Weaving the strands together for a stronger future: Responding to the mental health needs of Pacific children and young people

Abstract

Objective

The aim of this paper is to summarise the findings of a virtual workshop at the Creating Futures 2023 Conference held on October 18 with 45 participants attending from Fiji, PNG, Solomon Islands, the Federated States of Micronesia, Cook Islands, Australia and New Zealand. Brief presentations about future mental health needs of Pacific children & young people were followed by small group discussions. These focussed on how island nation participants could “make it real” by considering actions to promote mental health and wellbeing in their communities.

Conclusions

A wide variety of actions and strategies were recommended, spanning the implementation of national plans, integrating culture, preventing suicide, including the voice of children and managing trauma. The small group discussions found that the range of responses to meet future needs demanded a broad public health response, significant workforce development and the promotion of mental health.

For children and youth, the impact of the Covid-19 pandemic and the effects of climate change present a formidable challenge. Communities are focussed on developing and maintaining psychological resilience in young people and highlighting the need to respond comprehensively to mental health (MH) needs and support well-being (WB).

Regardless, the prevalence of mental health conditions in young people is increasing. ¹ Across Oceania the public health burden of MH conditions for all age groups rose steadily from 1990 to 2019 as measured by disability adjusted life years (DALYs) ¹ and is predicted to rise further. ² Among children and adolescents, DALYs attributed to anxiety and conduct disorders have increased most, particularly post-pandemic. ¹ As a group, mental and substance abuse disorders were the leading cause of disability in the total Pacific population. ¹

Children conceived or born experiencing adverse circumstances, such as poverty, the impacts of climate change, parents’ poor parenting skills or overwhelming experiences such as family and domestic violence, are at increased risk of developing mental health problems later in life. ³

The workshop included five (5) brief presentations on topics corresponding to the sub-headings that follow. The 45 participants participating in the workshop self-selected to allocate themselves to one of the 5 separate small groups to consider the relevance of the material presented in each brief presentation to their particular contexts and communities in the Pacific. They then engaged in group discussion to generate options for strategies to respond to the challenges of mental health needs in children and young people and highlight their findings. These were documented by whoever the group chose as spokesperson to summarise their deliberations. Notes on the summaries & findings were in turn documented by the first author & form the basis of the findings and conclusions noted in this article.

Preventing youth suicide

The increase in disability arising from increasing rates of mental disorders in children and youth, combined with persisting challenges arising from climate change, poverty, substance abuse and other adverse experiences, maintains an elevated risk for youth suicide. In some countries in the Western Pacific, suicide rates are amongst the highest in the world, ⁴ and are particularly concerning in young people. Climate change amplifies health risks as it poses both physical and existential threats to Pacific Island communities. ⁵

An Australian systems approach to suicide prevention, the Life Span Integrated Framework ⁶ highlights nine evidence-based strategies. It provides a coordinating framework for shaping local, community and specific responses to preventing suicide (including in youth). It was presented for discussion as this approach involves those with lived experience and takes into account specific historical, cultural, economic and social contexts. ⁶

This small group discussion generated recommendations to implement youth suicide preventive strategies such as (i) prioritising availability of support for emotional distress and parent/child relationship difficulties, (ii) bringing child and youth support and welfare skills into both primary and secondary school settings and (iii) appropriate training of community members as gatekeepers.

Implementing a multisectoral multiagency child and adolescent mental health plan in Papua New Guinea (PNG)

UNICEF (United Nations Children’s Fund) ⁷ conducted research into implementing mental health and psycho-social support and services (MHPSS) regionally in PNG. Gaps were identified in the current health, education, child protection, justice, child support and welfare service systems. ⁷ Gaps were also noted in national programs (i) to support maternal and responsive care from parents or care-givers, (ii) to address mental health literacy and stigma, (iii) that limit funding and resources allocated to mental health, (iv) with poor service coordination and (v) with limited implementation of mechanisms in health and other sectors (e.g. education) to identify children at risk and address their needs.

15 recommendations were identified for staged implementation, commencing with the World Health Organization Mental Health Gap Action Programme (WHO mhGAP) ⁸ workforce training focussing on children and adolescents MH needs initially. A working group led by the National Department of Health with leaders from social welfare, education and justice sectors oversaw this initiative.

The small group discussion noted that social determinants of child and adolescent mental health, such as family and domestic violence, unemployment, poor access to training opportunities and stigma of mental illness required targeting by broadening psycho-social responses to better address these factors. Child development surveillance and promoting maternal health care could reduce future needs by providing the best start early in life.

Integrating culture into child and youth mental health

The numbers of Aboriginal and Torres Strait Islander children in out-of-home care and youth justice systems have increased over the last 10 years. ⁹ While this cohort make up only a small proportion of the Queensland population, they account for nearly half of all children referred to child and adolescent mental health. ¹⁰ Hence, integrating culture into their assessments and case formulations is vital. However, within mental health and forensic systems there is minimal understanding of cultural norms, and their impacts on behaviours. Excluding cultural factors from assessments and formulations compromises the outcomes for our children and risks perpetuating trauma onto the next generation. In response, Aboriginal and Torres Strait Islander mental health and forensic staff developed strategies that incorporate models of Aboriginal and Torres Strait Islander peoples’ social and emotional wellbeing and mental health. This has been a catalyst for change in thinking about the role of culture in children’s assessments, formulations, and diagnoses.

The small group discussion highlighted the impact of colonization in the Pacific causing social trauma and racism. This in turn has contributed to breaking down social and cultural norms. Alcohol and other drug abuse can be seen as one symptom of the impact of colonization and should be addressed as a priority.

It will be critical to integrate workforce development to identify cultural presentations, maintain cultural safety and interact in a culturally informed way.

Trauma in children and young people

Children and young people from Pacific Islands are at risk of experiencing natural disasters, and of developing trauma- related sequelae.

Psychological trauma is an emotional and physical response to an overwhelming, frightening event where recovery is difficult. Many will adjust through their own resources supported by family and community. Some remain overwhelmed with distress, which challenges their functioning. A range of psychological problems and diagnoses may arise including Post Traumatic Stress Disorder (PTSD), with its triad of arousal problems, reliving experiences, and avoidance.

Four intervention principles for trauma are:

(i) Physical safety, (ii) psychological safety, (iii) emotional regulation skills development and (iv) processing traumatic memory and emotions. ¹¹ Each principle needs to be achieved in turn for successful recovery. Physical safety is first, including food, shelter and reuniting children with their parents. After physical safety is achieved, a lack of safety may persist, necessitating supportive therapeutic, family and community relationships for psychological safety. Individuals need skills to manage emotional dysregulation and avoidance. Psychotropic medications may have a role. Physical security, psychological safety and emotional management skills allow the processing of traumatic memory and emotions though talking, play and other techniques.

The knowledge, skills and attitudes needed by a trauma capable workforce are described on Australian websites.^12,13

Collaborating with children, families, and practitioners across communities to respond to disasters

This workshop focussed on elevating the voices of children, families, and practitioners in disaster affected communities in the Pacific. ¹⁴ Including these voices can drive the MH sector to innovate solutions for climate adaptation to support child MH. Proactively including lived experience in designing, delivering and holding accountable service responses can improve the quality of responses to disasters.

The presentation reported on priorities of Emerging Minds, leading the National Workforce Centre for Child Mental Health (NWCCMH); to build family, workforce, organisational, and system capacity to advance the mental health of infants, children and families as part of disaster response and recovery. As an Australian initiative, integrating wisdom and expertise from lived experience, research, and practice delivers knowledge translation approaches in disaster affected communities.

The presenters also raised a collaboration of Emerging Minds with Whāraurau, a New Zealand initiative for infant and child mental health, which was established as part of the workforce response to Cyclone Gabrielle’s impact in 2023. The principles around international collaboration ¹⁵ (including trust, mutual respect and reflective listening) were emphasised, as was the importance of incorporating lived experience.

The small group discussion reported that collaborating to actively include local lived experience expertise in multisectoral and community MH service design increased their effectiveness and reach.

Conclusions

The presentations in this workshop triggered reflections by participants on their strategies and responses to addressing mental health needs of children and youth in their communities.

The key themes emerging included addressing social determinants, refocussing on mental health promotion, illness prevention and targeting the early years of life to include good maternal care and parenting support. In addition, a rights-based perspective that acknowledges cultural diversity, colonial and post-colonial histories and the importance of social inclusion should underpin such actions.

Given how limited access to mental health care is currently, the importance of placing young people with lived experience at the centre of the care system was identified as a key strategy to reduce stigma, improve system quality of care and potentially improve access for those not usually reaching care.

Workforce development must include building capacity to respond to trauma after disasters and to youth suicide supported by a readily available comprehensive integrated MH care system including adequate resourcing of front-line workers in the community.

All of the foregoing requires national leadership and multisectoral coordination to expand the domains (schools, welfare, health, community) across which MH care and supporting WB can be advanced.

Upcoming Creating Futures meetings can take the pulse on progress in this field. They can promote recent developments and highlight innovation arising from responses to emerging MH needs of young people in Pacific Island nations.