Carers of Indigenous children: services and systems failure? Where to next?

We need solutions that adequately engage Indigenous carers in mental health care

In this issue of the MJA, Anna Williamson and colleagues report that 18% of a sample of primary carers of Indigenous children in urban New South Wales exhibit high or very high rates of psychological distress.1 This paper raises a number of questions. One in three carers reported that they or a relative had been removed from their primary carer as a child. This figure is astoundingly high, and leads us not only to wonder whether this rate of removal is similar in other populations in Australia, but also why the rate of psychological distress is not higher. Williamson and colleagues found no correlation between the carer having been removed themselves and currently high distress levels. We suggest that the small number involved (28, or 5% of the sample) affected the power of the analysis to detect a difference; the lack of association may reflect a psychological survival strategy of suppression, as has been found by research into the effects of childhood trauma.2

The reported high rates of distress in urban NSW carers of Aboriginal children prompts us to ponder the rates in other parts of Australia. Comparative data about parenting is sparse, with differing outcome measures and sample demographics used, but an Australian study found the rate of depressive symptoms in Indigenous mothers during the postnatal period was 12%.3 While acknowledging that this study employed a different measure (Edinburgh Postnatal Depression Scale) and targeted an earlier parenting stage, 12% is lower than the figure reported by Williamson and colleagues for their urban NSW sample. Very few studies have explored psychological distress in Indigenous communities; this must be rectified to ensure that appropriate services can be developed to support community needs.

The association between previous mental health treatment and high rates of psychological distress points to our need to find solutions that adequately engage Indigenous carers in mental health care, possibly over the longer term. Indigenous people make up only 3% of Australia’s population, but the number of community mental health occasions of service (2013–2014) was 3.3 times higher for Indigenous (1067 per 1000) than for non-Indigenous Australians (324 per 1000).4-6 This disproportionate use of services by Indigenous people should lead us to ask: why is our care in this area not better?

The average number of mental health visits per person per year was 5.8 in NSW, compared with almost twice this number (9.8 visits) for the rest of Australia.7 One could argue even 9.8 visits per year are unlikely to be adequate for an Indigenous client to develop the trust necessary for effective mental health support. The current approach of mental health services administering acute care, with a high turnover because of demand, does not support Indigenous clients and their families. With 40% of the population in this study affected by removal from family and carers, carers validly worry that children might be removed if they seek assistance with mental health from mainstream services.

Williamson and colleagues suggest funding Aboriginal Community Controlled Health Services (ACCHS) to improve mental health care within this culturally accepted system. There are currently over 150 ACCHS centres across the country; while they are a critical part of the solution, they will not bridge the need for care of acutely unwell patients, or for those geographically remote from such a service. We need to be more creative about how to engage Indigenous people in mainstream mental health services so that geographical shortfalls in ACCHS do not entail limitations to culturally appropriate medical care. Prioritising the mental health training of Aboriginal health workers and other clinicians in these services is an essential investment for improving Indigenous community trust in mental health services.

Mental health services need to be designed according to the specific needs of Indigenous families, including support for those who are suffering distress related to forced removal. Long term engagement with mental health support programs, both through ACCHS and mainstream services, is essential across life; Williamson and colleagues have highlighted the importance of parental mental health care for Aboriginal children. Funding mental health programs in the 87% of ACCHS centres not currently funded for this purpose is an important step for service delivery in the communities that have access to ACCHS.8

Further research should clarify the rates of psychological distress in Indigenous Australians in different contexts including during parenting and the perinatal period. In addition, research should examine the numbers of Indigenous Australians who experienced forced removal during childhood and the impact of the Stolen Generations, and investigate their psychological effects on a person’s ability to parent. Despite the good will of clinicians, current approaches to providing mental health services are not appropriately or effectively servicing the Indigenous, and major investment in training and the services of both ACCHS and mainstream services is a national priority.