ONE of the major challenges we have to address in the area of child mental health is that of terminology: the mismatch in language use between the education and health sectors.
In dealing with mental health issues at a time of life when they are so dependent on their social ecosystem, the language we offer children themselves to discuss mental health is important in helping families understand and navigate the various individual paths to wellness. Agreeing on a common language is an important consideration in our efforts to address the needs of children experiencing mental health issues.
Child mental health problems are common. A recent national survey found almost 14% of 4–17-year-olds have a diagnosable mental health condition; this equates to almost 600 000 Australian children and young people. Research from the Murdoch Children’s Research Institute found that paediatricians are seeing increasing numbers of children with mental health issues, outpatient departments of public hospitals have long waiting lists for children with developmental and behavioural problems, and there has been an increase in the number of 10–14 and 15–19-year-old children and adolescents with mental health problems presenting to hospital emergency departments. In addition, teachers report increased numbers of children with mental health issues such as anxiety and depression.
The mental health service system in Victoria is currently unable to adequately meet the needs of children with mental health problems. Children’s mental health services in the community are oriented towards the treatment of existing problems, with access and equity barriers preventing children and their families from receiving timely and equitable care. Health and educational professionals in the universal system who identify children with behavioural and emotional problems often struggle to receive support and guidance, and referral pathways to secondary and tertiary services are often poorly delineated.
With calls for mental health policy and services to focus on prevention and early intervention (here, here and here) and the acknowledgement that pathways to adolescent and adult mental health problems often emerge in childhood, there is finally growing policy attention on children’s mental health.
There are a number of likely reasons why a focus on child mental health has taken so long. First is the complexity of child mental health, which ranges across a wide spectrum from building resilience and prevention through to early intervention and treatment of established problems. This involves a large number of professionals – maternal child health nurses, early childhood professionals, GPs, teachers, paediatricians, psychologists, social workers, psychiatrists, and others. Parents are central as children are not free agents – any sort of intervention has to be mediated through the parent–child relationship. This can be problematic as many parents have their own mental health issues, and family disadvantage and dysfunction often contribute to pathways to problems in their children. Consequently, decisions about resourcing and prioritising funding are complex and understandably difficult for governments.
Second, the service system for children and their families is very fragmented, so that efforts at creating a system of services that promote resilience and provide timely and equitable access to services are challenging. Referral pathways are often not well delineated and there are long waiting lists for services, especially in the public sector (here, here and here).
Third, there are compelling workforce issues – many professionals, especially in the universal sector, feel that they lack the expertise to engage children and families around these issues. This is now being addressed through national professional development programs such as those offered by Emerging Minds and Beyond Blue.
Parental perception of a child’s need for help is a critical first step in the prevention and early management of emerging behavioural and emotional problems, and a key determinant of whether parents seek help; however, not all parents have an appropriate understanding of their children’s behavioural and emotional development. A recent national survey found that many Australian parents have poor mental health literacy, particularly regarding preschool and primary school children. Even when a mental health disorder is diagnosed, a significant proportion of parents do not seek any help, while those that do often have difficulty accessing the help that they need. Some parents do not know where to go for help, while others are daunted by long waiting lists or services that they cannot afford.
Finally, and importantly, there is a lack of consensus and indeed confusion around terminology. In our experience, the term “child mental health” does not resonate with many parents – some will default to “mental illness”, and then to “psychiatry”, “diagnosis” and “medications”, resisting the idea of their child on medication. Others will confess to having concerns about their child’s behaviour – aggression, anxiety, social isolation etc – but will deny their child has a mental health problem.
There are marked differences in the language that different professional groups use to discuss child mental health. For example, the educational sector tends to use words such as wellbeing, resilience, and social-emotional learning, while health professionals use terms such as problems, deficits, disorder, and other DSM-type diagnoses. Given the reliance on the DSM-IV or ICD-10 for diagnosis, the health care sector tends to take a binary “in” or “out” approach to mental health, whereas, in reality, child mental health problems are much more than black or white, often presenting as developmental and behavioural concerns that may not lend themselves to a clear diagnosis. Despite this, in both the educational and health service systems a diagnosis is often required for the child to receive additional services.
This lack of a common language is often commented on by various stakeholders (here and here), and acts as a barrier to advocacy efforts to make child mental health a policy and funding priority. It also contributes to a perceived lack of public discourse and media attention to child mental health, and, in our experience, stymies attempts to develop a more responsive and integrated approach to these problems, one that addresses the whole spectrum from prevention through to treatment.
There is a need to engage the public in a productive understanding of children’s mental health in order to increase support for policies and programs that advance the promotion of good mental health and the treatment of poor mental health.
More so than for adults or adolescents, children exist within and are dependent on their social ecosystem: parents, siblings, aunts, teachers, peers and parents of peers. Problems and concerns and approaches to addressing their needs must be communicated between key stakeholders in a manner that is understood by everyone, regardless of their professional background. Importantly the language used should be easily accessible to the children themselves.
Children spend the most time within this ecosystem of parents, siblings, aunts, teachers, peers and parents of peers, and universal platforms such as schools are ideally positioned to promote good mental health, identify any emerging problems early in a non-stigmatising way and, after discussion with the family, refer as appropriate for further assessment and management. Again, language is important.
A shared language needs to take the differences between adults and child mental health into account. We need a shared language that is accessible to the key players in a child’s life, and communicated easily to children themselves. The language needs to reflect the fluid, developmental nature of mental health status in children, allowing for problems to emerge and resolve, and for other contextual factors such as mental health competence to be considered when evaluating a child’s mental health status. In considering a mental health continuum, positive mental health, which is not simply the absence of disease, cannot be overlooked.
If we could reach a consensus on the way we use language around child mental health this could greatly strengthen our efforts to transform child mental health, and ultimately, this may help to identify those in need of extra support, and facilitate access to the right care at the right time.
Dr Simone Darling is the Program Manager for Mental Health Research and Policy, Murdoch Children’s Research Institute (MCRI). She is also Program Manager of the Digital Health Translation and Implementation Program at MCRI.
Professor Frank Oberklaid AM, AOM, is a paediatrician who up until recently was the Foundation Director of the Centre for Community Child Health at the Royal Children’s Hospital Melbourne, and is Co-Research Group Leader (Policy, Equity and Translation) at MCRI.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.