Workforce planning for children and young people's mental health care
Authors: Nicholas M Kowalenko, Gordana Culjak
Journal: The Lancet Public Health (2018)

Mental health problems and disorders start in childhood and adolescence and can have lifelong effects.1Felitti VJ Anda RF Nordenberg D et al.Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults.Am J Prev Med. 1998; 14: 245-258Summary Full Text Full Text PDF PubMed Scopus (9643) Google Scholar Exposure to trauma in childhood might be psychiatry's greatest public health challenge—as Sara and Lappin recently stated in The Lancet Public Health.2Sara G Lappin J Childhood trauma: psychiatry's greatest public health challenge?.Lancet Public Health. 2017; 2: e300-e301Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar Yet services to adequately address this health problem, and mental disorders in general in young people, are scarce. In their Article in The Lancet Public Health, Leonie Segal and colleagues3Segal L Guy S Leach M Groves A Turnbull C Furber G A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study.Lancet Public Health. 2018; 3: e296-e303Scopus (17) Google Scholar outline their needs-based workforce model for effective delivery of community mental health care to infants, children, and adolescents in South Australia. This study is timely given that child mental health disorders affect one in seven of the population aged 4–17 years in Australia.4Lawrence D Hafekost J Johnson SE et al.Key findings from the second Australian Child and Adolescent Survey of Mental Health and Wellbeing.Aust N Z J Psychiatry. 2016; 50: 876-886Crossref PubMed Scopus (151) Google Scholar The study adds to the group's interest in developing models for workforce planning5Furber G Segal L Leach M et al.Preventing mental illness: closing the evidence–practice gap through workforce and services planning.BMC Health Serv Res. 2015; 15: 283Crossref PubMed Scopus (26) Google Scholar and in quantifying the population effect of exposure to risk factors in childhood on adult mental health.6Guy S Furber G Leach M Segal L How many children in Australia are at risk of adult mental illness?.Aust N Z J Psychiatry. 2016; 50: 1146-1160Crossref PubMed Scopus (15) Google Scholar In a previous study,7Segal L Guy S Furber G What is the current level of mental health service delivery and expenditure on infants, children, adolescents, and young people in Australia?.Aust N Z J Psychiatry. 2018; 52: 163-172Crossref PubMed Scopus (10) Google Scholar this group showed that the mental health needs of the youngest age groups (0–4 years) are underserved by a factor of ten compared with those of youth (18–24 years). Segal and colleagues3Segal L Guy S Leach M Groves A Turnbull C Furber G A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study.Lancet Public Health. 2018; 3: e296-e303Scopus (17) Google Scholar applied their model to a population aged 0–17 years, which was chosen based on the most common age range for Child and Adolescent Mental Health Services (CAMHS) in the UK and Australia. The model used diverse, high-quality data sources and included the prevalence of mental disorder, as well as cut-points for maternal psychological distress (to derive need in the first 2 years of life) and data from psychological screening instruments. The authors found increased need in late adolescence, which is consistent with epidemiological data.4Lawrence D Hafekost J Johnson SE et al.Key findings from the second Australian Child and Adolescent Survey of Mental Health and Wellbeing.Aust N Z J Psychiatry. 2016; 50: 876-886Crossref PubMed Scopus (151) Google Scholar The systematic approach used by the authors to establish patient complexity and consider its developmental context is novel. The population of children and young people with tertiary-level needs in the study was very large. Policy settings, such as those in the Australian Government Department of Health's Fifth National Mental Health and Suicide Prevention Plan,8Australian Government Department of HealthThe Fifth National Mental Health and Suicide Prevention Plan.http://www.health.gov.au/internet/main/publishing.nsf/content/mental-fifth-national-mental-health-planDate: 2017Date accessed: May 21, 2018Google Scholar have assumed a key role for primary-level services in addressing the burden of mental disorders in children and adolescents, but evidence for the effectiveness of this approach is scant.9Bower P Garralda E Kramer T Harrington R Sibbald B The treatment of child and adolescent mental health problems in primary care: a systematic review.Fam Pract. 2001; 18: 373-382Crossref PubMed Scopus (89) Google Scholar Models of care for this age group have not been well developed or adequately tested, neither across the age range nor across tiers of care.10Newman L Birleson P Mental health planning for children and youth: is it developmentally appropriate?.Australas Psychiatry. 2012; 20: 91-97Crossref PubMed Scopus (6) Google Scholar Substantial investment in primary mental health care for youth aged 12–25 years in Australia has resulted in only modest effects.11Jorm AF How effective are 'headspace' youth mental health services?.Aust N Z J Psychiatry. 2015; 49: 861-862Crossref PubMed Scopus (21) Google Scholar Additionally, despite access of youth to primary care increasing greatly in the country, the population prevalence of mental disorders has not yet decreased.12Mulder R Rucklidge J Wilkinson S Why has increased provision of psychiatric treatment not reduced the prevalence of mental disorder?.Aust N Z J Psychiatry. 2017; 51: 1176-1177Crossref PubMed Scopus (34) Google Scholar At present, data are insufficient to compare the relative efficacy and cost-effectiveness of different service models, so the fact that the scope of care in this study3Segal L Guy S Leach M Groves A Turnbull C Furber G A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study.Lancet Public Health. 2018; 3: e296-e303Scopus (17) Google Scholar was referred to as tertiary-level mental health needs is novel. However, as the authors note,3Segal L Guy S Leach M Groves A Turnbull C Furber G A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study.Lancet Public Health. 2018; 3: e296-e303Scopus (17) Google Scholar the unmet need for this population does not necessarily justify only a tertiary service response, but may require other service responses, providing that high-level workforce competencies are available in the workplace. Segal and colleagues3Segal L Guy S Leach M Groves A Turnbull C Furber G A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study.Lancet Public Health. 2018; 3: e296-e303Scopus (17) Google Scholar challenge existing estimates of workforce need, estimating that they should be increased more than five times the current service level. In calculating these estimates, the authors assume 100% coverage of the population, but existing planning frameworks, such as Australia's Draft National Mental Health Services Planning framework,8Australian Government Department of HealthThe Fifth National Mental Health and Suicide Prevention Plan.http://www.health.gov.au/internet/main/publishing.nsf/content/mental-fifth-national-mental-health-planDate: 2017Date accessed: May 21, 2018Google Scholar estimate 100% coverage only for those with the most severe disorders, 80% coverage for moderately severe disorders, and 50% coverage for mildly severe disorders, generating smaller workforce estimates. Other commentators have also noted the short-fall in the skilled workforce to address the need in clinical service delivery in the context of escalating demand for services.13Perera J Wand T Bein KJ et al.Presentations to NSW emergency departments with self-harm, suicidal ideation, or intentional poisoning, 2010–14.Med J Aust. 2018; 208: 348-353Crossref PubMed Scopus (80) Google Scholar, 14Thabrew H Henderson S Hazell P Moor S Kowalenko N Kenn F Is it time for child psychiatry to grow up?.Aust N Z J Psychiatry. 2017; 51: 971-973Crossref PubMed Scopus (6) Google Scholar The study3Segal L Guy S Leach M Groves A Turnbull C Furber G A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study.Lancet Public Health. 2018; 3: e296-e303Scopus (17) Google Scholar places greater emphasis than usual on the patient journey and clinicians' consensus to delineate clinical pathways and roles. Another approach in Australia, albeit in adults, has taken diagnosis as the cut-point and identified best-practice treatment from published guidelines.15Andrews G Collaborating Centre for Classification in Mental Health Tolkien II: a needs-based, costed, stepped-care model for mental health services: recommendations, executive summaries, clinical pathways, treatment flowcharts, costing structures. World Health Organization, Collaborating Centre for Classification in Mental Health, Sydney, NSW2006Google Scholar Segal and colleagues' case for downplaying practice guidelines in their model is contentious, but has some support in the literature on children and adolescents.16Williams R Hazell P Implementing guidance and guidelines for developing and delivering equitable child and adolescent mental health services.Curr Opin Psychiatry. 2009; 22: 339-344Crossref PubMed Scopus (5) Google Scholar As their findings are systematically derived, they will likely spark active debate, some controversy, and further research to inform workforce planning to adequately meet the needs of children and adolescents. It seems quite possible that meeting these needs will require a much greater investment in the workforce than previously considered. We declare no competing interests. A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods studyOur novel needs-based workforce model produced actionable estimates of the community workforce needed to address tertiary-level mental health needs in infants, children, adolescents, and their families in SA. A considerable expansion in the skilled workforce is needed to support young people facing current distress and associated family-based adversities. Because mental illness is implicated in so many burgeoning social ills, addressing this shortfall could have wide-ranging benefits. Full-Text PDF Open Access