Clinicians' Perceptions of The Australian Paediatric Mental Health Service System: Problems and Solutions
Clinicians' Perceptions of The Australian Paediatric Mental Health Service System: Problems and Solutions
Clinicians' Perceptions of The Australian Paediatric Mental Health Service System: Problems and Solutions
Research
Abstract
Objectives: Despite substantial investment by governments, the prevalence of mental health disorders in developed
countries remains unchanged over the past 20 years. As 50% of mental health conditions present before 14 years of age,
access to high-quality mental health care for children is crucial. Barriers to access identified by parents include high costs
and long wait times, difficulty navigating the health system, and a lack of recognition of the existence and/or severity of
the child’s mental health disorder. Often neglected, but equally important, are clinician views about the barriers to and
enablers of access to high-quality mental health care. We aimed to determine perspectives of Australian clinicians includ-
ing child and adolescent psychiatrists, paediatricians, psychologists and general practitioners, on barriers and enablers
within the current system and components of an optimal system.
Methods: A total of 143 clinicians (approximately 35 each of child and adolescent psychiatrists, paediatricians, child
psychologists and general practitioners) from Victoria and South Australia participated in semi-structured phone
interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study
aims.
Findings: Clinician-identified barriers included multi-dimensional family factors, service fragmentation, long wait
times and inadequate training for paediatricians and general practitioners. Rural and regional locations provided addi-
tional challenges but a greater sense of collaboration resulting from the proximity of clinicians in rural areas, creating
an opportunity to develop support networks. Suggestions for an optimal system included novel ways to improve
access to child psychiatry expertise, training for paediatricians and general practitioners, and co-located multidisci-
plinary services.
1
entre for Community Child Health, Murdoch Children’s Research Institute and The Royal Children’s Hospital Melbourne, Melbourne, VIC,
C
Australia
2
Melbourne School of Population and Global Health, The University of Melbourne, VIC, Australia
3
Children’s Bioethics Centre, The Royal Children’s Hospital, Melbourne, VIC, Australia
4
Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
5
Mental Health, The Royal Children’s Hospital, Melbourne, VIC, Australia
6
Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
7
School of Psychology, University of Adelaide, Adelaide, SA, Australia
8
Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
9
Health Services Research Unit, The Royal Children’s Hospital, Melbourne, VIC, Australia
Corresponding author:
Harriet Hiscock, Centre for Community Child Health, Murdoch Children’s Research Institute and The Royal Children’s Hospital Melbourne,
Flemington Road, Parkville, Melbourne, VIC 3052, Australia.
Email: harriet.hiscock@rch.org.au
Conclusion: Within the current mental health system for children, structural, training and workforce barriers prevent
optimal access to care. Clinicians identified many practical and systemic ideas to improve the system. Implementation
and evaluation of effectiveness and cost effectiveness of these ideas is the next challenge for Australia’s children’s mental
health.
Keywords
Health service use, children, mental health, qualitative
Participants were sourced via three key strategies: web- were developed using an inductive approach (Elo and
sites linked to professional organisations, e.g., find a Kyngäs, 2008).
Psychiatrist (The Royal Australian and New Zealand Three researchers (K.P., H.W. and S.R.) developed the
College of Psychiatrists, 2020); key informants (Marshall, initial coding schema which was reviewed by senior
1996) from within professional networks of the clinicians; researchers (L.G. and H.H.) and applied to all transcripts.
and Internet searches of the first five pages on Google. Categories were developed in line with the primary
Where recruitment strategies generated lists larger than research questions and themes were identified using the
20 clinicians for each group, a statistician not associated processes of content analysis. Regular discussion between
with the project assigned a random number to each clini- members of the research team ensured a rigorous process
cian and the clinicians were contacted in order of the of qualitative coding to identify similarities and differ-
numerical number assigned. ences, enabled iterative development and validation of
emergent themes. The lead analyst was a female Master of
Procedures Public Health (K.P.) with no clinical training. K.P. com-
pleted analysis until data saturation was achieved in rela-
A total of 143 (of 270 specialists and 165 GPs contacted) tion to the research question. A further eight transcripts
semi-structured phone interviews were conducted with cli- were then reviewed for each clinician type. Findings are
nicians (35 child and adolescent psychiatrists, 37 child psy- reported in line with the COnsolidated criteria for
chologists, 35 paediatricians and 36 GPs) from Victoria and REporting Qualitative research (COREQ) (Tong et al.,
South Australia between March 2018 and February 2019. 2007) checklist.
Participants were provided with one of two alternately
allocated vignettes: either a child experiencing symptoms
of ADHD or a child with symptoms of anxiety (see Results
Supplemental Material) prior to the interview, to orientate Demographics
them to the population of interest. Interviews lasted approx-
imately 45 minutes. A semi-structured interview guide was Characteristics of participating clinicians are shown in
used to ensure the key questions were covered, but also Table 1. There was a spread of clinician types across prac-
allowed participants to discuss what was important to them. tice and socioeconomic settings. More respondents prac-
Detailed field notes were kept of all interviews. tised in metropolitan than rural/remote areas and more
Reflexivity was maintained by ongoing discussions psychologists practised in private than public settings,
between researchers and a reflexivity journal. Interviews likely reflecting workforce distributions.
were audio recorded and transcribed verbatim. Transcripts
were validated, de-identified and participants assigned Findings
pseudonyms. Transcripts were then coded for analysis
using NVIVO 12.0 (NVivo, 2017) software. Analysis of the interview transcripts from a broad range of
participants revealed important themes which are presented
using verbatim quotes.
Analyses Some quotes have been truncated for space reasons
The study research aims provided the broad focus for anal- without changing the meaning. This is represented by an
ysis but following coding more ‘interpretive’ constructs ellipsis (...).
The overall study identified five overarching key metropolitan peers. Table 2 provides a detailed summary of
themes. In this paper, we provide a summary of findings system issues and solutions.
from one key theme: health sector challenges and compo-
nents of an optimal system for child and adolescent mental
Clinician reports describing workforce
health care. Other key themes included health system fund-
barriers to access and solutions towards
ing models (with some overlap of the findings in this
optimal care
paper); an evidence-based role for the education sector;
role of emotion and perceptions about mental health; and Limited numbers of child and adolescent psychiatrists was
supporting parents to support their child. identified as an issue by all clinician groups including child
and adolescent psychiatrists themselves. GPs and paediatri-
cians feel they can manage some mental health conditions
Clinician reports describing system barriers but expressed a desire for more support from child and ado-
to access and optimal care lescent psychiatrists for more complex cases. Psychiatrists
All clinician groups raised issues about access to services. see one of their roles as consultants and advisors to other
Access to services is restricted by degree of severity and professions.
complexity of the condition, age ranges for specific ser- A more general shortage of trained professionals for
vices, fragmentation of services with no roadmap to navi- younger (<12 years) children was seen across the sample.
gate, out-of-pocket costs and lengthy waiting times. Publicly funded psychologists were recognised as a
Clinicians identified multi-dimensional interrelated particularly scarce resource by all clinician groups.
individual and family factors which influence access to ser- Combined with lengthy waiting lists this led to clinician
vices, including severity and complexity of the condition, burnout, particularly in regional areas. Clinicians expressed
geographic location of services, age of the child/adolescent, the view that in some cases employment contracts were
parental factors (e.g. health literacy, mental health, capacity short term and this led to high turnover in staff. In addition,
to pay) and individual personal circumstances such as the workload in regional areas also had an impact on
employment status. recruiting new staff.
At the extreme ends, i.e., when a child had conditions Many clinicians identified that the system of care is top
sufficiently complex and severe to have access to publicly heavy with a focus on specialist medical staff when some
funded child and adolescent mental health services first-line mental health care management could be under-
(CAMHS) or when families had a high degree of health taken by other professions, provided they were trained in
literacy and were able to pay for services, services were mental health.
relatively easier to access. Variability in the quality of services provided both at the
The term the ‘missing middle’ was used to describe individual clinician level and organisational level was
those that fell outside these two extremes and described a identified.
very large group of families, children and adolescents. GPs are typically considered to be generalists. Clinicians
The CAMHS model was identified as positive, in terms suggested that opportunities for GPs to specialise in mental
of many practitioners in one setting but clinicians also sug- health services could be valuable; however, some GPs did
gested that public mental health services (and specifically not have an interest in paediatrics and/or mental health and
CAMHS) have strict criteria for accepting a referral through others felt they did not have the skills to treat mental health
their intake processes and their capacity covers only a small conditions.
proportion of the need. Within all clinician groups, appropriate training and pro-
Although long waiting times were perceived to be more fessional development was identified as a challenge par-
likely to occur in public settings, clinicians perceived that ticularly for those in regional areas. Table 3 provides a
private services also had long waiting lists in all profes- summary of clinician identified workforce challenges and
sions. This was reflected as impacting both referral to other possible solutions.
service providers and waiting times for clinicians’ own
practices. This varied according to location and was
Clinician reports describing the challenges
reported to be worse in rural and low socioeconomic areas
of working together to improve outcomes
where provision of specialist services is limited.
Furthermore, clinicians identified that the need to travel All clinician groups expressed the view that working
long distances was challenging for families. together would improve care. However, the health care sys-
However, a greater sense of community and collabora- tem is not structured for clinicians to deliver coordinated
tion resulting from the proximity of clinicians in rural areas care.
provides an opportunity to develop support networks. This Many clinicians across all clinician groups wanted
was perceived to provide a mechanism for closer liaison clearer referral pathways and better communication
and more coordinated care than that experienced by their between clinicians.
Table 2. Clinician reports describing system barriers to access and optimal care.
Complex systems – multiple factors impact access to services Integrated multi-disciplinary services
Representative quote Representative quote
‘It’s actually appreciating why kids can’t get to appointments. It’s not ‘I mean in some way it would be nice to see a kind of, well, a
just that they can’t afford it; it’s that Mum’s having her own panic department of paediatrics in each region, that focuses on children,
attack and can’t drive her that day, or they didn’t get the appointment well you know, the developmental stages from nought to 18 or even
because Mum’s phone’s been cut off because she couldn’t pay it, higher in terms of physical, social, emotional needs so that you know,
or they didn’t get the appointment because they’re actually living everything is much more integrated’. (VIC Child and Adolescent
in their car because Dad’s come home and kicked them out’. (VIC Psychiatrist 10, public and private)
Paediatrician 10, public/private)
Rules and restrictions but no roadmap about how and where Information about how and where to access services with assertive
to find appropriate services* follow-up
Representative quote Representative quote
‘I’ve heard people talk about the missing middle and I’ve ‘From experience, I know that parents struggle to navigate the system
experienced that so often and its really frustrating ... and it happened and sometimes the clinicians don’t know what the pathways are ...
this morning with the young person I saw who has been suicidal off if there is a simpler pathway that the parents can follow and the
and on ... [service] didn’t feel he needed an inpatient admission, he practitioner knows where to direct them, then that will be the easiest
doesn’t fit criteria for [mental health service] and he says to me that thing. ... and then some mechanism of making sure that this child and
he tried a number of psychologists in his local area, he’s been to the family is followed through ... and the child is not being lost’. (SA
[service] and it didn’t help ... and then I’m sort of left, stuck, and not Child and Adolescent Psychiatrist 4, public/private)
really knowing where to fit him in the system’. (VIC Paediatrician 1,
public)
*Identified as a barrier by parents (Lawrence et al., 2016: Sawyer et al.,
2000)
Out-of-pocket costs for services* Increased rebates for bulk billed services
Representative quotes Representative quote
‘Some of the parents clearly say, “I can’t even afford the $50 extra ‘... they currently can come and not have to be out of pocket but it
gap that they charge us”’. (VIC Paediatrician 28, public/private) relies on the clinician bulk billing the service, and the bulk bill rates
‘Well, they have to wait ’cause they can’t have treatment. They haven’t changed since about 2010. So the burden then is put back
don’t have a choice. Like you know, if you’re broke you don’t onto the clinicians. So if that was gone, if the clinicians could still be
have access, that’s the reality’. (SA Psychologist 5, public/private) paid properly and the patient wasn’t out of pocket, that would be
*Identified as a barrier by parents (Lawrence et al, 2016; Sawyer great’. (VIC Psychologist 6, private)
et al., 2000)
(Continued)
Table 2. (Continued)
Quotes describing problems Quotes suggesting solutions
Effective communication between practitioners was summary of clinicians’ views of the challenges in commu-
considered an enabler for optimal care. In the absence of nication and how to address them.
a systematic way of communicating, clinicians identified
ad hoc arrangements they had developed which were
Discussion
effective in supporting children and families to receive
improved care. This is the first study reporting clinicians’ perceptions of
Some ad hoc arrangements develop from connections the major barriers faced by Australian young people and
with colleagues. their parents when seeking help for common child and ado-
However, others developed their own support networks lescent mental health conditions.
without a personal relationship. Co-location was a possible Clinicians identified barriers at three levels: (1) parent
enabler of improved communication. Table 4 provides a – poor mental health literacy, competing life stressors;
Table 3. Clinician reports describing workforce barriers to access and solutions towards optimal care.
System reliant on specialist services Use of other workforces, e.g., Mental health nurses, for first line of
Representative quote mental health response
‘What I find as a general paediatrician in the community is that I end Representative quote
up being everything. I’m the social worker and the speech pathologist ‘... mental health nurses or mental health OTs can manage it. You
and the nurse, and they end up getting someone who’s quite know, there a place for that stepped up care approach so that
expensive but very well-trained holding a lot of stuff that could be there’s a mental health nurse in every GP practice ..., skills training
done by a case manager ...’ (VIC Paediatrician 10, public/private) or parenting training or sleep training or behaviour training ...’ (SA
Psychologist 3, private)
Table 3. (Continued)
Lack of interest in mental health Opportunities for GPs to specialise in (child) mental health services
Representative quote Representative quote
‘I see my role as, I often compare this to say, heart disease. I see a ‘I think GPs are really important, but again, if you think the skillset
patient, I diagnose. I can work-up, I can do the blood test and I can of paediatricians is varied, the skillset of GPs is very varied. I think
come up with what I think is the diagnosis and then I refer to the that GPs who are interested in child and adolescent health should be
specialist. And then the specialist takes over and treats them. And I supported and they should be educated on child physical and mental
think that’s how mental health should be. Because as GPs we don’t health’. (VIC Paediatrician 6, public/private)
have the skills to carry out counselling and advice and all those
things’. (SA GP 10, bulk billing/private)
Variability in the quality of services provided Medicare item numbers for mental health trained GPs
Representative quotes Representative quote
‘GPs who are perhaps less inclined towards managing mental health ‘In an ideal world I’d like to do what the government did a few years
on their own, and there are GPs who just flatly refuse to. They tell ago, and chucked a whole lot of money at training GPs in mental
patients, and we know who those ones are because, you know, when health in adults, and released MBS item numbers so that they could
they refer to a psychiatrist it’s just a one-liner, “Please take over the be remunerated for doing this kind of work, as part of improving
care”’. (SA Child and Adolescent Psychiatrist 2, public/private) mental health in adults, but doing this in kids and so that GPs will
‘Well if we start with at the GP level, so I feel relatively confident have a module to do, and once they’ve done that module in three or
and happy seeing adolescents for mental health issues, but not all four conditions, then this module will allow them to manage these
GPs would feel the same. And that may be because, they simply don’t conditions in a way that’s clearly evidence based, and also allow those
see many adolescents, or they don’t see a lot of mental health. So I GPs that have done this module- there will be a period of assessment-
think there’s a large variation between GP’s in terms of experience, and then they should be allowed to prescribe the stimulant
knowledge, skills, and I guess general comfort in managing these treatment’. (VIC GP 1, bulk billing/private)
issues. That’s potentially a barrier there, that they may not be getting
the treatment they need from the GP’. (VIC GP 15, bulk billing/
private)
Lack of services for children under 12 years Specialist services for children under 12 years
Representative quote Representative quotes
‘I’m getting clients re-referred back to me because they’re not seeing ‘... children’s centres, and they are funded by the Department for
kids that young. So they’re calling themselves a child psychologist but Education. They’re sort of places where there are often childcare,
they’re not actually seeing children under the age of eight ... there’s possibly kindy. They often do have a speech pathologist and OT
just not enough trained professionals’. (SA Psychologist 3, private) onsite, and they may have a social worker, they currently provide
services up until five years, and sometimes up until eight years. So I
think that sort of service, if expanded, and if able to provide more
assessments. So, at the moment they don’t do a lot of assessments,
it’s mostly sort of, general support stuff. But if they were able to
provide more developmental assessments, if they were able to
provide more social work support, more parenting support to
families, and perhaps expand the age up until sort of 12. I think the
potential there for, you know, really a lot more support for families, I
think that would be really useful’. (SA Paediatrician 1, public)
‘But they only start from twelve as well. So there’s kind of that
missing for children. Like a [service] equivalent for children where
it’s not government, which is a very complex, low SES, high risk one.
Not privately where they’re paying up to a hundred dollar gap but
that, yeah [service] equivalent for children’. (SA Psychologist 5, public/
private)
(2) service – long wait times, restrictive entry criteria, barriers are also similar to those reported in our smaller
large out-of-pocket costs, fragmentation of services; and (n = 30) study of clinician perspectives about the care of chil-
(3) workforce – need for better training, need for better dren with complex mental health conditions using ADHD
access to specialist support for GPs. These clinician- and Autism as exemplars (Paton and Hiscock, 2019). The
identified barriers are strikingly similar to those reported consistency of results across these different groups suggests
by parents in the two Australian child and adolescent that these barriers should be given the highest priority in
national mental health surveys (Lawrence et al., 2015; future planning for services designed to help children and
Sawyer et al., 2000). For example, parents in both sur- adolescents with mental health problems in Australia.
veys also reported that not knowing where to get help, This study extends previous work by including GPs as
long waiting lists, high costs and geographical distance respondents. Results from GPs highlight the extent to
were major barriers to getting effective help for children which these clinicians want better access to secondary con-
and adolescents with mental health problems. The sultation with mental health specialists and also better
Table 4. Clinician reports describing the challenges of working together to improve outcomes.
Lack of structures within the health system to support communication Formalise communication mechanisms between clinicians
Representative quotes Representative quotes
‘I don’t think private psychiatrists or GPs have very much time to ‘I guess I have built up a big enough, sort of, referral base that I can
liaise with each other, and I think I write these lengthy letters every actually pick up the phone and ring, and say, “Look, I’ve got this
now and again and I wonder who reads them ... when I do have family, what can we do?” And usually, if you’ve got a relatively good
conversation with GPs, even really short ones, I think we both come relationship with the other providers, they’ll, you know, they’ll fit
out of it better off’. (VIC Child and Adolescent Psychiatrist 1, public/ them in ... Yeah and that’s taken me years to establish. You know, 20
private) or more years’. (VIC GP 19, private)
‘There’s probably not a lot of communication between psychiatrists ‘... One good discussion often shores up their [GP’s] understanding
and paediatricians around management of children with mental health and in a sense, they can get on with the work. But a lot of it comes
disorders. There’s no real forum for that to occur. ... So I can actually down to having my own personal connections with paediatricians,
say to you, that with regards to children that I look after, it’s very GPs, allied health professionals, that I know, and that know me.’ (VIC
unusual for me to get on the phone and even speak to a psychiatrist. Child and Adolescent Psychiatrist 31, public/private)
Maybe there needs to be some sort of you know ability for that to ‘So I’ve sort of made friends with the psychiatrist and I’ve text and emailed
happen’. (SA Paediatrician 9, public) her. I have never seen her ... She’s been kind enough to reply. And I’ve sent
a few referrals on to her but, again, she’s very expensive and she’s private
so not all my patients can see her’. (SA Paediatrician 4, private)
training, particularly in relation to the management of acute Care, Queensland Children’s Health, personal communica-
child and adolescent mental health problems. tion). More intensive approaches include the REsource for
This study focused more specifically on mental health Advancing Children’s Health (REACH) project in the
care than previous studies (as opposed to education and United States (The Reach Institute, 2020) which provides
social care), purposively sampling clinicians working interactive skills building followed by a 6-month case-
across diverse socioeconomic areas and including ADHD based distance-learning programme or the United
and anxiety as the two most common child mental health Kingdom’s general practitioner with special interest (GPSI)
disorders. We could find no other study reporting on clini- model where GPSIs take referrals from other GPs and work
cian views of how to improve the mental health system for within integrated consultant-led clinical teams in addition
children. Although the study is limited to clinicians work- to specialists (Yellamaty et al., 2019). This model has been
ing in one of two States in Australia, we believe results are associated with superior patient satisfaction and compara-
readily generalisable to all Australian States and Territories ble outcomes to specialists but requires appropriate train-
(Paton and Hiscock, 2019). ing, mentoring and ongoing professional development for
Our findings suggest several avenues for improving the GPs and employers adopting this role.
current system for children and are especially pertinent Co-location of ‘private’ and ‘public’ services that provide
given the potential increase in mental health problems with help for the emotional, physical and social needs of children,
the Covid-19 pandemic. These avenues include increasing parents and families has the potential to overcome several
the availability of specialist mental health support to non- current service barriers identified by clinicians and parents.
specialists such as GPs and paediatricians via email, tele- For example, co-location of such services has the potential to
phone or telehealth, as per successful US models (Sarvet reduce current service fragmentation and to make it easier
et al., 2010). With the Covid-19 pandemic, most clinicians for parents to know where to get help for problems in these
have pivoted to telehealth. Anecdotally, this seems to suit areas. The latter is an important issue because comorbid
many families and clinicians, but rigorous evaluations are problems at the child, parent and family levels are common
yet to be published and telehealth may not deliver effective among children and adolescents with mental health prob-
care for children and adolescents with complex mental lems. Co-location of services would allow children and par-
health problems. ents to more easily access services that could address a range
Clinicians also called for a centralised service that pro- of such comorbid problems. The closer proximity of services
vides information on services and pathways in a staged would also encourage better co-ordination and information
manner, responding to the child’s needs. While some major flow between staff in co-located services.
mental health initiatives provide this type of support for The current Medicare emphasis on funding based on the
adolescents and adults (e.g. Beyond Blue, 2020), they do ‘fee for service’ concept limits opportunities for even co-
not provide information relevant to children under 12 years located staff and services to work together in a coordinated
of age. Furthermore, many websites suggest patients should and cooperative manner. This is a significant problem for
seek help from GPs in the first instance, but our study sug- the effective assessment and management of children with
gests that GPs want more effective specialised support mental health problems, many of whose mental health
when assessing and treating child and adolescent mental problems are entwined with family, education and social
health problems. issues – all of which may need addressing before a child’s
Many clinicians in this study called for increased train- mental health will improve. As recommended in the
ing in child mental health, including practical experience recently released Productivity Commission into Mental
working in public specialist mental health services. For Health (recommendation 10.3) (Productivity Commission,
GPs, this would require significant changes to their current 2020), funding models that encourage different clinicians
vocational training requirements for paediatrics which and services to work together more effectively have the
largely focus on medical and not mental health or behav- potential to help address this issue.
ioural problems (The Royal Australian College of General In summary, the provision of help for children and ado-
Practitioners (RACGP), 2020). Telementoring is one lescents with mental health problems in Australia has often
approach that might allow for GPs to upskill in child mental floundered as a result of major structural, training, resource
health. Project ECHO is a telementoring model which uses and workforce issues. Clinicians in this study identified a
proven adult learning techniques and interactive video range of barriers and potential solutions to these problems.
technology to connect groups of community providers with It is notable that the issues identified by clinicians were
specialists at centres of excellence in regular real-time col- strikingly similar to those identified by parents in the two
laborative sessions (Zhou et al., 2016). Queensland Australian national child and adolescent mental health sur-
Children’s Health has been using the Project ECHO model veys. The challenge now is to get the Australian Government
(Queensland Children’s Health, 2020) for ADHD and along with State and Territory Governments to use the
behavioural concerns, with positive feedback from clini- information provided by both clinicians and parents when
cians involved (Dr Newcomb, Medical Director Integrated developing, implementing and evaluating new systems of
care for Australian children and adolescents with mental Jorm AF, Patten SB, Brugha TS, et al. (2017) Has increased provision
health problems. of treatment reduced the prevalence of common mental disorders?
Review of the evidence from four countries. World Psychiatry 16:
90–99.
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Chadstone, VIC, Australia: QSR International Pty Ltd.
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