Is it time for child psychiatry to grow up?

Gone are the days when children were seen and not heard. However, their mental health needs continue to be underserved in Australia and New Zealand. Currently, there are 386 accredited members of the Faculty of Child and Adolescent Psychiatry in Australia and 46 in New Zealand. This represents about 10% of the psychiatry workforce. However, infants, children and adolescents comprise around 19% of the population in Australia and 23% in New Zealand, where they make up about 40% of the Maori and Pacific Island populations. This long-standing disparity is often accepted on the basis that children are less likely to have mental health problems, that their problems are less severe and that their problems can be managed more readily by non-specialist clinicians. Each of these assumptions is incorrect. Three quarters of serious mental health problems begin before 25 years of age. The prevalence and severity of mental health problems during infancy, childhood and adolescence is increasing. One in seven (14%) of Australian children aged between 4 and 17 years have been found to have experienced a recent mental health disorder, of which 25% were considered moderate and 15% severe. A similar rate of mental health problems (15%) has been found in New Zealand children and adolescents aged between 0 and 19 years.

It is well established that psychiatric disorders in childhood are a strong predictor of morbidity in adult life (Rutter et al., 2006). Some features that demarcate child from adult mental disorders are the markers of impairment. These are educational rather than occupational function, peer and family rather than marital relationships and the fact all children have a caregiver, even if that person is not a parent. A consequence of the relative shortage of child and adolescent psychiatrists is that only half of children with mental health needs access services and only 7% are seen by a child psychiatrist. Mental and behavioural disorders are the leading cause of disability adjusted life years (DALYs) in Australians aged 5–14 years, yet treatment rates for major childhood mental disorders remain low. The greatest cost/benefit ratio for public mental health investment is in the childhood age range; yet it is not a key mental health funding priority (Whiteford et al., 2013). Children most likely to be undeserved include those with long-term physical conditions, those in out-of-home care, those with intellectual disability or substance abuse problems and those experiencing family violence, in detention or in forensic settings. Very conspicuous among those underserved are Aboriginal and Torres Strait Islanders, Maori, Pacific Island and all culturally and linguistically diverse populations. Additional consequences of untreated or undertreated mental health problems include educational and therefore subsequent occupational impairment, and youth suicide. For the latter, New Zealand has one of the highest rates among the Organisation for Economic Co-operation and Development (OECD) countries.

The workforce of child psychiatrists

Overall, there are 1.6 full-time equivalents (FTEs) of child and adolescent psychiatrists per 100,000 people in Australia and 1.0 FTE per 100,000 in New Zealand. Not all these psychiatrists treat children; some are medical administrators and others in private practice choose to treat adults. Around 160 other psychiatrists work in youth mental health services. Almost 800 psychiatrists in Australia report working with children and adolescents, particularly in rural areas, and child psychiatrists from overseas (usually affiliates of the college) fill a number of workforce gaps, particularly in New Zealand. Australia and New Zealand sit in the mid-range internationally for child psychiatry FTE per head of population. FTE targets are lower than for other developed nations. The Mental Health Commission in New Zealand recommends 2.0 FTE Child and Adolescent Mental Health Service (CAMHS) psychiatrists per 100,000 and the New South Wales Health Centre for Mental Health (Australia) cites 2.5–5.0 FTE per 100,000. In contrast, the Royal College of Psychiatrists (UK) recommends 3.6–4.8 per 100,000 and the American Academy of Child and Adolescent Psychiatry (USA) recommends 12.0 FTE per 100,000.

Access to services

Geographically, there are greater numbers of child psychiatrists in major cities than in rural areas, as in any specialty. Around one-third of Australian child psychiatrists work exclusively in private practice, while a quarter work in a mixture of private and public settings. In New Zealand, less than 10% of child psychiatrists work in private practice. Access to child psychiatrist expertise is affected by more than simply the number of qualified specialists. Many child psychiatrists work part-time and administrative and team requirements can limit their actual face-to-face clinical availability. Those working in public community clinics often find themselves in cumbersome team settings where too much time is taken with administrative meetings and routine data collection. Despite this, the wait time for an appointment at some specialist CAMHS clinics in Australia is shorter than it is for secondary referring services such as community child health, which could and should be managing low severity mental health problems. The extension of some CAMHS services to serve people up to the age of 25 years is also likely to place a further strain on limited resources. Conversely, establishing shared pathways with other areas of health for the management of conditions such as attention deficit and hyperactivity disorder (ADHD) and neurodevelopmental disorders may help reduce the burden on mental health services.

Recruitment

Recruitment into child psychiatry has been static over the past 10 years and there is a shortage of advanced training posts. Currently, there are 80 child psychiatry trainees in Australia and New Zealand. Based on future projections, approximately 200 additional child and adolescent psychiatrists will need to be trained in Australia and 100 in New Zealand over the next 10 years to reduce unmet need. If the workforce is to reflect the client population, targeted investment is needed in training clinicians from Aboriginal, Torres Strait Islander, Maori and Pacific Island cultures. Special attention is also needed to adequately equip child psychiatrists to work with the underserved populations described above. Increased support for dual training between psychiatry and other specialties, particularly paediatrics, will be valuable in this regard.

The role of the child psychiatrist

The child and adolescent psychiatrist’s role is constantly changing. Within clinical services, there are often flatter hierarchies than in other areas of health and increasingly shared roles between members of multidisciplinary teams. Relationships with team members may be affected by numerous factors including individual personalities, clinical belief systems, service demands, overt and covert power dynamics between different disciplines and lack of role clarity. Leadership positions may be avoided by child psychiatrists due to time pressure, a lack of confidence in undertaking such roles and the lack of financial incentive.

Some might argue that child psychiatrists are not actually the answer to the increasing burden of childhood mental health issues, due to their limited number and costliness. Should health services be more focused on the expansion of other types of clinicians, support staff and peer workers instead? Such task shifting has been proposed for low- to middle-income countries (LAMIC), and texts such as ‘Where there is no child psychiatrist’ (Eapen et al., 2012) support this approach. In developed countries, a stepped care system that includes integrated primary, specialist and e-mental health services is more appropriate to achieve state-of-the-art, comprehensive mental health care. Child and adolescent psychiatrists are well placed to support primary level and specialist intervention by other practitioners while focusing on specialist assessment and treatment for children and adolescents with moderate to severe mental health problems.

Provision of specialist psychiatric skills requires broad training and investment. Infant, child and adolescent mental health problems often have complex biological, psychological and systemic origins, so training in the use of behavioural, cognitive, systemic, psychodynamic and cultural ‘lenses’ with which to view these problems is indispensable for their accurate recognition and treatment. Such comprehensive training is presently available only through The Royal Australian & New Zealand College of Psychiatrists (RANZCP)-supported training programmes. Lloyd et al. (2006) have proposed 12 clinical issues in which the contribution of a child psychiatrist is essential. The first five are psychosis, severe depression, organic states, severe somatoform disorders and self-harm, suicide or harm to others. Understanding the long-term trajectory of childhood mental health problems and the impact of adult mental health issues upon children’s mental health is a key to achieving successful outcomes and why adult training remains a prerequisite to subspecialty training in child psychiatry. Having an understanding of medical issues and good relationships with paediatric colleagues, with whom children with higher needs are more likely to come into contact, are also essential for achieving holistic care.

Academic child psychiatry

There can be few areas in psychiatry more in need of progress in knowledge. While academic psychiatry in general is recognised as endangered both here and overseas, academic child psychiatry is in a much worse plight. The evidence base for treatment of child mental health problems is still at an early stage, despite the remarkable opportunities that are emerging across the board. For example, in epidemiology, New Zealand has already shown how work of the highest quality can be sustained over long time periods, yielding information of invaluable clinical value. Such assets deserve to be further built upon, with longitudinal studies that include intervention. There are emerging cost-effectiveness data on the societal gains from early universal interventions, especially in schools (Campion, 2013), and in another large field, research on the neuroscience of child development is replete with attractive questions of fundamental clinical significance.

Sadly, in the present climate, most psychiatric research in Australia and New Zealand is being done outside child psychiatry. We are missing almost an entire generation of academic child psychiatrists owing in part to a lack of junior university positions which could foster career development. Within child and adolescent services, working conditions are often inimical to research because they consume the clinician’s energy in other directions, possibly even more than happens in adult psychiatry. What is needed for both countries is an ambitious, long-range plan to create a cohort of able investigators, some of whom will be child psychiatrists. Such a plan requires vision and inspiration, with the knowledge that the outcomes will be emerged only some decades ahead. Below, we offer some recommendations along these lines.

Recommendations

1. At a binational level, the RANZCP would make an enduring contribution if it created a Task Force to examine the present situation and its implications for national health. On the basis of its findings, it should make recommendations to the Department of Health and Ministry of Health in our two countries about policy, funding and training priorities.

2. In conjunction with the RANZCP and local workforce development agencies, the Australian Department of Health and New Zealand Ministry of Health should more actively promote the growth of the current child and adolescent psychiatry workforce via recruitment and retention at undergraduate, postgraduate and mid-career levels. The aim should be a minimum of 4.0 FTE child and adolescent psychiatrists per 100,000 general population.

3. The RANZCP should consider additional investment in subspecialty training in areas such as infant mental health, alcohol and drugs, intellectual disability, youth forensics, consult-liaison psychiatry and indigenous mental health. This includes supporting dual-training fellowships between psychiatry and relevant disciplines such as paediatrics and addiction medicine.

4. To improve academic child psychiatry, the RANZCP should seek the development of more junior research-related posts. In addition, in collaboration with Health and Medical Research Councils, consideration be given to establishing or expanding ‘Centres of Research Excellence’ in each country with clinically focused research agendas. It is from such centres that child psychiatrists with advanced research ability will, in due course, emerge.

5. Finally, at an individual level, child and adolescent psychiatrists should regularly evaluate their specialist, administrative and leadership roles within multidisciplinary teams and clinical services to ensure that they function at the ‘top of scope’ no matter what their working environment. Encouragement of junior colleagues, active support of research, conscious maintenance of work–life balance and considered succession planning towards the end of formal roles are all likely to improve personal effectiveness and career satisfaction.

Tempting as it is sometimes to identify with the helplessness of the children with whom we work, we can also learn from them. It really is time for our profession to grow up.