Associations between ongoing COVID-19 lockdown and the financial and mental health experiences of Australian families.

In 2020, Australia's successful COVID-19 public health restrictions comprised a national "initial lockdown" (March-May) and "ongoing lockdown" (July-November) for metropolitan Victorian residents only. We evaluated associations between ongoing lockdown and family finances and mental health. In the June and September 2020 Royal Children's Hospital National Child Health Polls, caregivers of children in Victoria and New South Wales (NSW) reported the following: job/income loss; material deprivation (inability to pay for essential items); income poverty; mental health (Kessler-6); perceived impact on caregiver/child mental health; and caregiver/child coping. Data from caregivers (N = 1207/902) in June/September were analysed using difference-in-difference modelling (NSW provided the comparator). During Victoria's ongoing lockdown, job/income loss increased by 11% (95%CI: 3%-18%); Kessler-6 poor mental health by 6% (95%CI: -0.3%-12%) and perceived negative mental health impacts by 14% for caregivers (95%CI: 6%-23%) and 12% for children (95%CI: 4%-20%). Female (vs. male) caregivers, metropolitan (vs. regional/rural) families, and families with elementary school-aged children (vs. pre-/high-school) were the most affected. The ongoing lockdown was associated with negative experiences of mental health, employment and income, but not deprivation or poverty, likely because of government income supplements introduced early in the pandemic. Future lockdowns require planned responses to outbreaks and evidence-informed financial and mental health supports.

How long and how much? Wait times and costs for initial private child mental health appointments.

AIM: To determine: (i) wait times and out-of-pocket costs for children attending private specialists for initial mental health appointments; and (ii) whether these differed between specialists working in metropolitan versus rural areas and in low, medium and high socio-economic areas. METHODS: Prospective secret shopper study whereby a researcher posed as a parent seeking an appointment for her child with anxiety or attention-deficit/hyperactivity disorder. We contacted 317 private paediatrician, psychiatrist and psychologist practices in Victoria and South Australia between 12 March and 5 May 2019. RESULTS: One third (29.8%) of private practices were closed to new referrals. The average wait times for paediatricians, psychiatrists, and psychologists were 44, 41 and 34 days, respectively. Average out-of-pocket costs quoted were AU$120 for paediatricians, AU$176 for psychiatrists and AU$85 for psychologists. CONCLUSION: Parents face extensive wait times and substantial out-of-pocket costs when seeking private mental health services for their child.

Assessment and management of tic disorders and Tourette syndrome by Australian paediatricians.

AIM: The diagnosis and management of tic disorders and Tourette syndrome (TS) can be challenging. A better understanding of current approaches by paediatricians is important to inform research and education to improve patient outcomes. We aimed to investigate current assessment and management practices for tics/TS by Australian paediatricians. METHODS: An online survey was sent to members of the Australian Paediatric Research Network. Primary outcomes of interest included assessment processes, referrals, behavioural interventions and pharmacological management. Four scenarios were presented to elicit information regarding treatment of different types of cases. RESULTS: Of 340 eligible paediatricians, 139 (41%) responded, with 116 (84%) reporting that they diagnose and manage tics/TS as part of their practice. Questionnaires were used more to identify comorbidities (43%) than to quantify tics (12%). Referrals were most likely to be made to psychologists. Medication was considered important in the management of TS by 45% of respondents, with clonidine identified as the first-choice medication by 69%. There was wide variation in both the pharmacological and behavioural management strategies reported. CONCLUSIONS: There is substantial practice variation among Australian paediatricians in the assessment and management of patients referred with tics/TS. This may reflect insufficient evidence regarding best practice, as well as limited training in this area. There is a need for improved education of Australian paediatricians in the assessment and management of tics/TS, as well as further research to identify optimal treatments.

Trends in Prevalence and Management of Childhood Anxiety by Australian Pediatricians.

OBJECTIVE: Rising anxiety rates and equity of care are ongoing concerns. Through 2 pediatric practice audits conducted 5 years apart, we aimed to determine the change in 1) anxiety diagnoses; 2) associated comorbid diagnoses; 3) variance in management by location; and 4) child, family, and pediatrician predictors of management. METHODS: Members of the Australian Paediatric Research Network (APRN) were invited to participate in patient-level prospective national pediatric practice audits in 2008 and 2013. Pediatricians were asked to complete standardized forms for 100 consecutive patients or all patients seen over 2 weeks, whichever was completed first. Demographic data, diagnoses, medications, and referrals were collected. Logistic regressions were conducted, clustered at the pediatrician level. RESULTS: Of eligible APRN pediatricians in 2013 and 2008, 48% and 66% participated and contributed 7102 and 8345 consultations, respectively. Anxiety diagnoses increased over the 5-year period (4.4% vs 7.6%; P < .001), as did proportions with comorbid autism spectrum disorder (18.4% vs 29.5%; P < .001) and sleep problems (5.1% vs 9.5%; P = .02). There was an increase in the prescription of core anxiety medications, with prescription of selective serotonin reuptake inhibitors increasing from 2.0% to 27.7% (P = .01). Children were more likely to be referred to a psychologist if they were seen in metropolitan practices (odds ratio = 2.0; 95% confidence interval, 1.1-3.9; P = .03) or had learning difficulties (odds ratio = 2.1; 95% confidence interval, 1.1-3.9; P = .03). CONCLUSIONS: Prevalence of anxiety among children and adolescents attending pediatricians nearly doubled over the 5-year period. Children in regional and remote locations are less likely to be referred to psychological services, prompting concerns about inequity in access to care.

Health Care Costs Associated With Parent-Reported ADHD: A Longitudinal Australian Population-Based Study.

OBJECTIVE: To examine the health care costs associated with ADHD within a nationally representative sample of children. METHOD: Data were from Waves 1 to 3 (4-9 years) of the Longitudinal Study of Australian Children ( N = 4,983). ADHD was defined by previous diagnosis and a measure of ADHD symptoms (Strengths and Difficulties Questionnaire [SDQ]). Participant data were linked to administrative data on health care costs. Analyses controlled for demographic factors and internalizing and externalizing comorbidities. RESULTS: Costs associated with health care attendances and medications were higher for children with parent-reported ADHD at each age. Cost differences were highest at 8 to 9 years for both health care attendances and medications. Persistent symptoms were associated with higher costs ( p < .001). Excess population health care costs amounted to Aus$25 to Aus$30 million over 6 years, from 4 to 9 years of age. CONCLUSION: ADHD is associated with significant health care costs from early in life. Understanding the costs associated with ADHD is an important first step in helping to plan for service-system changes.

Assessment of children with learning and behavioural problems: comparison of a multidisciplinary and sole paediatrician model.

AIMS: This study aimed to compare multidisciplinary (MD) versus sole paediatrician (SP) assessment models for children with learning and/or behaviour difficulties. METHODS: Children aged 4-12 years referred for an MD or SP assessment of learning and/or behavioural concerns were invited to participate. At baseline, parents completed surveys assessing child behaviour (Strengths and Difficulties Questionnaire; SDQ) and quality of life (QoL) (Pediatric Quality of Life Inventory 4.0; PedsQL). Following the assessment, parents completed a survey evaluating their satisfaction with the assessment. Parents completed a survey at 3-4 months post-assessment assessing: (i) adherence to recommendations; (ii) perceived changes in child functioning; and (iii) child QoL and behaviour. RESULTS: The parents of 66 children (82% male) participated in the study. Parents reported satisfaction with both assessment models; however, parents in the MD group reported better understanding of their child's difficulties than the SP group (P = 0.03). Parents in the MD group were less likely to report that 'recommendations were useful and practical' compared with the SP group (P = 0.01). There was no significant change in child behaviour or QoL in either group from baseline to 3-4 months post-assessment. CONCLUSIONS: Parents attending both clinics were satisfied with the assessment process. MD assessment of children with suspected learning and/or behavioural concerns appears to have the additional benefit of helping families to better understand their child's difficulties. Fewer families attending MD clinics reported that recommendations were useful and practical compared with the SP model.

Current Australian pediatric practice in the assessment and treatment of ADHD.

OBJECTIVE: To study the characteristics of children diagnosed with attention-deficit/hyperactivity disorder (ADHD) in Australia, and the assessment and management practices of their pediatricians. METHODS: A 2-week practice audit was conducted in a large representative sample of Australian general/community pediatricians. Pediatricians completed an audit form for all patients seen. Demographic details, diagnoses, treatments, and referrals made were recorded for each consultation. RESULTS: A total of 199 pediatricians completed the audit (response rate 66%). There were 1528 consultations with patients with ADHD. Eighty percent of the subjects were male, and mean age at diagnosis was 9.1 years (range 3-19 years). Most patients (60%) had 1 or more comorbidity identified, although the reported rates of anxiety (8%) and oppositional defiant disorder (15%) were lower than expected. Patients with ADHD were more likely than patients with other diagnoses to be seen in private practice settings (76% vs. 65%; P < .001). Children with ADHD were referred to numerous services at diagnosis, most commonly psychology (32%). Stimulant medication or atomoxetine was prescribed for 40% at initial diagnosis and 80% at continuing consultation. Overall, methylphenidate was the most common medication prescribed (63%), with a minority prescribed dexamphetamine, atomoxetine, or clonidine. Eighteen percent were prescribed 2 or more medications. Medication prescription was predicted by age but not by gender or socioeconomic status. CONCLUSIONS: ADHD is the most frequent diagnosis seen by Australian pediatricians, with some patients being seen into early adult life. Comorbidities appear to be inconsistently identified, with some possibly underdiagnosed. Older children are more likely to be prescribed medication.

Unmet developmental, behavioral, and psychosocial needs in children attending pediatric outpatient clinics.

OBJECTIVE: In this study of children attending general pediatric hospital outpatient clinics, we aimed to examine the proportion of (1) children with developmental and behavioral concerns; (2) parents with mental health problems; and (3) families with less than adequate psychosocial resources. We were also interested in the extent to which pediatricians discussed these problems with parents. METHODS: This was a cross-sectional study of families with children aged 4 to 8 years attending pediatric outpatient clinics at the Royal Children's Hospital, Melbourne. The Strengths and Difficulties Questionnaire, Parents' Evaluation of Developmental Status, Kessler-6 Scale for Psychological Distress, and Family Resource Scale were administered postvisit to assess development and behavior, parental mental health, and psychosocial resources. Parents were asked whether these issues were discussed during the consultation. RESULTS: A total of 162 families participated. Behavioral concerns were identified in 26% of children and concerns about language and motor development in 24% and 11%, respectively. Only 39% of consultations included discussion about development and 46% about behavior. Almost two-thirds (64%) of families reported less than adequate psychosocial resources, yet fewer than 10% of consultations included discussion of this, and only 7% addressed parental mental health. Parental perception of reasons why concerns were not discussed included "not relevant" (47%) and "the doctor did not bring it up" (21%). Only 2% of parents "didn't want to discuss the concern." CONCLUSIONS: A high proportion of children and families attending pediatric outpatients have unidentified concerns in development and/or behavior, and parents have mental health or psychosocial issues; these concerns are often not discussed, and thus opportunities for timely intervention are missed.

Managing sleep problems in school aged children with ADHD: a pilot randomised controlled trial.

OBJECTIVE: To evaluate the feasibility and helpfulness of a behavioral sleep program for children with ADHD, and explore the impact of different program dosages on child and family outcomes. METHODS: Randomised trial comparing a brief (1 session, n=13) and extended (2-3 sessions, n=14) sleep program in children with ADHD (aged 5-14 years) and at least one behavioral sleep disorder (American Academy of Sleep Medicine Criteria). Outcomes included helpfulness and use of interventions, child sleep (parent-reported sleep problem; Child Sleep Habits Questionnaire), ADHD symptoms (ADHD IV Rating Scale), daily functioning (Daily Parent Rating of Evening and Morning Behavior), quality of life (Pediatric Quality of Life Inventory), and caregiver mental health (Depression Anxiety Stress Scales). RESULTS: Twenty-seven families (63% of those eligible) took part. Most parents would recommend the program to others (95%) and found the strategies helpful. Five months post-randomisation, 67% of parents in both groups reported that their child's sleep problems had resolved. Child quality of life, daily functioning, and parental anxiety also improved in the extended group only (Cohen's d: 0.39, 0.47 and 0.50, respectively). There was minimal change in ADHD symptom scores from baseline to 5 months in either group. CONCLUSIONS: A behavioral sleep intervention in children with ADHD is feasible to deliver and improves child sleep by parent report. The extended program resulted in greater improvements in child and caregiver outcomes.

The time and practice challenges of developmental-behavioral pediatrics: an Australian national study.

OBJECTIVE: : Developmental/behavioral diagnoses are common in pediatric practice but, until the impact on pediatricians of caring for these children is quantified, training and remuneration barriers are unlikely to be addressed. In a prospective audit of Australian office-based pediatricians, developmental-behavioral and medical consultations were examined regarding (1) consultation characteristics, (2) child and parent health, and (3) referrals and investigations ordered. METHODS: : In 2008, all 300 eligible members of the nationwide Australian Paediatric Research Network were invited to prospectively record standardized information for every consultation over 2 weeks or 100 consecutive patients, whichever came first. After coding all diagnoses, consultations were classified as developmental/behavioral, medical, or "mixed." These groups were compared using simple 3-group comparisons (Aims 1 and 2) and logistic regression (Aim 3). RESULTS: : One hundred ninety-nine (66%) pediatricians recorded 15,360 diagnoses for 8,335 consultations (34% developmental/behavioral, 48% medical, and 18% mixed). Compared with medical patients, developmental/behavioral patients were older, more likely to be male, and required on average ∼9 minutes more time per consultation; self-reported parent health was worse; and referrals were more common (odds ratio 2.2, 95% confidence interval 1.9 to 2.5; p < .0001), but investigations less common (odds ratio 0.4, 95% confidence interval 0.3 to 0.4; p < .0001). Child health was worst in the "mixed" group. CONCLUSION: : Developmental/behavioral consultations are common in pediatric office settings. They are time-consuming, often lead to referrals, and the worse health reported by their parents may pose additional challenges. Pediatric training and funding models must address these barriers if adequate and comprehensive care is to be accorded to these complex patients.

Children Attending Paediatricians Study: a national prospective audit of outpatient practice from the Australian Paediatric Research Network.

OBJECTIVE: To audit general paediatric outpatient practice in Australia, including consultation characteristics and management patterns, diagnoses, factors associated with diagnoses, and billing practices. DESIGN, SETTING AND PARTICIPANTS: In October-November 2008, members of the Australian Paediatric Research Network (APRN; a national network of paediatricians established to facilitate multisite secondary care research) were invited to prospectively complete brief standardised data collection forms for 100 consecutive patients or all patients during a 2-week period, whichever came first. MAIN OUTCOME MEASURES: Length of consultation and type of diagnoses made; proportions recorded as having medications, investigations or referral; odds ratios for factors associated with diagnoses; and proportions of Medicare items billed. RESULTS: Of 300 APRN members, 199 (66%) completed data forms for 8345 consultations in which 15 375 diagnoses were made (mean, 1.8 diagnoses per consultation); 46.0%, 30.9% and 22.8% of consultations involved 1, 2 and ≥ 3 diagnoses, respectively. New and review consultations lasted a mean of 41 (SD, 20) and 26 (SD, 15) minutes, respectively. The most common diagnoses were attention deficit hyperactivity disorder (18.3%), baby checks (9.1%), and learning difficulties (7.5%). Patients seen in 47.5% of consultations had medications (eg, prescriptions, vaccinations) recorded, and patients in 27.2% of consultations were referred elsewhere, usually to a subspecialist or psychologist (31.6% and 26.6% of referrals, respectively). Male sex of the child and owning a Health Care Card were associated with most developmental-behavioural diagnoses. Paediatricians tended to bill for single disease/non-complex consultations, even when seeing a child with multiple problems. CONCLUSIONS: Australian paediatricians see children with a range of diagnoses that are often multiple and complex. Our findings provide directions for future secondary care research, and may inform workforce planning and paediatricians' training requirements.

The diagnostic outcomes of children with suspected attention deficit hyperactivity disorder following multidisciplinary assessment.

AIM: To undertake a retrospective analysis of the patients referred with suspected attention deficit hyperactivity disorder (ADHD) to a multidisciplinary clinic at the Royal Children's Hospital, Melbourne between 2004 and 2007. This study aimed to determine the proportion of children diagnosed with ADHD, the frequency of comorbid diagnoses, and the level of functional impairment of referred children. METHODS: Data regarding the demographic characteristics, clinical features, assessment findings and suggested management of patients who attended the ADHD Assessment Clinic were reviewed. RESULTS: Sixty-four children (58 males, 6 females) aged between age 4 and 8 years 11 months (M = 6.84, SD = 1.24) were referred. 43 children (67%) were diagnosed with ADHD and 32 (74%) of these were diagnosed with at least one comorbid condition, most commonly, oppositional defiant disorder (ODD; 51%) and speech/language disorder (23%). Of the 21 children who were not diagnosed with ADHD, approximately one-third were diagnosed with ODD and one-third were diagnosed with a specific learning disorder. Overall, the children referred to the clinic had poor quality of life by caregiver report; however, this did not differ between children who were diagnosed with ADHD and children who were not. CONCLUSION: Comprehensive evaluation of children with suspected ADHD resulted in an alternative primary diagnosis in one-third of cases. Three-quarters of children diagnosed with ADHD had one or more comorbid diagnoses. A multidisciplinary model of assessment can be effective in identifying a range of problems in this patient group, and help to inform targeted interventions.

Information needs of parents of children with attention-deficit/hyperactivity disorder.

OBJECTIVE: To determine the information needs of parents of children with attention-deficit/hyperactivity disorder (ADHD). METHOD: A cross-sectional survey of parents recruited from pediatric hospital clinics, support groups, and newspaper advertisements in Victoria, Australia, was undertaken. Parents completed a questionnaire covering information sources accessed, the quality of this information, the information content they considered important and their preferred information modes. RESULTS: Survey data were collected from 99 parents. Parents most frequently accessed information from pediatricians (89%), books (78%), general practitioners (65%), and schools (61%). Pediatricians were rated highest as a useful, trusted, easy-to-understand, and up-to-date information source. Parents placed most importance on causes and symptoms at the time of diagnosis. Parents preferred to receive verbal information from a professional (69%). CONCLUSION: Information provision for parents of children with ADHD is a continuous process. Although they access a range of sources and modes, parents prefer verbal information delivery.

Developmental assessment of children: a survey of Australian and New Zealand paediatricians.

OBJECTIVES: To determine the current practice for developmental assessment of children by Australian and New Zealand paediatricians. To determine factors associated with higher levels of self-reported confidence and expertise in developmental paediatrics and factors associated with better practice. METHODS: A cross-sectional postal survey of Australian and New Zealand paediatricians conducted in 2003, enquiring about their training in developmental paediatrics and their practice for evaluating development. RESULTS: Of 811 questionnaires sent, 590 (73%) were returned. Ninety-one respondents indicated that they did not see children with developmental issues leaving 499 surveys for analysis. The overwhelming majority of paediatricians felt that more training was required in developmental paediatrics (88%) and that there was a need to be taught a formal developmental assessment tool (83%). Higher self-ratings of confidence and expertise in developmental paediatrics were associated with a period of formal developmental training (OR (95% CI) 2.7 (1.6-4.4), 3.4 (2.0-5.8), respectively), and being taught a formal developmental assessment tool (OR (95% CI) 2.0 (1.2-3.2), 2.2 (1.3-3.7), respectively). Predictors of paediatricians performing a formal developmental assessment included formal developmental training (OR (95% CI) 2.0 (1.1-3.8)) being taught an assessment tool (OR (95% CI) 2.8 (1.5-5.2)) and mandatory training (OR (95% CI) 2.4 (1.4-4.1)). CONCLUSIONS: Developmental paediatrics is a significant and important part of paediatric practice. This survey suggests, however, that paediatric training and continuing education should have not reflected this practice. The overall method and content of developmental training including whether formal assessment tools should be taught needs to be reviewed and revised.