The association of child protection contact with mental health‐related hospitalisations of adolescents, and their costs

Mental health challenges during adolescence are a critical public health concern, especially among young people at particular risk. The study reported by Judd and colleagues1 in this issue of the MJA highlights the substantial mental health‐related hospitalisation burden among adolescents aged 12–17 years who have had contact with child protection services. In their whole‐of‐population descriptive study, including 175 115 South Australian adolescents born during 1991–1999, they found that 44.9% of mental health‐related hospitalisations were of young people with histories of child protection contact before the age of 11 years, despite only 15.5% of all adolescents having had such contact. Adolescents placed in out‐of‐home care as children were at particular risk. Strengths of the study include the use of comprehensive linked data; limitations include the non‐inclusion of private hospitals data and the underestimation of the overall mental health‐related burden by focusing solely on hospitalisations.1 The study by Judd and colleagues helps highlight the implications and cost to the health care system of mental health problems among people who had contact with child protection and the importance of developing strength and long term resilience.

The link between child maltreatment and mental health problems is well established,2,3 and the impact of multiple forms of child maltreatment has recently been described.4 Children who experience abuse and are removed from their families often struggle with mental health or behavioural challenges that make it harder to establish safe, secure, and trusting relationships, and they are at greater risk of mental health problems during adolescence, a key stage in emotional and social development. The trauma of abuse, combined with the instability of the child protection system, leads to complex mental health care needs.

The findings reported by Judd and her colleagues1 support the view that adolescents who have had child protection contact, especially those placed in out‐of‐home care, are more frequently hospitalised because of their mental health problems than other adolescents.5 In Australia, mental health care is divided between public and private systems, which leads to challenges and barriers with respect to access, waiting times, resources, and costs, further disadvantaging adolescents with histories of child protection contact.6 Differences between services make navigating the health system complex, and available services may not adequately meet the needs of young people, especially if the services are not trauma‐informed and culturally safe. The fragmentation of care between providers and sectors often leads to interruption of care and the loss of routine follow‐up that could help manage emerging health problems.7

The lack of timely and appropriate community‐based mental health care probably leads to more hospitalisations during mental health crises, placing a financial strain on the health care system. Mental health‐related hospitalisations cost billions of dollars each year,8 and particular risk groups, including people with child protection contact, account for substantial numbers of these hospitalisations. Investing in accessible, trauma‐informed community mental health care could improve outcomes for young people at risk,9 and help reduce the number of hospital admissions needed. Adolescents with untreated or poorly managed mental health problems are also at greater risk of other negative outcomes, including poor academic performance, substance misuse, aggression, and inadequate reproductive health, as well as deteriorating mental health.9 The societal costs, such as lost productivity and criminal justice costs, further exacerbate inequalities for this group.

Our focus should be targeted interventions that avert mental health crises in adolescents who have had contact with child protection. Not only is access to and engagement with trauma‐informed mental health care crucial, but also providing early targeted health services. Intervening at the point of first contact with health systems could reduce the risk of future mental health problems. Better models of mental health care for children who have contact with child protection services have long been recommended; a multidisciplinary framework for delivering integrated primary health, specialist, mental health, and wrap‐around services for young people is essential.7 Specialised, community‐based, multidisciplinary hubs are cost‐effective for both the economy and the health system in the long term.

We need to move from crisis‐driven support to prevention, including providing support even before children come into contact with protection services. Addressing the broader social determinants of mental health, such as poverty, family dysfunction, and housing instability, must be priorities.10 Adolescents in the child protection system often come from disadvantaged backgrounds, where multiple stressors contribute to poor mental health. Collaborative efforts by the health care, child protection, education, and justice systems are essential for providing holistic care that meets both their mental health care needs and the social challenges these young people face.

In conclusion, the findings of Judd and colleagues1 support those of other studies that point to a pressing need for reform in how we approach mental health care for adolescents who have been in contact with child protection services. By providing early, trauma‐informed interventions and addressing the social determinants of health, we can reduce the long term mental health burden and alleviate the financial strain on the health care system. Failing to act will only perpetuate the cycle of trauma, poor mental health, and escalating health care costs.