countries with >1% prevalence

Risk factors:

• Bare feet walking
• Contact with human waste or sewage
• Occupations e.g., farming, coal mining
• HIV Infection
• Signs and symptoms (non-exhaustive list):
• Unexplained (GI) symptoms
• Eosinophilia

Diagnostic methods:

• Stool ova, cyst, parasites. Serology for strongyloidiasis

Suggested actions:

• Presumptive treatment if from high endemicity and diagnostics unavailable/impractical. 
• Treatment with Ivermectin is recommended.

Schistosomiasis

Risk factors:

• Exposure to contaminated freshwater

Signs and symptoms (non-exhaustive list):

• Unexplained (GI) symptoms
• Eosinophilia

Diagnostic methods:

• Stool ova, cyst, parasites.
• Urine ova, cysts, parasites
• Serology for schistosomiasis

Suggested actions:

• Presumptive treatment if from high endemicity and diagnostics unavailable/impractical.
• Praziquantel is the treatment of choice.

Helminths - includes roundworm, hookworm, and whipworm

Risk factors:

• Exposure to contaminated freshwater

Signs and symptoms (non-exhaustive list):

• Unexplained (GI) symptoms

Diagnostic methods:

• Stool ova, cyst, parasites

Suggested actions:

• Presumptive treatment if from high endemicity and diagnostics unavailable/impractical.
• Treatment with mebendazole or albendazole is safe and effective
   

Syphilis

Risk factors:

• Unprotected sexual activity
• History of sexual abuse
• Concomitant STI

Signs and symptoms (non-exhaustive list):

• Chancre-anogenital painless 
• Maculopapular rash
• Signs of congenital syphilis

Diagnostic methods:

• Syphilis serology

Suggested actions:

• Treatment as per local guidelines 
• Sexual health promotion: safer sex, contraception.
   

Chlamydia

Risk factors:

• Unprotected sexual activity
• History of sexual abuse
• Concomitant STI

Signs and symptoms (non-exhaustive list):

• Asymptomatic
• Urethral discharge
• Vaginal discharge
• Lower abdominal pain
• Newborn conjunctivitis

Diagnostic methods:

• Urine sample
• Vulvo-vaginal swab

Suggested actions:

• Treatment as per local guidelines 
• Sexual health promotion: safer sex, contraception.

Gonorrhoea

Risk factors:

• Unprotected sexual activity
• History of sexual abuse
• Concomitant STI

Signs and symptoms (non-exhaustive list):

• Urethral discharge
• Dysuria
• Vaginal discharge
• Newborn conjunctivitis

Diagnostic methods:

• Urine sample
• Vulvo-vaginal swab

Suggested actions:

• Treatment as per local guidelines 
• Sexual health promotion: safer sex, contraception.

Immunisations

Many children and young people of refugee and asylum seeking background will have unknown vaccination status. Paediatricians will need to assess the likelihood that standard immunisation protocols / WHO Immunisation Schedules would have been followed in the child or young person's country of origin.

Completing the routine childhood vaccination schedule and additional vaccinations recommended by the JCVI (Joint Committee on Vaccination and Immunisation) is very important for children of any age, (see RCPCH Vaccination in the UK) 

For individuals with uncertain or incomplete immunisation status, the recommended schedule can be found on the UK Government website. These UK Health Security Agency (formerly Public Health England) principles should be followed:

• Unless there is a reliable vaccine history, individuals should be assumed to be unimmunised, and a full course of immunisations planned.
• Individuals coming to the UK part-way through their immunisation schedule should be transferred onto the UK schedule and immunised as appropriate for their age.
• If the primary course has been started but not completed, it should continue where left off. There is no need to repeat doses or restart the course.
• Plan the catch-up immunisation schedule with the minimum number of visits and minimum possible timescale. 

Mental health

There are clearly many reasons for refugee and asylum seeking children and young people to have emotional health difficulties, related to experiences in their home country, on the journey to the UK and situation in the UK. There may be reactive, underlying and undiagnosed mental health needs.

After arrival in the UK there may be ongoing discrimination, lack of access to education, and the need to navigate the immigration system, which can lead to further distress.

Children and young people may not wish to talk about what has happened, so it is important not to push them if they are not ready and find ways to help them engage with services. Young people may not be used to mental health being openly discussed and of course, language may be a barrier to support. The wider environment and sense of belonging is key.

Unaccompanied asylum seeking children and young people may benefit from specialist support from Child and Adolescent Mental Health Services (CAMHS). Third sector services such as the Refugee Council play a significant role in support.

It is vital that paediatricians practice trauma-informed care and consider different factors that may be impacting the child and their presentation.

Main issues to consider:

• Traumatic experiences can include exposure to war and conflict, torture, physical and sexual abuse, detention in the UK or in transit. This may eventually be diagnosed as PTSD (post-traumatic stress disorder), but for some children the trauma is ongoing, with concern about family and managing the immigration system.
• Exaggerated responses to normal emotional triggers may be a response to trauma and toxic stress. This needs to be taken into account when considering other conditions e.g. neurodevelopmental or trying to explain and support challenging behaviour.
• Disruption of important routines e.g. activities of family life, play, education. This can have profound impacts on children particularly at vulnerable life phases e.g. attachment in infancy, independence during puberty.
• Disruption to sleep, related to journeys and need to travel at night, fears for safety at night, flashbacks, lack of safe place, comfort toys/environment. This can have a negative impact on physical and emotional health, behaviour and learning/development.
• Poor mental health of parents or siblings impacting on children.

Outcomes of a health assessment

Supporting young people and carers to access physical and mental healthcare and resources to make informed decisions about health is critical. Recommendations may include:

• Organising screening blood tests and other screening/assessments as needed, e.g. hearing.
• Referring to nutrition or breastfeeding advice if needed. Advice to follow department of health recommendations regarding vitamin supplements and consideration of daily multivitamin.
• Routine surveillance with optician and dentist.
• Ensuring vaccinations are up-to-date (managed in primary care).
• Liaising with primary care, schools, health visitors and/or school nurses to support development and emotional health.
• Support and referrals for mental health support.
• Specific investigations, referral and treatment for communicable disease.
• Ensure registered with a GP practice and NHS number. (9 )
• Information about how the NHS works and other services that may be available to support them, including third sector and social services.
• Wider recommendation to support education, activity, social, cultural needs.

Wider determinants of health

Several social determinants impact on a child’s health outcomes, including poverty and education. Paediatricians should signpost families to support services and specific links/resources such as the Refugee Council or Doctors of the World. All local authorities will have webpages which signpost family support and/or the local offer and contact details for local health visitor/school nurse/family support workers.

The RCPCH will be publishing resources and information regarding poverty and the impact on families, children and young people.

• Access to education - in the UK, all children, regardless of migration status, are entitled to school. (10 )
• Socioeconomic status - child poverty is a known social determinant of health and wellbeing: poverty is associated with worse developmental and health outcomes. (11 ) 
• Social networks and culture - access to faith or cultural groups, building friendships, opportunities for social and physical activity can support good mental health and build resilience.
• Families - if carers/connected people are in the UK, their health is another determinant of child health and it may be helpful to signpost families to support for adults, such as their GP, and other organisations, such as Doctors of the World or other local institutions supporting refugee and asylum seeking people.

Access to health care

Facilitation of access to healthcare is vitally important to improve health outcomes.

This includes:

• Supporting refugees and asylum seekers to access the necessary service at the right time and place
• Designing NHS services to become more accessible to this vulnerable population. 
• Please see the guide RCPCH Rights to Access Healthcare.

Safeguarding and child protection issues

• If an unaccompanied child presents, having not previously been known to social services, an immediate referral needs to be made to the local authority children's social care. Although the unaccompanied asylum seeking child will need to make an asylum application as soon as possible, the primary concern is safeguarding and ensuring that they are taken into the care of the local authority, who then have a duty to care for them, including help with legal representation. 
• Paediatricians are encouraged to explore and understand the patient’s background and their journey, such as their country of origin, countries or territories through which they passed or where they may have stayed prior to arriving in the UK and the circumstances that led them to migrate. These questions can be triggering for young people and it can be hard for them to differentiate between health and immigration type questions. Many refugees come from countries where health authorities are complicit with government officials, so there may be understandable mistrust.
• Paediatricians should also assess a young person's vulnerabilities to sexual exploitation and risk of trafficking and modern slavery. If there are concerns about potential exploitation please refer to the RCPCH Modern Slavery guidance.
• Exposure to violence, rape and / or other trauma should be explored sensitively. Not all young people are able to disclose on first assessment if they have been the victim of assault, and this will need careful inquiry. 
• Paediatricians should ask girls / young women if they have ever been subjected to Female Genital Mutilation (FGM). They should be informed that FGM is illegal in the UK, including when a child is taken out of the country for the procedure. If they have been 'cut', a referral should be made to a local specialist unit for a follow-up assessment.
• Paediatricians should ask about current experiences of bullying or racism and consider whether and how a lack of social support or educational place may also increase their vulnerability.
• Safeguarding concerns may also arise following an unsafe environment for the child in temporary accommodation or due to neglect or physical abuse.

Please see the Child Protection Companion for further information.

Children in detention

Children and young people may be placed in detention centres.

The Refugee Council have produced an information briefing, which includes statistics on the number of children entering detention. (12 )

There are significant safeguarding issues for children housed in detention centres. If a professional becomes aware of a minor in a detention centre, social services should be notified as soon as possible.

Age assessment

Many asylum seekers will have no documentary evidence of their birth date and therefore other methods of age assessment are currently being undertaken within the UK to establish whether they are under the age of 18 years. This has implications for the outcome of their asylum claim and for their ability to access health services, education and welfare support.

The RCPCH does not support paediatricians being involved in age assessments of asylum seeking young people because of the concerns regarding the evidence base for accurate age assessment and the ethical considerations relating to the impact on children as outlined below. 

Article 3(1) of the Convention on the Rights of the Child gives every child the right to have his or her best interests assessed and taken into account as a primary consideration in all actions or decisions that concern him or her.

There are two main factors to consider regarding age assessment of young people – the accuracy of age assessments and the ethics of undertaking these assessments. 

It is difficult to determine a young person’s age accurately. A child’s physical, emotional and developmental presentation is influenced by a myriad of factors including but in no way limited to their ethnicity, socio-economic environment and nutritional status. It is especially important to acknowledge the impact of adverse experiences, conflict, trauma, violence and forced migration on a child. Currently the Home Office and the Association of Directors of Children's Services have produced joint working guidance about how UK Visas and Immigration decide applications in England. Age assessment guidance has also been developed in Scotland and Wales.

Age assessment by examination and X-rays is imprecise and at best can determine what stage of puberty a child is at and with that an estimated range for their age. The British Society for Paediatric Endocrinology and Diabetes states that the timing of puberty is extremely variable and impacted by genetics as well as environmental and social factors. Completion of growth occurs at the end of puberty, so if a child starts puberty early, they will finish growing whilst still in their early teens. Conversely, if a child starts puberty late, they may not finish growing until well over the age of 18 years. Current methods for bone age X-ray assessments, such as the Greulich and Pyle method, use X-rays taken from ‘average’ Caucasian children and again will vary enormously depending on what stage of puberty a child is at. 

The British Dental Association has vigorously opposed the use of dental X-rays to determine whether asylum seekers have reached the age of 18, stressing they are not a reliable way establishing age and the use of dental X-rays can over or underestimate the age of adolescents significantly.

Exposing anyone to radiation from X-rays unnecessarily should be carefully considered and for non-clinical purposes the RCPCH considers it unethical. The CQC regulates the use of ionising radiation set out in The Ionising Radiation (Medical Exposure) Regulations 2017/2018, and state that, ‘justifying each exposure to ensure the benefits outweigh the risks’. 

There have been a number of judgements in case law about who should hold the burden of proof about a child’s age. Given the lack of evidence regarding the accuracy of age assessment the RCPCH believe that young people should be given the benefit of doubt with regards to their age.

The RCPCH view is that age assessments require informed consent, which has to be freely given, and it is difficult to ensure this is taking place if vulnerable young people are assessed under duress.
Consent is not valid if coerced. Young people in this situation may feel that they are compelled to agree to the process. In addition, given their past adverse experiences, young people in this situation may not have the capacity to consent to the age assessment process.

The RCPCH believes there is a potentially harmful impact of enforced age assessment on a child’s physical and emotional well-being. As well as the harmful impact of inaccurately assessing a young person as being an adult, we also acknowledge concerns around wrongly assessing an adult as a young person. This is because of the risks some adults may pose to children if they are placed with children in care placements and education settings. We also acknowledge there are implications for resource allocation, such as access to health services, education and welfare support, for children in care if adults are incorrectly placed as children.

Acknowledgements

Authors

Dr Vicki Walker, Looked After Children Lead, RCPCH
Dr Sarah Boutros, Paediatrician, RCPCH
Dr Bhanu Williams, Paediatrician, RCPCH
Dr Allison Ward, Paediatrician, RCPCH
Dr Sarah Eisen, Paediatrician, RCPCH
Dr Christian Harkensee, Paediatrician, RCPCH
Dr Catarina Soares, Paediatrician, RCPCH
Dr Laura Wood, Paediatrician, RCPCH
Dr Geoff Debelle, Paediatrician, RCPCH
Dr Behrouz Nezafat
Dr Ken Wu
Ms Olivia Lam, Policy Lead, RCPCH
Dr Alison Steele, Officer for Child Protection, RCPCH
RCPCH Child Protection Standing Committee

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