Building a shared language for child mental health: 3 years on

IN 2019, unaware of the impending social, economic and medical challenges society would shortly face as a result of the COVID-19 pandemic, we wrote an InSight+ article calling for a shared language of child mental health.

Our aim was to help overcome the stigma children and their families often experienced when seeking support for mental health concerns, as well as the challenges they faced in accessing and navigating a fragmented and seriously overloaded service system.

Pre-pandemic reports (here, here and here) had acknowledged the growing mental health crisis, and particularly noted the fragmented and inadequate mental health system. It was recognised that child mental health required a different approach to adolescent or adult mental health, as children are not their own free agents and exist within an ecosystem of adults who make decisions on their behalf – parents, grandparents, teachers, school aides, GPs and other health care professionals.

After being crowded out by adult and adolescent mental health, the recommendations from these reports meant that child mental health was finally beginning to capture the attention of policy makers.

When the pandemic struck in early 2020, a series of unparalleled preventative measures were enforced by federal and state authorities to minimise the spread of COVID-19. These included physical distancing; the closure of schools, playgrounds, workplaces and non-essential services; limits on the reasons to leave home; and in Victoria during the height of stage 4 restrictions, a military-enforced curfew and a 5 km travel limit.

As a result of the stressors associated with COVID-19 and the measures described above, there has been a significant impact on the mental health of Australian children, with parents reporting that approximately 63% of children aged 5–14 years have experienced a worsening in their mental health, and wait lists for services are straining under the weight of the surge in demand.

There has been a slow but sure shift beginning to emerge in approaches to child mental health, but the pandemic has further strengthened the argument for conceptualising and fast-tracking new models of care.

Traditionally, mental health treatment has involved a single patient with a single provider in a physical office. However, given the ongoing and increased access barriers facing children and their families, we must now start thinking about a distributed network of multimodal care (ie, telehealth, digital interventions, lay-provider service delivery, prevention and public health, integrated service hubs) that includes cross sector (ie, education, health, social services) and multidisciplinary (ie, teachers, school counsellors, GPs, psychologists, paediatricians) collaboration, and with the child and family as active participants. This network approach begins to shift the focus of child mental health away from the reactive, medicalised space of treating established problems largely in tertiary settings, towards a focus on prevention and early intervention in community, educational and primary health care settings.

In supporting a broader approach to child mental health, the National Children’s Mental Health and Wellbeing Strategy proposed a “fundamental, cultural shift in the way we think about the mental health and wellbeing of children” to a continuum-based model.

This model predicates that child mental health and wellbeing exists on a continuum ranging from being well (where children experience a state of positive health and wellbeing), through to coping, struggling, and then unwell, where children experience considerable challenges and require additional support to manage their mental health. This conceptualisation of mental health aims to move away from stigmatising terminology such as “meets criteria” or the language of “diagnosis”, “disorder” or “illness” to a more dynamic and functional approach. Here, the child’s innate ability, with the support of parents, to cope and adapt and draw on mental resources is considered and promoted, and common fluctuations in a child’s mental health that are inevitably part of growth and development are normalised rather than medicalised.

To build on the growing and widespread support for a continuum approach, we undertook an empirical study (being prepared for publication) to explore the specific language that resonates with parents, educators and health professionals. Our study comprised three phases: a comprehensive literature review; a Delphi study to seek consensus from key stakeholders on wording for the anchor points for the continuum; and user testing of prototypes generated during phase two. The outcome of this work is the Children’s Wellbeing Continuum, a tool that uses words, colours and icons to visually communicate that children’s mental health exists across a continuum. This enables reflection on the mental health and wellbeing of each individual child rather than against a set of diagnostic criteria. The anchor points of the Children’s Wellbeing Continuum range from “good” (shown in green), through to “coping” (yellow), “struggling” (orange) and “overwhelmed” (red). The results of our study support empirically the language of a Children’s Wellbeing Continuum, and demonstrated that the concept and language is relevant to and accessible for Aboriginal and Torres Strait Islander and culturally and linguistically diverse communities.

In practice, this continuum approach using accessible language can be used as a tool to generate initial and ongoing conversations about a child’s wellbeing (eg, between a child and a key adult, parents and schools, schools and/or parents and health care providers) and provides an opportunity to reflect on a child’s mental health and wellbeing across settings (eg, home and school).

Using the Continuum in this way can help identify children who are struggling but have not reached threshold for a diagnosis. This facilitates prevention and early intervention by providing an opportunity for parents and professionals to strengthen the scaffolding around a child before a mental health concern becomes an entrenched problem and requires specialist services. This approach starts with parents, recognising that they are the experts on their child, and aims to promote parental mental health literacy and confidence.

Further validation for a continuum approach to the language of child mental health has come from the Mental Health in Primary Schools pilot currently being implemented in Victorian primary schools. Approximately 150 classroom teachers, school leaders and school wellbeing staff responded to a survey exploring mental health literacy among education professionals. Between 90% and 99% of staff felt confident they could recognise where a child was placed on a mental health continuum. In contrast, only 65% felt confident to recognise a child with “attention problems”, and 58% felt confident to recognise a child with “anxiety problems”. These data suggest that using a mental health continuum might make educators feel more confident to recognise and therefore seek appropriate support for children with mental health concerns.

In summary, the Children’s Wellbeing Continuum has potential to play an important role in reducing stigma, facilitating the early detection of children who are struggling, and organising appropriate supports to prevent their progress to more serious mental health problems. The Continuum is not intended to replace diagnosis, which is an important part of child mental health; rather it helps to normalise the way children react and adapt to the challenges of everyday life.

Dr Simone Darling is the Senior Program Manager and Research Fellow in the Mental Health Research and Policy Group, Murdoch Children’s Research Institute (MCRI). She is also Social Innovation Lead at the MCRI.

Professor Frank Oberklaid AM, OAM, 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 necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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