Improving mental health has been a national priority for several years now in Australia, and many aspects of the national effort are undergoing rapid reform and thus beginning to bear fruit. But not all! In what follows, I take a look at one of the most important but relatively neglected aspects of mental health. How do you fare in your knowledge of the area of children’s mental health? Take the quiz with me...
QUESTION 1: What are the earliest and clearest signs of mental health problems?
Improving mental health has been a national priority for several years now in Australia, and many aspects of the national effort are undergoing rapid reform and thus beginning to bear fruit. But not all! In what follows, I take a look at one of the most important but relatively neglected aspects of mental health. How do you fare in your knowledge of the area of children’s mental health? Take the quiz with me...
My informal surveys show that most psychologists and psychiatrists produce very interesting but largely incorrect answers to this question. The most common responses include environmental conditions such as poverty, and in terms of the child, ADHD or anxiety and depression disorders. We now have longitudinal population studies from all over the world showing that in fact, conduct problems in early childhood are the single most reliable precursor for mental disorders in adulthood. Conduct problems (CPs) are defined here to mean the cluster of aggressive, antisocial behaviour problems such as Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) identified in the DSM. According to the National Mental Health Report (Department of Health and Ageing, 2010), these problems are the most prevalent in childhood and adolescence:
The Australian child and adolescent survey conducted in 1998 found that 14% of children and young people (or 500,000 persons) are affected by mental disorders within any six month period. This includes about 93,000 with anxiety or depression, 200,000 with aggressive behaviour and another 93,000 with attention disorders. (p.17).
Most of us are aware that CPs are predictive of adult antisociality and substance abuse problems; however, it is not widely known that conduct problems in children are the most common precursor across the spectrum of adult mental health disorders. Findings from the Christchurch Longitudinal study (Kim-Cohen et al., 2003) led the authors to conclude:
Adult psychiatry has tended to ignore conduct disorder, assuming it leads only to adult antisocial personality disorder, a relatively rare disorder that is difficult to treat successfully. However, this study suggests that juvenile conduct disorder cases constitute a vital prevention opportunity for reducing the burden associated with many major adult psychiatric disorders. (p.715)
Or from the Great Smoky Mountains longitudinal study (Copeland et al., 2010):
Our findings suggest that ODD is a singular disorder in being part of the developmental history of many young adult affective and anxiety disorders. No other childhood or adolescent disorder demonstrated such pleiotropic effects ...
One accepted measure of the utility of a psychiatric diagnosis is the extent to which it predicts future psychiatric functioning. On this measure, ODD may be in a class by itself. (p.771)
Further, the prediction afforded by these problems is not restricted to mental health problems; CPs are associated with large increases in physical health burden through life, associated with, for example, poorer status on dental health and lung function, and an increased number of GP and hospital visits (Odgers et al., 2007).
ANSWER: CONDUCT PROBLEMS
Conduct problems in children are the most reliable early indicator of adult mental health problems. They are associated with a broad range of adverse outcomes in mental and physical health.
QUESTION 2: What are the best interventions for conduct problems in children?
A wealth of evidence shows that good parenting is the ‘clean water’ of mental health and parenting interventions are the ‘clean water’ of child psychiatry. The review by Brestan and Eyberg (1998) of “29 years, 82 studies, and 5,272 children” led them to conclude that behavioural parent training for CPs is perhaps the best supported and most effective of all psychosocial interventions for mental health problems. Specifically, early identification/referral and evidence-based treatment of CP (roughly before adolescence) leads to positive change in approximately 50-60 per cent of cases (Brestan & Eyberg, 1998). These interventions focus on teaching parents how to positively engage with their child to promote prosocial behaviour, and effectively reduce aggression and antisocial behaviour using non-violent, sensitive discipline strategies, all within the context of empowering parents and improving their own and their family’s health.
The science of these parenting interventions began in the 1960s using the idea of ‘coercive family process’ in which aggressive loops become self-sustaining (Patterson, 1982), arguably one of the great ideas of the 20th century in the behavioural sciences. This early research showed that programmed changes in parental responding led to reliable and clinically-significant changes in child behaviour. From the 1980s onward, programs were packaged into readily disseminated modules that have spread all over the world and have considerable empirical support in efficacy and effectiveness trials, for example, The Incredible Years, Parent-Child Interaction Therapy, Triple P and Multisystemic Therapy, just to name a few. As noted, these interventions represent one of the major achievements of the mental health sciences.
Further, these interventions are cost effective. Our 12-month follow-up data with primary CPs (ODD or CD) treated at the UNSW Child Behaviour Research Clinic using a 10-week evidence-based parenting program (Dadds & Hawes, 2006) show that approximately 60 per cent of cases move into the non-clinical range, which is a typical outcome for evidence-based interventions in this area. The interventions average 10 one-hour sessions at a cost of $1,800 per child ($180 x 10, using typical current clinical psychology rates). Untreated, the cost of 100 CP children to the Australian community is estimated to be $14 million (from Scott et al., 2001; Mihalopoulos et al., 2007). Treating 100 CP children would take approximately $180,000 in direct costs and, at a success rate of 60 per cent, would reduce the lifetime health and social costs associated with these children by approximately $8 million.
ANSWER: BEHAVIOUR-FOCUSSED PARENT TRAINING
Parenting programs for treating child conduct problems are one of the top achievements of the mental health sciences.
QUESTION 3: Does this mean that bad parenting is to blame for conduct problems?
Poor quality parenting is one of the most reliable associates of conduct problems in children (Green et al., 2010); however this does not mean it is a causal variable and that parents can or should be blamed. It is excruciatingly difficult to disentangle biological and environmental pathways in the development of CPs, and complex genetic and psychological pathways interact to create the developmental pathways. Surprisingly though, some of the most intractable forms of conduct problems in children are the least attributable to poor parenting (Viding et al., 2005). Just as the fact that pain killers can cure a headache does not mean that headaches are caused by lack of pain killers, it does not follow that the effectiveness of parent training programs means poor quality parenting is the causal variable.
Children with CPs are very difficult to parent, and it is very easy to see poor parenting as a cause when it may be being driven by the child’s problems. Scholarly reviews of the research indicate that the evidence for child behaviour problems leading to poor parenting is just as strong as the evidence for the reverse causal direction (see for example Pardini, 2008). Similarly, poverty, stressful neighbourhoods and other psychosocial stressors can render even the best parenting as ineffective.
The reality is that parents are generally the best resource a child has, and similarly, parents are the best resource the mental health system has for maximising child health.
ANSWER: NO
There is no single cause of child conduct problems. While quality of parenting is correlated with child conduct problems, it is just as much a product of the problems as a cause. It is, however, the main solution!
QUESTION 4: How many children and families in need actually access these treatments?
Only 25 per cent of Australian children with a mental health diagnosis, and 12 per cent with ‘sub-clinical' problems, access any services (Sawyer et al., 2000). The percentage accessing a dedicated mental health service is far lower, and those who receive a state-of-the-art evidence-based intervention would be appallingly low.
This is due to a range of factors including mental health literacy in families, isolation from services, and resource limitations within existing mental health services. At present, there are no approved guidelines within the Australian mental health community for the assessment and treatment of CPs, leading to a wide disparity in the quality and accessibility of services. Further, childhood conduct problems are frequently regarded as behavioural issues rather than mental health problems, and therefore deemed ineligible for treatment within specialist mental health services. Regardless of what types of evidence-based treatments are available, without attention to improving workforce education and service delivery, the majority of need will not be met.
Australia has a proud record of developing evidence-based early interventions, treatments and services for mental health in young people and evidence-based practices are increasingly being adopted broadly; to name but a few, there are the roll-outs of Triple P parenting programs for early onset behavioural problems, and strategies such as KidsMatter, that should produce specific benefits to mental health in Australia. These improvements, however, are piecemeal and sporadic and depend largely on the availability of local services. In the most recent survey of mental health in Australian children, the rates at which children and their families were accessing and receiving evidence-based interventions was unacceptably low. Regardless of what evidence-based treatments are available in the scientific literature, without attention to improving workforce education, access and delivery, the majority of children’s mental health needs will not be met.
Rural children and families are particularly badly served (Griffith & Christensen, 2007).
According to the Royal Flying Doctor Service, people who live and work in rural, regional and remote communities experience stress related health problems, in particular psychiatric disorders, 28 per cent more than their urban counterparts (RFDS Annual Report, 2000). Only 21.5 per cent of psychologists are working in rural and remote regions (Mathews et al., 2010). This equates to between 0.83 psychologists per 10,000 head of population in very remote areas to 3.44 in inner regional centres, compared to 5.92 psychologists per 10,000 head of population in major capital cities. Moreover, the rural sector tends to attract the youngest and hence least experienced health professionals. As the National Inquiry into the Human Rights of People with Mental Illness (Burdekin, 1993) summarised: “The irony is that many of the areas where the need is greatest, the services are fewest ... mental health services for children and adolescents are almost entirely non-existent” (p.678). Improved access to evidence-based treatments should be a priority for all children regardless of where they reside.
ANSWER: 25 PER CENT OR LESS
Only a small percentage of children with conduct problems are receiving appropriate early intervention.
QUESTION 5: Does Australia’s health system support evidence-based treatments for these children?
Australia has one of the best health care systems in the world and has recently emphasised mental health as a national priority. However, the answer to this question is probably no.
First, like most other countries, the vast majority of mental health expenditure is targeted at adults. In Australia, the expenditure of Child and Adolescent Mental Health Services is only 9.1 per cent of mental health expenditure (DoHA, 2010). This is extraordinary given the science on how these disorders develop.
Second, children with conduct problems have historically been ignored, and at worst, excluded, from many child mental health services (e.g., Kennair, Mellor, & Brann, 2011) This is changing as the evidence weighs in and new treatments are disseminated; however, many child mental health agencies still do not see conduct problems as within their brief.
Third, Medicare under its Better Access inclusion of psychology treatments inadvertently encourages the use of ineffective treatments for these children. That is, Medicare only funds consultations with the specific person who attracted the diagnosis, referral and mental health plan. In the case of conduct problems, this is the child, not the parent, and seeing the parent(s) alone for parent training program – a necessary requirement of most evidence-based parent training programs – is not fundable. On the contrary, seeing the child for several weeks for individual treatment is fundable. A quick search of the web shows the ubiquitous growth of specialised child psychology clinics that offer child focussed social skills training, anger management, self-esteem training, play therapy, and so on. All of these are supported by Medicare but are of dubious benefit for CPs. Provision of an individually delivered evidence-based parenting program which requires the clinician to hold sessions solely with the parents is not supported by Medicare.
ANSWER: NO!
Australia spends a tiny proportion of the mental health budget on children. Medicare currently only funds treatments for conduct problems in children that are of dubious benefit. Parent training sessions alone with parents are not supported under current Medicare items for psychologists.
QUESTION 6: Does Australia have a policy/strategy in place for conduct problems in children?
Ten years ago, references to children and early intervention were quite rare in national mental health policy and references to conduct problems in mental health policy did not exist. The good news is that the science is out there and governments are catching on that mental health problems begin early, are most commonly expressed as conduct problems, and are detectable and amenable to effective interventions! Revisions of Australia’s mental health policies are recognising that early intervention is an effective priority and that conduct problems are one of the best places to spend our precious resources. Examples of this progress can be found in the Federal Government’s National Mental Health Reforms 2011-12 (http://www.health.gov.au/internet/publications/publishing.nsf/Content/nmhr11-12~nmhr11-12-priorities~children). There are huge gaps in policy, however, that need to be addressed.
The National Health and Medical Research Council, the peak body responsible for developing health advice for the Australian community, health professionals and governments, has a wonderful array of clinical practice guidelines including ‘Guidelines to promote the wellbeing of animals used for scientific purposes’, ‘Using Socioeconomic Evidence in Clinical Practice Guidelines’ and the wonderfully recursive ‘A guide to the development, evaluation and implementation of clinical practice guidelines’. It does not, however, have clinical practice guidelines for conduct problems in children.
- As noted above, parent sessions in evidence-based treatments for these children are not supported by Medicare for psychologists.
- Cooperative linkage between schools, child mental health services and juvenile justice (where many of the most severe children with CP end up) is non-existent or haphazard at best.
ANSWER: YES AND NO!
Mental health reforms and priorities for attention are increasingly recognising childhood onset, early intervention and the need to include conduct problems. However, specific policies, practice guidelines, Medicare support and explicit service linkages do not yet exist.
QUESTION 7: Can we improve existing treatments?
There are some ways that we can substantially improve the outcomes of current treatments. The first thing we can do is ensure that evidence-based interventions are available and being taken up by those in need. Thus, Australia needs to improve mental health literacy about conduct problems and provide more child mental health services staffed by clinicians who can and will deliver evidence-based treatments. More broadly, this will involve policy makers: coming to recognise that conduct problems are a critical first sign of mental health problems; developing national policies, strategies and expenditure to give priority to these problems; ensuring clinicians are trained and willing to deliver evidence-based interventions; and amending Medicare items to appropriately fund evidence-based interventions.
A major barrier is that many parents do not or cannot engage and implement the parenting strategies that form the basis of best practice treatments. It doesn’t matter if the program is Triple P, the Incredible Years, Circle of Security, or Multisystemic Therapy, if the parents don’t turn up and play their part, the program is lost for the child. Despite this, little research is being invested in how to set up and run child mental health services in a way that maximises parental engagement. Systemic strategies, like designing services around parents’ schedules and transport (Ingoldsby, 2010), using telephone reminders and training clinicians in engagement strategies (Watt & Dadds, 2007), all significantly influence parental engagement rates. We have known about the importance of these service and contextual variables since the 1980s, but the need for service innovation to effectively deal with contextual-parental problems remains high and generally neglected. Further, many parents are unable to implement strategies because of their own problems, and it is critical that there is more effective linkage of child to adult mental health, drug and alcohol, corrective and family court services.
As skilled clinicians know, a barrier to effective practice is the current one-size-fits-all model that characterises mainstream approaches to CPs in child psychology and psychiatry. Children with conduct problems are not a unified group. The DSM system tells us little of any use for designing specific treatments for individual children, and current parent training programs are not tailored to identifiable characteristics of individual children or identifiable subgroups of children. Individual differences in emotionality, impulsivity, social understanding, co-occurring social fears, and so on, are the rule in children with CPs. Rather than a one-size-fits-all model, skilled clinicians know that the way forward lies with characterising specific dimensions of dysfunction that are related to basic neural systems underlying development and psychopathology on the one hand, and the needs of children and families on the other, without restriction to a specific diagnostic category (see Kendler et al., 2010; Insel & Wang, 2010).
Can science catch up with skilled clinicians by moving beyond current diagnostic models and one-size-fits-all interventions to develop algorithms for carefully matching interventions to specific child characteristics? I believe we can. We now know wonderful things like: how the quality of specific parenting practices at critical times determine which of the child’s genes are turned off and on; and how these changes translate into specific neural receptor patterns, thus altering vulnerability to lifetime mental health problems and changing the quality of parenting the next generation will receive (e.g., Kaffman & Meaney, 2007). The critical ingredients in this new and rapid progress are a beautiful mix of biology, behaviour and developmental timing! This is not just blue-sky speculation. There are many practical examples of how mental health, and specifically conduct problems, will benefit from the new translational neuro-behavioural sciences, but some of the most exciting examples are bio-behavioural approaches to the attachment system (e.g., Guastella & MacLeod, 2012), fear learning (e.g., Deveney, 2009) and cognitive enhancement (e.g., Brady, Gray, & Tolliver, 2011) that are spurning a whole new generation of mental health treatments.
ANSWER: YES!
We can improve existing treatments by improving availability of evidence-based services, designing services that overcome common barriers to engagement, and moving beyond the current one-size-fits-all approach to diagnosis and treatment provision.
In summary, I have tried to set out a story about the application of science to conduct disorders in young children. Our policy leaders, community and especially psychologists can no longer let these children inhabit the dark corners of the health, mental health, juvenile justice and education systems. They are not just naughty children, they are not just a product of shoddy parenting, they are not just problems for the crime and justice systems. Rather, these conduct problems are the earliest reliable sign of risk for lifelong health and mental health difficulties. This is not to say that many children with conduct problems will not emerge as healthy happy adults. Some clever changes to our mental health systems will play a part in ensuring that as many children as possible succeed in this course.