The role of psychiatrists in the prevention and early intervention of mental illness in infants, children and adolescents

Definition

Prevention and early intervention is any activity which is aimed at identifying and / or treating risk factors for, or early symptoms of, emotional and behavioural disturbance that may lead to mental illness in childhood or adolescence.

Background

Mental health problems during early years can have enduring consequences if left unresolved (Raphael, 2000) not only by placing individuals at increased risk of difficulties in adult life, but also by placing increased pressure on limited community service resources (Sawyer et al, 2000). Early identification of children with behavioural disorders, and individuals at risk of developing mental health problems, is crucial. Psychiatrists, by virtue of their training and experience, have a key role in the early detection, assessment and treatment of mental disorders and problems in children and adolescents. Working with parents, children, families, care providers and early childhood educators, psychiatrists need to raise awareness of prevention and early intervention for mental illness and the avenues available for assistance.

Evidence

The Child and Adolescent component of the Australian National Survey of Mental Health and Wellbeing reported in 2000, that 14% of children and adolescents experience mental health problems (Sawyer et al, 2000). The finding is consistent with estimates derived from other countries (Sawyer et al, 2000; O'Connell et al, 2009). Given the enormous personal and societal burdens of mental disorders, and with most mental illness beginning in childhood or adolescence (Kessler et al, 2005), it is necessary to focus on early interventions aimed at preventing the progression of mental disorders.

Research demonstrates that early therapeutic intervention can be highly effective at limiting the severity and/or progression of problems (Hazell, 2000) and that first symptoms of behavioural problems typically precede a mental, emotional or behavioural disorder by two to four years (O'Connell et al, 2009). The evidence-based research continues to expand and strengthen the argument in favour of these strategies as having the potential to be both beneficial and cost-effective.

Efforts to maximise a child’s mental health and reduce the burden of mental illness require a whole-of-community approach. Policies and practices need to be informed by collaborative research involving medicine, health, education, welfare and justice (Australian Medical Association, 2006). This approach requires improved coordination between all medical practitioners involved in child and youth health and development; particularly community based general practitioners, paediatricians, child and adolescent psychiatrists, other psychiatrists and allied health and nursing workforces. Additionally, coordination and communication is also required with other involved parties, such as parents, guardians, families, professional care providers, teachers, school counsellors, social workers and welfare and justice officers.

Child and adolescent psychiatrists can offer unique insight into the need to integrate biological, psychological and social aspects of individual, family and community experiences as the only way to gain a comprehensive understanding of mental health problems and work towards positive mental health (Lonie et al, 2009). Unfortunately, the high prevalence of children and adolescents with mental health problems is in direct contrast with a limited number of child and adolescent psychiatrists. Additionally, the proportion of funding allocated to child and adolescent mental health does not match the proportion of the population experiencing problems (Birleson et al, 2000). These disparities mean that child psychiatrists are unable to provide direct care for all those who need it. Sawyer et al in 2000 found that only one out of every four Australian young people with mental health problems received professional help, including only 50% of those with the most severe problems (Sawyer et al, 2000).

Responding to the mental health needs of the community requires adequate levels of services and staff and a responsive and integrated health workforce that delivers quality and sensitive care. An effective multidisciplinary Child and Adolescent Mental Health Service includes expertise from a wide range of disciplines including child psychiatry, nursing, psychology, social work, speech therapy and occupational therapy. Critical to the success of the prevention and early intervention of mental illness in childhood, is broadening the roles and priorities of child and adolescent psychiatrists and general psychiatrists to reduce the prevalence of mental health problems proactively though provision of leadership to multidisciplinary teams, training of other professionals, and advocating for service provision improvements.

Recommendations

In addition to their role in assessment and treatment of individual children and assistance for their families, child psychiatrists can and should adopt other roles and responsibilities in a more proactive manner aimed at reducing the prevalence of mental health problems. These roles can include:

• ensuring the appropriate provision of evidence-based prevention and early intervention strategies
• providing leadership to multidisciplinary teams and enhancing collaboration across disciplines and services
• the provision of training and information to other professionals on the complexities of child development and mental health, including professionals completely outside the traditional health sector (e.g. teachers, police, politicians etc)
• mentoring and assistance for psychiatric registrars and psychiatrists in understanding the importance of prevention and early intervention
• using influence and authority to provide protection and early intervention for high risk infants, children and adolescents (Lonie et al, 2009; Austin, 2003)
• lobbying governments at all levels for strategic policy development and implementation
• advocacy for service provision improvements
• research and evaluation of prevention and intervention programmes.

The Faculty of Child and Adolescent Psychiatry (FCAP) can play a key role in supporting these additional functions of child psychiatrists. To assist in achieving progress in relation to these recommendations, RANZCP, through its membership and national and regional structures, will work to:

• create opportunities to share current knowledge about prevention and early intervention with other disciplines, organisations and the community as a way of increasing the understanding about the importance of the prevention of mental illness in infants, children, and adolescents
• continue to develop training and continuing medical education programmes for all psychiatrists to enhance understanding of the importance of prevention and early intervention of mental illness in infants, children and adolescents
• increase the capacity of the child and adolescent mental health workforce through strategies to promote psychiatry to medical students
• Lobby for increased funding and staffing levels for child and adolescent mental health services to meet the proportion of the population experiencing problems
• endeavour to develop specific education and upskilling programmes on prevention and early intervention, including family based approaches and biopsychosocial perspectives for psychiatrists and other health and childhood professionals – including education about the impact of parental mental illness on children
• enhance collaboration across services through improved communication between a multidisciplinary workforce to best identify and manage mental health problems early
• increase awareness of mental health issues and mental health literacy among gatekeepers and other health care workers (particularly GPs, psychologists, allied health and nurses)
• improve partnerships with education, child protection, family court, corrections, allied health practitioners and existing providers who have community networks for families in need
• promote cultural competence for early intervention and prevention staff
• develop a referral directory of psychiatrists with special interest and expertise in prevention and early intervention of mental illness in infants, children and adolescents
• make a recommendation on the number of child and adolescent psychiatrists necessary per 100,000 of the population to allow effective levels of prevention and early intervention work to be undertaken
• identify specific gaps in service delivery, knowledge, and research which may cause barriers for prevention and early intervention of mental illness in infants, children and adolescents and lobby for development in policy, funding and research to support this work
• identify opportunities to address the gaps identified above and advise government and other stakeholders about effective strategies.

Further reading

RANZCP Report from the Faculty of Child and Adolescent Psychiatry. ResourcesPrevention and early intervention of mental illness in infants, childhood and adolescents: Planning strategies for Australia and New Zealand, 2010

RANZCP Position statement 56: Children of parents with mental illness

RANZCP Position statement 63: The prevention and early intervention of mental illness in infants, children, and adolescents

Responsible committee

Faculty of Child and Adolescent Psychiatry