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 Proportion of children in state and in the bottom of CSE quintile (per cent) Child Social Exclusion Index < 15yo

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 ($), : 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 ($), : 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 In infancy: as stable and appropriate attachment figure

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 (Schore, 2000; Glover, 2011; Perry, 1995 )

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 Disorder- disinhibited; EEG- Low levels of activity; MRI small brain- reduced 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 20% of 0-18 population Our aims: 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 RISK DIAGNOSIS

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

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  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

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 Community