Supporting children's mental health in primary schools: a qualitative exploration of educator perspectives.

Schools are often seen as a key setting for the provision of mental health support for children. This study aimed to explore the professional perspectives of primary school educators in Victoria, Australia, regarding how schools can support the mental health of their students. Semi-structured interviews and focus groups were conducted with 17 primary school educators, from four schools. Thematic analysis was used to generate themes from the data. This study indicates that educators report significant concerns about the complexities of their role and their capacity to support children's mental health due to a lack of resources, overwhelming demands, and inadequate training. Educators highlighted the importance of partnership and communication with families and of a school culture that prioritises mental health. This study provides insights into external factors that can undermine effective support of children's mental health within primary schools and indicates a need for a more integrated approach to supporting children's mental health across education and healthcare.

Barriers and enablers faced by regional and rural schools in supporting student mental health: A mixed-methods systematic review.

BACKGROUND: Australian policy reports recommended schools to be leveraged to better support student mental health, with a focus on regional and rural areas where students have poorer mental health outcomes. In designing solutions to address this systemic gap, decision-makers require an understanding of the barriers and facilitators experienced by regional and rural schools. However, current literature has focused on metropolitan schools and neglected to explore facilitators. OBJECTIVE: To review the evidence on barriers and facilitators in delivering student mental health support experienced by regional and rural schools in Organisation for Economic Co-operation and Development nations. DESIGN: A mixed-methods systematic review of peer-reviewed and grey literature. FINDINGS: The search identified 4819 studies. A full-text review by 2 reviewers resulted in 5 papers, which met the inclusion criteria and were assessed using methodological appraisal. One study used qualitative data, 2 studies used quantitative data, and 2 studies were a mixed-methods design. DISCUSSION: While there was a paucity of studies, this review draws together the most up-to-date research. The barriers and facilitators were categorised into 3 themes: access to services and resources; mental health literacy of staff and parents; and communication and collaboration between stakeholders. CONCLUSION: This review presents a comprehensive synthesis of the literature and highlights opportunities to leverage rural and regional schools to support student mental health, focusing on the quality of communication and collaboration, and increasing access to services and resources, and mental health literacy. Research should explore the unique advantages of rural and regional areas to inform policy, including a focus on strengths.

Adaptation of the Ages and Stages Questionnaire for Remote Aboriginal Australia.

A key challenge to providing quality developmental care in remote Aboriginal primary health care (PHC) centers has been the absence of culturally appropriate developmental screening instruments. This study focused on the cross-cultural adaptation of the Ages and Stages Questionnaires, 3rd edition (ASQ-3), with careful attention to language and culture. We aimed to adapt the ASQ-3 for use with remote dwelling Australian Aboriginal children, and to investigate the cultural appropriateness and feasibility of the adapted ASQ-3 for use in this context. We undertook a qualitative study in two remote Australian Aboriginal communities, using a six-step collaborative adaptation process. Aboriginal Health Workers (AHWs) were trained to use the adapted ASQ-3, and follow-up interviews examined participants' views of the cultural acceptability and usefulness of the adapted instrument. The adapted ASQ-3 was found to have high face validity and to be culturally acceptable and relevant to parents, AHWs, and early childhood development experts.

Challenges in monitoring the development of young children in remote Aboriginal health services: clinical audit findings and recommendations for improving practice.

INTRODUCTION: Early detection of developmental difficulties is universally considered a necessary public health measure, with routine developmental monitoring an important function of primary healthcare services. This study aimed to describe the developmental monitoring practice in two remote Australian Aboriginal primary healthcare services and to identify gaps in the delivery of developmental monitoring services. METHODS: A cross-sectional baseline medical record audit of all resident children aged less than 5 years in two remote Aboriginal health centres in the Northern Territory (NT) in Australia was undertaken between December 2010 and November 2011. RESULTS: A total of 151 medical records were audited, 80 in Community A and 71 in Community B. Developmental checks were more likely among children who attended services more regularly. In Community A, 63 (79%) medical records had some evidence of a developmental check and in Community B there were 42 (59%) medical records with such evidence. However, there was little indication of how assessments were undertaken: only one record noted the use of a formal developmental screening measure. In Community A, 16 (16%) records documented parent report and 20 (20%) documented staff observations, while in Community B, the numbers were 2 (3%) and 11 (19%), respectively. The overall recorded prevalence of developmental difficulties was 21% in Community A and 6% in Community B. CONCLUSIONS: This is the first study to describe the quality of developmental monitoring practice in remote Australian Aboriginal health services. The audit findings suggest the need for a systems-wide approach to the delivery and recording of developmental monitoring services. This will require routine training of remote Aboriginal health workers and remote area nurses in developmental monitoring practice including the use of a culturally appropriate, structured developmental screening measure.

Primary health-care costs associated with special health care needs up to age 7 years: Australian population-based study.

AIM: We studied infants and children with and without special health care needs (SHCN) during the first 8 years of life to compare the (i) types and costs to the government's Medicare system of non-hospital health-care services and prescription medication in each year and (ii) cumulative costs according to persistence of SHCN. METHODS: Data from the first two biennial waves of the nationally representative Longitudinal Study of Australian Children, comprising two independent cohorts recruited in 2004, at ages 0-1 (n = 5107) and 4-5 (n = 4983) years. Exposure condition: parent-reported Children with Special Health Care Needs Screener at both waves, spanning ages 0-7 years. OUTCOME MEASURE: Federal Government Medicare expenditure, via data linkage to the Medicare database, on non-hospital health-care attendances and prescriptions from birth to 8 years. RESULTS: At both waves and in both cohorts, >92% of children had complete SHCN and Medicare data. The proportion of children with SHCN increased from 6.1% at age 0-1 years to 15.0% at age 6-7 years. Their additional Medicare costs ranged from $491 per child at 6-7 years to $1202 at 0-1 year. This equates to an additional $161.8 million annual cost or 0.8% of federal funding for non-hospital-based health care. In both cohorts, costs were highest for children with persistent SHCNs. CONCLUSIONS: SHCNs incur substantial non-hospital costs to Medicare, and no doubt other sources of care, from early childhood. This suggests that economic evaluations of early prevention and intervention services for SHCNs should consider impacts on not only the child and family but also the health-care system.

Struggling at school - a practical approach to the child who is not coping.

BACKGROUND: Children struggling at school represent a very substantial segment of paediatric morbidity.1 Up to 20% of children have learning or behavioural problems that interfere with school functioning, which suggests this is a significant public health issue. There is evidence that persistent school problems can have a negative impact on a range of outcomes throughout the life course into adult OBJECTIVE: To provide an approach to the assessment of the child who presents with problems at school. DISCUSSION: The reasons for children's school problems are many and varied - there are a number of biological and environmental factors that can have a role. Sometimes the aetiology is clear but often it is obscure. A comprehensive assessment of these children is important and results in a management plan that addresses the child's strengths and weaknesses. The general practitioner can play an important part in the early identification of these children, as well as providing informed, ongoing follow up and advocacy.

It's time: a new era for paediatrics and child health in Australia.

The Australian College of Paediatrics (ACP) was established in 1978; part of the stated rationale was to 'acquire equal status to other colleges in medicine' ... and to become ... 'to which governments, or other organisations dealing with children, could officially turn to for advice'. After less than 2 decades, the ACP ceased to exist, and paediatricians became members of the Paediatrics and Child Health Division of the Royal Australasian College of Physicians (RACP). Many would now argue that the decision to dissolve the ACP and instead become a division within the RACP, though not taken lightly and made for what seemed at the time to be good reasons, might have been a mistake. While there have been some benefits, overall the public profile and national influence of paediatricians has been diminished. Paediatricians as a group have had little influence on policy formulation as it pertains to children and families, and the present administrative arrangements within the RACP raise considerable bureaucratic barriers for paediatricians to be able to contribute in a constructive and timely manner. It is suggested that paediatricians cannot be effective advocates for the health and wellbeing of children when they are but a relatively small and powerless group that resides within a large body of professionals whose primary interest is in various aspects of adult medicine. It is time that paediatricians (re)established their own college and controlled their own destiny. While such a step is not without its challenges, many would argue that it is an essential and timely step if we are to address our political and public health responsibilities.

Paediatrician's role in caring for children with learning difficulties.

AIM: Children with learning difficulties are commonly seen in Australian paediatric outpatient settings. The practice patterns of paediatricians in assessing, referring and managing these children are unknown, and there is no consensus on best practice. We thus aimed to examine the consistency between Australian paediatricians': (i) assessment; (ii) referral; and (iii) management of children presenting with learning difficulties. METHODS: All 373 paediatrician members of the Australian Paediatric Research Network were invited to participate in an online survey in 2010. Paediatricians who saw children with learning difficulties were asked questions about their assessment, referral and management practices. RESULTS: Of 181 (49%) paediatricians to complete the survey, 140 (77%) reported seeing patients with learning difficulties. Most often, paediatricians supplemented their clinical assessments with audiology assessments (75%), teacher or parent questionnaires (60-65%), or teacher contact (51%). Paediatricians used medical investigations (40%), direct assessment tools (27%) or a school visit (4%) less often. Most paediatricians referred children with learning difficulties to educational psychology (84%), special education (61%) or speech therapy (66%) services but less often to occupational therapy (34%) or mental health (15%) services. The most common management strategies were to provide a report to the school (76%) or parents (66%) and to make recommendations around sleep hygiene (75%) and for tutoring (66%). CONCLUSIONS: Australian paediatric practice in this area is diverse, with the greatest variability around management practices. These data provide a case for designing and implementing evidence-based guidelines for the paediatric care of children who struggle to learn in school.

A health-education intervention to improve outcomes for children with emotional and behavioural difficulties: protocol for a pilot cluster randomised controlled trial.

INTRODUCTION: One in seven (14%) children aged 4-17 years old meet criteria for a mental illness over a 12-month period. The majority of these children have difficulty accessing clinical assessment and treatment despite evidence demonstrating the importance of early intervention. Schools are increasingly recognised as universal platforms where children with mental health concerns could be identified and supported. However, educators have limited training or access to clinical support in this area. METHODS AND ANALYSIS: This study is a pilot cluster randomised controlled trial of a co-designed health and education model aiming to improve educator identification and support of children with emotional and behavioural difficulties. Twelve Victorian government primary schools representing a range of socio-educational communities will be recruited from metropolitan and rural regions, with half of the schools being randomly allocated to the intervention. Caregivers and educators of children in grades 1-3 will be invited to participate. The intervention is likely to involved regular case-based discussions and paediatric support. ETHICS AND DISSEMINATION: Informed consent will be obtained from each participating school, educator and caregiver. Participants are informed of their voluntary participation and ability to withdrawal at any time. Participant confidentiality will be maintained and data will be secured on a password protected, restricted access database on the Murdoch Children's Research Institute server. Results will be disseminated via peer-reviewed journals and conference presentations. Schools and caregivers will be provided with a report of the study outcomes and implications at the completion of the study. TRIAL REGISTRATION NUMBER: ACTRN12621000652875.

Role of Pediatricians, Pediatric Associations, and Academic Departments in Ensuring Optimal Early Childhood Development Globally: Position Paper of the International Pediatric Association.

ABSTRACT: Early childhood (birth-8 years), particularly the first 3 years, is the most critical time in development because of the highly sensitive developing brain. Providing appropriate developmental care (i.e., nurturing care, as defined by the World Health Organization [WHO]) during early childhood is key to ensuring a child's holistic development. Pediatricians are expected to play a critical role in supporting early childhood development (ECD) through providing developmental services such as developmental monitoring, anticipatory guidance, screening, and referral to medical and/or community-based services when delay is identified. Pediatricians are also expected to serve as advocates within their clinics and communities for improved delivery of ECD services, such as advocating for increasing funding for ECD initiatives, increasing insurance coverage of ECD services, and working to increase other pediatricians' awareness of the principles of ECD and how to deliver developmental services. However, this does not always occur. Typically, pediatricians' training and practice emphasizes treating disease rather than enhancing ECD. Pediatricians are further hindered by a lack of uniformity across nations in guidelines for developmental monitoring and screening. In this article, we present the vision of the International Pediatric Association (IPA) of the roles that pediatricians, academic departments, medical training programs, and pediatric associations should fulfill to help support ECD, including raising ECD to higher levels of priority in routine pediatric care. First, we present the challenges that face these goals in supporting ECD. We then propose, with supportive literature, strategies and resources to overcome these challenges in collaboration with local and international stakeholders, including the IPA, the WHO, UNICEF, and the World Bank.

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.

Is my child normal? Milestones and red flags for referral.

BACKGROUND: Developmental problems in young children are common and have lifelong implications for health and wellbeing. Early detection of developmental problems provides an opportunity for early intervention to shift a child's developmental trajectory and optimise their potential. OBJECTIVE: This article describes and recommends a broader concept of developmental surveillance that should replace the reliance on traditional methods of early detection such as milestone checklists, parent recall, developmental screening tests and clinical judgment. DISCUSSION: General practitioners and other professionals in regular contact with children and their families are ideally placed to monitor a child's development, detect problems early and to intervene to optimise the child's development and thus promote long term health and wellbeing. Developmental surveillance involves eliciting parental concerns, performing skilled observations of the child, and providing guidance on health and development issues that are relevant to the child's age and the parents' needs. Standardised tools are available to assist GPs to elicit parental concerns and guide clinical decision making.

It's time to eliminate the mismatch between pediatric training and practice.

The quality of pediatric clinical practice is dependent on the training received during residency. It is assumed that the content of the training will adequately prepare pediatricians for the sorts of problems and issues they will be asked to manage in community settings. While over the past several decades there have been major changes in pediatric morbidity, there is evidence that training and service delivery models have not evolved; there is a significant mismatch between training and evidence-based clinical practice. A recent paper published in this journal (1) drew attention to the inadequacy of pediatricians' training in child development. The reality of major gaps in the content and experiences of pediatric training in Israel are widely held, and there have been repeated calls for an increased focus on community child health and developmental and behavioural pediatrics. While it appears that finally there are some small initial steps to this end, it is strongly recommended that there be a long overdue, radical rethink of pediatric training programs.

Study protocol: the sleeping sound with attention-deficit/hyperactivity disorder project.

BACKGROUND: Up to 70% of children with Attention-Deficit/Hyperactivity Disorder (ADHD) experience sleep problems including difficulties initiating and maintaining sleep. Sleep problems in children with ADHD can result in poorer child functioning, impacting on school attendance, daily functioning and behaviour, as well as parental mental health and work attendance. The Sleeping Sound with ADHD trial aims to investigate the efficacy of a behavioural sleep program in treating sleep problems experienced by children with ADHD. We have demonstrated the feasibility and the acceptability of this treatment program in a pilot study. METHODS/DESIGN: This randomised controlled trial (RCT) is being conducted with 198 children (aged between 5 to 12 years) with ADHD and moderate to severe sleep problems. Children are recruited from public and private paediatric practices across the state of Victoria, Australia. Upon receiving informed written consent, families are randomised to receive either the behavioural sleep intervention or usual care. The intervention consists of two individual, face-to-face consultations and a follow-up phone call with a trained clinician (trainee consultant paediatrician or psychologist), focusing on the assessment and management of child sleep problems. The primary outcome is parent- and teacher-reported ADHD symptoms (ADHD Rating Scale IV). Secondary outcomes are child sleep (actigraphy and parent report), behaviour, daily functioning, school attendance and working memory, as well as parent mental health and work attendance. We are also assessing the impact of children's psychiatric comorbidity (measured using a structured diagnostic interview) on treatment outcome. DISCUSSION: To our knowledge, this is the first RCT of a behavioural intervention aiming to treat sleep problems in children with ADHD. If effective, this program will provide a feasible non-pharmacological and acceptable intervention improving child sleep and ADHD symptoms in this patient group. TRIAL REGISTRATION: Current Controlled Trials ISRCTN68819261. ISRCTN: ISRCTN68819261.

Early Minds: a pilot randomised controlled trial of a mindfulness program in early learning centres.

BACKGROUND: Optimal mental health is critical for a child's learning and academic functioning. As a universal service, early education centres play an important role in promoting children's mental health. Social-emotional learning programs are efficacious in reducing behavioural difficulties, enhancing competence, and improving learning abilities. Mindfulness practices, known to promote health and wellbeing in adults, have been adapted to education programs for younger populations, including pre-school children. Despite an increasing use of mindfulness-based programs in pre-school settings, there is a limited number of randomised trials and paucity of data on implementation fidelity of these programs. 'Early Minds' is a mindfulness-based program developed by Smiling Mind for 3-5-year-old children. This paper describes a protocol of a pilot randomised control trial, evaluating the implementation of the program in early learning centres (ELCs, i.e. pre-schools) in Melbourne, Australia. The primary aim of this pilot study is to examine the feasibility, acceptability, and fidelity of the program. The secondary aims are to assess the acceptability of the design and measures and to investigate preliminary impacts of the program on child social-emotional outcomes. METHODS: A convenience sample of six ELCs are recruited. Participants include educators, children, and their parents from 3- and/or 4-year-old ELC rooms. Upon completion of baseline surveys, rooms are randomly allocated to intervention and control arms by an independent statistician. 'Early Minds' is designed in a flexible delivery manner; meditations and activities are completed at least three times a week. Educators are trained in the program and have access to the activities and meditations on an app. Parents are encouraged to practice with their children at least three times a week. Educators document implementation fidelity throughout the 8 weeks of the program. Parents and educators complete follow-up surveys at 3 and 12 months post-randomisation, capturing feasibility and acceptability, child social-emotional behaviour and sleep, and educator, parent, and family wellbeing outcomes. DISCUSSION: This pilot study is the first to assess a mindfulness-based program in ELCs in Australia. Data on feasibility and acceptability, implementation fidelity, and potential impact on children's behaviour will inform the design of adequately powered evaluation trials. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry, ACTRN12618000435280. Date registered 26 March 2018.

Improving preventive and health promotion care for children.

The emerging science in early childhood development challenges past paradigms of health care. There is consideration within the profession of paediatrics, and health care more broadly, of how to make systems of care more responsive to the developmental and social needs of young children and their families. Some countries have physician-centric models, either general physicians or paediatricians, while others rely on nurses. There is increasing recognition that the goal of any model should be parent-professional partnership that puts families at the center, elicits and responds to family needs, anticipates and supports families with developmental transitions, and fits within a seamless system of services and supports.