A call for mental health illiteracy: Response to Samuel

Samuel (2020) raised a number of concerns about our advocacy for a national initiative to improve child mental health literacy (MHL; Viewpoints: ‘A national child mental health literacy initiative is needed to reduce childhood mental disorders’; Tully et al., 2019). In our article, we highlighted the lack of MHL regarding mental health disorders in children aged below 12 years and argued that to achieve increased uptake of professional help by those in need and to reduce stigma, a national initiative focussed on increasing child MHL was needed. Samuel’s commentary expressed three key concerns with a child MHL initiative: limited efficacy of available treatments, the negative impact of labelling disorders in children and the complexity of biopsychosocial explanations of mental disorders. While these issues are not central to the aims of increasing MHL (defined as improving knowledge and beliefs about mental disorders which aid their recognition, management or prevention; Jorm et al., 1997), it is nevertheless important to respond to the concerns raised by Samuel.

Samuel’s first argument against a child MHL initiative relates to the efficacy of existing treatments. He argued that since treatments have low efficacy, there is little point increasing knowledge regarding childhood disorders and their treatment. As examples, he emphasised the limited effectiveness of treatment for adult depression and noted there was inadequate research on childhood depression. As the prevalence rates of childhood depression are relatively low compared to other childhood disorders, it is perhaps not the best example to consider in terms of treatment efficacy. If we consider disruptive behaviour disorders (DBDs; Oppositional Defiant Disorder and Conduct Disorder) as an alternative example, where the prevalence rates in children are higher, the gold standard treatment for these disorders (namely, parent training programmes) are highly efficacious, with two variants classified as ‘well-established treatments’ (Kaminski and Claussen, 2017). Longitudinal research also indicates childhood DBDs are implicated in the developmental trajectories of a range of adult disorders, including depression and anxiety. Thus, effective early treatment of DBDs has the potential to not only ameliorate symptoms of these disorders in the childhood years but also to prevent or attenuate symptoms of a range of other disorders later in life. Similar evidence is available for the treatment of childhood anxiety in which a range of programmes are available that deliver reliable and robust improvements. This positive evidence is at odds with Samuel’s first argument. However, even for disorders where treatment efficacy is lower, we believe this is not a cogent argument against increasing MHL. Providing information about treatment availability and efficacy is an important part of any MHL campaign and critical to improving treatment uptake.

Samuel’s second argument against a child MHL initiative is that the diagnosis of mental disorders in childhood may be associated with stigma. While we agree that this is an important concern, the primary focus of a child MHL initiative would not be on increasing the diagnosis of disorders in children, but rather helping parents (and the general public) to understand symptoms, aetiology, prevention and treatment. In addition, it may be simplistic to assume that the effects of diagnoses on children are negative. In fact, a systematic review on stigma in children and young people found that stigma appeared to be unaffected by labelling (Kaushik et al., 2016). There is clearly a need, however, for more research on stigma related to childhood disorders.

Samuel’s final argument concerns the complexity of communicating biopsychosocial explanations of child mental health disorders in an MHL campaign. We agree that communicating such explanations may be challenging in practice, and research would be needed to inform this. Samuel’s latter two arguments highlight the importance of further research that would be needed to inform such a campaign, and as we argued in our original paper, research into the constructs of child MHL and stigma is indeed needed.

In conclusion, we wish to highlight the points where we agree wholeheartedly with Samuel. We agree it is imperative that the burden of childhood mental health disorders is reduced, children and their families must be supported to author their narratives in their own language and the mental health needs of children must be conceptualised based on the individual child’s context. Importantly, we believe it is possible to improve child MHL through a national awareness campaign without compromising on these issues. Should Australia continue on its current path, with low levels of community knowledge of childhood mental health, we will no doubt continue to have high prevalence rates and low levels of treatment uptake among children and families. We continue to argue for the importance of a national child MHL initiative, while encouraging further discussion and debate on this issue among child psychology and psychiatry experts.