Australian pre-school children are set to be screened for early signs of mental illness as part of an extension to the voluntary Government funded program, Healthy Kids Check. The Department of Health and Aging via it website say that the program aims to improve the health and well-being for Australian children by encouraging early detection of lifestyle risk factors and physical health issues, and facilitating early intervention strategies through the Healthy Kids Check Medicare items. This initiative aligns with the broader policy agenda of optimising outcomes for children through attention to health, learning and development.
The Australian Medical Association – AMA – currently supports the Federal Governments initiative to look for early signs of mental illness in three-year-old children. Though this hasn’t always been the case. In 2010, the then AMA President, Dr Andrew Pesce said via statement that the AMA supported the principle that parents should be given greater incentive to take personal responsibility for making sure that their children have a healthy start to life, but the Healthy Kids Check program was not the right way to achieve this outcome ::::
“The AMA agrees that it is important to ensure that the health of children is checked from an early age on an ongoing basis” Dr Pesce said. “GPs assess children each and every time they see them, looking at things such as growth, vision, hearing and language development, as an integral part of high quality general practice.” Dr Pesce said in 2010.
Dr Pesce went on to say that the Healthy Kids Check program had not been as successful as the Government hoped because it comes too late in a child’s development and is not based on the best practice guidelines for prevention that have been developed by the Royal Australian College of General Practitioners.
Healthy Kids Check is linked directly to the governments immunisation program, it is an extension of that program. The Health Departments web site outlines that the new mental health check should be delivered before or at the same time as the four year old immunisation in order for parents to receive the Medicare rebate. The site says if your child has not already received this immunisation, you should arrange for them to have one through your family medical practice or immunisation clinic.
The Australian government has essentially modularised the Healthy Kids Check program, adding in mental health, to a program that includes disease prevention, oral and aural health checks.
Current AMA federal president Steve Hambleton, says he supports the initiative and says children who may have mental health problems usually start exhibiting symptoms when they turn three.
“Three year old children will be doing things at the end of their third year that are very different,” he said. ”We want to make sure that we select our children that have got real broad based problems not just individual things like fear of the dark or the fear of monsters and that sort of thing, which is normal for three year olds.”
But Dr Hambleton says it is important the process does not medicalise normal behaviour.
“Things that they are looking for are autism spectrum disorder which is a broad base multi area problem, behavioural sensory and communication issues, depression and anxiety,” r Hambleton said.
The Healthy Kids Check will be predominately conducted by GPs who will refer children with troubling behaviour to psychologists and paediatricians. The program will cost $11 million over five years and is expected to identify about 27,000 children who would benefit from extra support.
Dr Hambleton said that at the age of about three-and-a-half, some of these problem will show up that you can intervene with.
Federal Mental Health Minister Mark Butler says the first five years of a child’s life are vitally important to setting the foundations for school and adulthood.
“It will be voluntary for families and they’ll be able to go along to a GP and just check their child is tracking well in terms of his or her emotional and social well being,” he said.
“The expert panel is also putting together a map of services to consider on the advice of their GP.”
Child health and welfare specialist Gillian Calvert does not think children who are treated under the program will feel singled out and isolated.
“I think if a child has such behavioural and emotional problems that they are going to get help and to get some services for some sort, then they already have a sense that they’re a little bit different,” she said. ”And what getting help does is help them deal with that sense of difference.”
She says the program should also focus on training GPs. ”I think there are always concerns about net-widening so it’s really important that we have good and ongoing training of the general practitioners,” she said.
However, one of the most influential psychiatrists in the United States says the Federal Government’s program to screen three-year-olds for mental health problems is “ridiculous” and potentially dangerous. Professor Allen Frances, an Emeritus Professor at the Duke University, has raised concerns about the scheme.
Professor Frances is highly critical of the latest edition of the manual and warns that if it is issued unamended it will “medicalise normality”
“My experience is that the hardest diagnoses in our field are in the youngest children,” he said. ”Kids have developmental changes that are dramatic in a very short period of time. So, I would be the most cautious in doing anything psychiatrically with very young children.
Professor Frances was the chairman of the American Psychiatric committee that produced the current edition of the Diagnostic and Statistical Manual of Mental Disorders, which psychiatrists around the world call their bible.
“Parallel to that, the most adventurous of all the diagnosticians in psychiatry, are the child psychiatrists.”
Psychiatrists supporting the program say early identification of mental illness is essential to properly treating it before it becomes extreme, but Professor Frances says that is not practical given the current knowledge base.
“There’s absolutely no evidence at all that we can predict accurately who will go on to have a mental disorder,” he said.
“There can be lots of unintended negative consequences to labelling children who essentially are normal and will grow out of whatever problem they have at that moment.
“I just got an email this morning from a mother in America whose child had been diagnosed as autistic. And the description in the report did not resemble her child at all.
“A label like ‘autism’ can be obviously devastating, but even less severe labels can have a dramatic effect on expectations, on the way the child feels about himself, his role in the family. I would be very cautious about labels, especially in young children, especially because they’re so likely to be wrong.”
Professor Frances says there are many individual differences between children, and, except in very clear-cut cases, diagnoses are likely to be wrong.
“It’s ridiculous to be doing it with three-year-olds,” he said. ”But even with older children you have to be very, very cautious in making diagnoses in children who are undergoing developmental challenges, and have different rates of growth.”
He says the biggest single problem in the field is the push to medicalise behaviour to ensure medical treatment is funded.
“I think that the first six sessions or so, first six visits with a physician or psychologist shouldn’t require a diagnosis,” he said. ”I think that requiring a diagnosis from the very start leads to over-diagnosis and that diagnostic inflation leads to way too much treatment.”
And he says although drugs can be very helpful for those who need them, they are unnecessary and, in some cases, dangerous for those who do not.
“There are all sorts of short-term side effects in terms of problems with sleep and eating,” Professor Frances said. ”Some of the kids are going to have problems that may be worsened by stimulant drugs and the long-term effects are largely unknown.”
Professor Frances is critical of the current edition of the Diagnostic and Statistical Manual of Mental Disorders and says the manual is expanding the boundaries of psychiatry at the expense of the shrinking realm of normal.
Professor Frances is calling for psychiatrists to relinquish their monopoly on defining disease in the manual.
“Psychiatric diagnosis is too important to be left with any small group or one profession, and policy decisions, in Australia for instance, for the whole country may be determined by what’s in the manual, or what’s not in the manual. I don’t think decisions this important should be made quickly or be made by just a small panel of experts. Experts are important in decision-making, but inherently have their own biases and their own pet ways of looking at things. I think you need a wider view, you need experts from the all the mental health disciplines. From health economics, from public policy and from primary care. The decisions shouldn’t be made based on the narrow conception of how this particular expert would treat his next patient.”
Earlier today, the Federal Mental Health Minister, Mark Butler, weighed into the discussion, announcing that he had concerns about possible over reactions to clinical experts advice post screening of children in the program. Mr Butler said there will always be the danger of misdiagnosis or overprescribing. But, says this is why experts have spent months getting the program precisely right.
“The experts who have been designing this tool have made it very clear that their overriding objective has been to do no harm, to provide a positive opportunity to families to take their children at that critical time of three years of age.” Mr Butler said. ”Obviously, we need to make sure through the advice of the clinical experts that it’s conducted in the best way possible and that there’s not an over reaction. I’m very confident that the people we have around the table designing this piece of work have that absolutely at the front of their mind.”