Cultural considerations in assessment

Assessing children and adolescents is best done in a semi-structured way in order to establish rapport, engage the child and collect information. This relationship building approach is particularly important at the first interview when parents are usually included. Further interviews may need to be more structured, especially when assessing for diagnostic criteria, medico legal reports etc.

Rho and Rho (2009) suggest that: 

• Having a parent or caregiver present may be useful in the initial interview.
• A qualified interpreter is important and the child should not be expected to act as an interpreter.
• A holistic approach is mandatory when working with children.
• Time should be taken to explain what a mental health worker is and what services are available.
• The use of questionnaires has been found to be useful but care needs to be taken when analysing the results of questionnaires as many scores have a Western bias. Allowances must be made for language and cultural differences.

Issues to be aware of during assessment and history taking

• There may be cultural differences in expectations of child development.
• An accurate age may be difficult to ascertain for children from refugee backgrounds.
• Trauma history: A thorough background history including exposure to traumatic events needs to be taken. This should include: the nature and extent of exposure to trauma, the age of the child at the time the maximum disruption occurred, and the degree to which the family was able to stay intact.
• Developmental delays in refugee children may result from chronic infections in childhood (for example cerebral malaria, from recurrent illness or from environmental deprivation due to war and famine.
• Hearing impairment may be due to past or current infection, exposure to explosive noise in war zones, or blows to the head. Hearing impairment in children may lead to developmental delays and learning difficulties. Hearing testing should be considered if indicated.
• Check for visual impairment if indicated.
• Physical health: The following should be considered (Ministry of Health, 2012):
  • Weight and height percentiles and a weight history.
  • History of malnutrition.
  • Anaemia is common in children from refugee backgrounds.
• Parents may not be aware of disability services and supports and how to access these.
• Keep in mind that some families may be reluctant to identify concerns, for fear of affecting their success in applying for permanent status.
• School readiness:
  • Ask whether a child has had prior access to schooling.
  • Second language learners — children not proficient in English— may be equal in their physical readiness to learn, but behind in their language, general knowledge, communication and cognitive development.
  • If a child has an additional developmental problem, it is important to link the child to programmes that improve school readiness, such as structured preschool programmes, as well as other developmental services.
• Sexual health history:
  • Children and adolescents (female and male) from refugee backgrounds may have been sexually assaulted during refugee flight and refugee camp experiences. Addressing sexual assault needs to be managed with extreme sensitivity. This matter should usually be discussed without other family members present.
  • Address developmentally appropriate sexual activity including safer sex issues.
  • Be aware of underage marriage.
  • Culture and health-belief assessment tool (CHAT).

The Culture and Health-Belief Assessment (CHAT) tool can be used in a wide variety of clinical settings, with patients from any cultural background. The questions listed in CHAT are intended to stimulate discussion, giving the clinician a greater understanding of the client’s health-belief model, health practices and expectations for treatment (Adapted from Kleinman et al., 1978).

• What do you think caused your illness?
• Why do you think your illness started when it did?
• What does your illness do to you? How does your illness work?
• How bad (severe) do you think your illness is? Do you think it will last a long time, or will it be better soon, in your opinion?
• What do you fear most about your illness?
• What are the chief problems that your illness has caused for you?
• When you have a problem, to whom do you turn for help?
• For your future care, who would you like to be involved?
• What have you done to treat your illness?
• What kind of treatment do you think you should receive?
• What are the most important results that you hope to receive from treatment?
• Is there anything that might conflict with your treatment regimen?
• Are you feeling uncomfortable or uncertain about what we have decided?