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Journal of Paediatrics and Child Health 43 (2007) 101102 101

2007 The AuthorsJournal compilation 2007 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

doi:10.1111/j.1440-1754.2007.01025.x

Correspondence: Dr Peter Birleson, Child and Adolescent Mental Health

Service Administration, Upton House, PO Box 94, Box Hill, Vic. 3128,

Australia. Fax: +61 3 9895 4073; email: peter.birleson@easternhealth.

org.au

Accepted for publication 24 October 2006.

EDITORIAL COMMENT

Behavioural pediatrics and mental health programs:A case for integration?

their psychometrics.4 The SDQ performs well as a measure of

change and a screening tool in CAMHS, so Developmental

Behavioural Paediatric Clinics could consider using it for these

purposes.

Paediatricians have a strong interest in diagnosing and treat-

ing child and adolescent mental health problems, which they

see in considerable numbers. The paper makes the reasonable

claim that in a rational system of care, such as that described

by Raphael, general practitioners would treat mild problems

themselves and refer children with more severe and complex

disorders to secondary service providers, such as paediatricians

and psychologists.5 The most severe, complex and high risk

cases would be referred to CAMHS and other specialised mul-

tidisciplinary (tertiary) clinics in paediatric hospitals. An effec-

tive system of mental health care would also have clear

pathways of care agreed between providers, so that children

could be sent quickly to the right provider for the most appro-

priate level of help. The SDQ could be used as a tool here to

help determine problem severity and impact. Paediatric services

and CAMHS everywhere need to co-ordinate their services

more systematically, and could experiment with a range of

collaborative models for service provision to children who

present very complex problems, such as those with neuro-

behavioural problems or eating disorders.

The paper also makes helpful suggestions for improvingtraining for paediatricians. As psychological and behavioural

problems are such a large part of current childhood morbidity,

6-month attachments in mental health or developmental

behavioural settings seem barely adequate to equip registrars

with the skills they need. Unfortunately, the small numbers of

available registrar posts not occupied by psychiatry trainees

limits exposure to CAMHS clinics. Acute health, community

health and mental health service systems continue to operate

separately when it comes to planning the training of junior

doctors. It is time to change this with more integrated intersec-

toral planning by Health Departments. Current registrar posi-

tions only meet historical training needs, and increasing needs

for service means that additional mental health training posi-

tions are required for paediatricians, along with enhanced edu-

cation in the practice of psychological medicine. The National

Survey findings and those of the International Review of the

Second Mental Health Plan provides ample evidence that cur-

rent needs are not being met, and that mental health services

for children need expanding.6,7 Roongpraiwan and colleagues

are optimistic that a National Action Plan on Mental Health may

result in new services and better training possibilities.

There is no reason to be sanguine about this, and strong

lobbying is required to advocate for the needs of children at the

state level. The new Medicare funding will increase access

This study makes an important contribution to the literature by

using the Strengths and Difficulties Questionnaire (SDQ) in a

paediatric clinic population to measure morbidity. It is not sur-

prising that half the children and over 60% of adolescents

attending clinics for developmental and behaviour problems

were found have scores in the abnormal range by parental

rating. These patients were referred for disruptive behaviour,

anxiety problems and relationship difficulties, learning difficul-

ties, language and communication disorders, habit and sleep

disorders. Many of these problems are identical with those

presented to Child and Adolescent Mental Health Services

(CAMHS), and we know that chronic health problems, learning

problems and developmental weaknesses are potent risk factors

for psychiatric disorders.1 While CAMHS clients had higher

Emotional problem scores, and Behaviour Clinic clients had

higher Hyperactivity scores, there was considerable overlap in

total scores and impact scores, especially in older groups.

See related article by Roongpraiwan et al. on pp. 122126.

The SDQ is a useful instrument for several reasons. It is freely

available; has parent and self-rating versions; and provides a

rough guide to psychopathology. It can be downloaded from

several websites (http://www.sdqinfo.com/), and was chosen

under the Australian National Mental Health Strategy as theconsumer and parent report tool in the suite of routine outcome

measures now used in publicly funded CAMHS. Around the

time the SDQ was chosen, Mellor carried out a normative study

in Victoria on a representative sample of 910 children aged

between 7 and 17 years,2 and has published Australian popula-

tion norms for the SDQ, with ranges for the top 10% of abnor-

mal scores and 20% of borderline abnormal scores. The

Australian Mental Health Outcomes and Classification Network

(AMHOCN) plans to put these norms on its website, which

already provides SDQ data collected at admission, review and

discharge occasions from ambulatory and inpatient CAMHS.3 A

Decision Support Tool can be also be downloaded for service

providers to examine clients scores to determine their signifi-

cance. This has been available for the Health of the Nation

Outcome Scales this year and will shortly be offered for the

SDQ. In addition, the site also contains a review of all the

standardised outcome measures with useful information about
http://www.sdqinfo.com/http://www.sdqinfo.com/


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102 Journal of Paediatrics and Child Health 43 (2007) 101102

2007 The AuthorsJournal compilation 2007 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

Comparison of mental health symptoms P Birleson

nationally to private mental health services, but public mental

health services are a state responsibility, and the lions share of

funding here has historically gone to adults. Childrens mental

health services have been funded at a quarter of the per capita

rate received by adults.8 While the massive burden of disease

from mental disorders and the importance of need reduction

through early intervention are increasingly recognised, the

focus of adult mental health services remains on schizophrenia.This distracts from the fact that mental illness burden comes

largely from other disorders, which have their origins in child-

hood.9 US data show that 50% of all mental disorders have their

onset before the age of 14 years.10 UK data show that rates of

childhood mental disorders have been increasing over the past

25 years.11 However, funding bodies have not yet accepted that

a serious investment in prevention means expanding primary

and secondary mental health services for children to treat prob-

lems before these become entrenched. This is one area where

child psychiatrists and paediatricians can speak with one voice

better mental health services for children means less suffering

and fewer sick adults. This paper helps us see why we must

work together on this.

References

1 Meltzer H, Gatward R, Goodman R, Ford T. The Mental Health of

Children and Adolescents in Great Britain. London: Office for National

Statistics, Stationery Office, 1999.

2 Mellor D. Normative data for the Strengths and Difficulties

Questionnaire in Australia. Aust. Psychol. 2005; 40: 21522.

3 Australian Mental Health Outcomes and Classification Network. Child

and Adolescent National Outcomes and Casemix Collection Standard

Reports, 1st edn, Version 1.1. Brisbane: Australian Mental Health

Outcomes and Classification Network. Available from: http://

www.mhnocc.org/amhocn/ [accessed 18 December 2006].

4 Pirkis J, Burgess P, Kirk P, Dodson S, Coombs T. Review of Standardized

Measures Used in the National Outcomes and Casemix Collection

(NOCC). Australian Mental Health Outcomes and Classification Network,

2005. Available from: http://www.mhnocc.org/amhoch/[accessed 18

December 2006].

5 Raphael B.A Population Health Model for the Provision of Mental

Health Care. Canberra: Commonwealth of Australia, Ausinfo, 2000.

6 Sawyer MG, Arney FM, Baghurst PA et al.The Mental Health of

Young People in Australia: Child and Adolescent Component ofthe National Survey of Mental Health and Well-Being . Canberra:

Commonwealth Department of Health and Aged Care, Mental

Health Branch, 2000.

7 Thornicroft G, Betts VT. Findings from the International Review of the

Second National Mental Health Plan for Australia. Canberra: Mental

Health and Special Programs Branch. Department Health and Ageing,

2001.

8 Department of Health and Aged Care. National Mental Health Report

2000: 6th Annual Report: Changes in Australias Mental Health Services

Under the First National Mental Health Plan 19931998. Canberra:

Commonwealth Government, 2000.

9 Tolkein II Team. Tolkein II: A Needs-Based, Costed Stepped Care Model

for Mental Health Services. Sydney: WHO Collaborating Centre for

Classification in Mental Health, 2006.

10 Kessler RC, Berglund P, Demler O et al. Lifetime prevalence and age ofonset distributions of DSM IV disorders in the National Co-morbidity

Survey Replication.Arch. Gen. Psychiatry 2005; 62: 593602.

11 Collishaw S, Maughan B, Goodman R., Pickles A. Time trends in

adolescent mental health. J. Child Psychol. Psychiatry 2004; 45: 1350

62.

Dr Peter Birleson

Director, Eastern Health

CAMHS

Upton House

Box Hill

Victoria, Australia
http://www.mhnocc.org/amhoch/http://www.mhnocc.org/amhoch/


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