AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
Anxiety, depression and early intervention in children and young
people: a collaborative rural and remote model.
Warren Bartik, Child and Adolescent Intervention Programs, New England Area Health
Service; Nick Kowalenko, Department of Child and Adolescent Psychiatry, Royal North Shore
Hospital; Kathy Whitefield, Department of Child and Adolescent Psychiatry, Royal North
Shore Hospital; Ann Wignall, Northern Sydney Area Mental Health.
Summary
Introduction
Aims
Method
Results
Conclusion
References
This project was funded by the Commonwealth Department of Health and Aged Care under the RHSET Project.
Mental health issues for young people, particularly anxiety and depression, are increasing in severity and frequency. Rural and remote health areas generally have limited specialist services to assess and manage young people with mental health problems and treatment and management is often shared across a number of other service providers.
The model described is a best practice collaboration between a metropolitan service
with specific skills and expertise in early intervention and treatment, and the New
England Health Service as a rural/remote area developing its child and adolescent mental
health service. This collaboration has worked to develop rural practitioner’s skills
through placement, training workshops and supervision with results indicating a resultant
increase in skills and competence to manage a range of intervention in child and
adolescent mental health.
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Whilst as many as one third of the Australian population live outside major centres and cities, the needs and special characteristics of rural health and mental health have often been overlooked (1). Of particular concern are the needs of children and adolescents who comprise approximately 25% of the NSW population and approximately 30% of the population of the New England area (2). Adolescence is a critical time in relation to mental health, with evidence suggesting mental disorders are increasing in both frequency and severity during these developmental years (3) and appearing at earlier ages (4).
The New England Area of NSW covers an area of 100 000 sq. klms with a population of 175 000 including a youth population of approximately 52 000. The New England area has the highest number of Aboriginal people of any health area in NSW (10 221) including a youth population of approximately 4800 (47%). Two regional cities, Armidale and Tamworth, account for 75 000 people with the remaining population broadly distributed across rural towns and small (<200 people) communities. Shared care between interagency workers and other allied health professionals is the adopted model for much of the area given the small number of child and adolescent mental health workers. Access to expert or specialist mental health clinicians (primarily Sydney or Brisbane) is limited and problematic due to transport, family upheaval and separation, interruption to school, work and financial constraints.
The challenge for rural and remote areas with limited specialist clinicians and services and the inevitable tyranny of distance, is how to identify young people with anxiety and depression and manage and treat their disorders, but also be able to implement effective early intervention strategies.
This paper describes a project funded by the Commonwealth Department of Health and
Family Services under its Rural Health Support Education and Training Program (RHSET) and
also reflects priorities under the Second National Mental Health Plan.
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The project aims to develop and sustain a rural service model targeting young people with anxiety and depression by building on and strengthening a rural-metropolitan partnership between Child and Adolescent Intervention Programs – Mental Health (CAIP) New England Health Service, and the Department of Child and Adolescent Psychiatry at Royal North Shore Hospital (RNSH), to provide training, supervision and clinical support for rural and remote mental health professionals. This is achieved through the development and piloting of a best practice rural professional staff support model. The resultant skilled health workers with access to outreach support, consultation and liaison aims to assist with high quality identification, prevention and management particularly of depression and anxiety, and increase the accessibility of services to young people in the New England Area.
The project comprised three main components:
- Placements providing intensive training and clinical experience for CAIP staff with North Sydney Area Health Service at RNSH
- Training workshops in the New England area for rural and remote health and other professionals in evidence-based early intervention initiatives and programs, and the prevention, identification and management of depression and anxiety
- Consultation for CAIP staff by child and adolescent mental health clinicians at RNSH utilising site visits, telehealth and telephone conferencing to support the implementation of early intervention initiatives
The project worked to make use of the existing infrastructures to ensure the success of the intervention. Training networks running in the area, supported by staff from Mental Health Prevention and Promotion, were used to promote and administratively manage the training workshops. Existing relationships with education staff (including District Guidance Officers and School Counsellors) were expanded to support conjoint training and develop service partnerships.
A public health approach was utilised and included:
- Using local media to publicize the project
- Linking the project to the Barraba Community Depression Project (an existing health promotion project)
- Linking with existing management structures in the area (specifically Education Department) to support collaborative Health & Education initiatives
- Encouraging collaboration between disciplines, geographical areas and health services
- Supporting the New England infrastructure to implement the innovative aspects of the
project by providing expertise, advice, support, education and training.
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Unique characteristics of rural mental health staff
Staff working in rural and remote mental health settings are faced by unique pressures and stresses. They are often isolated professionally and support is limited. Staff usually work in a ‘generalist’ model, requiring them to be competent in a wide range of activities from individual therapeutic interventions to group-based prevention work and office-based administration (6). Despite the wide range of therapeutic interventions required to be implemented by these staff, the vast majority rate themselves as being under skilled, particularly highlighting a lack of professional supervision and direction (7). This results in staff sometimes feeling unable to deal with common mental health problems (7) and this problem is compounded in rural areas that generally attract less experienced staff.
Meeting the education and support needs of rural mental health staff requires the use of innovative strategies (8) that focus on practical education, skill development and the practice of newly acquired skills in a supportive environment.
Child and adolescent mental health services in the New England area have been fairly recently established and have a specific early intervention focus. This reflects the developing population based public health approach to prevention and early intervention in mental health, but also recognizes resource limitations. This new approach to mental health service provision requires the need to not only train and support CAIP staff, but also to educate and inform other stakeholders about this area of intervention.
Depression in young people
Considerable clinical and epidemiological research supports the high prevalence of anxiety and depressive disorders in young people. However, depression and anxiety in young people is poorly recognised and under diagnosed, particularly in rural and remote areas. This is of particular concern with depression identified by the World Health Organisation (WHO) as the major health problem by the year 2010. Statistics identify the suicide rate for young rural males aged 15-19 as having increased four fold over the last 30 years and up to three-quarters of young people who die by suicide also suffer from depression (5).
Anxiety in young people if not diagnosed and treated can lead to severe debilitation. This can manifest itself in children and adolescents with poor school performance and often severe impairment of developmental milestones particularly those impacting on family and peer relationships. Young people, and particularly adolescents, with anxiety or depression, may adopt maladaptive coping strategies that result in further complicating the course of their illness.
The high prevalence of depression and depressive symptoms in young people is a major focus of concern. Up to 24% of young people will have suffered at least one episode of major depression by the age of 18 with first onset of depression commonly reported to be between 15-19 years of age (5). The opportunity to intervene early in adolescent depression is key strategy. Thus it is necessary for rural health and other workers to be able to recognise early warning signs and be able to implement early intervention strategies.
The project provided an ideal opportunity to train rural professionals in the delivery
and implementation of a program recently developed and trialled by RNS for early
intervention with depression. Adolescent Coping with Emotions (ACE) is an early
intervention, cognitive-behavioural program targeting 14-16 year olds that aims to improve
young people’s resilience by teaching effective coping strategies to help deal with
current problems and potential future difficulties. An innovative aspect of the program is
its implementation in schools with small groups of 6-10 students using group leaders from
education (school counsellors) and community adolescent mental health workers. The program
is being rigorously evaluated, using immediate pre, post and long-term follow-up testing.
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Anxiety in young people
Anxiety is often regarded as a passing complaint. However, this is not the case for a significant proportion of young people. Left untreated, childhood anxiety disorders become more chronic over time with social problems, poor problem solving, poor peer associations and related psychosocial difficulties (9). Research also indicates that anxious children are at risk to become depressed later in adolescence (10).
RNSH in conjunction with Macquarie University has developed a group-based intervention program for young people with anxiety disorders titled Fear Master. Limited rural access to the program is available via the Royal Far West Children’s Health Scheme to support a young person and their family to attend the anxiety clinic in Sydney. The project partnership has supported training in this program with the aim of local delivery of Fear Master in the New England.
Perinatal mental health
Perinatal mental health refers to the social and emotional wellbeing of women and their infants from conception until 24 months postpartum. This crucial life stage provides many opportunities for promoting mental health and fostering infant development. As women and their families frequently come into contact with primary health care providers at this time, an opportunity for effective early intervention is made available.
PPRAMH Training aims to help professionals:
- facilitate identification of mothers and families at risk of, or suffering from, perinatal mental health disturbances;
- ensure the most effective interventions are provided;
- promote perinatal mental health, enhance resilience and optimise the emotional and physical health of infants; and
- minimise the impact of perinatal mental health problems on families.
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CAIP staff attended clinical placements at Royal North Shore Hospital. Training workshops were then planned for delivery in the New England area utilising both RNSH specialists and local CAIP staff. The workshops focused on identification and management of depression and anxiety disorders in children and young people, specific skills development in Cognitive Behaviour Therapy and its application in group processes for indicated groups of young people, and other early intervention initiatives. CAIP staff, having attended clinical placements at RNSH and with specific interests (i.e. anxiety management) then became an area resource with additional clinical skills to help co-ordinate local training and offer support to other workers. Consultation and supervision sessions were established to support local clinicians. Evaluation frameworks were implemented for all stages of the project.
Clinical placements
Seven professionals from the New England Area Health Service attended four-day placements at the Department of Child and Adolescent Psychiatry RNSH. Participants were three psychologists, a registered nurse (employed as a project worker focusing on children of parents with a mental illness), an Aboriginal project officer, a social worker (employed as a youth counsellor) and a youth counsellor.
Placements provided clinical exposure and experience as well as opportunities to
network with city-based services and staff. Participants stated that they hoped the
placement would provide them with knowledge and skills about PTSD, anxiety, depression,
conduct disorder, anger management, grief and bereavement. They also hoped to improve
their skills in individual and group interventions through observation and participation,
particularly by having an opportunity to observe a variety of clinicians and clinical
settings. CAIP staff were also hoping to have opportunities to discuss individual cases,
and to network and personally visit relevant Sydney-based services.
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Training courses
To ensure appropriate training workshops with relevant staff, a steering committee was developed comprising key rural and metropolitan health personnel and stakeholders. Consultation networks were developed between key stakeholders to steer the implementation of the training and ensure that information about the training courses was efficiently distributed and made available to important rural health staff.
Ten days of professional training were conducted by RNSH staff consisting of:
- ACE
Two experienced ACE Leaders conducted the two-day ACE Group Leader Training Program. It addressed implementation and evaluation of the program, screening procedures for the inclusion of students and the core skills to run the program in rural areas. ACE training was run in two centres in the New England Health Area, Barraba and Inverell, and was attended by 45 staff, including 31 School Counsellors.
- Fear Master
Fear Master is a group based intervention program for children and young people with diagnosed anxiety disorders. The program is a family based group cognitive-behavioural intervention. The training workshop was run by two clinical psychologists and delivered in Tamworth to 20 participants.
- Promoting perinatal resilience and mental health (PPRAMH)
This training program was developed to enhance skills in mental health promotion, prevention and early intervention. This training facilitated identification of mothers and families at risk of, or suffering from, perinatal mental health disturbances. It aims to develop skills to minimise the impact of perinatal mental health problems on families. Training was conducted in Tamworth by a child psychiatrist from RNSH and Family Care Centre Director from Sydney. The workshop was attended by 22 participants.
- Post-traumatic stress, grief and bereavement
This one day training program focused on the effects of stress, grief and bereavement on young people and their mental health and coping. It covered types of trauma and trauma reactions as well as teenage grief reactions and the role of family therapy. A social worker and service director from RNSH conducted the training in Tamworth with 22 participants.
- Introduction to anxiety and depression in young people and basic Cognitive Behavioural Therapy (CBT) skills.
This one day workshop targeted more isolated generalist staff whose work brings them into contact with young people who may have depression and anxiety problems, but for whom there are extremely limited mental health service available. Training covered the prevalence, maintenance and prognosis of anxiety and depression together with an introduction to treatment techniques including CBT. The workshop was conducted in Moree for 14 participants comprising mental health workers, Education Department staff, counsellors from Aboriginal Medical Services, a psychologist from the Department of Community Services and other health and child health staff.
Consultation
On-going clinical supervision and out-reach support for CAIP staff and other rural
professionals was provided through on-site consultations and telehealth conferencing. Four
site visits were conducted by senior clinicians from RNSH. These provided the opportunity
for clinical case review, program discussion and support. Three consultation sessions have
been conducted using telehealth conferencing between Tamworth and RNSH. One of these
sessions was utilised for supervision with CAIP staff and school counsellors who had
delivered the ACE program in the area.
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Rural employees cited the following as the main problems they face working in rural areas:
- Limited resources50%
- Limited clinical supervision65%
- High caseloads50%
- Limited services to refer clients to65%
- Few professionals to consult with65%
- Limited funding for/access to professional development30%
- Isolation and lack of peer support30%
- Attitudes to mental health in small country towns15%
Things that would help support rural staff in their roles:
- More training opportunities80%
- More access to clinical supervision50%
- Links with other services50%
- More peer support15%
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Training programs
Following each of the 5 training programs, participants completed comprehensive evaluations to assess the overall quality of the training, the mode of delivery, style and presentation of the training, the content of the course and the relevance of the training to the rural working environment. Overall evaluations demonstrated that:
- 81% of participants agreed that the training met their expectations
- 87% agreed that appropriate information was presented
- 84% agreed that they had been taught skills that would be useful in their day to day practice
Suggestions for further training included infant mental health, counselling skills, case conferencing, child psychiatry, and early psychosis, working with children of mentally ill parents and children’s behaviour problems.
Specific changes to knowledge and skill levels as a result of each training course were
also assessed.
The theory and strategies related to cognitive therapy are a major focus of the ACE Group Leader Training. Following the training, 98% of participants reported that they had at least sufficient knowledge to apply the theory and strategies of cognitive therapy with support and guidance, whilst 65% stated they felt confident to apply their skills without assistance.
The ACE training program’s focus on Behaviour Therapy resulted in 95% of training participants reporting at least sufficient knowledge to apply their new behaviour therapy skills with guidance or supervision, and 66% reporting confidence to implement the strategies independently.
Overall, 91% of participants felt the training had improved their knowledge in relation
to the prevention of depression in young people to such an extent that they felt confident
in implementing their new knowledge and skills in identification of risk factors,
assessment and treatment of mood related disorders.
90% of participants felt they had gained sufficient knowledge and skills in CBT to implement the strategies either independently or with some supervision. 64% of participants felt able implement the strategies independently, with half of these feeling they would have sufficient skills in CBT to train others.
95% felt their knowledge in relation to identification and diagnosis of anxiety had
increased to such an extent that they had sufficient knowledge to apply the information to
their work (30% felt they required more supervision or guidance).
Participants’ knowledge about the symptoms of perinatal mood disorders was dramatically increased. 60% of participants felt they had sufficient knowledge to implement assessments without guidance and 66% felt able to assess risk factors without support (compared to 14% at pre-intervention for both).
72% of participants felt that the training had provided them with sufficient knowledge
and skills to make use of the Edinburgh Postnatal Depression Scale as a screening tool and
77% felt able to reliably assess the safety of mothers and their babies (compared to only
14% at pre-intervention).
More than half of the participants reported feeling capable of implementing at least some of the strategies introduced during the course if some guidance was available. 65% of participants felt confident to implement the concepts of critical incident management without support. 91% felt they had at least a working knowledge of trauma reactions and 81% reported satisfactory understanding of prevention and intervention strategies useful for managing trauma in children and adolescents. 90% of participants reported feeling capable of implementing the basic strategies of bereavement counselling either with supervision or independently and 89% felt they had at least satisfactory knowledge of the issues and signs of teenage grief.
- Introduction to anxiety and depression.
50% of participants reported they had sufficient knowledge of anxiety and depression and would be able to implement basic intervention strategies. Although 25% of participants did report greater confidence in working with young people with anxiety and depression, they reported that the limited access to other professional staff would continue to have an impact on the extent to which they might apply their new skills.
Clinical placements
Placements were identified by CAIP staff as an excellent resource both in developing individual skills and for networking. Staff relished the opportunity to observe other clinicians and to participate in the range of intervention programs that were on offer at RNSH. Opportunities to visit centres that are rare in rural areas, such as an Aboriginal Health Centre, were identified as being particularly valuable. Two participants stated they would have liked more time to observe clinical interviews, assessments and interventions.
Staff reported that they felt considerably more confident, particularly in relation to working with children and young people, and that the clinicians they observed were happy to spend time talking and discussing issues. A strong rapport has been built up between metropolitan RNSH clinicians and CAIP staff and this facilitates phone case discussion and support on an informal needs basis.
100% of participants agreed that the placement met their expectations and their
individual aims. 60% of participants commented that they would appreciate more training,
particularly in anxiety management and group programs.
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This project set out to provide a best practice model based on a collaborative partnership between a rural and metropolitan service. The aim was to draw on the clinical and professional expertise of RNSH as a metropolitan service with specialist skills and programs in the area of early intervention, anxiety and depression in young people and then help foster and support delivery of skills and programs in the New England as a rural and remote area.
Results from the evaluation framework have been extremely positive with rural professionals reporting greater work satisfaction, an increase in their skill levels and increased opportunities for clinical and professional support. This partnership has resulted in specific outcomes for the CAIP service in New England enabling it to implement the ACE program in four schools in the area as well as enhanced anxiety management through increased skills resulting from Fear Master training. Skills developed have particularly supported the early intervention approach of CAIP.
The project has also worked to ensure networks have been developed and sustained within the New England region so as to maximise outcomes for the project and offer ongoing effective interventions for young people. This co-ordinated approach has developed and maintained partnerships, particularly those between education and health at all levels.
Rural staff exposed to clinical placements and training workshops have all detailed greater confidence in their ability to offer interventions in the area of anxiety and depression in young people. The ongoing opportunities for clinical support and liaison have also been invaluable to support those rural clinicians in the delivery of their services.
This collaborative project is an example of a best practice model with the capacity to
assist development of rural and remote child and adolescent mental health services and
workers to better offer services for young people with anxiety and depression. It is a
replicable model with practical considerations that supports the orientation of rural
services to an early intervention focus in keeping with the current policy directions in
child and adolescent mental health.
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