Introducing the National Workforce Centre for Child Mental Health
Though many Australian infants and children experience mental health difficulties, these difficulties often go undiagnosed or the families lack access to appropriate services. This article describes the state of child mental health and the mental health sector in Australia then introduces a new initiative for improving workforce capacity: the National Workforce Centre for Child Mental Health. This Centre is a collaboration between Emerging Minds, the Australian Child & Adolescent Trauma, Loss & Grief Network at the Australian National University, the Australian Institute of Family Studies, the Parenting Research Centre, and the Royal Australian College of General Practitioners, and aims to build the identification, assessment, and support skills of professionals and organisations who work with children or parents.
Infants and children are exposed to many experiences, both nurturing and stressful, that influence their mental health (Dogar, 2007). Early childhood mental health involves being able to experience, manage and express emotions; form close, satisfying relationships; and explore and discover the environment (KidsMatter, 2012). Most children learn to cope with adversity, express and regulate emotions, form close and secure relationships, and explore their environment with behaviours appropriate to their individual personality, ecological environment and developmental stage. As well as physical development, children develop socially and emotionally, that is they develop skills around managing relationships, their feelings and interactions with their broader environment. The majority of children, with support from the adults in their life, learn to express and manage emotions in healthy ways, nurture social relationships and successfully contend with life's challenges.
A substantial minority of infants and children, however, experience more frequent or intense difficulties with their emotions, thoughts, behaviours, learning and/or relationships. Extensive evidence now exists regarding the developmental origins of adult mental health difficulties from adverse experiences in infancy and childhood (Anda et al., 2006; Merrick et al., 2017; Norman et al., 2012; Scott, Varghese, & McGrath, 2010). Despite the prevalence and serious immediate and long-term impact of these challenges, infants and children at risk of, or experiencing, mental health difficulties often go unrecognised, lack access to adequate assessment of their needs, and have low levels of access to services with the capacity to offer appropriate levels of support (Milburn, Lynch, & Jackson, 2008; Paula et al., 2014; "'Serious gaps' in crisis care for children", 2017). This article focuses on child mental health in Australia, outlining the context behind the recent establishment of the National Workforce Centre for Child Mental Health (National Workforce Centre; 2017).
Prevalence of infant and child mental health conditions in Australia
There are a number of challenges to providing a clear picture of infant and child mental health in Australia (MacDonald et al., 2005; Twizeyemariya, Guy, Furber & Segal, 2017). Differences in methodology, study parameters and focus, and age limits mean it can be difficult to streamline the myriad studies into a single overall review. However, thanks to ongoing longitudinal studies such as Growing up in Australia: The Longitudinal Study of Australian Children, which commenced in 2004 and follows the development of 10,000 children and families, and the Mater-University of Queensland Study of Pregnancy, which commenced in 1981 with a study of 8,556 pregnant women and continues to follow their children and grand-children, we have a better developmental and ecological understanding of infant and child mental health than ever before.
Notably, there is a lack of information on the mental health of Australian infants under 2 years. This may partly be because of a reluctance to apply diagnostic labels to the earliest signs of disturbance when they can often be transient in the context of rapid developmental changes (von Klitzing, Dohnert, Kroll, & Grube, 2015). It is also further complicated by the fact that the first year of an infant's life is so intimately embedded within parent and caregiver relationships. One way of identifying the number of infants who may be at risk of developing mental health problems is to look to the prevalence of women experiencing postnatal depression and anxiety, as researchers have found positive correlations between an infant's exposure to maternal depression (prenatal and postnatal) and increased risk of neurodevelopmental and/or psychopathological disorders (Pawlby, Hay, Sharp, Waters, & O'Keane, 2009; Soe et al., 2016; Waters, Hay, Simmonds, & van Goozen, 2014).
Infant mental health conditions may present as prolonged dysregulated moods, excessive separation anxiety or problems with sleeping, eating or crying (von Klitzing et al., 2015). If maternal data is taken as an approximate proxy for infant mental health difficulties, then up to 14% of infants may be at risk (Perinatal Anxiety and Depression Australia, 2017). This estimate is similar to results from international epidemiological studies, which indicate that 16-18% of children suffer from a mental health condition at some time during their first five years (see Table 4) (von Klitzing et al., 2015).
The 2015 Australian Child and Adolescent Survey of Mental Health and Wellbeing (Young Minds Matter) (Lawrence et al., 2015) provides detailed information on the prevalence of mental health conditions (i.e., depressive disorder, anxiety disorders, ADHD and conduct disorder) among children and adolescents aged 4-17 years. This survey found that 13.6% of children aged 4-11 years experienced mental health conditions of clinical significance in the previous 12 months. The prevalence of mental health conditions was higher in males (16.5%) than females (10.6%), which can be largely attributed to the higher prevalence of ADHD in males (10.9%) compared to females (5.4%). However, there is some evidence to suggest that this prevalence may be influenced by perceptions of gender; a number of studies have found that ADHD is diagnosed and treated more often in boys than in girls because they are more likely to exhibit hyperactivity and/or disruptive behaviours (Rizzo, 2016; Skogli, Teicher, Andersen, Hovik, & Øie, 2013), while girls with ADHD are more likely to have the predominantly inattentive subtype and are less likely to manifest problems in school (Biederman et al., 2002; Rucklidge, 2010). Australian researchers have also found parents and teachers are less likely to seek mental health and/or learning assistance for girls with ADHD symptoms because they believe it will be less effective than it is for boys (Ohan & Visser, 2009), though data suggests current treatments are likely to be equally effective for both genders (Rucklidge, 2010).
Behavioural and/or attention problems during childhood can indicate past or ongoing exposure to adversity, as children with emotional, mental or behavioural conditions are more likely to have experienced adversity or trauma (Bethell, Gombojav, Solloway, & Wissow, 2016). Behaviours associated with infant and child mental health are often misunderstood as being "naughty" or intentionally wilful, and therefore it is less likely that an appropriate and effective solution will be applied (World Health Organization, 2005).
Growing Up in Australia: The Longitudinal Study of Australian Children (LSAC) (Smart, 2010) followed two groups of children over two waves aged 2-3 years and 4-5 years, who were assessed for problem behaviours and competencies. Problem behaviours were ordered from the most to least common into typologies of externalising (56% of children were sometimes or often restless or unable to be still), internalising (49% of children were sometimes or often afraid of certain places, animals or things), dysregulation (50% of children sometimes or often refused to eat, while 41% sometimes or often had trouble adjusting to changes), and other (47% sometimes or often ran away in public places, while 35% sometimes or often did not react when hurt) (percentages are rounded here to the nearest decimal). LSAC also documented specific behavioural problems in 2-3 year olds such as nightwaking (11%) and destructiveness (5%), and in 4-5 year olds such as restlessness/inattention (12%), worrying (3%), tendency to lose their temper (8%), fidgeting (9%) and disobedience (2%) (Smart & Sanson, 2008). Many of these are common childhood behaviours but mental illness symptoms can often be recognised by their unusual duration, frequency and/or intensity.
Focusing on strengths and vulnerabilities
Many children demonstrate resilience, which is adaptive functioning over time in a context of adversity, after exposure to hardship (Center on the Developing Child, 2015; Dubowitz et al., 2016; Masten & Obradovic, 2006). However, when vulnerabilities in the child's life outweigh the child's strengths, mental disorder can result (World Health Organization, 2005). Vulnerabilities are areas in the child's life that could benefit from added support, and include individual factors (such as developmentally inappropriate emotional and/or behavioural responses) and interactions between the child and their environments (such as family stress or problems at school or in the community) (Hunter, 2012). Vulnerabilities are complex and interconnected, and it is common for infants and children to be faced with multiple vulnerabilities, which substantially increases their risk of experiencing mental health difficulties (Guy, Furber, Leach, & Segal, 2016; Kitzmann, Gaylord, Holt, & Kenny, 2003).
Examples of commonly identified strengths and vulnerabilities are provided in Table 1, which is structured according to the ecological level at which the strengths and vulnerabilities occur (i.e., child, family or social environment). Each child will have a unique profile of strengths and vulnerabilities, and it is important for professionals to understand these in order to better assess their requirements and supply effective care.
The cumulation of multiple mental-health risk factors signifies increased risk for developing a mental health condition in later life. There are also a number of Australian children experiencing 4-5 or more risk factors for mental illness, which indicates a higher risk for mental health difficulties. Data from LSAC (Guy et al., 2016) found that at 0-1 years, 16.1% of Australian children had four or more risk factors for adult mental illness. The most prevalent risks among infants were a parent's problem alcohol use, parent mental illness, and mental illness during pregnancy. By 4-5 years, the rate of children experiencing four or more risk factors had risen to 19.2% and, by 6-7 years, to 25.2%. By 10-11 years, 32.8% of Australian children had experienced four or more risk factors. The most common risk factors among high-risk children (i.e., those with five or more risk factors) aged 10-11 years were parent hostility (68.3%), bullying (45.5%) and low parental warmth (43.6%). The increase in risk prevalence rates over time likely indicates risk accumulation, which Guy and colleagues (2016) note is partly due to early-life exposure to risk factors.
Sources: Baxter, 2012; Conley & Rudolph, 2009; Cooklin, Giallo, D'Esposito, Crawford, & Nicholson, 2013; Farrant, 2014; Fryers & Brugha, 2013; Guy et al., 2016; Hogan, Phillips, Howard, & Yiengprugsawan, 2014; Lawrence et al., 2015; Lucas, Nicholson, & Erbas, 2013; Perales, O'Flaherty, & Baxter, 2015; Sanson, Smart, & Mission, 2011; Smart, 2010; Warren & Yu, 2016.
Some groups of infants and children are at a much greater-than-average risk of experiencing multiple vulnerabilities, and are more likely than others to be diagnosed with mental health conditions. Children in out-of-home care, for instance, are more likely to have experienced greater socio-emotional and behaviour problems than other children (Burns et al., 2004). Similarly, children exposed to maladaptive parenting or marital conflict have a significantly greater risk of developing emotional symptoms (Lucas et al., 2013), and financial hardship has consistently been found to predict negative mental health outcomes (Hardt et al., 2008; McLaughlin et al., 2011; Rutherford, Hill, Sharp, & Taylor-Robinson, 2017).
Many Indigenous families and communities in contemporary Australia face immense challenges. Indigenous children are more likely to experience multiple risk factors for mental health; over 45% of children aged 6-10 years were exposed to six or more risks for mental illness. There is also substantial risk in infancy with 67% of children exposed to three or more stressful family events before the age of 1 year (Twizeyemariya et al., 2017). Their strength and resilience is compromised by multiple complex problems, including historical and ongoing dispossession, marginalisation and racism, as well as the legacy of past policies of forced removal and cultural assimilation (Human Rights and Equal Opportunity Commission, 1997).
The Australian Child Wellbeing Project report (Redmond et al., 2016) highlighted a number of unique strengths and vulnerabilities associated with Indigenous children and families, including strengths such as cultural identity, community connections and unique family systems (as conceptualised broadly in kinship networks), and vulnerabilities such as intergenerational trauma, cultural disconnection and family disruption.
While Indigenous children are generally disadvantaged compared to mainstream children in regards to health and socio-economic outcomes (Biddle, 2014), Redmond and colleagues (2016) point out that this information "needs to be balanced with empirical evidence that captures the complexities of how culture and family interact with material and social conditions to shape the wellbeing of Indigenous young people" (p.14). Psychosocial resilience, which is defined as an individual's ability to successfully maintain or regain healthy mental functioning in the face of social disadvantage or life adversities (Rutter, 1987), is crucial to an individual's overall state of physical and mental health.
When confronted with adverse or traumatic experiences, individuals with higher resilience coped more effectively and had reduced levels of emotional distress afterwards than those with lower resilience (Hjemdal, 2006; Hoge, Austin, & Pollack, 2007; Southwick, Vythilingam, & Charney, 2005). Regardless of the type of adversity, the most common factor among mentally resilient children is the presence of at least one supportive relationship with a parent, caregiver or other adult (Center on the Developing Child, 2015). Therefore, among Indigenous youth, strong community and family relationships, as well as links to cultural traditions, are important components of a resilience framework (Chandler & Lalonde, 1998). It is vital for service and health providers to have an understanding of culturally specific protective factors and how these can help to mitigate risk factors.
Which workforce groups are currently supporting infant and child mental health?
Many workforce groups come in contact with infants and children at risk of, or currently experiencing, mental health difficulties. However, the Australian health system is "fragmented and uncoordinated" and there is a lack of early intervention initiatives for children and youth (Roxon, Macklin, & Butler, 2011). It is not always clear what mental health services are available for infants and children specifically, as they are often packaged in with other family health services or non-specialist mental health services such as general practice (GPs), pediatricians, child and maternal health services, and child and family wellbeing and welfare programs. Additionally, the Australian child mental health services that do exist often struggle to bridge the gap between health locale and places where children spend most of their time, such as school, child care and home (Roxon et al., 2011).
The Young Minds Matter (Lawrence et al., 2015) survey indicated that 13.7% of all children aged 4-11 years had accessed a mental health service in the previous 12 months. However, out of 4-11 year olds who identified as having a mental health condition, less than half (48.9%) had accessed services in the past 12 months. General practitioners were the most commonly accessed service and source of referral to other health professionals (29.8% of 4-11 year olds), followed by paediatricians (22.5% of 4-11 year olds). General practitioners, as primary care physicians, are also responsible for developing mental health care plans for patients that grant access to psychological services and Medicare-funded mental health care.
A recent benchmarking study by Segal, Guy, and Furber (2017) reviewed mental health service provision for infants, children and young people by Commonwealth and state and territory funded mental health services. It is clear from this review that current levels of access to mental health services do not match levels of need across the life span. Table 2 shows that among children under 17, the 0-5 age group has the highest prevalence of criteria for a mental illness diagnosis combined with the lowest overall percentage of access to specialist mental health services. This means that there is a large disparity between need and service access.
Sources: a Guy et al., 2016; d Lawrence et al., 2015; e National Survey of Mental Health and Wellbeing (2007); c Segal et al., 2017; b von Klitzing et al., 2015.
Often, children under 5 years cannot articulate their emotions in the same way adults can, and infants cannot articulate them at all. There is also widespread belief in the community that infants and toddlers are too young to remember things that happen to them (World Association for Infant Mental Health, 2016), which indicates that the public are misinformed about the importance of the early years for social and emotional development. This difficulty in recognising and understanding mental health symptoms and risk factors means it is even more important for professionals and those who work with children and families to be educated in signs and symptoms, good practice and care for this age group.
Introducing the National Workforce Centre for Child Mental Health
Currently, the infant and child mental health workforce operates across a range of disciplines and traditionally siloed departments (Priddis, Matacz, & Weatherston, 2015). Furthermore, vulnerable populations are at higher risk of missing out on mental health services due to the lack of service integration and existing social and financial barriers this lack helps sustain (Whiteford et al., 2014). Initiatives such as SAFE START in New South Wales and the establishment of the Mental Health Commission in Western Australia have contributed to a growing awareness that women in the perinatal period, infants and children are vulnerable populations with specific needs. However, there are residual gaps around how health practitioners can translate knowledge into evidence-based practice.
Globally, there is growing awareness of the importance of upskilling those who work with infants, children and families (Priddis et al., 2015), so service providers are better able to identify, assess and support mental health issues in this population. Increasing the capacity of workforces to respond to the mental health needs of infants and children requires a deliberate, systematic and long-term response.
In response to The National Review of Mental Health Programmes and Services (National Mental Health Commission, 2014), the Australian Government has recently invested in a National Workforce Centre for Child Mental Health (National Workforce Centre), which is a collaboration between Emerging Minds, the Australian Child & Adolescent Trauma, Loss, & Grief Network at the Australian National University (ANU), the Australian Institute of Family Studies (AIFS), the Parenting Research Centre (PRC), and the Royal Australian College of General Practitioners (RACGP).
The National Workforce Centre aims to develop workforce capacity by developing, using and promoting a strengths-based and trauma-informed approach to infant and children's mental health among services working directly with infants, children and parents. Strengths-based approaches focus on children and families' positive resources and capabilities instead of the more traditional focus on deficits and pathologies (Hunter, 2012). A trauma-informed approach to care requires an understanding of how adversity and resilience may impact individuals, a commitment to reducing harm and recognition of the unique profile of strengths and vulnerabilities each child has (Bremness & Polzin, 2014).
Trauma and resilience are often spoken about in tandem but they are not opposite ends of the same spectrum. A child may show signs of being highly traumatised and resilient at the same time (Harvey, 2007). Research suggests resilience may be "domain-specific"; children may exhibit signs of competent functioning in one area (i.e., academic achievement) but show deficits in another (i.e., social relationships) (Luthar, 2006).
The National Workforce Centre also aims to develop capacity in structural change, action planning and implementation, with a focus on regional needs, and organisational change with the end goal of helping service providers promote resilience-building within children and better identify, assess and support infants and children at risk of mental health difficulties.
There are four key components to the National Workforce Centre:
1. An online workforce gateway for members of diverse workforce groups to access resources such as practice guides, training, webinars, tools and apps. Cutting-edge research will be translated into evidence-based practice and an accessible online gateway will be created to help service providers better recognise signs and symptoms of infant and child mental health issues. Previous knowledge interventions have suggested that even in workforce groups with a high foundational knowledge of adversity and mental illness symptomology (such as child welfare and social workers), education and training modules were valuable in facilitating early intervention success (Conners-Burrow et al., 2013).
The National Workforce Centre aims to target both clinical and non-clinical services working with children and parents (see Table 3) to deliver an integrated system of trauma-informed care, while also supporting the child's right to have input into the discussions and decisions surrounding their care, in accordance with Article 12 in the Convention on the Rights of the Child which states that "the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child" UN General Assembly, 1989, p. 3).
2. The National Workforce Centre initiative has employed workforce development officers with specialist knowledge in the areas of infant, child, adolescent and adult mental health to develop resources and training courses to support the development of workforce capacity. As part of this work, needs assessments will be conducted with relevant workforce groups (e.g., GPs) to ensure that the materials developed are relevant to their intended audiences.
3. A national network of regionally based Child Mental Health Workforce Consultants to support workforce development systems change, knowledge exchange and collaboration. To support implementation, small teams of Child Mental Health Workforce Consultants who work at state and regional levels will support the uptake and implementation of evidence-based practice approaches for identification, assessment and support in the promotion of children's mental health. These consultants will be responsible for the development of high-level relationships with Primary Health Networks and key stakeholders. More broadly, they will be responsible for building and supporting organisational and workplace culture to embrace a range of practices and attitudes aimed at "keeping child mental health in mind".
4. A communication and knowledge translation strategy to support the implementation of evidence-informed practice. Recognising that knowing what works is not sufficient to affect change, the National Workforce Centre will use an evidence-informed implementation framework (National Implementation Research Network, 2018) to assess, plan and track implementation capacity-building efforts across the three phases of implementation. The exploring phase is characterised by recognising an opportunity for improvement and developing a roadmap of changes required to successfully implement new practices. The installing phase involves supporting the organisation to prepare for the implementation of new practices. Finally, the implementing phase is the period of ongoing monitoring and problem solving once new practices are in place.
The National Workforce Centre builds upon previous Australian initiatives focused on infant, child and parent mental health designed to improve workforce capacity to respond to the needs of infants and children. Each of the five organisations involved in the National Workforce Centre brings different strengths and expertise to the collaboration, including insight into the workforce development needs of numerous health and welfare sectors across the Australian service system. In bringing together existing groups of health, research, evaluation, implementation and communication professionals, the National Workforce Centre will support nationally coordinated and integrated initiatives to improve mental health outcomes for Australian children.
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The National Workforce Centre for Child Mental Health is an Emerging Minds initiative supported by the Australian Institute of Family Studies (AIFS), Australian Child and Adolescent Trauma, Grief and Loss Network (ACATGLN) at Australian National University, Parenting Research Centre (PRC) and Royal Australian College of General Practitioners (RACGP). In leading this initiative, Emerging Minds welcomes the opportunity to work with like-minded partners to improve the capacity of professionals who work with children or parents to identify, assess and support children at risk of experiencing mental health difficulties.
Bradley Morgan, Emerging Minds. Nicola Palfrey, Australian Child and Adolescent Trauma, Grief and Loss Network, ANU. Rhys Price-Robertson, Australian Institute of Family Studies. Sophie Guy, Emerging Minds. Jessica Masters, Australian Child and Adolescent Trauma, Grief and Loss Network, ANU.
In this issue
- What promotes social and emotional wellbeing in Aboriginal and Torres Strait Islander children?: Lessons in measurement from the Longitudinal Study of Indigenous Children
- New estimates of the costs of children
- Who supports equal rights for same-sex couples?: Evidence from Australia
- The evolution of family research at AIFS: Talking with past Institute leaders
- Introducing the National Workforce Centre for Child Mental Health: Improving the lives of infants, children and families
- A brief history of Family Matters
- A population approach to the prevention of child maltreatment: Rationale and implications for research, policy and practice