Effectiveness of the Koorliny Moort out-of-hospital health care program for Aboriginal and Torres Strait Islander children in Western Australia

There is a well documented disparity between health outcomes for Aboriginal and Torres Strait Islander children and those for the non-Aboriginal Australian population.1 The reasons for this disparity are complex and multifactorial. Aboriginal children in remote areas are more likely to suffer from infectious illnesses as a direct result of factors such as overcrowded housing.2 There is also concern about the increasing risk of diabetes, obesity, and the social and emotional wellbeing of Aboriginal children living in both urban and rural environments.3–5

Despite this high burden of disease, Aboriginal children and their families are less likely to interact with health care services.2,6,7 Contributing factors to this lack of engagement include racism, lack of cultural security, restricted access to and choice of services, inadequate community consultation, and prior negative health care experiences.6,8–10 In addition, many services are not perceived as welcoming to Aboriginal families.1,11 Aboriginal children are more likely to present later to hospital than is optimal, and to be admitted after presenting to an emergency department.12

In Western Australia, the Koorliny Moort out-of-hospital care coordination program was designed to bridge the gap in providing services to Aboriginal children who need hospitalisation or out-of-hospital services. Koorliny Moort means “Walking with families” in the language of the Noognar people of the Whadjuk Nation. The Noongar people are the traditional owners of the land on which Princess Margaret Hospital for Children is located.

The primary objective of our study was to assess the effect of the Koorliny Moort program on emergency department presentations. Secondary objectives were to assess its effect on hospital admissions, length of stay, and out-of-hospital follow-up appointments. We also assessed whether these effects were modified by age at referral, geographic region or referral source.

Methods

Setting

The Koorliny Moort program has been part of service provision at Princess Margaret Hospital for Children since 1 August 2012. Princess Margaret Hospital provides tertiary inpatient and outpatient services to all children in WA. The Koorliny Moort program was funded to include the three WA regions that include 70% of all Aboriginal children in WA (Kimberley, Pilbara, Perth metropolitan).

Inclusion criteria

All Aboriginal children aged 0–16 years who resided in the Kimberley, Pilbara or Perth metropolitan regions were eligible for the program. Referrals were accepted from Aboriginal Community Controlled Health Services (ACCHS), general practitioners, allied health staff, Medicare Locals, community workers, and specialist doctors. Self-referrals from families were also included.

Referrers were encouraged to refer children who had failed to attend appointments or who had complex problems or social or behavioural problems, or when the referrer experienced difficulties engaging with the family. We also accepted referrals from families who wished their children to be reviewed closer to home and country.

Interventions

The Koorliny Moort team included an Aboriginal senior program manager, two nurses, an administrative assistant, a senior Aboriginal senior social worker, two Aboriginal liaison officers, two part-time developmental paediatricians, and a senior paediatric trainee doctor.

The program provided three key interventions: partnership with community-based primary care providers (especially ACCHS), nurse-led care coordination, and outreach care closer to home. Partnerships with primary care providers included those with ACCHS, general practitioners, practice nurses, community health nurses, Medicare Locals, and social services. We provided support for following up clients, as well as training and capacity building for improving skills and knowledge in developmental and ambulatory care for Aboriginal children. Nurse-led care coordination involved assistance with combining and coordinating appointments to minimise travel and disruption, providing choices for appointments closer to family homes, assisting in locating medical records and results, planning hospital discharge, providing health advice and social, cultural and family support, and telehealth services. Outreach care encompassed social work, and nursing and paediatrician follow-up care as close to the family home as possible, including outreach clinics, assistance with social problems, vaccination, and developmental paediatric management.

Data collection

The administrative assistant collected data about the date of referral, reason for and source of the referral, and the age, sex and postcode of residence of the child. An independent analyst extracted de-identified data on hospital admissions, length of stay, emergency department presentations and outpatient appointments (attended and non-attended) from WA Department of Health databases.

Analysis

All children who were referred between 1 August 2010 and 31 July 2014 and for whom at least 2 months of pre- or post-program data were available were included in the analysis. Each child acted as their own control. The pre-program period extended from 1 August 2010 to the time of referral. The post-program period was from the time of referral to 31 July 2014. If a child was born after 1 August 2010, the date of birth was used as the base point. Occasions of service and person-time (in days) were compared for each child before (pre-program) and after their referral (post-program).

The proportion of children who received at least one occasion of service (emergency department presentations, hospital admissions) was calculated, with the total number of children who had at least one occasion of service as the numerator and the total number of children in the program as the denominator. For the analysis of non-attended appointments, the denominator was the number of children who had had at least one scheduled appointment. Logistic generalised estimating equations were used for analysis, and odds ratios calculated. This approach is often used to analyse variables that can be correlated over time, such as the frequencies of health care events in pre- v post-intervention designs.

The incidence of occasions of service was calculated using the number of occasions of service as the numerator and the total number of person-days as the denominator. Analyses also used generalised estimating equations modelling, and incidence rate ratios (IRRs) were calculated. Negative binomial models with an exchangeable correlation structure were used because count data were overdispersed.

We also assessed whether the effect of the Koorliny Moort program was modified by age at referral (children under 5 years of age v those at least 5 years old), geographic region (Perth metropolitan v non-metropolitan WA) or referral source (primary care staff v other referral source). Statistical analyses were performed with Stata 13.1 (StataCorp).

Sample size determination

Sample size estimations were based on the primary outcome measure (proportion of children with at least one emergency department presentation). We calculated that 820 children were needed to detect an improvement of at least 20% in emergency department presentations (α = 0.05, 80% power; assuming a baseline prevalence of 50%).

Ethics approval

Ethics approval was obtained from the WA Aboriginal Health Ethics Committee and the Child and Adolescent Health Service Ethics Committees.

Results

Between 1 August 2012 and 31 May 2014, 942 children were referred to the program (Box 1). The mean time spent by children in the program was 383.7 days (SD, 198.1 days).

More than half (57%) of the referrals were from the metropolitan region, and 501 children (53%) were under 5 years of age at the time of referral. One hundred and twenty-two of our children (13%) were adolescents aged 12–19 years; 309 (33%) resided in areas with the greatest socio-economic disadvantage (Socio-Economic Indexes for Areas [SEIFA] quintiles 1 and 2)13 (Box 2). Primary care providers had referred 429 of the children (46%), and ACCHS 237 (25%). More than half the children (55%) had multiple health problems. Of these, 17.4% were classified as having developmental delay and 11.7% had behaviour or mental health problems. In the metropolitan region, referrals for children with problems related to social and emotional wellbeing accounted for 45% of referrals (Box 3).

The proportion of children with at least one emergency department presentation decreased significantly from 44.8% during the pre-program period to 21.1% during the post-program period (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.23–0.40; P < 0.001) (Box 4). The incidence of emergency department presentations also decreased significantly (IRR, 0.47; 95% CI, 0.43–0.53; P < 0.001) (Box 5).

The proportion of children with at least one hospitalisation significantly decreased from 43.7% during the pre-program period to 28.3% in the post-program period (OR, 0.51; 95% CI, 0.43–0.61; P < 0.001) (Box 4). The incidence of hospitalisation also decreased significantly (IRR, 0.70; 95% CI, 0.62–0.79; P < 0.001), as did length of stay (IRR, 0.23; 95% CI, 0.21–0.25; P < 0.001) (Box 5).

The number of children with at least one scheduled appointment increased by 17 percentage points from 587 children (62%) pre-program to 742 (79%) post-program (Box 4, Appendix 1). Characteristics of children with and without scheduled appointments were similar (Appendix 1). The proportion of children who failed to attend at least one outpatient appointment decreased significantly from 67% in the pre-program period to 58% post-program (OR, 0.69; 95% CI, 0.56–0.87; P = 0.001) (Box 4). The incidence of non-attended appointments also significantly decreased (IRR, 0.83; 95% CI, 0.74–0.94; P = 0.003) (Box 5).

In the stratified analyses, the effect of the program was not modified by region or referral source (Box 5, Appendix 2). In contrast, the effect of the program on outpatient non-attendance was modified by age group (Box 5). The program significantly reduced outpatient non-attendance by 31% in children younger than 5 years old (IRR, 0.69; 95% CI, 0.58–0.82; P < 0.001), but not in children aged 5 years or more (IRR, 0.99; 95% CI, 0.83–1.18; P = 0.915; for interaction between age and program: P < 0.001). The effect of the Koorliny Moort program on emergency department presentations and hospitalisation was not significantly affected by age group (Box 5).

Discussion

Our program reduced emergency department presentations and hospitalisations and improved attendance at outpatient appointments by referred Aboriginal children. These effects were observed in children from both metropolitan and regional areas, and these effects were sustained over the 2 years of the program. These findings suggest that it is possible to positively influence the health-seeking behaviour of families of Aboriginal children by engaging Aboriginal people in their health care, providing effective communication between health service providers, and delivering a coordinated program of care led by Aboriginal service providers. These conclusions are especially important given that Aboriginal children are among the most difficult to reach and the most disadvantaged children in WA, as reflected in the extremely high non-attendance rate at appointments before the introduction of our program.

The proportion of children who received scheduled appointments increased by 17 percentage points, indicating an overall increase in access to care. Improvements were observed among children from both metropolitan and non-metropolitan regions, regardless of referral source, suggesting that our service was both effective and able to meet the needs of rural and primary care providers. Our program showed greater effects on outpatient attendance in children under 5 years of age. Thirteen percent of our children were adolescents aged 12–19 years. It is known that adolescents are difficult to engage and make poor use of health care services,14,15 but the sample size was not sufficient to separately assess the effects of the program in this important age group.

The impact of our program is consistent with previous investigations that have found the use of health care services can be improved by ambulatory care, central coordination and inter-agency communication.12,16–18 However, few studies have assessed the effects of out-of-hospital care on health service use by disadvantaged and Aboriginal populations. Out-of-hospital Aboriginal midwifery group practices report improved utilisation and satisfaction rates of 40–60%.19–21 Innovative ACCHS services have also been reported to improve satisfaction and quality of care.19,20 However, there appear to be no studies that have examined the impacts of out-of-hospital services on disadvantaged Aboriginal children. A recent study reported that more than 40% of presentations by Aboriginal children to emergency departments could be categorised as preventable.11,22 However, our study is the first to test and evaluate an approach to improving out-of-hospital services for Aboriginal children.

Our study has some limitations. The program provided three key interventions that improved the choice of services offered to families, but we were not able to assess the effects of the individual components of the intervention, as they were interconnected. The study participants were selected by a restricted number of pathways, and the final sample may not be fully representative of the wider community. A cluster randomised controlled trial would have been a better design, but it was not possible to implement such an approach in our complex service environment. We also considered whether the reduction in hospitalisations and emergency department presentations could be explained by the natural history of childhood illnesses, which tend to improve over time or as the child grows up. However, all of the children had complex chronic medical problems or medical conditions that required intensive medical and developmental care for a number of years, and their post-program use of hospital services remained high.

Our study has a number of implications for policy and program development. Many investigations, particularly of Aboriginal health, have described problems without attempting to test potential solutions. Our findings suggest it is possible to improve health-seeking behaviour and health outcomes for Aboriginal children by engaging Aboriginal families with health services, improving communication between health service providers, and coordinating Aboriginal service provider-led care. However, more information about the individual components of the program is needed, as well as about the perspectives and priorities of Aboriginal families and service providers. We are undertaking a qualitative project to examine these aspects, and will use the results to improve our program. We are also aware that our focus was on the most complex children with established medical conditions. Funding and service delivery, however, should be directed towards prevention and early detection rather than to tertiary services. We are developing a program to improve the primary care of disadvantaged Aboriginal children, and will report on its effects in a future article.

Box 1 –
Referrals to the Koorliny Moort program, 1 August 2012 – 31 May 2014, by region

Box 2 –
Demographic data for the children referred to the Koorliny Moort program, 1 August 2012 – 31 May 2014, by region of residence

	Metropolitan	Non-metropolitan	Total

Number of children (% of total sample)	536 (57.2%)	406 (43.1%)	942
Number of children under 5 years of age (%)	290 (54.1%)	211 (52.0%)	501 (53.2%)
Mean age of children (SD), months	65.9 (55.9)	69.5 (58.5)	67.5 (57.0)
Number of boys (%)	309 (57.6%)	228 (56.2%)	537 (57.0%)
Number of children residing in most disadvantaged areas* (%)	52 (9.7%)	257 (63.3%)	309 (32.8%)
Number of children referred by Aboriginal medical service staff (%)	159 (29.7%)	78 (19.2%)	237 (25.2%)
Number of children referred by primary service providers (%)	328 (61.2%)	101 (24.9%)	429 (46.1%)
Mean number of specialists (SD) involved before program began	2.2 (2.3)	2.0 (2.1)	2.1 (2.2)
Mean number of child-days (SD) in the program	427 (201)	476 (206)	448 (204)
Median number of child-days (IQR) in the program	442 (260–597)	492 (345–680)	465 (272–630)

IQR = interquartile range; SD = standard deviation. All percentages are column percentages, except in the first row (number of children). * Socio-Economic Indexes for Areas (SEIFA) quintiles 1 and 2.

Box 3 –
Reasons for referral of children to Koorliny Moort, 1 August 2012 – 31 May 2014*

	Metropolitan		Non-metropolitan		Total
	Number	%	Number	%	Number	%

Number of children	536		406		942
Social and emotional wellbeing
Developmental delay	141	26.3%	23	5.7%	164	17.4%
Behaviour	83	15.5%	8	2.0%	91	9.7%
Mental health	18	3.4%	1	0.2%	19	2.0%
Surgical
Orthopaedics	36	6.7%	106	26.1%	142	15.1%
Ophthalmology	30	5.6%	39	9.6%	69	7.3%
Ear, nose and throat	40	7.5%	51	12.6%	91	9.7%
Plastics	13	2.4%	25	6.2%	38	4.0%
Dental	4	0.7%	10	2.5%	14	1.5%
Burns	3	0.6%	6	1.5%	9	1.0%
Other surgical	16	3.0%	45	11.1%	61	6.5%
Medical
Neurology	62	11.6%	63	15.5%	125	13.3%
Respiratory	63	11.8%	47	11.6%	110	11.7%
Prematurity	47	8.8%	26	6.4%	73	7.7%
Nutrition	41	7.6%	14	3.4%	55	5.8%
Infectious disease	36	6.7%	10	2.5%	46	4.9%
Cardiac	30	5.6%	20	4.9%	50	5.3%
Renal	29	5.4%	15	3.7%	44	4.7%
Endocrine	29	5.4%	17	4.2%	46	4.9%
Haematology/oncology	8	1.5%	5	1.2%	13	1.4%
Gastroenterology	41	7.6%	12	3.0%	53	5.6%
Other medical	28	5.2%	17	4.2%	45	4.8%
More than one problem	247	46.1%	272	67.0%	519	55.1%

* Children could have more than one referral problem.

Box 4 –
Proportion of children who had at least one occasion of service, pre- and post-Koorliny Moort program, 1 August 2012 – 31 May 2014

	Pre-Koorliny Moort Program		Post-Koorliny Moort Program		Odds ratio (95% CI)	P
	Total children	Number (%)	Total children	Number (%)	Odds ratio (95% CI)	P

Emergency department presentations
Total	942	422 (44.8%)	942	199 (21.1%)	0.33 (0.27–0.40)	< 0.001
Metropolitan	536	285 (53.2%)	536	149 (27.8%)	0.34 (0.27–0.43)	< 0.001
Non-metropolitan	406	137 (33.7%)	406	50 (12.3%)	0.28 (0.20–0.39)	< 0.001
Hospital admissions
Total	942	412 (43.7%)	942	267 (28.3%)	0.51 (0.43–0.61)	< 0.001
Metropolitan	536	219 (40.9%)	536	121 (22.6%)	0.42 (0.33–0.54)	< 0.001
Non-metropolitan	406	193 (47.5%)	406	146 (36.0%)	0.62 (0.75–1.10)	< 0.001
Non-attended appointments*
Total	587	394 (67.1%)	742	432 (58.2%)	0.69 (0.56–0.87)	0.001
Metropolitan	320	232 (72.5%)	440	282 (64.1%)	0.68 (0.51–0.92)	0.011
Non-metropolitan	267	162 (60.7%)	302	150 (49.7%)	0.66 (0.48–0.90)	0.009

* For the analysis of non-attended appointments, the denominator was the number of children with at least one scheduled appointment.

Box 5 –
Incidence of occasions of service, pre- and post-Koorliny Moort program, 1 August 2012 – 31 May 2014*

	Pre-Koorliny Moort program		Post-Koorliny Moort program		Unadjusted IRR
	Event incidence rate (per 1000 person-days)	Mean number of events (SD)	Event incidence rate (per 1000 person-days)	Mean number of events (SD)	IRR (95% CI)	P

Emergency department presentations
Total	1.96	1.14 (2.19)	0.98	0.44 (1.26)	0.47 (0.43–0.53)	< 0.001
Hospital admissions
Total	857	0.91 (2.59)	1.16	0.52 (1.52)	0.70 (0.62–0.79)	< 0.001
Length of hospital stay
Total	8.81	5.14 (15.10)	3.44	1.54 (6.42)	0.23 (0.21–0.25)	< 0.001
Non-attended appointments
Total	4.06	2.50 (3.72)	3.53	1.63 (2.31)	0.83 (0.74–0.94)	0.003
Children, < 5 years of age	4.57	2.29 (3.45)	3.53	1.61 (2.26)	0.69 (0.58–0.82)	< 0.001
Children, ≥ 5 years of age	3.72	2.71 (3.96)	3.54	1.65 (2.37)	0.99 (0.83–1.18)	0.915

IRR = incidence rate ratio (pre- v post-Koorliny Moort program). * This table summarises the unstratified analysis (all 942 children); the stratified results by age for non-attended appointments are also included because they provide the only instance of a significant difference. For full summary of stratified results, see Appendix 2.

A vision for GPs

The training that aspiring GPs receive should be responsive to local health care needs and include greater prevocational rotation opportunities in areas such as paediatrics, obstetrics and anaesthetics, the AMA has said.

Setting out its vision for GP training, the peak medical organisation said that although the current system was world-class, it needed to evolve and improve to make sure it produced practitioners well placed to meet future health care needs.

The AMA said the training system needed to develop a workforce that met individual and community needs, served the most disadvantaged, and achieved health equity.

To do this, GP registrars needed to be trained to the point where they could safely undertake independent practice and viewed professional development and lifelong learning as essential to high quality practice.

AMA President Professor Brian Owler said general practice was the cornerstone of the health system, and the Vision Statement set out what the AMA considered to be core values and priorities of high quality GP training.

“GPs are the first port of call when Australians feel unwell or want health advice, and directly manage 90 per cent of the medical problems they are presented with,” Professor Owler said.

Evidence indicates that most people have a usual general practice or practitioner, and Professor Owler said GPs were a very cost effective part of the health system, accounting for just 7 per cent of total health spending.

The AMA has developed the Vision Statement for General Practice Training 2016 to guide its advocacy on improvements to GP training, and as a way to promote general practice as a career.

There are currently around 4500 registrars undertaking GP training, and there are concerns that not enough medical graduates are opting for a career in general practice.

Professor Owler said that, by highlighting the professional and personal rewards of general practice, the Vision Statement would encourage more to consider it as a career.

The GP workforce is ageing, and is unevenly distributed around the country, providing uneven access to care.

While the big cities have a relatively high concentration of GPs, there is often a shortage in rural areas, and bonded programs and other Government attempts to redress this have met with only limited success.

The AMA has proposed that there be much greater investment in GP training opportunities in regional and rural areas.

The AMA Vision Statement for General Practice Training 2016 is at ama-vision-statement-general-practice-training-2016

Adrian Rollins

Rural practice the prize for Australian Medicine reader survey winner

Caption: Australian Medicine reader survey winner Jezreel Blanco receives her Apple iPad Pro from AMA President Professor Brian Owler

As she prepares to embark on a career as a rural GP, Australian Medicine reader survey winner Jezreel Blanco’s one concern about winning the latest generation Apple iPad Pro is that it will out-match the speed of bush internet connections.

Adelaide-based Jezreel won the iPad after her name was randomly selected from more than 1500 readers who took part in the Australian Medicine survey, and was excited to receive the prize from AMA President Professor Brian Owler earlier this week.

The GP trainee is currently a resident at Flinders Medical Centre and is busily accruing the skills and experience she thinks will be vital to working as a general practitioner in a rural practice. She has already spent some time in obstetrics and paediatrics, and is currently working in an emergency department, where she hopes to gain experience in trauma care.

It is quite a shift in focus from Jezreel’s initial career as a medical scientist. Following a four-year degree at Sydney University, she worked in a coordinating centre for neonatal research, which she found to be too removed from the frontline of care for her liking.

“We were doing research on neonatal illnesses, but I never got to meet the families who were effected,” Jezreel said. “I was very interested in meeting with them and working them.”

It was this realisation that spurred her to undertake a medical degree, and to soon become a rural GP – even if the internet access isn’t great.

Adrian Rollins

Psychostimulants ‘over prescribed for ADHD’

Practitioners need to be more careful when assessing and diagnosing attention deficit hyperactivity disorder (ADHD), experts say.

In an editorial published in the Medical Journal of Australia, Dr Adrian Dunlop, from the University of Newcastle, and Professor Louise Newman, from the Centre for Women’s Mental Health at the Royal Women’s Hospital in Melbourne wrote that the implication of overdiagnosis is that disorders of children are being ‘medicalised’.

“There are risks for children that the use of stimulant medication is a simplistic attempt to find solutions to more complex problems underlying behavioural and emotional difficulties,” they wrote.

They said there has been a rise in ADHD diagnoses since the 1970s, which is in part due to an increasing understanding and awareness of risk factors.

When diagnosing, other conditions such as trauma-related neurodevelopmental difficulties, autistic spectrum disorder, and fetal alcohol spectrum disorders need to be excluded.

“It is therefore important that diagnosis includes a clear differential approach and that it is not made in a perfunctory fashion,” they wrote.

There are no national guidelines, however the Royal Australian and New Zealand College of Psychiatrists supports the Canadian or United Kingdom guidelines for ADHD treatment.

Related: ADHD critique divides specialists

Those guidelines both highlight the need for comprehensive assessment for ADHD.

There is also an approach supported by specialist medical colleges that suggests the ‘universal precautions’ concept could be applied, which routinely assesses all patients for risk of diversion, misuse or overdose both before and on an ongoing basis while prescribing psychoactive drugs.

“While careful assessment and universal precautions will not stop all non-medical use of prescription stimulants, including poisonings, they remain practical and feasible approaches to limit misuse,” the authors concluded.

ADHD and psychostimulants — overdiagnosis and overprescription

Careful assessment and universal precautions are necessary

Attention deficit hyperactivity disorder (ADHD) is the most widely studied child and adolescent mental health disorder, yet it remains the subject of ongoing debate, both about the validity of the diagnosis and its treatment. Increasing rates of psychostimulant prescription highlight the possibility of overprescription and overdiagnosis with the implication that disorders of children in particular are being “medicalised”. There are risks for children that the use of stimulant medication is a simplistic attempt to find solutions to more complex problems underlying behavioural and emotional difficulties1, and risks in adolescents and adults prescribed or exposed to stimulants, including poisonings, as identified in this issue of the MJA.2

Several factors appear to contribute to the increasing diagnosis of ADHD since the 1970s, before which the diagnosis was relatively rare. On the positive side, there is increasing awareness of the associated developmental morbidity and implications of early attentional disorders and related neurodevelopmental problems; increasing scientific understanding of the risk factors for neurodevelopmental difficulties such as ADHD, which are very broad and include in utero, peripartum and postpartum factors, with genetic and environmental components; and increasing recognition of the coordinated educational and family support needs for children with this spectrum of difficulties and evidence from a range of randomised control trails about the importance of comprehensive intervention. Despite this, the controversies around ADHD persist without consensus as to whether increases in diagnosis and treatment result in symptom reduction and improved long-term outcomes.3

The controversy around ADHD and its treatment has contributed to emotive and highly polarised discussions, with proponents of both over- and underdiagnosis positions. As is often the case, the complexity of this situation means that there are many developmental pathways to the condition commonly diagnosed as ADHD, and a major issue remains in the need for comprehensive assessment, which excludes other conditions. ADHD may be confused with other conditions, such as trauma-related neurodevelopmental difficulties, autistic spectrum disorder, and fetal alcohol spectrum disorders. In these instances, stimulants may be of benefit. The use of medication in various neurodevelopmental conditions may be quite appropriate but should not be seen as the sole treatment approach. It is therefore important that diagnosis includes a clear differential approach and that it is not made in a perfunctory fashion. It is also crucial that attention is paid to the needs of families, including parenting interventions and other strategies to support the development of positive emotional relationships and security of attachment in children who have major challenges in both behavioural and emotional regulation.

The issues related to the prescription of stimulant medications are also complex. There are increasing rates of prescription, especially of methylphenidate and an associated increase in poisonings.2 The proportion of deliberate overdoses and associated suicidal behaviour is of particular concern. Given concerns about the use of stimulant medication across the community in general, it is in some ways unsurprising that psychostimulants that may be appropriately prescribed can be misused. This pattern of greater rates of prescribing of psychoactive medications being associated with greater rates of misuse has also been dramatically and tragically seen with opioids.4

In the absence of national guidelines, the Royal Australian and New Zealand College of Psychiatrists5 supports the use of Canadian6 or United Kingdom 7 guidelines for ADHD treatment. Both highlight the need for comprehensive assessment of ADHD and substance use disorders. An approach supported by specialist Australian medical colleges that has been suggested for opioid prescription could be adapted for stimulant prescribing for ADHD.8 The concept of “universal precautions” implies routinely assessing all patients for risk of diversion, misuse or overdose, both before and on an ongoing basis while prescribing psychoactive drugs.

With regard to prescribing stimulants for ADHD, this approach could include ensuring comprehensive assessment with alternative diagnoses considered. These include multimodal non-pharmacological approaches to ADHD treatment; assessing all patients (including parents of children) for current and past history of substance use disorders; clinical assessment and drug toxicology to assess medication adherence and exclude substance use disorders; treatment agreements including informed consent; and addressing assessment of non-medical use. If substance use disorders are identified, they warrant concurrent specialist treatment.

In addition, prescription monitoring programs may have a role;9 however, with the exception of Tasmania, this has not occurred to date in Australia. While careful assessment and universal precautions will not stop all non-medical use of prescription stimulants, including poisonings, they remain practical and feasible approaches to limit misuse.

Rethinking autism

Neurotribes: the legacy of autism and how to think smarter about people who think differently. Steve Silberman. Sydney: Allen & Unwin, 2015 (544 pages, $35). ISBN 9781760113629.

Silberman is a popular award-winning investigative journalist with writings in the New Yorker, Time, Nature, Wired and Salon. He is an engaging author who tends to tackle the big picture issues with a focus on the social construction of illness models. In Neurotribes, with a foreword by Oliver Sacks, he presents a social history of autism with a call for rethinking the condition and tolerance for what he calls “neurodiversity”. This is a plea for conditions such as autism and attention deficit hyperactivity disorder to be rethought as naturally occurring cognitive variations with distinct strengths, as opposed to seeing them as diseases or deficits. Silberman argues that autistic conditions have long contributed to history and to the development of culture, making the point that in contemporary high-tech societies, the strengths of focused individuals with the brain capacities to understand and develop computer technologies are actually an asset. He observes that this has been a misunderstood condition with an array of different theoretical models for understanding it. Currently, the aetiology of autism is of great relevance as we are witnessing ongoing debates about its origin, with theories as diverse as parenting deficits to routine vaccination reactions. Neurotribes certainly manages to provide a well researched overview of the thinking about autism. Silberman is particularly critical of theories relating to pathogenic parenting and the so-called “refrigerator mother” as a cause of autistic spectrum disorder, and his discussion of the political issues surrounding the condition makes for a very interesting social account. This is a valid argument but one that needs to be balanced with an acknowledgement of the real social and interpersonal deficits that people with the condition can experience. As for most complex conditions, there is more than one reading of its history, but Silberman’s analysis is certainly of great relevance as we struggle with contemporary challenges, diagnosis and treatment.

Trends in drug use among adolescents admitted to residential treatment in Australia

In Australia, trends in drug use are primarily measured through two population surveys.1,2 These show alcohol, cannabis and tobacco to be the most commonly used drugs among adolescents. The National Drug Strategy Household Survey found that methamphetamine use has remained very low (2%) and stable among 14–19 year olds, with no rise in methamphetamine use overall in the population; however, there was a change in the main form, with crystal (“ice”) replacing powder.2

Population-level surveys are not sensitive to changes in use of drugs, which have a low prevalence in the general population by different age groups. Our report examines trends in reported current drug use and drug of greatest concern among an adolescent population admitted to four residential treatment sites across New South Wales and the Australian Capital Territory from 2009 to 2014. These young people are likely to be excluded from population surveys.3

The study sample included 865 adolescents, aged 14–18 years, admitted to residential treatment between 1 July 2009 and 31 December 2014, representing a large proportion of the adolescent residential treatment population in NSW and the ACT.4 Analyses included log-binomial regression for trends by admission year and multiple log-binomial regression to control for changes over time in sociodemographic characteristics.

The mean age of the study population was 16.6 years and 72.6% were male (Box 1). Over a third (37.2%) were referred by juvenile justice staff or self-reported criminal activity. Methamphetamine was the only drug to show an upward trend in the reporting of drug of greatest concern (Box 2), from 10.8% in 2009 to 48.4% in 2014 (relative risk [RR] per year, 1.37; 95% CI, 1.27–1.47); and in current use of drug at admission, from 28.8% in 2009 to 59.4% in 2014 (RR per year, 1.15; 95% CI, 1.09–1.22). Trends in methamphetamine use remained significant after controlling for sociodemographic characteristics. Alcohol, cannabis and tobacco use remain high, with 64.1% of participants reporting currently using alcohol, 85.2% cannabis and 72.7% tobacco in 2014.

Among 321 participants reporting current methamphetamine use, those reporting inhaling smoke or vapour increased from 12.5% in 2009 to 85.5% in 2014 (RR per year, 1.21; 95% CI, 1.15–1.27). Different forms of methamphetamine were not recorded; however, ice is commonly inhaled, which suggests that the main form used by participants has changed. There were associations between methamphetamine use and number of places lived and enrolment in a special class at school, suggesting that young people who may have learning difficulties or unstable accommodation may be at a higher risk of methamphetamine use or that use may result in learning issues and unstable accommodation.

Although self-reporting is common in behavioural research, there may be some response bias. For example, recent media attention may have increased reporting of methamphetamine as the drug of greatest concern. Under-reporting of methamphetamine use may also have occurred due to stigma. However, we found similar trends on both measures. The questions used were drawn from scales in the Brief Treatment Outcome Measure, which was developed in six phases including testing psychometric properties with treatment clients, a 30-month clinical trial in selected rural and metropolitan health services and clinician feedback.5

In contrast to stable population-level trends, methamphetamine use among this adolescent population has increased substantially. To equitably address methamphetamine-related harms, population surveys and health campaigns should be supplemented by a targeted approach to monitoring, prevention and treatment of at-risk groups.

Box 1 –
Sociodemographic characteristics of participants (n = 865)*

Characteristic	No. of participants

Mean age, years (SD)	16.6 (1.0)
Male	628 (72.6%)
Ever suspended or expelled from school	725 (83.8%)
Ever enrolled in special class at school	340 (39.3%)
Places lived in previous 6 months
1	287 (33.2%)
2	235 (27.2%)
3	160 (18.5%)
≥ 4	183 (21.2%)
Arrests in previous 3 months
0	279 (32.3%)
1	241 (27.9%)
2–3	233 (26.9%)
≥ 4	112 (12.9%)

* Data are number and proportion of participants unless otherwise indicated.

Box 2 –
Trends in drug of greatest concern, by year of admission (n = 865)

[Editorial] Air pollution: consequences and actions for the UK, and beyond

“The time has now arrived to take air pollution, as currently encountered in the UK, much more seriously…It should be considered a major public health problem…It is our view that this requires urgent, determined, and multidisciplinary action that is long overdue. Indeed, if we do not act now, our children and generations to follow will be those who suffer from our failure to act.” So concludes Stephen Holgate, chair of the Royal College of Physicians/Royal College of Paediatrics and Child Health (RCP/RCPCH) Working Party on Air Pollution, in his preface to one of the clearest calls to action to advance the UK’s environmental health.

Let them out

Picture: paintings / Shutterstock.com

The Federal Government’s refugee policies will come under attack at a forum being organised by the AMA to highlight the enormous harm caused by indefinite detention.

As doctors at Brisbane’s Lady Cilento Children’s Hospital stand steadfast in their refusal to discharge a one-year-old girl who faces being sent back to the immigration detention centre on Nauru, hundreds are expected to attend an AMA forum in Sydney on 21 February condemning the treatmernt of asylum seekers.

AMA President Professor Brian Owler, who will address the forum, is expected to highlight concerns about the standard of health care provided to asylum seekers, particularly those held in offshore facilities, and to call for the immediate release of all children currently being detained.

The forum, which is expected to be attended by leading clinicians, entertainers, commentators, jurists and religious leaders, comes as the Government advances plans to deport 267 asylum seekers, including 72 children, to Nauru after seeing off a High Court challenge to the legality of its offshore detention regime.

In a landmark decision, the High Court rejected the claim by a Bangladeshi woman detained by immigration authorities that the Government’s arrangement with Nauru breached the Constitution.

The nation’s highest court ruled that the Commonwealth’s memorandum of understanding with the Nauruan Government was authorised by section 61 of the Constitution, and its move to hire Transfield to operate the detention centre on the island was “a valid law”.

Releasing an AMA Position Statement on the health care of asylum seekers late last year, Professor Owler said that although the number of children being held in detention had declined dramatically under the Coalition Government, the practise needed to end completely.

“Detention has severe adverse effects on the health of all asylum seekers, but the harms in children are more serious,” Professor Owler said late last year. “Some of the children have spent half their lives in detention, which is inhumane and totally unacceptable.

“These children are suffering extreme physical and mental health issues, including severe anxiety and depression. Many of these conditions will stay with them throughout their lives.”

The forum, which will be held at the Ionic Room, SMC Conference and Function Centre, 66 Goulburn Street, Sydney on Sunday, 21 February from 11am, will also hear from leading child health experts from the Children’s Hospital at Westmead, including Consultant PaediatricianProfessor Elizabeth Elliott; Clinical Professor, Paediatrics and Child Health, Professor David Isaacs; and Paediatric Nurse Alanna Maycock.

Meanwhile, the Government is being frustrated by the action of doctors, nurses and hospital administrators in refusing to discharge children who face being returned to detention.

Since 12 February, doctors at the Lady Cilento Children’s Hospital have refused to release baby Asha, who was evacuated there from Nauru after being badly burnt by boiling water.

A hospital spokesman told the ABC that the child would not be discharged until a “suitable home environment is identified, as is the case with every child who presents at hospital”.

The spokesman said decisions relating to treatment and discharge were made by qualified clinical staff “with the goal of delivering the best outcome”.

The decision is a rebuke to the Government over the quality of care it provides for detainees, particularly those held offshore.

It echoes similar action taken by doctors at Melbourne’s Royal Children’s Hospital late last year.

The AMA said all asylum seekers and refugees should have universal access to basic health care, something that was “clearly not happening.”

The AMA Position Statement on the Health Care of Asylum Seekers and Refugees can be viewed at: position-statement/health-care-asylum-seekers-and-refugees-2011-revised-2015

The details of the AMA forum on asylum seeker health are:

Date: Sunday, 21st February 2016

Venue: Ionic Room, SMC Conference and Function Centre, 66 Goulburn St, Sydney

Time: 11:00am – 1:00pm

RSVP: By COB Thursday, 18th February 2016 to amaforum@ama.com.au

Adrian Rollins

Novel insights, challenges and practical implications of DOHaD-omics research

The basic tenet of developmental origins of health and disease (DOHaD) research is that perinatal health behaviours of the mother and father, as well as those of the child in early life, can have a significant impact on the future health of the child and that of subsequent generations. Studies exploring DOHaD investigate how early life exposures increase susceptibility to later adverse health outcomes from medical and public health perspectives. This altered health risk appears to occur through reprogramming of physiological systems away from their normal developmental trajectories, and highlights the plasticity of organ systems in the perinatal periods.1 Recent research in this field has focused on the potential for these physiological changes to exert trans-generational effects, without the requirement for further exposures in subsequent generations.2 This appears to occur through genetic and environmental interactions, resulting in phenotypic changes that persist across generations.

The emergence of “-omics” biotechnologies (eg, genomics, proteomics and metabolomics) has revolutionised physiological research in the DOHaD field. From the genome to the epigenome, microbiome and metabolome, research investigating pathways leading to disease has never before had the technology to investigate physiology in such a high throughput, data-rich capacity. We summarise this emerging research capability and its application in DOHaD studies to explain how environmental and social factors, such as diet, stress and exposure to toxins, affect our physiology and become inherited, leaving a legacy of disease susceptibility for future generations.

The epigenome

The epigenome refers to changes made to the genome that result in altered transcriptional activity in the absence of DNA sequence alterations. This highly dynamic process, occurring in response to several external factors, is stably maintained and endures over multiple generations. Epigenetic mechanisms regulating gene expression, including DNA methylation, histone modifications and the actions of small non-coding RNAs, each contribute to tissue-specific gene expression and an altered cellular phenotype. The introduction of efficient sequencing and microarray techniques has facilitated the study of these epigenetic mechanisms.

The interaction between epigenetic inheritance and environmental exposures has been recognised as an important determinant of phenotypic outcomes for offspring.1 Exposures of the mother can result in epigenetic modifications in the developing fetus and the germline.3 Such transmission is not restricted to maternal exposures, and recent evidence shows that epigenetic modifications are also inheritable down the paternal line.4 Specifically, a murine model of paternal obesity has shown altered methylation and microRNA profiles,4 which highlights the role of the father’s contribution to inheritable disease susceptibility. Further, data from the Överkalix Swedish tri-generation population study have shown that the mortality risk ratio of grandchildren was associated with the food supply available to their same-sex paternal grandparent.5 Whether an epigenetic mode of inheritance can contribute to such human outcomes is as yet unknown, but is expected, given the strong parallels observed between animal and human trans-generational studies. Single-generation epigenetic effects have been seen in humans, eg, maternal depression in the third trimester of pregnancy is associated with increased methylation of the NR3C1 gene in cord blood mononuclear cells, in conjunction with altered stress responses in the infants at 3 months of age.6 Increased methylation of this same gene was found in the brain tissue of adolescents with a history of child abuse who later committed suicide,7 and in lymphocytes of 11–21-year-olds after childhood maltreatment, and is associated with poor psychological health.8 Together, these studies suggest that early epigenetic modifications may increase vulnerability to poor long-term health in humans. Recognition of epigenetic mechanisms that contribute to poor outcomes may contribute to interventions to reverse these effects. For example, rat offspring exposed to low maternal grooming behaviour have increased DNA methylation of the hippocampal glucocorticoid receptor gene, which is reversed by increased care provision in early postnatal life.9 Similar epiphenotypes are observed in infant saliva, when high tactile stimulation of the infant in the postnatal period normalises glucocorticoid receptor hypermethylation induced by maternal depression.10

The microbiome

The human microbiome is the collection of microorganisms that inhabit the human body, including commensal and symbiotic microbes. The study of the microbiome and its role in disease onset has been made possible by the introduction of large-scale sequencing techniques and gene expression arrays. These techniques have increased our ability to understand the contribution of the maternal microbiome to disease in subsequent generations. For example, altered bacterial colonisation of the alimentary tract of piglets, after antibiotic and stress exposure in early life, has been associated with immune development perturbations.11 This may have particular implications for preterm children, for whom exposure to antibiotics and stress is common in early life. Already, preliminary studies of the microbiome in preterm twins have shown that an altered pattern of microbial gut colonisation precedes the development of necrotising enterocolitis.12 In humans, obesity,13 smoking14 and different modes of delivery (eg, vaginal versus caesarean)15 are common potential prenatal factors that can influence maternal and neonatal microbiomes. An altered microbiome can also contribute to epigenetic changes.16

The metabolome

The metabolome is the complete set of metabolites (compounds of low molecular mass found in biological samples) that regulate cell and tissue growth, development, survival, maintenance and responses to the environment. The potential for metabolomic profiling to provide a phenotypic signature of pathophysiology has been recognised.17 Methods to assess the metabolome rely on high-resolution analytics, including mass spectrometry, nuclear magnetic resonance spectrometry and Fourier transform infrared spectroscopy. Unlike the epigenome and the microbiome, the metabolome can be highly dynamic and is able to change in short time frames, ranging from seconds to minutes. The choice of sampling material is therefore an important consideration and a challenge. The decision on sampling material will be specific to the research question and critical to the interpretation of results. For example, blood samples reflect highly dynamic responses, but hair samples reflect prolonged exposure and can therefore provide a more stable phenotype.18 The large volume of data generated by such techniques can provide insight into interactions between metabolites, genes, transcripts and proteins.19 These data can be highly informative about mechanisms leading to disease and the impact of environmental exposures on system physiology, such as the developmental impact of prenatal exposure to the endocrine disruptor, bisphenol A.20

The potential for metabolomics platforms to be used to identify biomarkers predicting pregnancy outcome is already becoming apparent. These platforms include observations of differences in the neonatal blood metabolome across gestational ages (differences that are dependent on postnatal age at sampling21) and specific pathology and illness severity;22 a study linking the maternal hair metabolome with fetal growth restriction;18 and an ongoing prospective study for early prediction of pre-eclampsia23 (trial NCT01891240).

Challenges to -omics approaches in DOHaD research

Use of these emerging biotechnological approaches in DOHaD research shows clear promise in expanding our current knowledge of mechanisms driving intergenerational transmission of disease and heightened disease susceptibility in individuals after specific exposures in early development. While such large volumes of biological data using these -omics approaches provides enormous opportunity, some challenges remain in their application and interpretation. The first challenge relates to identifying the appropriate time for tissue sampling, given the current limited use of these approaches in this field. Healthy ranges are also yet to be established, a limitation that occurs with any advance in technology and will be overcome through public sharing of data. To establish healthy ranges, sampling from multiple time points and multiple tissues will be necessary. This information will benefit the design of future studies, in which sampling can then occur at a single time point during tissue-specific sensitive periods to yield the most reliable, valid and interpretable data. The establishment of normative ranges will also help elucidate many other current unknowns in this area, including understanding what sample sizes are needed to identify meaningful effects; understanding and predicting the stability of -omics profiles; identifying the effects of a “second hit” or multiple exposures; understanding whether the duration or timing of each exposure is important in determining outcome; and understanding whether a genetic susceptibility is needed for the intergenerational transmission of poor outcomes or whether this is a highly conserved process.

Once we have identified biomarkers or signatures predictive of poor maternal, fetal or neonatal outcomes, the next critical step is to use this information to identify how to normalise these effects. This will necessitate an understanding of how postnatal factors normalise or exacerbate the -omics profile induced by the early life environment. Longitudinal studies of twins have provided some preliminary evidence of environmental influences, exploring the stability of the epigenome across the first 18 months of life and the degree of epigenetic discordance between siblings with a shared genetic and environmental background.24 Continued longitudinal assessments of these children will increase our understanding of the role of the environment on the epigenome through life. The impact of additional exposures in pregnancies of these subsequent generations has also yet to be identified, because few studies have assessed the potential for -omics profiles to be modified beyond the second generation.2

Recommendations for future studies

We highly recommend collaborative studies that integrate data derived from multiple platforms, collected from samples throughout early development and linked to clinical health outcomes. Analysis of samples from current and planned randomised controlled trials will allow the effects of standard care and interventions to be assessed concurrently. These studies will facilitate our understanding of disease susceptibility, onset and progression to a degree that has not previously been possible.

Implications for policy and practice

Effective interventions applied at critical periods of development can substantially reduce future disease burden. The potential for this research to be translated into tangible health benefits for child health and future generations is therefore enormous, aligning with the growing demands of national health regulatory bodies to focus efforts on preventative health care. The outcomes of this research could then potentially be used by health advocates to improve policy and practice, by clinicians and health workers to promote and support healthy perinatal behaviours, and be communicated to the wider community to optimise future child health.

Information on DOHaD and early life healthy behaviours is becoming more readily available, but it is unclear whether this is being effectively communicated to the health care providers who need it most, that is, those in direct contact with women who are pregnant or planning a pregnancy. For example, surveys of general practitioners reveal that they have limited knowledge of nutritional requirements in pregnancy, and also feel uncomfortable providing this information to women due to a lack of confidence.25 Knowledge gaps such as this must be urgently addressed to optimise the health of future populations. Similarly, while the internet is teeming with websites offering advice for pregnant and breastfeeding women, these often contain inaccurate or misleading advice and conflicting information. Evidence-based online resources to which women can be directed for accurate health information are needed.