Crying shame

A chronic shortage of child and adolescent psychiatrists is leaving vulnerable children and young people without necessary treatment

In south-west Sydney, a specially designed house is home to six young people. The boys and girls aren’t family, except in the sense of a shared history of complex and enduring abuse and oblivion-seeking drug-taking, self-harm and often prostitution. They are as young as 12 years old.

Sherwood House is surrounded by garden, but is a secure facility, meaning none of the six can leave of their own free will. But Sherwood isn’t a juvenile justice facility.

It is a therapeutic care centre belonging to the New South Wales Department of Family and Community Services in partnership with the federal Department of Health, and is one of a small but growing collection of similar secure homes around the country.

These “homes” provide care and treatment for children and young people caught at the pointy end of today’s severely overstretched youth mental health services.

Increasingly, the evidence shows that such young victims of abuse may be helped and kept out of such facilities by the earliest possible intervention, with a combination of primary care and psychiatric treatment for post-traumatic stress disorder (PTSD) from as young as 3 years old.

But while child and adolescent psychiatrists (CAPs) are now identifying the need, chronic workforce shortages in child psychiatry and inadequate resources appear to be getting in the way of effecting even the small differences that may be of great benefit.

Those who have been working in the field for many decades say that the situation is worse than ever before and is still deteriorating.

This is occurring at a time when, in NSW, there is now only one juvenile mental health bed per 500 severely and enduringly mentally ill young people.

And with roughly 10 000 babies being born in the state each year, there are as few as five new graduates with training in advanced child and adolescent psychiatry entering the workforce.

It has compelled those working in the field — not only in psychiatry, but also in primary care and allied health — to have powerful informal systems in place so as not to be overwhelmed by the community’s need.

“Child psychiatrists have erected large triage walls around them to survive but see an increasingly troubled population”, Dr Kenneth Nunn, a senior child psychiatrist at the Children’s Hospital at Westmead, Sydney, who has worked closely with those at Sherwood House, tells the MJA.

Dr Nunn is the chair of the NSW Branch of the Royal Australian and New Zealand College of Psychiatry’s (RANZCP) Faculty of Child and Adolescent Psychiatry and says the crisis has been brought about by a combination of lack of planning, ongoing workforce shortages and poor resource allocation.

The system is at the point of being overwhelmed, he says, and in August outlined the problems facing child and adolescent psychiatry in NSW to the Minister for Health Jillian Skinner and the NSW Mental Health Commissioner John Feneley. The Minister is yet to reply.

While there is gross underservicing in NSW, and similarly in Victoria, Dr Nunn’s national counterpart at the RANZCP, Dr Nick Kowalenko, says that in the Northern Territory, Western Australia and Queensland the shortage is even more acute.

In late 2012, Health Workforce Australia (HWA) identified psychiatry in general as a red flag area for potential workforce shortages in its forecasts up until 2025.

Child and adolescent psychiatry wasn’t mentioned as a subspecialty within the report but such specialists make up about 10% of the psychiatric workforce.

According to HWA figures, that workforce had dropped from 2981 in 2009 to 2586 in 2011.

A 2010 RANZCP planning report for infant, child and adolescent mental health explicitly identified recruitment and workforce shortages as major problems for the field.

The consequences of the shortage have been hinted at in the only epidemiological study of child and adolescent mental health yet done, which was completed at the turn of the millennium.

It found that 14% of 6 to 16-year-olds had mental health problems but less than a quarter of those were receiving treatment.

The consequences can be severe

Earlier this year in a submission to the NSW Supreme Court in support of Sherwood, Dr Nunn pointed to the example of the recently convicted murderer, Daniel Stani-Reginald, as a possible outcome of inadequate care.

Despite the self-evident traumatic experience of having had his father kill his mother, and subsequent social impairment and a clearly altered personal function, Stani-Reginald had not met the psychiatric criteria for illness or intervention at that time and intensive inpatient treatment had not been available during his critical teenage years.

“When you have a shortage like this, what happens is that child psychiatrists then only do the pointy end of the work, which means a lot of work that child psychiatrists are so good at doing, doesn’t actually happen”, Dr Magella Lajoie, director of training in child and adolescent psychiatry at the NSW Institute of Psychiatry, tells the MJA.

But Dr Lajoie is enthusiastic about the rewards for those working in the field and says evidence of the need for and benefits of early intervention for children with mental health problems is rapidly building.

“The most exciting advances in psychiatry during the past decade have been in neuropsychiatry and the evidence of the effects of trauma”, she says.

“This means that for a lot of the illnesses now appearing in adolescents and adults there is much clearer evidence that they have a root in childhood or even the mother, before the child was born. It is negating the nurture versus nature argument. There is no distinction between nature and nurture. It’s an intricate web.”

The training process for psychiatry, including subspecialties such as child and adolescent psychiatry, was changed by the RANZCP this year so that the fellowship can now be achieved in 5 years, rather than the previous 6-year training requirement.

Drs Lajoie, Bowden, Kowalenko and Nunn hope that the shorter training period will encourage more medical graduates to consider specialising in the field.

Australia is not alone in struggling with this problem. There are similar shortages of child and adolescent psychiatrists in much of the developed world.

Recent research in the United States and Europe suggests that introducing students and graduates to the subspecialty and its research and results is effective in building numbers, and also in building expertise in those working in related fields such as paediatrics.

The latter is particularly valuable at a time when research by the Australian Paediatric Research Network shows that a significant amount of paediatricians’ clinical time is now devoted to children with mental health and behavioural issues.

Dr Lajoie’s colleague at the Institute and former chair of the NSW Faculty, Dr Michael Bowden, says the challenges of the field are also the sources of its greatest satisfaction.

“When you’re working with children, they’re always part of a larger system — not only the family, but the peer group, education and so on. You have to think about groups and interactions within groups, which makes it very complex”, he says.

“Those of us working in child psychiatry, we love that kind of complexity and that you do get to work in teams.”

To that end, the recent changes to Medicare, opening it to psychological and other allied health treatments, have also made it much easier to build teams to work with troubled young people in the private sector.

Looking ahead, Dr Kowalenko says that the need for psychiatric expertise in children is only likely to increase with what he predicts will be a second wave of intervention — following on from the work of Professor Patrick McGorry in the adolescent and young adult realm.

“There’s been an explosion in the recognition of child and adolescent mental health problems — part of that has been the recognition of youth problems. And the second wave of early intervention, which is going to be about younger kids, those under 8 years, hasn’t really even started yet.”

All the research is pointing to the importance of providing early and ongoing help for children subject to abuse and other forms of trauma in the hope of avoiding incarceration in facilities such as Sherwood.

“It’s only just beginning to be recognised that children who have been abused probably have PTSD and it needs to be specifically treated”, Dr Kowalenko says. “Once you leave it too long, you’re in this horrible situation where you create the fairly chronic problems.”

Dr Nunn is nearing retirement after a career that has included leading the Department of Child Psychiatry at both the Children’s Hospital at Westmead and St Thomas’s in London, as well as stints with Justice Health in NSW and as Professor of Psychiatry at the University of Newcastle.

He says that, ultimately, amid such limited resources, Sherwood becomes a place of real hope for kids who have lost everything.

“I cannot tell you the joy of seeing the kids in there. Can you believe that such lives could be rebuilt?”