Childhood mental disorders: A forgotten problem?

Over the last 20 years, recognition of the importance of good health for economic productivity has encouraged substantial research aimed at identifying health conditions that have the greatest adverse impact on individuals, families and communities. To do this, the impact of different health problems is compared on the basis of their prevalence, level of disability and cost (in both human and fiscal terms). This work has consistently shown that on all three dimensions, childhood mental disorders rate extremely highly (Institute for Health Metrics and Evaluation, 2013; Kessler et al., 2005; Knapp et al., 2011).

Key facts about mental disorders experienced by young people aged <15 years in Australia include the following:

• Approximately 14% of children in Australia (equivalent to approximately 580,000 children <15 years) have a mental disorder at any point in time;

• Approximately 50% of all mental disorders have their onset before the age of 14 years (Kessler et al., 2005);

• Mental and substance use disorders are the leading cause of years lived with disability (YLDs) and disability-adjusted life years (DALYs) for children aged <15 years, accounting for 20.5% of YLDs and 16.7% of DALYs (Institute for Health Metrics and Evaluation, 2013);

• Many childhood mental disorders persist into adolescence and adulthood (Kessler et al., 2012);

• The financial costs imposed on non-health agencies such as education, social services and justice, and also individual families are high (Knapp et al., 2011).

There is also good evidence that the incidence and prevalence of childhood mental disorders are not declining. This suggests that current approaches being used to reduce childhood disorders are not effective.

A continuing challenge for children’s advocates is that the full extent of the public health problem posed by childhood mental disorders has only become evident in the last 20 years. Furthermore, these disorders continue to attract social stigma and are more commonly experienced by children living in families with limited financial and social resources, and where parents themselves may have experienced mental disorders and other adversities. As a result, advocacy for children with mental disorders remains weak despite strong evidence that problems in this area are of major public health importance.

Knapp et al. (2011) have shown that many interventions for mental disorders represent ‘outstandingly good value for money’ (p. 43). However they also note that benefits of interventions for children are often spread over many years. This is an impediment for programme implementation in an era when governments and health systems give priority to interventions that can achieve their benefits in short periods of time. This priority has led to an emphasis on programmes designed to treat existing health problems, particularly problems that are in crisis. A much lower priority has been given to the development and implementation of interventions that focus on prevention or health promotion where benefits are spread over longer time periods. Given this, it is not surprising that the resources provided to address childhood mental disorders are substantially less than would be warranted by an objective assessment of the fiscal and personal impact of these problems.

A significant weakness of previous attempts to improve the effectiveness of Child and Adolescent Mental Health Services (CAMHS) has been the lack of a strong evidence base to guide the change process and reluctance by governments to commit sufficient resources to deal with the major public health problem posed by child and adolescent mental health problems. As a result, reforms and reviews repeatedly focus on general issues such as how to reorganise existing services and how to improve clinical governance and care pathways. While it is important to monitor and review service issues such as quality of service coordination, clinical governance and care pathways, it is also important to recognise the very limited evidence that improvements to such ‘systems of care’ produce better outcomes for children and adolescents with mental health problems.

There are three steps that CAMHS could take to address these issues:

• 1. Make greater use of existing data routinely collected by CAMHS and place greater emphasis on collecting data that assess mental health outcomes

CAMHS typically have little ability to utilise the extensive data they collect about patient activity. This is an important issue for two reasons. First, there is evidence suggesting that rapid feedback of good quality data describing the extent to which a treatment programme is improving a child/adolescent’s mental health problems can increase the effectiveness of intervention programmes in clinical services. Second, a failure to base decisions on good quality outcome data risks the adoption of appealing ideas that are subsequently found to be flawed. Furthermore, unless benefits are monitored over time, it may be assumed that short-term benefits are associated with better long-term outcomes when this is not actually the case.

• 2. Make greater use of pragmatic trials designed to evaluate the effectiveness of new interventions delivered in routine clinical practice

Pragmatic trials are designed to evaluate the effectiveness of interventions in real-life routine practice conditions. In the case of CAMHS, such trials have the potential to generate new knowledge and improve both service outcomes and organisational culture. A combination of strong advocacy and a focus on interventions with the potential for immediate life-saving benefits has enabled the field of childhood cancer to establish a strong track record in this area. As a result, for many years, a large proportion of children in oncology units have participated in clinical trials often coordinated across multiple services. In contrast, only a tiny proportion of children attending CAMHS participate in outcome-oriented trials. Given this, it is not surprising that oncology services have achieved greater improvements to relevant outcomes than CAMHS. Strengthening the capacity of CAMHS to utilise pragmatic trials in order to develop, implement and evaluate new interventions delivered in routine clinical practice has the potential to reduce the incidence and prevalence of childhood mental disorders at a population level.

• 3. Place greater emphasis on ensuring that evidence-based interventions in all services responsible for the care of children and adolescents with mental health problems are implemented with a high level of fidelity

CAMHS have a key role to play in supporting children and adolescents with mental health problems. However, the high prevalence of mental health problems, their multifactorial aetiology and their broad impact mean that a reduction in the incidence and prevalence of problems is unlikely to occur unless all services with responsibility for the health, education and welfare of children and adolescents implement cost-effective targeted and universal programmes aimed at reducing child and adolescent mental health problems. Importantly, it is unlikely that education services will be able to improve learning outcomes at a population level as long as a large proportion of children and adolescents are experiencing a high level of mental health problems. All child and adolescent services need to consider carefully how they can effectively implement and evaluate best practice interventions, appropriate to their circumstances, with the aim of reducing child and adolescent mental health problems.

In conclusion, as highlighted by Insel et al. (2015), ‘in countries of all levels of wealth and development, mental illness affects almost every aspect of society and the economy’ (p. 128). Despite this, mental illness continues to be viewed as a problem affecting individuals and families rather than ‘a policy challenge with significant economic and political implications’ (Insel et al., 2015: 128). The early onset of many mental disorders during childhood, their chronic course and their broad impact means that if they are to overcome this challenge, governments must focus their endeavours more strongly on childhood. If they don’t, they may be too late!