The three year old social and emotional well-being check is good news

Minister for Mental Health and Ageing, Minister Assisting the Prime Minister on Mental Health Reform Mark Butler MP announced that the Healthy Kids Check (previously for four year olds) would be carried out at three years of age and include a social and emotional well-being component (Butler, 2011). It also assesses physical and oral health, growth, vision, hearing and development and is to be conducted in primary care by general practitioners, practice nurses and aboriginal health workers. One of the aims of this initiative is to provide opportunities for early intervention.

Media outlets reported that its bad news (Hall, 2012; Dunlevy, 2012) and an alternative view was expressed (Goodfellow, 2012). In principle, checking social and emotional well-being in pre-schoolers is supported by the Royal Australian and New Zealand College of Psychiatrists (RANZCP, 2012), but there is a risk there will be some devil in the detail.

Our New Zealand colleagues have some experience with this approach as the B4 school check (Health Department New Zealand, 2011) includes the use of a screening tool for social and emotional problems, the Strengths and Difficulties Questionnaire (Goodman et al., 2000).

Prevalence of psychopathology in early childhood

In the 1970’s United Kingdom studies identified 7% of pre-schoolers with moderate or severe behaviour problems (Richman et al., 1975) with follow-up at 8 years demonstrating the persistence of these problems (Stevenson et al., 1985). The prevalence of psychopathology in pre-schoolers in four US community samples ranged from 14-26% (Egger and Angold, 2006). With the development of the Preschool Age Psychiatric Assessment (PAPA) (Egger et al., 2006), pre-schoolers and their parents participating in structured diagnostic interviews in a well-designed Scandinavian study provided data resulting in an estimated population rate for any psychiatric disorder of 7.1%, including 1.5% with anxiety disorders, 2% with depressive disorders and the remainder with behavioural difficulties (Wichstrom et al., 2012).

Australian national population data is limited, 14% of 4-12 year olds in Australia are rated in the clinical range on dimensional assessments of psychopathology. Diagnostic interviews for children under six years were not conducted in the child and adolescent component of the National Survey of Mental Health and Well-being (Sawyer et al., 2000). For those with mental health problems, one in four accessed professional care, most commonly family doctors and paediatricians (amongst others).

While there is a lack of clarity regarding systems for diagnosis of mental health problems in this age group there is also a clear need to address difficulties in the relationship between parents and young children (Merry, 2009). Will the quality of parent-child relationships be a focus of the check?

Intervening effectively

A significant evidence base for the effectiveness of prevention and early intervention strategies for a variety of mental health problems exists (RANZCP, 2009). The evidence for effective intervention involves the active engagement of caregivers to alter the trajectory of onset of anxiety disorders following targeted prevention for at risk young children (Rapee et al., 2010) and for early intervention of post-traumatic stress disorder (Scheeringa et al., 2010). Aspects of child maltreatment are preventable and the Triple-P parenting program has shown positive effects on maltreatment and associated outcomes (MacMillan et al., 2009). A recent extensive review of childhood conduct problems (including a spectrum of anti-social, aggressive, dishonest, delinquent, defiant and disruptive behaviours) found that the evidence for effective intervention is strongest for the three to seven years age group (New Zealand Advisory Group on Conduct Problems, 2009).

The cost effectiveness of intervening in the early years has also been demonstrated (RANZCP, 2011). While there has been a focus on early intervention, specific population groups such as those in out of home care have poorer outcomes and often require on-going treatment and tertiary prevention (RANZCP, 2009). The specific mental health needs of children with neurodevelopmental problems and intellectual disability are significant (RANZCP, 2010).

Recent Australian longitudinal studies of the predictors of internalizing and externalising problems in pre-schoolers identified harsh discipline, maternal stress, substance abuse (Bayer et al., 2012) early paternal depression and maternal depression (Fletcher et al., 2011). The pre-school children of mentally ill parents have also been identified as an at risk group (Kowalenko et al., 2012). A recent American study reported that childhood adversity could potentially explain 32.4% of mental health disorders. The authors found that adversity related to problems in family functioning was significantly associated with all types of mental disorders (Green et al., 2010).

The Healthy Kids Check

The Healthy Kids Check social and emotional well-being component aims to identify 27,000 children in need over the next five years and anticipates that those identified will be further assessed in primary care services. Mapping of health services for pre-schoolers will occur to better inform health professionals and families about available services and pathways to care. An expert advisory group is advising the federal government and its recommendations are not yet available.

What should the three year old social and emotional well-being check include? Will it be a checklist, a screening test for pre-schoolers (as in New Zealand) or a risk assessment? Will it routinely assess parental, family and social risk factors given their importance in the genesis and persistence of early difficulties? How will the data collected dovetail with existing national initiatives? Will the information in the check link readily with psychosocial and mental health data routinely collected currently in the perinatal period to support continuity of primary care (Perinatal Mental Health Consortium, 2008)? Will it link with routine outcome measurement in Child and Adolescent Mental Health (CAMH) services (Kowalenko, 2009)? Will the check work in indigenous communities? Will intervention arising (when required) take into account the sociocultural factors that apply in indigenous communities (Mares and Robinson, 2012)?

Access to integrated care

One of the initiatives of the health reform agenda has been to expand Access to Allied Psychological Services (ATAPS) to improve access for children. Medicare Locals are being advised to prioritise access for children being managed by their general practitioner or paediatrician in the primary care setting (Australian Government, 2012). This seems a sound initiative given that a significant unmet need for children has been identified, where only one out of every four young people receive professional help and even less access specialist care (Sawyer et al., 2000).

How will access to specialist care be supported and integrated? Good practice amongst general psychiatrists’ identifies the children of their patients and a collaboratively developed management plan that targets children’s needs can be instigated (RANZCP, 2009). Will the Health Check assist these practitioners?

How many of the 27,000 pre-schoolers identified as in need might require and potentially benefit from child psychiatric or other specialist assessment and treatment? How many might access CAMH services or private psychiatric care? What will be the impact on service delivery given that developmentally appropriate models of care for mental health planning have been so limited for infants and pre-schoolers (Newman and Birleson, 2012)?

Given the considerable unmet needs of children it is doubtful that services funded by the states can expand capacity to meet the potential needs of this age group in the current funding climate. In most states, there is a policy gap with limited services for early childhood and pre-school mental health. How CAMHS relate to ATAPS in primary care will be of considerable interest. In some areas service reorganisation has consolidated the management and integration of perinatal, infant and early childhood mental health service delivery to develop comprehensive models of care to address the transition from parent and infant to early childhood care. In view of the relative underservicing of this age group RANZCP has, with the Australian Psychological Society and other key leaders in the field, led the promotion of Kids Life Centres to address the mental health needs of young children to better integrate primary and specialist mental health care (Childrens Mental Health Coalition, 2010). Even basic community care is limited with some states reporting serious difficulties delivering routine early childhood health monitoring and primary nursing care (West Australian Auditor General, 2011).

The evidence base for the current Healthy Kids Check is not well established (Alexander and Mazza, 2010). This will also be the case for the social and emotional well-being component, so monitoring, evaluation, audit and further research will be critical. The evidence base will not be the only consideration that continues to shape policy responses as mental health service provision for at risk children is a growing priority for a variety of reasons (The Hon James Wood AO QC, 2008).

It is crucial that the next Child and Adolescent component of the National Survey of Mental Health and Well-being monitors progress since 2000. It should specifically include the pre-school age group to establish the community prevalence of mental health problems and treated prevalence given the strategic importance of these issues to the health reform agenda.

So what is the news?

Pre-school mental health is a key component of mental health reform. It underscores the community’s investment in the second wave of early intervention in Australian mental health care policies that begin to focus on the mental health needs of those under twelve years of age and their families. Access to appropriate care might be problematic given capacity constraints, although initiatives in primary care might go some way to address this. The evidence for effective interventions is sound, but whether or not access to them can be facilitated with a social and emotional well-being check is unknown. In New Zealand pre-school screening for mental health problems is underway and we might potentially learn from this. How best to define the roles of primary, secondary and tertiary mental health care in comprehensive models of care that integrate their functions is a seriously underdeveloped aspect of health planning and CAMH service delivery for this age group. Investment in workforce development, evaluation of population mental health measures and monitoring Medicare Locals activities is required to implement the social and emotional well-being check and realise any potential benefits.

The initiative is a good start. On balance, the announcement is good news. But let’s continue to review this because some devil in the detail may yet appear!