Case Studies: Stories of children and youth new to Canada
Immigrant and refugee families may have faced considerable hardship and challenges before coming to Canada. When they arrive in Canada, they are faced with problems in several areas including language barriers, housing, access to local services, transportation problems, cultural differences, raising children, prejudice, isolation, and the weather. Part of the role of health professionals is to help newcomers integrate and adapt to their new lives.
The case studies in this section provide common examples of specific health issues that young newcomers to Canada and their families may face. These short vignettes are fictitious and based on the clinical experience of multiple contributors. They are intended to help clinicians become aware of such issues and how they can be addressed.
Our thanks to the staff at the following organizations for their thoughtful review and comment on these vignettes: Thorncliffe Neighbourhood Office, Immigrant Services Society of B.C.
A young child with possible tuberculosis and HIV/AIDS
Region of origin
Central Africa
Background
Some countries in Africa, Asia and other parts of the world continue to experience war, extreme poverty, child labour and child prostitution.
Overview
Nzuzi is a 6-month-old girl born in Canada. Her family arrived in Toronto from an African country that is at war internally. Her mother was 7 months pregnant, so she had no routine prenatal care.
For the past 2 weeks, Nzuzi has not been feeling well. She has a cough and low-grade fever. She is underweight, febrile (temperature 38.5°C) and tachypneic (respiratory rate 60 breaths/min) with fine crackles. She has an enlarged liver and spleen, and enlarged cervical lymph nodes. The differential diagnosis includes tuberculosis and HIV/AIDS.
Challenges
Knowing that the rape of women in some of these countries by rebels is a common method of terrorizing local villages, how would you compassionately and carefully ask about the mother’s health and whether she might have been raped and infected with HIV?
Key points
In this case, although Nzuzi might simply have a pneumonia, given that the family is from Africa and the presence of hepatosplenomegaly, the most likely diagnoses are TB or HIV/AIDS. However, both diagnoses would mean contact from someone else, and for HIV/AIDS that would mean that Nzuzi’s mother would have HIV/AIDS. Her mother may or may not suspect or know she has HIV/AIDS. This problem must be approached carefully and compassionately. The mother will need to be referred to an adult centre for diagnosis and management.
Related information
A young child with possible HIV/AIDS
Region of origin
Malawi
Background
Parents may be reluctant to have their child tested for certain illnesses, such as HIV and tuberculosis, because they fear results could adversely affect their immigration status. This fear usually leads to significant delay in seeking medical care for a sick child and therefore results in preventable deaths and unnecessary morbidity. Physicians should be knowledgeable of the family units of the parents and proactively ask about the other members who may not be present at visits.
Overview
Ateefa is an 18-month-old girl whose mother is from Malawi. Ateefa presents with a history suggestive of HIV/AIDS, but her parents refuse testing, fearing it might adversely affect their immigration status and put them at risk of deportation. You take the time to explain that diagnosing HIV would benefit Ateefa because she could start on antiretroviral therapy.
After extensive discussions through interpreters, the family agrees to testing and the child is started on antiretroviral therapy and appropriate preventive therapy for opportunistic infections. Two siblings are also tested and found to be HIV-negative, much to the relief of the parents.
Challenges
Knowing that an 18-month-old child diagnosed with HIV means that the mother also has HIV, how do you approach the family and explain the need for HIV testing for the child as well as for all family members?
Key points
The problem is challenging. To start, the health care professional should explain the features of HIV/AIDS to the family, stressing how patients with HIV/AIDS in Canada are not shunned or scorned as they may be elsewhere. In Canada, people with HIV/AIDS can live a long, normal life with good and careful treatment. Physicians should be never ending advocates of new immigrants at the decision making tables to ensure that rules are made clear to immigrants and allay many unfounded information on immigration leading to unnecessary fears.
Related information
A young boy with behavioural difficulties at school
Region of origin
The Caribbean
Background
Some men and women come to Canada to work, leaving children to be raised by grandparents or close relatives back home. Some of these children are brought to Canada later, to live in an unfamiliar culture and with parents they do not really know. Immigration status is also a factor. Visitors who stay in Canada, including children born outside the country, have no immigration status, whereas children born in Canada are Canadian citizens.
Overview
Jamal is a 10-year-old boy. He comes to your office with his mother, who is concerned about his progress and behaviour at school. His first report card shows that he is failing many subjects. The teacher also says he acts out in class, is often disobedient and disrespectful, and fights with other students.
Jamal’s mother came to Canada 8 years ago to attend school and work. From 2 years of age until 6 months ago, Jamal lived with his grandmother in Jamaica. He now lives with his mother and two half-sisters in Canada.
Challenges
What might explain some of Jamal’s difficulties in school? How would you try to help Jamal and his mother?
Key points
Jamal could certainly have a learning disability or ADHD (attention-deficit hyperactivity disorder). But given the history, his school difficulties could relate to moving to a new country and living with his mother, with whom he may have little rapport or attachment. He may also have hearing loss or vision inadequacy. Hearing and vision screening should be considered. Referral to a community agency working with West Indian families or for mental health or family counselling would be indicated.
Related information
A young boy with abdominal pain
Region of origin
Eastern Europe
Background
Roma refugees face considerable discrimination in regions such as Eastern Europe. At the time of writing, Citizenship and Immigration Canada considers some countries in those regions safe countries, where persecution is unlikely to occur. Therefore, refugee claims are less likely to be considered legitimate.
Overview
Marko is a 6-year-old boy presenting with abdominal pain who sometimes has accidental bowel movements. He has been in Canada for the past 4 months and recently started school.
Marko and his mother speak Hungarian and Czech, and are just learning English. His mother is vague in providing some details of their history and background, including where they have lived or their immigration status. It is also not clear which immunizations Marko has had or what schools he has attended. There are few details about his father.
Challenges
Reflecting that Marko and his mother might be Roma, and perhaps refugee claimants, how would you obtain information about him and his family history so that you could help?
Key points
While there might be a specific organic cause for Marko’s abdominal pain, it is likely related to some of the emotional and psychosocial problems experienced by his family. Some screen laboratory tests may be necessary. A more thorough psychosocial history is necessary, along with referral to a community agency that works with immigrant families and with Roma in particular. Further, if Marko’s immunization is not well documented, he may need to start on a new series of immunizations.
Related information
A young girl having difficulties at school
Region of origin
Colombia
Background
Some immigrants come to Canada from countries that experience crime and violence associated with drug trafficking.
Overview
Maria is an 8-year-old girl in Grade 3 at a local school. She lives with her mother and 5-year-old brother, who is in senior kindergarten. The family left Colombia 3 years ago because of the political situation. Maria’s mother works part-time in a doughnut shop and is trying to attend an adult language class to learn English. Maria’s father is still in Colombia, and the family hasn’t heard from him for the past 9 months.
Maria was referred to a community paediatrician because she is having difficulty with her school work. She is having problems learning to read and paying attention in class, and needs a lot of supervision to get her work done. Maria can be disruptive in class and picks fights with the teacher and students.
Challenges
What are the possible explanations for Maria’s difficulties at school? How would you try to help her?
Key points
There are many reasons for Maria to have difficulties with school. She may have a learning disability or ADHD (attention-deficit hyperactivity disorder) but her behaviour may also be related to limited school experience, the family’s emotional and psychosocial problems and her mother’s inability to help Maria with her school work. An open discussion with the school officials and teachers would be helpful. The school may consider placing her on the referral or wait list for a psychoeducational assessment through the school board. The school may also have some volunteer tutors who could help Maria with her homework. Referral to a community agency working with Latin American families would also be helpful.
Related information
A young girl with headaches
Region of origin
Russia, via Israel
Background
Some families come to Canada via other countries, such as Afghanistan via Pakistan or Russia via Israel. Indirect routes can pose a challenge when determining immunization status, for example, or for assessing disease risk based on region of origin.
Overview
Deborah is a 10-year-old girl. She presents with headaches, which she’s had 3 or 4 times weekly for the past month. Deborah has been sent home from school on many occasions. You are impressed that she speaks Russian and Hebrew, and is now learning English and French. However, you don’t know precisely where she has lived or what immunizations she has received.
Challenges
How would you determine Deborah’s background, immunizations and possible causes of her headaches?
Key points
Health professionals must keep the specific causes of headaches in mind, such as raised intracranial pressure or migraine headaches. But with Deborah, the headaches may also be a reflection of her move to a new home, the loss of familiar friends and school in Israel or Russia, and family stress. Rather than start by ordering a CT scan, you might consider symptomatic treatment, documenting with a headache diary, a more thorough psychosocial assessment and, possibly, referral to a community agency working with immigrant families. Further, if there is any question about Deborah’s immunizations, she may require a full set of vaccines. Some centres do serology for different infectious diseases (e.g., polio, measles, varicella) and provide immunization where a child does not have immunity. For a 10-year old girl from Russia and Israel, this approach may be appropriate.
Related information
Editor(s)
- Robert Hilliard, MD
- Mark Awuku, MD
Last updated: April, 2021