Transcript Conception to Community - Tasmanian Health Conference 2015

Conception to Community
Developing a Perinatal and Infant
Mental Health Service in Tasmania
Fiona Judd & Fiona Wagg
Tasmanian Health Conference July 2014
Tasmania : The Problem
High level of need
but limited economic base to fund services
• High rate of social disadvantage
(NATSEM, ANU, 2013; Kids Come First Update, 2013)
• Social gradient in health and mental health
(Stanley, Richardson, Prior 2005)
• Geographically dispersed population
• Limited resource base (West, Griffith Review, 2013)
NATSEM Data 2013
Poverty
Social Exclusion Index
NATSEM Data 2013
Child Social Exclusion Index < 15yo
Proportion of children in state and in the
bottom of CSE quintile (per cent)
Social Determinants of Physical and
Mental Health
• Socioeconomic gradients are increasing with
increasing gaps between advantaged and
disadvantaged groups in society. (Stanley et al, 2007)
• Health outcomes follow socioeconomic status:
obesity, diabetes, asthma;
developmental disability;
mental health problems
• Lowest 5% SES: only 13% of children problem free.
• Non disadvantaged upper 50% SES: 81% of children
problem free. (Christchurch Health & Development Study, 2009)
Tasmania: Teenage Pregnancy
Kids Come First, 2013
Tasmania: Children at Risk
Over last 10 years:
• 76% increase in child protection notifications
• Children < 5yo notifications more than doubled
• Most socially disadvantaged children 5x more likely to be
notified.
(Kids come first update, 2013)
National comparison:
• Lowest number of notifications investigated
• Highest number of notifications validated
• Number of children in out of home care doubled: 13/1000
• OOHC 30% higher than the national average. Highest rates in
Australia outside of indigenous communities. (AIHW 2014)
Limited Economic Resource Base
• Tasmania: 8.6% unemployment
c/f Australia 5.8%
• 1/3 of Tasmanians on Commonwealth
benefits;
• 1/3 of Tasmanians in public sector jobs
• 20% work for private corporations primarily
reliant on government contracts
• 10% in private enterprise with vested interest
in economic development (West, 2013)
CAMHS Funding by State
Per capita expenditure by states and territories on child and adolescent mental
health services ($), 2010-11: National Mental Health Report 2013
Perhaps funding is limited across
services?
General Adult MHS Funding by State
Per capita expenditure by states and territories on general adult mental health
services ($), 2010-11 : National Mental Health Report 2013
Child and Adolescent Mental
Health Services: Tasmania South
CAMHS staff
< 50% of benchmarks (MH-CCP 2010)
Children <18yo 25% of population
CAMHS budget 5% of MHS budget
No inpatient/day programme facilities
Perhaps adults have higher rates
of mental illness than children?
Of all mental illness
50% presents
before 12yo
75% by age 24
(WHO, 2003)
16% of 2-5yo have a
mental health problem
(Harvard Centre for Developing Child, 2006)
When should we intervene?
Intervention is most effective
when the brain
is most able to change
Neuroscience & Early intervention
• Conception to age two is the critical period in
brain development.
• Gene-environment interactions in utero and
during infancy shape the structure and
function of the brain.
• After age 2 capacity for change is limited.
• “Mother” is the environment for the infant.
• In utero: maternal nutrition, substance use,
mental illness and stress influence epigenetic
modification of gene expression
Brain development
Genes, Epigenetics
& Brain Development
• Epigenetics:
Experiences (nutrition, toxins, drugs, stress) leave a chemical
signature on the genes (methylation, histone modification)
changing how and when certain genes are turned on and off
without altering DNA in itself.
• Temporary epigenetic chemical modifications control
expression of most of our genes.
• However, certain experiences cause enduring epigenetic
modification in genes. This is true for genes playing key roles
in brain development and behaviour.
• Some epigenetic changes occurring in the foetus can be
heritable and passed on to later generations
Infant Development
• Infant’s environment is primary caregiver:
critical period for development of attachment
early maturation of socioemotional brain
• Secure attachment with an stable and appropriate
caregiver within first two years of life is necessary for
optimal neurodevelopment, health and well being
• Lack of a appropriate primary caregiver before age 2
leads to neurodevelopmental deficits and cognitive,
social and emotional disorders that later intervention
cannot remediate
• Toxic stress impacts on developing brain
Human Brain Development
- Synapse formation
Bucharest Early Intervention Project
• Romanian orphans <2yo.
• 3 groups: Never institutionalised
Removed to Foster Care
Remained in Institution
• Assessments: Physical growth; Cognitive function;
Language; Social/Emotional function; Attachment;
Behaviour; MRI; EEG
• Institutionalised children: growth retarded;
microcephalic; lower IQ (60-70); High rates of emotional
and behavioural problems; Language disorder; Poor
social/emotional skills: Reactive Attachment Disorderdisinhibited; EEG- Low levels of activity; MRI small brainreduced gray and white matter.
Bucharest Early Intervention Project
• Fostered Children: Improvements on most measures for those
fostered prior to age 2. Did not recover to be as Never
Institutionalised children. IQ 80 (normal 100). Persistent
problems with attention and executive functions. MRI showed
increased white but not grey matter. Earlier removal to foster
care lead to better outcomes.
• Those fostered after age two – almost indistinguishable from
Institutionalised group
• Child must be in safe, stable, appropriate attachment
relationship prior to age 2 to develop normally.
• Brain development is experience dependent and early
severe deprivation leads to smaller brain with fewer
neurones and fewer connections.
Impact of Abuse and Neglect
Perry, 2005
Adverse Child Events Study (ACE)
What are we doing?
Different rather than more…
PICAMHS:
Tasmania
South
Currently:
0-18yo population
10-15% have mental illness or disorder: 1ary &2ry services
CAMHS education, consultation, assessment
2-4% need direct CAMHS care
1% access CAMHS: 76% teenagers
Under 5yo
5% of CAMHS referrals
RISK
DIAGNOSIS
20% of 0-18 population
Our aims:
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•
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Consultation, collaboration, education and access across sectors.
Response to need not diagnosis.
Provision of service equitably to age groups: 20% <5yo.
Establishment of Perinatal and Infant Mental Health Service
The Conception to Community Initiative
Service Collaboration
Broader Role for Professionals
• Core only : “it’s not my concern”
• Core role plus referral: It’s a concern but refer
because it’s someone else’s job
• Other needs incidental but unavoidable:
“it’s not my core role but I have to do it”
• Other needs intrinsic part of my core role:
“it’s part and parcel of my job”
(Dorothy Scott, 1992)
Conception to Community : C2C
Vision
To develop an integrated perinatal and early
childhood mental health sector meeting the
needs of, and optimising the mental health
and well being of women, children and
families from conception to 5 years of age.
C2C: Working Groups
• Hospital based Services
• Community service pathways for co ordination
of care
• Education and training
• Communication Strategy
• Consumer and Carer Involvement
• Research Group
C2C: Hospital Services
• Women’s, Neonatal and Paediatric services,
PICAMHS, Adult MHS, Drug and Alcohol
• Federal funding for PICAMHS Registrar (STP) &
CNC
• Consultant Perinatal and Child Psychiatrists
from PICAMHS
• ATAAPS Psychologists
New referrals seen (per quarter) by PIMH
Team 2013-14
New Referrals seen (per quarter) PIMH team
2013/2014
Patient Characteristics
• Young parents, single parents, multiple
partners, multiple children
• Many disorders and adversities
• Transgenerational patterns of mental illness
and disadvantage
• Mediated by disorganised attachment: abuse,
neglect, trauma.
• Implications for therapeutic interventions
Disorganised Attachment
From all the measurements taken during
the first 6 years of life,
the strongest predictor
of psychopathology in adolescence (17.5 years)
was Disorganised Attachment,
measured at 12 and 18 months of age.
(Sroufe, Egeland, Carlson & Collins 2005)
5% of children in normal populations and
over 50% of children whose parents have severe
mental illness, alcohol and drug use or domestic
violence.
have Disorganised Attachment
This is a MAJOR PUBLIC HEALTH challenge
C2C: Education and Training
• Statewide training provided to approx 500 professionals:
o Maternity, Neonatal, Paediatric nursing, medical and allied health
staff
o Child Health and Parenting Nurses, Child Protection
o General Practitioners
o Perinatal and infant sector: education, NGOs, foster carers, early
childhood workers
o RHH Grand Rounds
• External training: Circle of Security, COPMI, NBO
• Conferences:
o TasHealth Conference October 2013; 2014
o Aracy/AAIMH Conference November 2013
o Post graduate nursing, allied health and medical education;
Undergraduate medical education
o UTas Perinatal and Infant Mental Health Unit
C2C: Research Group
• RHH Research Foundation Grant:
Collaboration with Menzies
Making it Count: establishment of the
Conception to Community public services
database
Making it Count: Growing Together.
• TEYF Grant:
Perinatal intervention for high-risk first time
mothers under 25yo.
The Future?
• Education & Training: across sector, shared understanding
• Good programmes operating across 1, 2, 3ry sectors
 cu@home; ECIS; Rehabilitation; LIL, Child and Family
Centres, TiK, EPAC; Good Beginnings, Family Support
• Structural changes to enhance collaboration. Across
services. Across levels of service. Financially. Statewide.
?Children’s Trust
• Policy changes to ensure all children protected in utero &
placed in secure attachment environment prior to age 2.
 Rights of the foetus/ Enhanced antenatal care options
 Primacy of welfare of the child
 Permanency planning
 Adoption/fostering. Therapeutic. ACF
The Future?
• Enhanced therapeutic capacity: infant/parent
Evidence-based models for effective therapies
Universal (NBO), Targeted () and Clinical (CoS)
Therapeutic interventions for those at highest
risk: Parenting with Feeling; Tulane
• Distribution of Resources:
 Equitably, across age range
In line with evidence-base: early intervention
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Community
• The foundations of a sense of community are created
in the attachments, bonds, sense of safety and
stimulus to growth, created in the first 3 years of life.
• Capacity building starts with creating the ability to
trust, love and share, grown in the relationships
between family members.
• Our most precious resource is emerging families.