Healthy children and adolescents are a key resource for the future well-being of our country. Mental health problems impose severe personal and financial burdens on children, families and the community. If effective mental health policy and services are to be developed, we need accurate information about the prevalence and distribution of problems, the degree of disability associated with these problems, and the services used by children, adolescents and families to get help. This survey provides information to facilitate the development of policy and services to provide more effective help for children and adolescents.
The survey has several strengths. First, it has benefited from the development during the past decade of improved instruments for assessing the mental health and quality of life of children and adolescents. The availability of these instruments has made it possible to obtain a clearer picture of the mental health and well-being of young people in Australia. Second, the survey obtained information about a broad cross-section of children and adolescents in different regions of Australia. This ensured that the results would be representative of a wide range of young people. Finally, the large number of participants has allowed detailed study of the characteristics of children, adolescents and families associated with mental health problems.
This chapter summarises the results of the survey and highlights some of the implications for services, consumers and researchers.
The prevalence of mental health problems
Quality of life
Patterns of service use
Adolescent mental health and health-risk behaviour
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The prevalence of mental health problems
- There is a high prevalence of mental health problems in all age and gender groups.
- There is a high rate of comorbidity among those with mental disorders.
- There is a higher rate of mental health problems among those living in low-income, step/blended and sole-parent families.
Fifteen percent of children and adolescents met symptom criteria for one of the three mental disorders assessed in the survey. Males were more likely to have one of these disorders than were females (19% versus 10%). This is not surprising, given that two of the three conditions studied (Conduct Disorder and Attention-Deficit/Hyperactivity Disorder) are known to be more common among males. Children aged 6 to 12 years were more likely to have a disorder than were adolescents aged 13 to 17 years (17% versus 12%). This finding was primarily due to the large number of children who met symptom criteria for Attention-Deficit/Hyperactivity Disorder. However, it is necessary to be cautious when interpreting the meaning of this high prevalence as two of the formal criteria identified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (American Psychiatric Association, 1994) could not be incorporated into the assessment of children. Inclusion of these criteria may have reduced the size of this prevalence estimate.
Implications for consumers, services and researchA large number of young people in Australia have mental health problems. The rate identified in the survey is very similar to the median prevalence of 12% reported by Verhulst and Koot (1995) in their review of 49 international studies conducted between 1965 and 1993. The consistency of our results with those of similar surveys conducted elsewhere shows that they are not an artifact of the survey's methodology.
Child and adolescent mental health problems are not equally distributed among all demographic groups. Rather, those in some groups (e.g., children in single-parent or low-income families) are more likely to have mental health problems than those in other groups. The identification of high-risk groups is important because it makes it possible to ensure that treatment and preventative programs are accurately targeted and resources efficiently employed. Services should be sensitive, for example, to the particular needs of single-parent or low-income families. As noted earlier, the results of this survey cannot explain why there are relationships between particular demographic characteristics and mental health problems. Understanding the mechanisms by which these relationships occur is a key topic that must be addressed by future research.
The high prevalence of problems and the limited number of trained clinicians available to provide help make it unlikely that specialised programs in secondary and tertiary treatment settings (e.g., child and adolescent mental health services and departments of psychiatry) will ever be able to provide direct care for all those with problems. There is therefore a need to identify alternative approaches to reduce the prevalence of child and adolescent mental health problems. Improved mental health literacy in the community is one approach that has the potential to help families select services that are appropriate to their needs and, where possible, become more effective at helping themselves. Better public understanding of mental health may also assist with the early detection of problems. Attempts to improve mental health literacy should not be limited to adults. Children and adolescents should be better educated about the nature of mental health problems and the steps they can take to promote their own mental health.
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Quality of life
- Children and adolescents with mental health problems have a poorer quality of life.
- Parents of children and adolescents with mental health problems report greater concern and worry about their children's health and less time for their personal needs.
Implications for consumers, services and researchA key element of health-related quality of life is its emphasis on an individual's subjective evaluation of his or her functioning. A growing body of evidence shows that this assessment provides a rich new perspective on the health problems experienced by children and adolescents. Although there is increasing information about the impact of physical illness on quality of life, there is a dearth of information about the effects of mental illness. This is a significant omission, as differences in impairment or quality of life may explain differences in the outcomes of mental health problems among children and adolescents. It is possible, for example, that those with significant school or peer problems may have more difficulty overcoming their mental health problems or may be less willing to seek help than other children or adolescents.
While mental health problems have an adverse impact on parents and families, family or school problems can also have a substantial effect on child and adolescent mental health. These reciprocal interactions are the focus of promising prevention and treatment programs that aim to reduce mental health problems by changing family, school or community systems. Professionals working in services responsible for helping young people must have the ability to design, implement and evaluate these new interventions. Currently, there are few people in Australia with the skills required to undertake this work.
Patterns of service use
- Few children and adolescents with mental health problems receive professional help.
- Family doctors, school-based counsellors and paediatricians provide the services most frequently accessed by children and adolescents with mental health problems.
The services most commonly utilised by children and adolescents with mental health problems are provided by school-based counsellors, general practitioners and paediatricians. Only a small percentage of those with problems had attended a mental health service during the six months prior to the survey. These results draw attention to the important role that school-based services and primary health care services play in the provision of help for young people with mental disorders. They also highlight the scarcity of mental health services for young people.
Parents frequently identified practical issues to explain why children and adolescents did not receive professional help. These included being unable to afford help; not knowing where to get help; seeking help but not receiving it; and having to wait too long before help was available. Fifty-seven percent of parents of children and adolescents with one of the three mental disorders reported that they had not attended services because they thought that they could handle the problem themselves. Only 6% of parents reported not attending services because they were afraid of what others might think.
Among adolescents, the major barriers to services were thinking nothing could help; not knowing where to get help; and being afraid of what other people might think. Concern about stigma was reported more frequently by adolescents than by parents. It is possible that stigma has a greater influence on the help-seeking behaviour of adolescents than on that of parents. This finding emphasises the importance of providing non-stigmatising services that are readily accessible to adolescents.
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Implications for consumers, services and researchThe survey's findings highlight the important role that primary health care and school-based services play in providing help for young people with mental health problems. If their staff are well-trained, these services can provide immediate practical help. However, the results also draw attention to the scarcity of specialised child and adolescent mental health services. In light of the scarcity of these services, it is not surprising that few young people access them.
We did not ascertain who provided the school-based counselling identified by parents and adolescents. It is possible that much of this counselling was provided by classroom teachers who have little formal training in the assessment and management of children with mental health problems. It is important that school-based counsellors receive good quality training to ensure that there are adequate numbers of well-trained staff at the point where large numbers of young people frequently seek help.
To function effectively, school-based services and primary health care services must also have ready access to support from specialised services. In many regions of Australia, due to the scarcity of child and adolescent mental health services, this is not possible. The scarcity of specialist services for young people with mental health problems is a fundamental problem. Until more specialist child and adolescent mental health services are available, appropriate support cannot be provided to school-based and primary health care services and specialised treatment will remain unavailable for many young people with mental health problems.
If professionals in primary health and school-based services have the skills to accurately identify young people with mental health problems, children and adolescents with less severe problems can be managed in primary care services, while those with severe or complex problems (such as depression or suicidal behaviour) can be referred to mental health services. Closer collaboration between mental health services should be promoted through the development of joint protocols describing clear pathways to specialised services and greater use of 'shared care'.
Coordination between different services, however, is not in itself sufficient to reduce mental health problems (Bickman, Guthrie, Foster, & Lambert, 1995). It is also necessary that interventions be effective in actual practice settings (as compared to evidence of 'efficacy' in controlled research settings). Currently, little is known about the effectiveness of many interventions provided by health, education and welfare services for young people with mental health problems. This issue must be addressed by well-designed studies used to evaluate the effectiveness of behavioural, social and pharmacological interventions. Over the past two decades, fields such as childhood cancer have achieved large reductions in morbidity and mortality through the close integration of service and research programs. There is an urgent need to achieve similar progress in the field of child and adolescent mental health.
Several barriers to services were identified. Being stigmatised by others was less often identified as a barrier by parents than were practical issues such as the length of waiting lists, not knowing where to get help, or the cost of services. The latter is a troubling issue in light of Australia's commitment to universal health care and the high prevalence of mental health problems among young people living in low-income families.
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Adolescent mental health and health-risk behaviour
- Adolescents reported a high prevalence of mental health problems.
- Adolescents with mental health problems reported a high rate of suicidal ideation and behaviour.
- Adolescents with mental health problems reported a high rate of health-risk behaviour, including smoking, drinking and drug use.
Another striking finding was the strong relationship between emotional and behavioural problems and rates of smoking and drinking. There was a consistent pattern in which adolescents with more problems reported more smoking and drinking. A similar association was evident between adolescent emotional and behavioural problems and the use of marijuana. Once again, there was a consistent tendency for a higher level of problems to be associated with more frequent marijuana use.
Implications for consumers, services and researchAdolescents with mental health problems do not have problems that are limited to a single aspect of their lives. Rather, their problems encompass a range of areas, including suicidal ideation, smoking, alcohol use and drug abuse. Furthermore, these problems frequently occur together.
The breadth of the difficulties experienced by those with mental health problems is a recurring theme in this report. It is clear that health services and other relevant services must avoid a narrow focus on these problems. Instead, they must develop the capacity to provide help for a range of problems, including smoking, alcohol use, and drug abuse. The conventional separation of mental health services and drug and alcohol services is a particular barrier to comprehensive service delivery. Joint policies and strategies must be developed that will establish effective links between school-based services, paediatricians, family doctors, mental health services, and drug and alcohol services.
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Concluding commentsThis survey represents only the first step in the process required to reduce the high prevalence of child and adolescent mental health problems in Australia. If it is to serve a useful purpose, results from the survey must be employed to develop better services for children and adolescents. The health funding allocated to child and adolescent mental health does not reflect the proportion of the population afflicted by problems in this area. As a result, in many regions a scarcity of child and adolescent mental health services means that specialist help is not available for young people. This issue must be addressed.
Many mental health problems experienced by young people have a chronic course and place individuals at increased risk for difficulties that continue into adult life. Mental health problems cause considerable personal distress and contribute to school failure, broken families and future unemployment. The heavy financial burden this imposes on the entire community would be greatly reduced if mental health problems were addressed at the earliest opportunity. There is a great need to design, implement and evaluate cost-effective interventions that focus on young children. These interventions should have the capacity to both reduce the number of existing mental health problems and to prevent the onset of future problems.
We suspect that many school-based counsellors, general practitioners, paediatricians and parents have not been trained to help young people with mental health problems. Increasing the skills of school counsellors, general practitioners and paediatricians should be a high priority. Formal and informal training, closer coordination between services, and the widespread use of 'shared care' could help overcome this problem. Many professional training programs are generic, however, and provide little specialised training in the prevention or treatment of child and adolescent mental health problems. Professional bodies responsible for these programs and tertiary educational institutions should increase their capacity to train professionals specifically in areas relevant to child and adolescent mental health. Increased funding should also be made available for programs that help parents learn how to provide better help for young people with mental health problems.
Research is needed to obtain a better understanding of the mechanisms that give rise to comorbidities, the causal pathways linking these comorbidities, and the interventions required to provide effective help. A major factor limiting this work in Australia is the paucity of people with the training required to undertake research in child and adolescent mental health. There are very few full-time researchers in this country investigating the causes, treatment or prevention of child and adolescent mental health problems. The unique characteristics of Australia mean that we cannot simply borrow our knowledge from overseas. If effective use is to be made of the limited resources available to reduce mental health problems, we must acquire the skills to increase our knowledge of these problems and ensure the rapid penetration of research findings into promotion, prevention and treatment services.
The present study provides an overview of the extent of child and adolescent mental health problems in Australia. There remains a great need, however, for more finely grained studies to explain the results and address issues outside the scope of this survey. For example, the survey provides no information about the nature and distribution of Anxiety Disorders or child abuse. It cannot explain why children and adolescents in families with less income have more mental health problems than do those in more affluent families. It also provides no information about the effectiveness of programs being provided for those with mental health problems who receive counselling in schools, attend family doctors or who receive help through mental health services. It is essential that the effectiveness of these interventions be properly evaluated to ensure that the limited resources available to help children and adolescents are effectively deployed.
The significance of the high prevalence of mental health problems has been highlighted by Murray and Lopez (1996), who point out that non-communicable diseases, such as mental illness are now the major cause of disability in developed countries such as Australia. Various combinations of genetic, family and social factors cause child and adolescent mental health problems. The complex aetiology, wide distribution and stigma associated with mental health problems present a major challenge for mental health promotion, prevention and treatment. It is worth remembering, though, that a similar situation existed when epidemics of infectious disease were the major cause of morbidity and death among children and adolescents. The solution to that problem required widespread improvements in sanitation, nutrition, housing, education and preventative health (Zubrick et al., 1995). Despite these difficulties, the challenge was met and infectious disease is no longer a major cause of death or disability among young Australians. Mental illness presents a similar challenge. If we fail to address this challenge, mental illness will continue to impose a heavy burden on our community, the lives of one in seven children in Australia will be blighted, and the hardships experienced by many Australian families will persist.
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