Commentary: The challenge of ensuring access to mental health services for children and adolescents

It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.

Hubert H. Humphrey (1977)

Adequate provision of mental health services to children and adolescents is vital to address the developmental origins of mental illness, particularly the relationship between childhood trauma and later mental illness (Carr et al., 2013; Sara and Lappin, 2017). In some instances, such as the behavioural disorders of childhood, the economic case for early intervention is compelling and the long-term savings accrue to health, welfare, justice and disability systems. The study reported by Segal et al. in this edition of ANZJP demonstrates that service access by the younger age groups, especially infants and young children, continues to be a challenge. The authors of this study report that less than 1% of 0- to 4-year olds received a mental health service in any one service setting. In contrast, approximately 10% of the group aged 18–24 years received an MBS service and 3.5% accessed state or territory funded services (excluding Emergency Departments). Only 2% of MBS Better Access expenditure was on the 0- to 4-year age group. This level of service and expenditure for the 0- to 4-year-old group stands in stark contrast to the Australian Burden of Disease Study (Australian Institute of Health and Welfare, 2016) which estimated a prevalence of 2.2% for severe mental disorder in this age group, and 4.4% and 8.8% for moderate and mild disorders, respectively. There is a clear service gap for this vulnerable youngest age group for whom the evidence strongly supports intervention and for whom the long-term negative consequences of trauma and untreated disorder are significant for the individual, their families and society.

Quantifying the level of service delivery is a first step in a planned approach to ensuring adequate mental health service response. Segal et al. used Australian government data sets to derive number of persons aged 0–24 years who received mental health services in 2014–2015, the number of services and expenditure. The study is limited to health sector data and does not capture mental health services delivered by paediatricians, community child health and non-government organisations, and other agencies such as education, child protection and juvenile justice. Importantly, though, the authors acknowledge the multiplicity of adversities faced by children and adolescents with mental health disorders and their families. They recognise the complexity of the child’s predicament and the high-level specialised workforce competencies required to work with infants and their care-givers and disturbed adolescents in chaotic systems. Multidisciplinary services capable of providing expert consultation to partners such as maternal and child health services, and general practitioners along with long-term care and specialised treatments are required. Mental health services integrated with child protection agencies, perinatal services and education have been demonstrated to be clinically cost effective (Knapp et al., 2011). Developing and evaluating specific interventions delivered in different service settings is a priority. For example, the positively evaluated Got It! programme in NSW is based on mental health clinicians delivering early intervention in the school setting in partnership with teachers to children with disruptive behaviours in the 5-8 year old age group. There are other examples of perinatal mental health clinicians working in partnership with child protection and maternity and early childhood services to deliver positively evaluated programmes. There is still much to do in workforce training to ensure an adequate supply of mental health professionals equipped to work with this younger age group and their families/carers and provide support to partner workforces in other settings. Thus, beyond assessing the current level of service against prevalence, it is essential to determine workforce demand and competency and evaluate which interventions produce cost-effective outcomes.

The draft Fifth National Mental Health Plan is due for publication in late 2017. It proposes that regionally planned and integrated mental health services across federal and state funded boundaries will provide stronger consumer-centred services and achieve improved consumer outcomes. Prevention, promotion and early intervention are priority areas. The challenge for local regional planning will be to recognise and prioritise the gaps in service provision for the younger population group and develop service systems and a specialist workforce. The contribution of Segal et al. in highlighting the current poor access to mental health services by the youngest population group is timely and an important signal to those seeking to develop effective approaches to addressing the current mental health needs of their local population and preventing significant mental health and societal burden in the future.

See Research by Segal and Furber. 52: 163–173.