Neuropsychological profiles of adolescents sentenced to detention in Western Australia with and without prenatal alcohol exposure.

BACKGROUND/AIMS: Youth with prenatal alcohol exposure (PAE) are under-recognised in the justice system, warranting improved identification. This study aimed to compare neuropsychological profiles of adolescents, with and without PAE and identify neuropsychological tasks predictive of PAE-group membership. It was hypothesised that participants with PAE would score significantly lower on neuropsychological tests. METHODS: Participants included 85 young people sentenced to detention (mean 15.7 years, 78 males), 46 with PAE. A one-way-multivariate analysis of variance tested differences in neuropsychological functioning between PAE/No-PAE groups, while logistic regression determined tests predictive of PAE. RESULTS: No statistically significant difference in test scores emerged between groups, and regression was not indicative of any models predictive of PAE-group membership. Neuropsychological profiles were characterised by both strengths and weaknesses, with lower verbal and mathematical skills. CONCLUSION(S): While no statistically significant differences were found between the groups, the results provided a unique insight into the neurocognitive profile of Australian youth in detention. Routine screening assessments were recommended for young people sentenced to detention.

Reframe the Behaviour: Evaluation of a training intervention to increase capacity in managing detained youth with fetal alcohol spectrum disorder and neurodevelopmental impairments.

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.

Hospital admissions in children with developmental disabilities from ethnic minority backgrounds.

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.

'That thing in his head': Aboriginal and non-Aboriginal Australian caregiver responses to neurodevelopmental disability diagnoses.

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.

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.

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.

Risk of Developmental Disorders in Children of Immigrant Mothers: A Population-Based Data Linkage Evaluation.

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.

Challenges in Accurately Assessing Prenatal Alcohol Exposure in a Study of Fetal Alcohol Spectrum Disorder in a Youth Detention Center.

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.

Are preterm birth and intra-uterine growth restriction more common in Western Australian children of immigrant backgrounds? A population based data linkage study.

BACKGROUND: To compare the prevalence of preterm birth, post term birth, intra-uterine growth restriction and distribution of Apgar scores in offspring of foreign-born women in Western Australia with that of their Australian-born non-Indigenous and Indigenous counterparts. METHODS: A population-based linked data study, involving 767,623 singleton births in Western Australia between 1980 and 2010 was undertaken. Neonatal outcomes included preterm birth, post term births, intra-uterine growth restriction (assessed using the proportion of optimal birth weight) and low Apgar scores. These were compared amongst foreign-born women from low, lower-middle, upper middle and high income countries and Australian-born non-Indigenous and Indigenous women over two different time periods using multinomial logistic regression adjusted for covariates. RESULTS: Compared with Australian born non-Indigenous women, foreign-born women from low income countries were at some increased risk of extreme preterm (aRRR 1.59, 95% CI 0.87, 2.89) and very early preterm (aRRR 1.63, 95% CI 0.92, 2.89) births during the period from 1980 to 1996. During the period from 1997 to 2010 they were also at some risk of extreme preterm (aRRR 1.42, 95% CI 0.98, 2.04) very early preterm (aRRR 1.34, 95% CI 1.11, 1.62) and post term birth (aRRR 1.93, 95% CI 0.99, 3.78). During this second time period, other adverse outcomes for children of foreign-born women from low income and middle income countries included increases in severe (aRRR 1.69, 95% CI 1.30, 2.20; aRRR 1.72, 95% CI 1.53, 1.93), moderate (aRRR 1.54, 95% CI 1.32, 1.81; aRRR 1.59, 95% CI 1.48, 1.70) and mild (aRRR 1.28, 95% CI 1.14, 1.43; aRRR 1.31, 95% CI 1.25, 1.38) IUGR compared to children of Australian-born non-Indigenous mothers. Uniformly higher risks of adverse outcomes were also demonstrated for infants of Indigenous mothers. CONCLUSIONS: Our findings illustrate the vulnerabilities of children born to foreign women from low and middle-income countries. The need for exploratory research examining mechanisms contributing to poorer birth outcomes following resettlement in a developed nation is highlighted. There is also a need to develop targeted interventions to improve outcomes for these women and their families.

Complexities of conducting research in adolescent refugees resettling in Australia.

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.

Paediatric asylum seekers in Western Australia: Identification of adversity and complex needs through comprehensive refugee health assessment.

AIM: 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. METHODS: 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. RESULTS: 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 experiencing >3 (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. CONCLUSIONS: 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.

Nutritional assessment of resettled paediatric refugees in Western Australia.

AIM: 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. METHODS: 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. RESULTS: 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 infants <12 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 those >24 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 children <24 months compared to older patients. CONCLUSIONS: 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.

Adversity and resilience amongst resettling Western Australian paediatric refugees.

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 <16 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. METHODS: 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. RESULTS: 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, age >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.

Development of a scale to evaluate midwives' beliefs about assessing alcohol use during pregnancy.

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 < 0.001 and r = -0.52, p < 0.001). CONCLUSIONS: Our analysis has identified key constructs underlying midwives' beliefs about the assessment of alcohol use during pregnancy. The AAA Scale provides a basis for improved clarity and consistency in the conceptualisation and measurement of midwives' beliefs which can be used to enhance our understanding of factors influencing midwives' ability to deliver interventions to prevent alcohol use during pregnancy. The constructs identified in this exploratory analysis require confirmatory analysis to support their validity and generalizability.

Fetal alcohol spectrum disorders: notifications to the Western Australian Register of Developmental Anomalies.

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.

Refugee children's play: Before and after migration to Australia.

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.

Midwives' knowledge, attitudes and practice about alcohol exposure and the risk of fetal alcohol spectrum disorder.

BACKGROUND: Midwives are an influential profession and a key group in informing women about alcohol consumption in pregnancy and its consequences. There are no current quantitative Australian data on midwives' knowledge, attitudes and practice in relation to alcohol consumption during pregnancy and Fetal Alcohol Spectrum Disorder. We aimed to reduce this knowledge gap by understanding midwives' perceptions of their practice in addressing alcohol consumption during pregnancy. METHODS: This cross-sectional study was conducted at 19 maternity sites across the seven health regions of country Western Australia. A questionnaire was designed following review of the literature and other relevant surveys. Midwifery managers of the maternity sites distributed questionnaires to all midwives working in their line of management. A total of 334 midwives were invited to participate in the research and (n = 245, 73.4%) of these were eligible. RESULTS: The response fraction was (n = 166, 67.8%). Nearly all (n = 151, 93.2%) midwives asked pregnant women about their alcohol consumption during pregnancy and (n = 164, 99.4%) offered advice about alcohol consumption in accordance with the Australian Alcohol Guideline, which states "For women who are pregnant or planning a pregnancy, not drinking is the safest option". Nearly two thirds (n = 104, 64.2%) of the midwives informed pregnant women about the effects of alcohol consumption in pregnancy, they did not always use the recommended AUDIT screening tool (n = 66, 47.5%) to assess alcohol consumption during pregnancy, nor conduct brief intervention when indicated (n = 107, 70.4%). Most midwives endorsed professional development about screening tools (n = 145, 93.5%), brief intervention (n = 144, 92.9%), and alcohol consumption during pregnancy and FASD (n = 144, 92.9%). CONCLUSION: Nearly all midwives in this study asked and advised about alcohol consumption in pregnancy and around two thirds provided information about the effects of alcohol in pregnancy. Our findings support the need for further professional development for midwives on screening and brief intervention. Policy should support midwives' practice to screen for alcohol consumption in pregnancy and offer brief intervention when indicated.

Fetal alcohol spectrum disorder: development of consensus referral criteria for specialist diagnostic assessment in Australia.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is known to be under-recognised in Australia. The use of standard methods to identify when to refer individuals who may have FASD for specialist assessment could help improve the identification of this disorder. The purpose of this study was to develop referral criteria for use in Australia. METHOD: An online survey about FASD screening and diagnosis in Australia, which included 23 statements describing criteria for referral for fetal alcohol syndrome (FAS) and FASD based on published recommendations for referral in North America, was sent to 139 health professionals who had expertise or involvement in FASD screening or diagnosis. Survey findings and published criteria for referral were subsequently reviewed by a panel of 14 investigators at a consensus development workshop where criteria for referral were developed. RESULTS: Among the 139 health professionals who were sent the survey, 103 (74%) responded, and 90 (65%) responded to the statements on criteria for referral. Over 80% of respondents agreed that referral for specialist evaluation should occur when there is evidence of significant prenatal alcohol exposure, defined as 7 or more standard drinks per week and at least 3 standard drinks on any one day, and more than 70% agreed with 13 of the 16 statements that described criteria for referral other than prenatal alcohol exposure. Workshop participants recommended five independent criteria for referral: confirmed significant prenatal alcohol exposure; microcephaly and confirmed prenatal alcohol exposure; 2 or more significant central nervous system (CNS) abnormalities and confirmed prenatal alcohol exposure; 3 characteristic FAS facial anomalies; and 1 characteristic FAS facial anomaly, growth deficit and 1 or more CNS abnormalities. CONCLUSION: Referral criteria recommended for use in Australia are similar to those recommended in North America. There is a need to develop resources to raise awareness of these criteria among health professionals and evaluate their feasibility, acceptability and capacity to improve the identification of FASD in Australia.

Hear Our Voice: Pediatric Communication Barriers From the Perspectives of Refugee Mothers With Limited English Proficiency.

BACKGROUND: Adverse health outcomes are more common for health consumers with limited English proficiency (LEP). This study examines the consumer experience of refugee mothers with LEP when communicating with paediatric health services. METHOD: A community-based participatory qualitative study engaging participants from refugee-like backgrounds. Focus groups and in-depth individual interviews (using professional interpreters) were conducted in community settings and analysed using Grounded Theory principles. RESULTS: Fifty ethnolinguistically diverse participants reported universal communication barriers; (i) "Negative health care experiences" (fear, helplessness, lack of safety, trust and dignity), (ii) "Ineffective health service communication and adverse outcomes", (iii) "Logistical access barriers" and (iv) self-sourced solutions". The "importance of professional interpreter utilisation" and subsequent "sense of empowerment" was unanimous. CONCLUSIONS: This study highlights gaps in current health interactions which negatively impact care, inclusion, and culturally safe engagement. Recommendations include orgainzational reform enhancing language services, increased cultural competency, long term support, and research with LEP populations.

Ngulluk Moort, Ngulluk Boodja, Ngulluk Wirin (our family, our country, our spirit): An Aboriginal Participatory Action Research study protocol.

Globally, Indigenous children have historical and contemporary connections with government child protection services that have caused significant harm to their long-term health and wellbeing. Innovative, culturally secure and recovery focussed service provision is required. This paper describes a research protocol that has been designed by Indigenous researchers led by Indigenous Elders, to explore culturally secure care planning and service delivery in out-of-home care agencies in Australia. Using participatory action research methods, we will collect data using a variety of forums, including focus groups and semi-structured interviews. These data will explore the challenges for out-of-home care agencies in providing culturally secure care-planning, cultural activity and resources, and explore solutions to address factors that influence health and can assist to redress social inequities for Indigenous children. We aim to recruit approximately 100 participants for the qualitative study and 40 participants for the quantitative survey. Study participants will initially be recruited using purposive sampling, and as the study progresses will be recruited using a mixture of purposive and convenience sampling techniques. The rich data that this study is expected to yield, will inform ways to collect cultural information about Indigenous children and ways to provide cultural connections and activities that will have benefit to Indigenous children and families, and a broad range of social services.

A modified Delphi study of screening for fetal alcohol spectrum disorders in Australia.

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.