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Abstract

Objectives:

Despite substantial investment by governments, the prevalence of mental health disorders in developed countries remains unchanged over the past 20 years. As 50% of mental health conditions present before 14 years of age, access to high-quality mental health care for children is crucial. Barriers to access identified by parents include high costs and long wait times, difficulty navigating the health system, and a lack of recognition of the existence and/or severity of the child’s mental health disorder. Often neglected, but equally important, are clinician views about the barriers to and enablers of access to high-quality mental health care. We aimed to determine perspectives of Australian clinicians including child and adolescent psychiatrists, paediatricians, psychologists and general practitioners, on barriers and enablers within the current system and components of an optimal system.

Methods:

A total of 143 clinicians (approximately 35 each of child and adolescent psychiatrists, paediatricians, child psychologists and general practitioners) from Victoria and South Australia participated in semi-structured phone interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study aims.

Findings:

Clinician-identified barriers included multi-dimensional family factors, service fragmentation, long wait times and inadequate training for paediatricians and general practitioners. Rural and regional locations provided additional challenges but a greater sense of collaboration resulting from the proximity of clinicians in rural areas, creating an opportunity to develop support networks. Suggestions for an optimal system included novel ways to improve access to child psychiatry expertise, training for paediatricians and general practitioners, and co-located multidisciplinary services.

Conclusion:

Within the current mental health system for children, structural, training and workforce barriers prevent optimal access to care. Clinicians identified many practical and systemic ideas to improve the system. Implementation and evaluation of effectiveness and cost effectiveness of these ideas is the next challenge for Australia’s children’s mental health.

Keywords

Health service use children mental health qualitative

Introduction

Mental health disorders are a leading contributor to the global burden of disease (Vos et al., 2020). Despite increased recognition and investment by governments in treatment, the prevalence of mental health disorders in developed countries remains unchanged over the past 20 years (Jorm et al., 2017). Fifty percent of mental health disorders begin before the age of 14 years (Kessler et al., 2005). Left untreated, they can have lifelong personal and societal impacts (Bor and Bor, 2001; Bosquet and Egeland, 2006). Thus, it is crucial to ensure that children with mental health problems can readily access high-quality mental health care.

The second Australian national Child and Adolescent Survey of Mental Health and Wellbeing (known as Young Minds Matter [YMM]) reported that approximately 14% of Australian children aged 4–17 years experienced a mental health disorder within a 12-month period (Lawrence et al., 2016). The most common diagnoses were attention-deficit hyperactivity disorder (ADHD, affecting 7.8%), followed by anxiety (6.9%). Only 50% of those with a mental health disorder had received services in the previous 12 months (Johnson et al., 2016). However, among these children, few receive a sufficient dose of care that would be likely to improve their symptoms (Mulraney et al., 2020; Sawyer et al., 2019).

A nuanced understanding of barriers and enablers to service access is needed to inform the development of policies and practices that will increase access and ensure that children who do attend services receive the right treatment at the right dose. Several studies have identified barriers to care consistently reported by parents. The most commonly reported barriers include high costs and long wait times, difficulty navigating the health system, a concern with being blamed for their child’s problems, and a lack of recognition of the existence and/or severity of the child’s mental health disorder (Lawrence et al., 2016; Reardon et al., 2017; Sawyer et al., 2000). Often neglected, but equally important, is understanding clinician views about the barriers to and enablers of access to high-quality care. We could find only one study (conducted by our group, Paton and Hiscock, 2019) of Australian clinician perspectives, but this study focused on autism and ADHD and did not include the views of general practitioners (GPs). In Australia, the majority of child and adolescent mental health care is provided by GPs, psychologists, paediatricians and psychiatrists (Johnson et al., 2016). As such we aimed to expand previous research by investigating the perspectives of Australian GPs, psychologists, paediatricians and psychiatrists on:

The barriers to access and optimal care within the current health system for children and adolescents with ADHD and anxiety;

Components of an optimal system.

We chose to focus on mild to moderate mental health problems (the ‘missing middle’; Rosenberg, 2015; Victorian Government, 2019) as these are more common than severe problems and lack of timely care may lead to deterioration in the problem.

Methods

This qualitative study was nested within a larger study ‘Towards an equitable mental health system for children in Australia’ (NHMRC grant 1129957), which investigated current use of mental health care by Australian children and adolescents and how best to improve care. The qualitative methodology for this project was based on interpretative description which aims to generate an understanding of complex clinical phenomena which can lead to applied outcomes in real-world circumstances (Thorne, 2016; Thorne et al., 1997).

Approval was received from Human Research Ethics Committee at The Royal Children’s Hospital, Melbourne, Victoria, Australia, (HREC37105) prior to commencement of the project. Prior to interviews, participants were informed that their participation was voluntary and unpaid. Verbal informed consent was sought.

Recruitment

A purposive sampling strategy was used to recruit clinicians in two states of Australia (Victoria and South Australia) spanning clinicians across low and high socioeconomic settings (based on socioeconomic index for advantage [SEIFA] of clinician practice postcode), major city and regional areas and public and private work settings.

Participants were sourced via three key strategies: websites linked to professional organisations, e.g., find a Psychiatrist (The Royal Australian and New Zealand College of Psychiatrists, 2020); key informants (Marshall, 1996) from within professional networks of the clinicians; and Internet searches of the first five pages on Google.

Where recruitment strategies generated lists larger than 20 clinicians for each group, a statistician not associated with the project assigned a random number to each clinician and the clinicians were contacted in order of the numerical number assigned.

Procedures

A total of 143 (of 270 specialists and 165 GPs contacted) semi-structured phone interviews were conducted with clinicians (35 child and adolescent psychiatrists, 37 child psychologists, 35 paediatricians and 36 GPs) from Victoria and South Australia between March 2018 and February 2019.

Participants were provided with one of two alternately allocated vignettes: either a child experiencing symptoms of ADHD or a child with symptoms of anxiety (see Supplemental Material) prior to the interview, to orientate them to the population of interest. Interviews lasted approximately 45 minutes. A semi-structured interview guide was used to ensure the key questions were covered, but also allowed participants to discuss what was important to them.

Detailed field notes were kept of all interviews. Reflexivity was maintained by ongoing discussions between researchers and a reflexivity journal. Interviews were audio recorded and transcribed verbatim. Transcripts were validated, de-identified and participants assigned pseudonyms. Transcripts were then coded for analysis using NVIVO 12.0 (NVivo, 2017) software.

Analyses

The study research aims provided the broad focus for analysis but following coding more ‘interpretive’ constructs were developed using an inductive approach (Elo and Kyngäs, 2008).

Three researchers (K.P., H.W. and S.R.) developed the initial coding schema which was reviewed by senior researchers (L.G. and H.H.) and applied to all transcripts. Categories were developed in line with the primary research questions and themes were identified using the processes of content analysis. Regular discussion between members of the research team ensured a rigorous process of qualitative coding to identify similarities and differences, enabled iterative development and validation of emergent themes. The lead analyst was a female Master of Public Health (K.P.) with no clinical training. K.P. completed analysis until data saturation was achieved in relation to the research question. A further eight transcripts were then reviewed for each clinician type. Findings are reported in line with the COnsolidated criteria for REporting Qualitative research (COREQ) (Tong et al., 2007) checklist.

Results

Demographics

Characteristics of participating clinicians are shown in Table 1. There was a spread of clinician types across practice and socioeconomic settings. More respondents practised in metropolitan than rural/remote areas and more psychologists practised in private than public settings, likely reflecting workforce distributions.

Table 1.

Clinician characteristics by Victoria (VIC) and South Australia (SA).

	Location^a		Socioeconomic status			Health setting
	Regional/remote (N)	Major city (N)	Low (N)	Medium (N)	High (N)	Private only (N)	Public only (N)	Public and private (N)
Psychiatrist	3 SA 11 VIC	9 SA 19 VIC	9 SA 23 VIC	7 SA 23 VIC	6 SA 21 VIC	0 SA 7 VIC	3 SA 7 VIC	6 SA 12 VIC
Psychologist	4 SA 9 VIC	7 SA 19 VIC	9 SA 14 VIC	9 SA VIC 22	8 SA 21 VIC	9 SA 22 VIC	1 SA 0 VIC	1 SA 4 VIC
Paediatrician	1 SA VIC 11	6 SA VIC 22	6 SA 27 VIC	5 SA 27 VIC	4 SA VIC 21	1 SA 4 VIC	2 SA 8 VIC	3 SA 17 VIC
General practitioner	3 SA 7 VIC	4 SA 24 VIC	6 SA 21 VIC	6 SA 23 VIC	2 SA 19 VIC	4 SA 12 VIC	0 SA 2 VIC	4 SA 14 VIC

Several clinicians practice in both regional/remote settings and major city settings.

Findings

Analysis of the interview transcripts from a broad range of participants revealed important themes which are presented using verbatim quotes.

Some quotes have been truncated for space reasons without changing the meaning. This is represented by an ellipsis (...).

The overall study identified five overarching key themes. In this paper, we provide a summary of findings from one key theme: health sector challenges and components of an optimal system for child and adolescent mental health care. Other key themes included health system funding models (with some overlap of the findings in this paper); an evidence-based role for the education sector; role of emotion and perceptions about mental health; and supporting parents to support their child.

Clinician reports describing system barriers to access and optimal care

All clinician groups raised issues about access to services. Access to services is restricted by degree of severity and complexity of the condition, age ranges for specific services, fragmentation of services with no roadmap to navigate, out-of-pocket costs and lengthy waiting times.

Clinicians identified multi-dimensional interrelated individual and family factors which influence access to services, including severity and complexity of the condition, geographic location of services, age of the child/adolescent, parental factors (e.g. health literacy, mental health, capacity to pay) and individual personal circumstances such as employment status.

At the extreme ends, i.e., when a child had conditions sufficiently complex and severe to have access to publicly funded child and adolescent mental health services (CAMHS) or when families had a high degree of health literacy and were able to pay for services, services were relatively easier to access.

The term the ‘missing middle’ was used to describe those that fell outside these two extremes and described a very large group of families, children and adolescents.

The CAMHS model was identified as positive, in terms of many practitioners in one setting but clinicians also suggested that public mental health services (and specifically CAMHS) have strict criteria for accepting a referral through their intake processes and their capacity covers only a small proportion of the need.

Although long waiting times were perceived to be more likely to occur in public settings, clinicians perceived that private services also had long waiting lists in all professions. This was reflected as impacting both referral to other service providers and waiting times for clinicians’ own practices. This varied according to location and was reported to be worse in rural and low socioeconomic areas where provision of specialist services is limited.

Furthermore, clinicians identified that the need to travel long distances was challenging for families.

However, a greater sense of community and collaboration resulting from the proximity of clinicians in rural areas provides an opportunity to develop support networks. This was perceived to provide a mechanism for closer liaison and more coordinated care than that experienced by their metropolitan peers. Table 2 provides a detailed summary of system issues and solutions.

Table 2.

Clinician reports describing system barriers to access and optimal care.

Quotes describing problems	Quotes suggesting solutions
Complex systems – multiple factors impact access to services Representative quote ‘It’s actually appreciating why kids can’t get to appointments. It’s not just that they can’t afford it; it’s that Mum’s having her own panic attack and can’t drive her that day, or they didn’t get the appointment because Mum’s phone’s been cut off because she couldn’t pay it, or they didn’t get the appointment because they’re actually living in their car because Dad’s come home and kicked them out’. (VIC Paediatrician 10, public/private)	Integrated multi-disciplinary services Representative quote ‘I mean in some way it would be nice to see a kind of, well, a department of paediatrics in each region, that focuses on children, well you know, the developmental stages from nought to 18 or even higher in terms of physical, social, emotional needs so that you know, everything is much more integrated’. (VIC Child and Adolescent Psychiatrist 10, public and private)
Fragmented services Representative quote ‘I guess that we’re looking at ... especially with a lot of the complex cases, that there is such a big overlap between their physical, particularly neurological development, their emotional needs, their experiences that ideally you’d want to handle the things together’. (VIC Child and Adolescent Psychiatrist 10, public/private)	Integrated multi-disciplinary services Representative quote ‘In the ideal world a lot of us would be co-located. ... we need more time, we also need funding for planning time and case consult and multi-disciplinary assessments and other services around providing best quality care’. (VIC Psychologist 14, private)
Rules and restrictions but no roadmap about how and where to find appropriate services* Representative quote ‘I’ve heard people talk about the missing middle and I’ve experienced that so often and its really frustrating ... and it happened this morning with the young person I saw who has been suicidal off and on ... [service] didn’t feel he needed an inpatient admission, he doesn’t fit criteria for [mental health service] and he says to me that he tried a number of psychologists in his local area, he’s been to [service] and it didn’t help ... and then I’m sort of left, stuck, and not really knowing where to fit him in the system’. (VIC Paediatrician 1, public) *Identified as a barrier by parents (Lawrence et al., 2016: Sawyer et al., 2000)	Information about how and where to access services with assertive follow-up Representative quote ‘From experience, I know that parents struggle to navigate the system and sometimes the clinicians don’t know what the pathways are ... if there is a simpler pathway that the parents can follow and the practitioner knows where to direct them, then that will be the easiest thing. ... and then some mechanism of making sure that this child and the family is followed through ... and the child is not being lost’. (SA Child and Adolescent Psychiatrist 4, public/private)
Restricted access to services (the missing middle)* Representative quotes ‘It’s a huge barrier because when we turn people away from CAMHS because they really don’t meet the complexity and what is needed to take someone on to the extremely expensive intervention of kind of case management and therapeutic care in CAMHS, then for a whole lot of them, it’s kind of “well, what now?”’. (VIC Child and Adolescent Psychiatrist 1, public/private) ‘So Child and Adolescent Mental Health are really important, but they’re also being marginalized in a way because now they’re being asked to only take referrals for sort of the most difficult, complex cases and yet there’s a big gap between what they can provide and what a private practitioner can provide with only ten sessions a year. There’s a whole gap in the middle there’. (SA Psychologist 2, private) *Identified as a barrier by parents (Lawrence et al., 2016; Sawyer et al., 2000)	Access to specialist services Representative quotes ‘I think would be really helpful if we had ... better access to clinical questions, so one thing you can do in the UK is send a fax with a clinical question, so essentially you’d send a referral letter and they send what their advice would be back, so it’s a same day advice service’. (VIC GP 2, private) ‘... we’re thinking about at least three monthly forums for GPs, where every three months, we invite the GPs to an education session from CAMHS, and then keep this as an ongoing thing where it’s also spreading the awareness, and also kind of helping the GPs to understand how mental health works, what is a triage for mental health? What to expect when they’re referred?, when to refer? ... and when CAMHS is saying we want to send down this client to the community, and they can be managed by the GPs, what are the expectations? All that is what we’re trying to kind of plan’. (VIC Child and Adolescent 6, public/private)
Out-of-pocket costs for services* Representative quotes ‘Some of the parents clearly say, “I can’t even afford the $50 extra gap that they charge us”’. (VIC Paediatrician 28, public/private) ‘Well, they have to wait ’cause they can’t have treatment. They don’t have a choice. Like you know, if you’re broke you don’t have access, that’s the reality’. (SA Psychologist 5, public/private) *Identified as a barrier by parents (Lawrence et al, 2016; Sawyer et al., 2000)	Increased rebates for bulk billed services Representative quote ‘... they currently can come and not have to be out of pocket but it relies on the clinician bulk billing the service, and the bulk bill rates haven’t changed since about 2010. So the burden then is put back onto the clinicians. So if that was gone, if the clinicians could still be paid properly and the patient wasn’t out of pocket, that would be great’. (VIC Psychologist 6, private)
Waiting times for accessing services* Representative quote ‘... long waiting lists for psychologists up here, sometimes six months. And similarly for paediatric reviews ... nine to twelve months is what I’ve heard of up here’. (VIC Child and Adolescent Psychiatrist 18, public) *Identified as a barrier by parents (Lawrence et al., 2016; Sawyer et al., 2000)	Grassroots mental health services* Representative quote ‘Ideally, it would be more publicly funded services, but also putting the services at a grassroots level; having it more accessible to families’. (VIC Paediatrician 10, public/private)
Impacts of geographic location* Representative quote ‘When I was in [country town] which is a remote, rural area, there was a huge non-compliance rate because the patients there were isolated in many, many situations. I certainly found that having an outreach clinic improved the situation ... but after hours, on the weekends was a bit difficult getting the psychiatry input’. (VIC Paediatrician 18, public) *Identified as a barrier by parents (Sawyer et al., 2000)	Collaboration provides support Representative quote ‘In the rural region, it’s very collaborative. You usually make some sort of connection and professional with the person on the other end of the phone. ... And you know, sort of get to know how the other works, and you’ll know their thresholds and their needs’. (VIC Child and Adolescent Psychiatrist 31, public)
Funding system Representative quotes ‘On one hand, the public sector wants more things to be shifted to us. On the other hand, we have noticed that it’s becoming very, financially hard, to be honest to you. If you want to do a proper mental health plan, looking at everything physical and mental side, you need at least half an hour, but how you going to run a medical centre if you do that?’ (VIC GP 6, bulk billing/private) ‘You’ve got some GP practices that would see without any exaggeration, they would see eighty cases a day. Eight zero. Well, there obviously not the sort of practice that is well suited to this sort of coordinating and case discussion’. (SA Child and Adolescent Psychiatrist 5, public /private)	Robust primary care system Representative quote ‘Primary care is not valued and that’s really obvious from the way the funding system works in the health system where you’ve got this very heavily funded tertiary system, which gobbles up all the money and primary care gets the crumbs. In lots of ways, it should be the other way around. If you had a really robust primary health care system where people could get, not just the mental health support that they needed for minimal cost to themselves, so it was very well funded, ... If you had that, and across the board, not just in mental health but in all aspects, then we wouldn’t need such a big tertiary system. There’d be a lot of stuff that would get sorted out at the primary care level, at the community level where it should get sorted out’. (SA GP 3, private)
Medicare items numbers Representative quote ‘One of the biggest obstacles I find is that ... there’s no facility under Medicare system to see the parent without the child, at least in the practice. And that can be problematic because a lot of the work most of the time needs to be done with the parents. (VIC Psychologist 6, private) ‘My ideal world is I don’t have a limit on sessions ... And I don’t have to always be thinking how am I going to make best use of this client’s 10 sessions? Do I use four now and save six for the end of the year when I know that she, historically, will have more issues as they get tired throughout the year?’ (VIC Psychologist 6, private)	Changes to Medicare funding Representative quote ‘... lift the restriction that you have to have the client present so that you could freely have sessions with just the parents on some occasions so that you could have that whole hour to talk with the parents and workshop with them’. (SA Psychologist 2, private) ‘We can’t charge for phone calls, but I think you know if you could speak to a client over on the phone and that could be billed under Medicare, that could be really helpful as well, ’cause I’ve had clients who can’t come in, you say can you call me for a therapy session, and it’s not covered by Medicare and they can’t pay, so I end up doing it pro bono. So stuff covered by Medicare, phone, Skype’s covered now, you know email maybe, that could be helpful’. (VIC Psychologist 5, private)

Clinician reports describing workforce barriers to access and solutions towards optimal care

Limited numbers of child and adolescent psychiatrists was identified as an issue by all clinician groups including child and adolescent psychiatrists themselves. GPs and paediatricians feel they can manage some mental health conditions but expressed a desire for more support from child and adolescent psychiatrists for more complex cases. Psychiatrists see one of their roles as consultants and advisors to other professions.

A more general shortage of trained professionals for younger (<12 years) children was seen across the sample.

Publicly funded psychologists were recognised as a particularly scarce resource by all clinician groups. Combined with lengthy waiting lists this led to clinician burnout, particularly in regional areas. Clinicians expressed the view that in some cases employment contracts were short term and this led to high turnover in staff. In addition, the workload in regional areas also had an impact on recruiting new staff.

Many clinicians identified that the system of care is top heavy with a focus on specialist medical staff when some first-line mental health care management could be undertaken by other professions, provided they were trained in mental health.

Variability in the quality of services provided both at the individual clinician level and organisational level was identified.

GPs are typically considered to be generalists. Clinicians suggested that opportunities for GPs to specialise in mental health services could be valuable; however, some GPs did not have an interest in paediatrics and/or mental health and others felt they did not have the skills to treat mental health conditions.

Within all clinician groups, appropriate training and professional development was identified as a challenge particularly for those in regional areas. Table 3 provides a summary of clinician identified workforce challenges and possible solutions.

Table 3.

Clinician reports describing workforce barriers to access and solutions towards optimal care.

Quotes describing problems	Quotes suggesting solutions
Lack of training for GPs Representative quote ‘Some are very proactive and are willing to work with young people who have mental health issues. ... but unfortunately I could say that a third or a quarter of GPs are very anti-mental health and I think that’s partly is because of the degree of anxiety that they feel as individual clinicians themselves, their lack of training ...’ (SA Child and Adolescent Psychiatrist 8, public/private)	Improved training for GPs Representative quote ‘GP trainees to be able to do more rotations, so long, extended rotations within a CAHMS service, I think would be very helpful’. (VIC Child and Adolescent Psychiatrist 4, public/private)
Lack of training for paediatricians Representative quote ‘As paediatricians, we tend to end up having to see these children and manage these children because of the stress on the mental health system and the lack of availability of you know, child psychiatrists in our public mental health system ... So I think that you know improved training, improved support around that for pediatricians, is really, really important’. (SA Paediatrician 1, public)	Improved PD and training opportunities Representative quote ‘There should be more training in paediatrics about mental health disorders for children, and there should be more training in psychiatry about paediatrics. That’s another practical thing, I think. But I don’t think it’s our job as paediatricians to take over what psychologists do’. (VIC Paediatrician 6, public/private)
Lack of Psychiatry availability Representative quote ‘Yeah, I had a GP in my rooms the other day very upset cause my books were closed, and was really angry about it actually, sort of yelling at my receptionist. . ...and then I called them back, and they were kind of making a few comments like, “what a luxury to be able to close your books, I should’ve been a child psychiatrist”’. (VIC Child and Adolescent Psychiatrist 1, public/private)	Novel ways to access psychiatry services Representative quotes ‘I think would be really helpful if we had ... better access to clinical questions, so one thing you can do in the UK is send a fax with a clinical questions, so essentially you’d send a referral letter and they send what their advice would be back, so it’s a same day advice service’. (VIC GP 2, private) ‘It’s really, it is kind of like a secondary consult service. I think that would be brilliant. We’re trying to build that into the Doctors in Schools program. Trying to get that to be like a peer support, and also secondary consult’. (VIC GP 31, bulk billing)
Appropriate utilisation of workforce Representative quote ‘I think we’ve got a system at the moment which to me is a little bit like expecting the cardiologist to see everyone with chest pain ... and we certainly don’t have enough cardiologists to do that ...’ (SA Child and Adolescent Psychiatrist 5, public/private)	Psychiatrists as consultants Representative quote ‘In my ideal world, I might have a more consultative educational role in discussing the more high-end complex cases, and holding systems, and all the anxieties that that provokes. Rather, than just coming in as specialists and writing a letter with a diagnosis on it’. (SA Child and Adolescent Psychiatrist 7, public)
System reliant on specialist services Representative quote ‘What I find as a general paediatrician in the community is that I end up being everything. I’m the social worker and the speech pathologist and the nurse, and they end up getting someone who’s quite expensive but very well-trained holding a lot of stuff that could be done by a case manager ...’ (VIC Paediatrician 10, public/private)	Use of other workforces, e.g., Mental health nurses, for first line of mental health response Representative quote ‘... mental health nurses or mental health OTs can manage it. You know, there a place for that stepped up care approach so that there’s a mental health nurse in every GP practice ..., skills training or parenting training or sleep training or behaviour training ...’ (SA Psychologist 3, private)
Challenges of staffing in regional locations Representative quotes ‘After I’m up in [regional towns] l often you have to carry very hard difficult caseloads. Often days when you’re the only ones there, and not having a colleague to talk and speak with is really hard, and we have a problem recruiting staff to the more regional clinics because there’s just not the staff in those towns’. (VIC Child and Adolescent Psychiatrist 31, public) ‘So obviously, training tends to occur in the capital cities, and so it’s difficult to organize that and particularly when you’re a bit thin staffing-wise’. (VIC Child and Adolescent Psychiatrist 18, public/private)	More funding Representative quote ‘a big grant of funding ... or at least potentially Commonwealth funding to support more visiting allied health type workers, you know, working in the country would be a great help’. (SA Child and Adolescent Psychiatrist 3, public/private)
Lack of interest in mental health Representative quote ‘I see my role as, I often compare this to say, heart disease. I see a patient, I diagnose. I can work-up, I can do the blood test and I can come up with what I think is the diagnosis and then I refer to the specialist. And then the specialist takes over and treats them. And I think that’s how mental health should be. Because as GPs we don’t have the skills to carry out counselling and advice and all those things’. (SA GP 10, bulk billing/private)	Opportunities for GPs to specialise in (child) mental health services Representative quote ‘I think GPs are really important, but again, if you think the skillset of paediatricians is varied, the skillset of GPs is very varied. I think that GPs who are interested in child and adolescent health should be supported and they should be educated on child physical and mental health’. (VIC Paediatrician 6, public/private)
Variability in the quality of services provided Representative quotes ‘GPs who are perhaps less inclined towards managing mental health on their own, and there are GPs who just flatly refuse to. They tell patients, and we know who those ones are because, you know, when they refer to a psychiatrist it’s just a one-liner, “Please take over the care”’. (SA Child and Adolescent Psychiatrist 2, public/private) ‘Well if we start with at the GP level, so I feel relatively confident and happy seeing adolescents for mental health issues, but not all GPs would feel the same. And that may be because, they simply don’t see many adolescents, or they don’t see a lot of mental health. So I think there’s a large variation between GP’s in terms of experience, knowledge, skills, and I guess general comfort in managing these issues. That’s potentially a barrier there, that they may not be getting the treatment they need from the GP’. (VIC GP 15, bulk billing/private)	Medicare item numbers for mental health trained GPs Representative quote ‘In an ideal world I’d like to do what the government did a few years ago, and chucked a whole lot of money at training GPs in mental health in adults, and released MBS item numbers so that they could be remunerated for doing this kind of work, as part of improving mental health in adults, but doing this in kids and so that GPs will have a module to do, and once they’ve done that module in three or four conditions, then this module will allow them to manage these conditions in a way that’s clearly evidence based, and also allow those GPs that have done this module- there will be a period of assessment- and then they should be allowed to prescribe the stimulant treatment’. (VIC GP 1, bulk billing/private)
Lack of services for children under 12 years Representative quote ‘I’m getting clients re-referred back to me because they’re not seeing kids that young. So they’re calling themselves a child psychologist but they’re not actually seeing children under the age of eight ... there’s just not enough trained professionals’. (SA Psychologist 3, private)	Specialist services for children under 12 years Representative quotes ‘... children’s centres, and they are funded by the Department for Education. They’re sort of places where there are often childcare, possibly kindy. They often do have a speech pathologist and OT onsite, and they may have a social worker, they currently provide services up until five years, and sometimes up until eight years. So I think that sort of service, if expanded, and if able to provide more assessments. So, at the moment they don’t do a lot of assessments, it’s mostly sort of, general support stuff. But if they were able to provide more developmental assessments, if they were able to provide more social work support, more parenting support to families, and perhaps expand the age up until sort of 12. I think the potential there for, you know, really a lot more support for families, I think that would be really useful’. (SA Paediatrician 1, public) ‘But they only start from twelve as well. So there’s kind of that missing for children. Like a [service] equivalent for children where it’s not government, which is a very complex, low SES, high risk one. Not privately where they’re paying up to a hundred dollar gap but that, yeah [service] equivalent for children’. (SA Psychologist 5, public/private)

Clinician reports describing the challenges of working together to improve outcomes

All clinician groups expressed the view that working together would improve care. However, the health care system is not structured for clinicians to deliver coordinated care.

Many clinicians across all clinician groups wanted clearer referral pathways and better communication between clinicians.

Effective communication between practitioners was considered an enabler for optimal care. In the absence of a systematic way of communicating, clinicians identified ad hoc arrangements they had developed which were effective in supporting children and families to receive improved care.

Some ad hoc arrangements develop from connections with colleagues.

However, others developed their own support networks without a personal relationship. Co-location was a possible enabler of improved communication. Table 4 provides a summary of clinicians’ views of the challenges in communication and how to address them.

Table 4.

Clinician reports describing the challenges of working together to improve outcomes.

Quotes describing problems	Quotes suggesting solutions
Lack of structures within the health system to support communication Representative quotes ‘I don’t think private psychiatrists or GPs have very much time to liaise with each other, and I think I write these lengthy letters every now and again and I wonder who reads them ... when I do have conversation with GPs, even really short ones, I think we both come out of it better off’. (VIC Child and Adolescent Psychiatrist 1, public/private) ‘There’s probably not a lot of communication between psychiatrists and paediatricians around management of children with mental health disorders. There’s no real forum for that to occur. ... So I can actually say to you, that with regards to children that I look after, it’s very unusual for me to get on the phone and even speak to a psychiatrist. Maybe there needs to be some sort of you know ability for that to happen’. (SA Paediatrician 9, public)	Formalise communication mechanisms between clinicians Representative quotes ‘I guess I have built up a big enough, sort of, referral base that I can actually pick up the phone and ring, and say, “Look, I’ve got this family, what can we do?” And usually, if you’ve got a relatively good relationship with the other providers, they’ll, you know, they’ll fit them in ... Yeah and that’s taken me years to establish. You know, 20 or more years’. (VIC GP 19, private) ‘... One good discussion often shores up their [GP’s] understanding and in a sense, they can get on with the work. But a lot of it comes down to having my own personal connections with paediatricians, GPs, allied health professionals, that I know, and that know me.’ (VIC Child and Adolescent Psychiatrist 31, public/private) ‘So I’ve sort of made friends with the psychiatrist and I’ve text and emailed her. I have never seen her ... She’s been kind enough to reply. And I’ve sent a few referrals on to her but, again, she’s very expensive and she’s private so not all my patients can see her’. (SA Paediatrician 4, private)
Difficulty accessing resources Representative quote ‘And I’m sure there are resources and central points of information available but then I don’t know about them. And so trying to sort of keep on top of what’s available, where, and when, it’s quite difficult’. (VIC GP 19, private)	Centralised system Representative quote ‘I would like central source of information, whether it’s like a website for example that is easy to access and navigate that gives me a list of people in my area in terms of whether psychologists or social workers or psychiatrists or whatever, who for example, see kids and adolescents. Or what they do, their approximate waiting times if they can tell that, fees, and then the best way to contact, whether email or phone or whatever. So that I can go to that and find that information quickly. There is for example the find a psychologist or find a psychiatrist with the Australian Psychological Society, but they don’t have much information, and you still have to ring around to find out if they are actually taking new patients and what are their fees, for example, so something that’s kind of regularly updated and comprehensive would be, I think quite a simple but very useful thing to do’. (SA GP 1, private)
Insufficient time for case management Representative quote ‘All of that stuff that would make it great quality care. You don’t get given time for report writing that would mean that you could get a really succinct letter out to a teacher that could change a lot of things at home. You don’t have the time allocated necessarily into your diary to do that because you have to see x number of clients in a week to get statistics’. (VIC Psychologist 16, public/private)	Upskilling as a means of case management Representative quote ‘the structure that we have developed for CAMHS in the region here, is pretty robust, I would say, and has been kind of reviewed as well, by quite a few. So having that front end and having this core case management upskilling of the second tier services, regular stakeholder meetings that we have planned ... I think that structure is ... at this stage, is near to ideal. It’s just the lack of resourcing for that structure’. (VIC Child and Adolescent Psychiatrist 6, public/private)
Process duplication Representative quote ‘I think there’s a lot of duplication. So I’ve done my thorough assessment, but so too has the paediatrician and so too has the psychologist and we all kind of applaud each other for getting the same history but really from the child and family point of view that’s the same history that’s been delivered three times over’. (SA Child and Adolescent Psychiatrist 5, public/private)	One stop shop Representative quotes ‘We already know that co-location of services, one stop shop, it’s good for everything. There is a lot more that I can chat about over a cup of coffee while in the kitchen when the kettle is boiling, than I can do writing on a letter head, which is going to take time and effort and everything. Paperwork is important ... but the nonverbal communication that goes with having a chat with the therapist is of utmost important. Paperwork is there. You need to just do the paperwork, but the strength that you can use in verbal communication overrides any of the paper communication’. (VIC Paediatrician 28, public/private) ‘What would be really good is if you had it all in the one setting, where they would just go to the one place where they could see the variety of people, instead of having to go to, say, a private paediatrician there, the private psychologist over there, you know the school over there, then the GP here and it’s all sort of very scattered. Not easy access for the families too, because often the families have got other kids as well, they’re competing interests. After school, they’ve got to be taken here, there and everywhere and it becomes very tricky for some parents’. (VIC GP 19, private)

Discussion

This is the first study reporting clinicians’ perceptions of the major barriers faced by Australian young people and their parents when seeking help for common child and adolescent mental health conditions.

Clinicians identified barriers at three levels: (1) parent – poor mental health literacy, competing life stressors; (2) service – long wait times, restrictive entry criteria, large out-of-pocket costs, fragmentation of services; and (3) workforce – need for better training, need for better access to specialist support for GPs. These clinician-identified barriers are strikingly similar to those reported by parents in the two Australian child and adolescent national mental health surveys (Lawrence et al., 2015; Sawyer et al., 2000). For example, parents in both surveys also reported that not knowing where to get help, long waiting lists, high costs and geographical distance were major barriers to getting effective help for children and adolescents with mental health problems. The barriers are also similar to those reported in our smaller (n = 30) study of clinician perspectives about the care of children with complex mental health conditions using ADHD and Autism as exemplars (Paton and Hiscock, 2019). The consistency of results across these different groups suggests that these barriers should be given the highest priority in future planning for services designed to help children and adolescents with mental health problems in Australia.

This study extends previous work by including GPs as respondents. Results from GPs highlight the extent to which these clinicians want better access to secondary consultation with mental health specialists and also better training, particularly in relation to the management of acute child and adolescent mental health problems.

This study focused more specifically on mental health care than previous studies (as opposed to education and social care), purposively sampling clinicians working across diverse socioeconomic areas and including ADHD and anxiety as the two most common child mental health disorders. We could find no other study reporting on clinician views of how to improve the mental health system for children. Although the study is limited to clinicians working in one of two States in Australia, we believe results are readily generalisable to all Australian States and Territories (Paton and Hiscock, 2019).

Our findings suggest several avenues for improving the current system for children and are especially pertinent given the potential increase in mental health problems with the Covid-19 pandemic. These avenues include increasing the availability of specialist mental health support to non-specialists such as GPs and paediatricians via email, telephone or telehealth, as per successful US models (Sarvet et al., 2010). With the Covid-19 pandemic, most clinicians have pivoted to telehealth. Anecdotally, this seems to suit many families and clinicians, but rigorous evaluations are yet to be published and telehealth may not deliver effective care for children and adolescents with complex mental health problems.

Clinicians also called for a centralised service that provides information on services and pathways in a staged manner, responding to the child’s needs. While some major mental health initiatives provide this type of support for adolescents and adults (e.g. Beyond Blue, 2020), they do not provide information relevant to children under 12 years of age. Furthermore, many websites suggest patients should seek help from GPs in the first instance, but our study suggests that GPs want more effective specialised support when assessing and treating child and adolescent mental health problems.

Many clinicians in this study called for increased training in child mental health, including practical experience working in public specialist mental health services. For GPs, this would require significant changes to their current vocational training requirements for paediatrics which largely focus on medical and not mental health or behavioural problems (The Royal Australian College of General Practitioners (RACGP), 2020). Telementoring is one approach that might allow for GPs to upskill in child mental health. Project ECHO is a telementoring model which uses proven adult learning techniques and interactive video technology to connect groups of community providers with specialists at centres of excellence in regular real-time collaborative sessions (Zhou et al., 2016). Queensland Children’s Health has been using the Project ECHO model (Queensland Children’s Health, 2020) for ADHD and behavioural concerns, with positive feedback from clinicians involved (Dr Newcomb, Medical Director Integrated Care, Queensland Children’s Health, personal communication). More intensive approaches include the REsource for Advancing Children’s Health (REACH) project in the United States (The Reach Institute, 2020) which provides interactive skills building followed by a 6-month case-based distance-learning programme or the United Kingdom’s general practitioner with special interest (GPSI) model where GPSIs take referrals from other GPs and work within integrated consultant-led clinical teams in addition to specialists (Yellamaty et al., 2019). This model has been associated with superior patient satisfaction and comparable outcomes to specialists but requires appropriate training, mentoring and ongoing professional development for GPs and employers adopting this role.

Co-location of ‘private’ and ‘public’ services that provide help for the emotional, physical and social needs of children, parents and families has the potential to overcome several current service barriers identified by clinicians and parents. For example, co-location of such services has the potential to reduce current service fragmentation and to make it easier for parents to know where to get help for problems in these areas. The latter is an important issue because comorbid problems at the child, parent and family levels are common among children and adolescents with mental health problems. Co-location of services would allow children and parents to more easily access services that could address a range of such comorbid problems. The closer proximity of services would also encourage better co-ordination and information flow between staff in co-located services.

The current Medicare emphasis on funding based on the ‘fee for service’ concept limits opportunities for even co-located staff and services to work together in a coordinated and cooperative manner. This is a significant problem for the effective assessment and management of children with mental health problems, many of whose mental health problems are entwined with family, education and social issues – all of which may need addressing before a child’s mental health will improve. As recommended in the recently released Productivity Commission into Mental Health (recommendation 10.3) (Productivity Commission, 2020), funding models that encourage different clinicians and services to work together more effectively have the potential to help address this issue.

In summary, the provision of help for children and adolescents with mental health problems in Australia has often floundered as a result of major structural, training, resource and workforce issues. Clinicians in this study identified a range of barriers and potential solutions to these problems. It is notable that the issues identified by clinicians were strikingly similar to those identified by parents in the two Australian national child and adolescent mental health surveys. The challenge now is to get the Australian Government along with State and Territory Governments to use the information provided by both clinicians and parents when developing, implementing and evaluating new systems of care for Australian children and adolescents with mental health problems.

Supplemental Material

sj-pdf-1-anp-10.1177_0004867420984242 – Supplemental material for Clinicians’ perceptions of the Australian Paediatric Mental Health Service System: Problems and solutions

Supplemental material, sj-pdf-1-anp-10.1177_0004867420984242 for Clinicians’ perceptions of the Australian Paediatric Mental Health Service System: Problems and solutions by Kate Paton, Lynn Gillam, Hayley Warren, Melissa Mulraney, David Coghill, Daryl Efron, Michael Sawyer and Harriet Hiscock in Australian & New Zealand Journal of Psychiatry

Supplemental Material

sj-pdf-2-anp-10.1177_0004867420984242 – Supplemental material for Clinicians’ perceptions of the Australian Paediatric Mental Health Service System: Problems and solutions

Supplemental material, sj-pdf-2-anp-10.1177_0004867420984242 for Clinicians’ perceptions of the Australian Paediatric Mental Health Service System: Problems and solutions by Kate Paton, Lynn Gillam, Hayley Warren, Melissa Mulraney, David Coghill, Daryl Efron, Michael Sawyer and Harriet Hiscock in Australian & New Zealand Journal of Psychiatry

Footnotes

Acknowledgements

We would like to thank Shea Rendall for her assistance in interviewing participants. This research project was completed as part of the ‘Towards an evidence-based and equitable mental health system for children in Australian project’.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: D.C. reports grants and personal fees from Shire, personal fees from Eli Lilly, personal fees from Medice, personal fees from Novartis, personal fees from Oxford University Press, grants from Vifor, personal fees from Servier, all outside the submitted work. All other authors have no financial relationships relevant to this article to disclose.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The project’s study design and conduct, data collection, management, analysis and interpretation were funded by National Health and Medical Research Council (NHMRC) Grant No. 1129957. H.H. is supported by NHMRC Practitioner Fellowship Award 1136222. The Murdoch Children’s Research Institute administered the grants and provided infrastructural support to its staff but played no role in the conduct or analysis of the research. D.F.’s position is funded by a Clinician Scientist Fellowship from MCRI. The Victorian Government’s Operational Infrastructure Support Program support research at the Murdoch Children’s Research Institute.

ORCID iDs

Kate Paton

Melissa Mulraney

Harriet Hiscock

Supplemental Material

Supplemental material for this article is available online.

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