mental health services, mental health, Torres Strait Islander, mental health problems, Aboriginal and Torres Strait Islander, Aboriginal people, Aboriginal person, non-Aboriginal, Canberra, kinship relationships, extended family, John Daniels, emotional problems, mental health service delivery, Anna B Williamson, mental health professionals, mental health problem, service access, sense of identity, Aboriginal Australians, Aboriginal Medical Service, qualitative study, Aboriginal concepts, Tharawal Aboriginal Corporation, group interviews, focus groups, Sydney, New South Wales, Naomi Mayers, social issues, Identity issues, young person, Aboriginal parents, emotional wellbeing, Addiction Medicine Unit, Sydney, NSW, Sydney, Telethon Institute for Child Health Research, National Indigenous, Beverley Raphael, Steering Committee for Indigenous Health Equality, National Strategic Framework, University of Western Sydney, Anna Williamson, Aboriginal Medical Service Cooperative Limited, Western Australian Aboriginal Child Health Survey, Australian National University, Australian Health Ministers, School of Public Health and Community Medicine, Equal Opportunity Commission, Fellowship Grant, Australia, Child Health Group, Curtin University of Technology, Sally Redman, the National Health and Medical Research Council, parts of Australia, Director of Health Services, Dudgeon P. Indigenous, Australian Institute of Health and Welfare, Baker IDI Heart and Diabetes Institute, study participants
SOCIETY, CULTURE AND HEALTH -- RESEARCH
Emerging themes in Aboriginal child and adolescent mental health: findings from a qualitative study in Sydney, New South Wales
Anna B Williamson, Beverley Raphael, Sally Redman, John Daniels, Sandra J Eades and Naomi Mayers
Improving mental health and social and emotional wellbeing and access to mental Health Service
s are key goals of the National Indigenous Health Equality Targets.1 These goals are relevant for Aboriginal childrTenheaMndedaidcaolleJsocuernntasl (o"fyAouunstgraplieaoIpSlSe"N),: who a0r0e25d-i7sp29roXpo1r7tioMnaaytel2y01ex0p1o9s2ed10to 6r0is3kfactor6s0fo5r poor mental health, including the ongoi©ngThgeriMef eadnicdalloJossurcnaul soefdAbuystrcaolilaon20is1a0tion, wsowcwio.emcjoan.coommi.caudisadvantage and discriminSaotcioienty.2, CInudlteuerde,arnedseHarecahlthin--dicRaetesseatrhcaht Aboriginal young people are significantly more likely than their non-Aboriginal counterparts to meet criteria for emotional or behavioural problems2 and to commit suicide,3,4 but less likely to access mental health services.2 Aboriginal and non-Aboriginal concepts of mental health are different.5 For Aboriginal Australians, mental health is an inseparable part of spiritual, cultural and social wellbeing, with the wellbeing of the individual, family and community inextricably linked.6 However, surprisingly little is known about Aboriginal concepts of young people's mental health, the factors that influence it, or how Aboriginal people
perceive child and adolescent mental health services
. To provide some insight into these issues, we outline themes related to the mental health of Aboriginal young people that emerged from focus groups conducted in Sydney. METHODS We collected qualitative data between April 2008 and September 2009 at three Aboriginal community-controlled health organisations (ACCHOs) in Sydney: the Aboriginal Medical Service Western Sydney, Tharawal Aboriginal Corporation, and the Aboriginal Medical Service Co-operative Limited in Redfern. Key contacts within each service used purposive sampling to recruit Aboriginal parents (visiting the centre for any reason) and workers (particularly those whose work involved young people or mental health) of both sexes to participate in either focus groups or small group interviews, depending on the preference of each medical service.
ABSTRACT Objective: To explore emerging themes related to the mental health of Aboriginal children and adolescents ("young people") arising from focus groups conducted in Sydney, New South Wales. Design, setting and participants: A qualitative study was conducted between April 2008 and September 2009 in three Aboriginal community-controlled health organisations in Sydney. A semi-structured approach was used in focus groups and small group interviews to elicit the views of 15 Aboriginal parents and 32 Aboriginal workers from a variety of health and social work backgrounds on important factors surrounding the mental health of Aboriginal young people. Results: Major themes identified were the centrality of family and kinship relationships, the importance of identity, confounding factors in the mental health of Aboriginal young people, and issues related to service access and implementation. Conclusion: Clinicians working with Aboriginal young people should be mindful of the critical importance of family and identity issues and should assess possible physical health
or social factors that may complicate a diagnosis. Improvements in access to mental health services for Aboriginal families and a more holistic approach to mental health treatment are urgently required. MJA 2010; 192: 603605
A semi-structured approach was used to elicit participants' opinions regarding the characteristics of Aboriginal young people with good mental health and the factors associated with its development; signs that young people have mental health problems; what causes these problems; how these problems are or should be managed; and the role of services. Focus groups and interviews were of 1 to 2 hours' duration, with two to 10 participants in each group. Interviews were audiotaped and data were transcribed by a person with no personal or professional connection to the communities involved in the study. Audiotapes were securely transported and stored in locked filing cabinets. Transcribed data were coded independently by A B W using the constant comparative method. The analysis of discussion was thematic.7 This study was approved by the Board of each participating ACCHO and the Ethics Committee
s of the Aboriginal Health and Medical Research Council of New South Wales, the University of Sydney
and the University of New South Wales. All focus group and small group participants provided written informed consent before the commencement of the groups.
RESULTS Forty-seven people participated; 30 were women. Fifteen participants were parents and 32 were Aboriginal workers (30 of whom were also parents). The mental health of young people was considered by all to be a major issue. Several key themes emerged and were categorised as family and kinship relationships, identity, confounding factors, and issues surrounding service access and implementation. There was much commonality in the views expressed by workers and parents, with the exception that workers expressed more concern about service access and implementation. Family and kinship relationships The importance of extended family
and kinship relationships was mentioned throughout all interviews and emerged as the dominant theme. I think that is the main thing. That's where it all starts and that's where it all ends. Like, the whole social and emotional wellbeing, it's in the family. (Female worker) Strong family connections and support were seen as the foundation of good social
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and emotional wellbeing among Aboriginal young people, while family problems were thought to be the primary cause of most difficulties. Peer relationships were considered to play a role in the mental health of young people, but their significance was generally viewed as minor compared with that of family relationships. The importance of a young person's relationship to family was demonstrated by many participants stating that it would be impossible to accurately assess the mental health of an Aboriginal young person without observing his or her interaction with relatives. Identity Participants agreed that a strong sense of identity as an Aboriginal person is vital to the wellbeing of Aboriginal young people. Identity issues were seen to emerge at a very young age for some children, often undetected, and to become a major source of difficulty. Close contact with extended family was viewed as essential for developing a strong sense of identity. . . . kids don't have a sense of belonging or who they are . . . so when there are elders or other people in the community who can let them know where they've come from, that really helps them . . . (Father) Confounding factors Participants considered behaviours such as becoming withdrawn and misbehaving at home or school to be problematic, and thought that these behaviours were sometimes caused by physical or social issues. Concerns were raised about Aboriginal young people being incorrectly diagnosed with mental health problems due to underrecognition of such issues. . . . unless you were absolutely aware of Aboriginal culture, Aboriginal health, the whole history, socioeconomic conditions and so on, and if you just approached this strictly from a mental health or emotional social wellbeing [viewpoint] without taking all the other issues into account, you could make the wrong decision and therefore subject not only the child, but the parents and everybody, to needless hours of the wrong way of treating it. (Female worker) Hearing, speech or learning difficulties and hunger (eg, going to school without breakfast) were of particular concern with regard to apparent behavioural problems.
Apparent emotional problems were thought to sometimes be a normal reaction to grief, family disturbances and overcrowding. Issues surrounding service access A major theme throughout was the extent to which many Aboriginal families felt unable to access mental health services, either for young people or their carers, for fear of government authorities becoming involved and children being removed. This was the case for minor as well as serious mental health problems and was seen as a dangerous situation that exacerbated the difficulties being experienced. No matter how miniscule the problem is they probably won't say anything, but that little problem grows into a bigger problem and it's not seen to -- fear of DOCS [Department of Community Services], fear of the police, fear of authorities. It's probably a hangover from way back . . . (Male worker) ACCHOs were noted to be places where families could feel safe in seeking help; however, participants believed that increased funding of child and adolescent mental health services was needed for most ACCHOs in Sydney. Participants felt that families were often better equipped than services to help young people with minor wellbeing issues, but services were seen as necessary in some situations. The majority of participants reported major problems with gaining access when services were sought. If you try to get a child into adolescent mental health you have a 3-year waiting list. It doesn't take 3 years for a child to harm themselves, and you can't wait . . . You get an assessment then you wait, and meantime you have a child who might do physical harm to another child or a parent or whatever, and parents just have to wait . . . (Female worker) Participants expressed frustration that services were often not made available to young people until a major problem, such as an arrest, had already occurred. On the other hand, participants felt that young people were sometimes referred to mental health services for normal behaviour. In particular, there was a perception that diagnoses of attention deficit hyperactivity disorder were too readily applied.
Issues surrounding how services are implemented Participants recognised that the mental health problems experienced by Aboriginal young people are influenced by many factors, ranging from family issues, to housing, to health. Consequently, collaboration across sectors was seen as essential if the causes of mental health problems are to be adequately addressed. Workers expressed frustration that such collaborations either did not appear to exist or were operating ineffectively so that families were often referred from service to service with little tangible benefit. All the social issues interlink, housing, education and so on . . . and there is no support system there whatsoever . . . You get this run-around referral. (Female worker) The involvement of Aboriginal workers in mental health service delivery to Aboriginal young people was seen as essential. In circumstances where this involvement cannot be direct, participants felt that non-Aboriginal clinicians should actively seek the advice and collaboration of Aboriginal mental health professionals
to ensure that their diagnoses and treatment plans are culturally appropriate. DISCUSSION The results of this study illustrate the cultural specificity of many of the factors underpinning the mental health of Aboriginal young people and their use of mental health services. They reflect the importance of obtaining Aboriginal input, and that of ACCHOs in particular, into mental health policy and service provision for Aboriginal young people. Our findings suggest that an exploration of issues surrounding extended family is an important starting point for clinicians working with Aboriginal young people. Indeed, given the perceived dominance of family in determining mental health status, involving family members may be particularly important. Peer relationships, while important, were seen to be less significant than family relationships. In particular, many participants felt that young people who interacted well with family had good mental health, regardless of any difficulties they may experience with peers or others. As has been noted for Indigenous adults,8-10 a strong sense of identity as an Aboriginal person was considered critical for the mental health of young people and essential to
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developing the resilience needed for overcoming the discrimination that Aboriginal people experience. Problems with identity can be extremely damaging and may be more common among those who do not have close contact with their extended family or an Aboriginal community to which they feel they belong. Such problems are complex11 and may be particularly difficult to recognise and address outside of clinical settings with Aboriginal workers who are able to provide the relevant cultural expertise. While the study reflects much commonality between Aboriginal and non-Aboriginal views of what constitutes problematic behaviour,12 a key concern raised was that Aboriginal young people may be incorrectly diagnosed with mental health problems due to behavioural or emotional problems caused by physical or social factors. In particular, hearing, speech and learning difficulties may lead to social withdrawal, disruptive behaviour and apparent difficulties with concentration. The results of our study suggest that clinicians should rule out or manage these issues before assuming a mental health problem is present, although it should also be recognised that both physical and mental health (social, emotional and behavioural) problems may be present. Major barriers to accessing mental health services were identified by participants, particularly workers, who reported that many families avoided accessing services because of the perceived potential for unwarranted intervention from government organisations. When services were sought, the waiting times for treatment were reported to generally exceed a year. While substantial unmet need for mental health services has been documented for Aboriginal2 and nonAboriginal Australian young people,13 it is unclear whether the major barriers to service are the same for both groups. A lack of intersectoral collaboration was also perceived as a key barrier to the effective prevention and treatment of mental health problems among Aboriginal young people. Participants recognised the multifactorial causes of apparent and actual mental health difficulties among Aboriginal young people and highlighted a need for services to adopt a partnership approach when working with families, to ensure that all relevant issues are addressed. The involvement of Aboriginal workers across all sectors was considered essential to ensure that services are delivered in a culturally appropriate manner. These recommendations are in keeping with the priorities outlined in the
National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Well Being 20042009.14 The findings presented here are derived from the views of participants recruited through ACCHOs located in Sydney. They do not necessarily reflect the views of other Aboriginal people living in Sydney or Aboriginal people living in other parts of Australia, given the high levels of diversity between communities. Our results suggest that clinicians should be mindful of critical issues for Aboriginal young people including family, identity, and physical and social factors that may confound their diagnoses. Non-Aboriginal clinicians should work closely with their Aboriginal colleagues in order to do this appropriately. An urgent need was identified for mental health services to become more accessible, culturally safe, and able to work with families holistically. ACCHOs may be ideally placed to address many of these concerns, provided adequate funding is made available. ACKNOWLEDGEMENTS We thank the study participants, their communities and the staff at the participating ACCHOs. This research was funded by the National Health and Medical Research Council
(NHMRC). Anna Williamson holds an NHMRC Public Health (Australia) Training Fellowship Grant (ID: 510 391). COMPETING INTERESTS None identified. AUTHOR DETAILS Anna B Williamson, BPsych(Hons), PhD, Research Fellow1,2 Beverley Raphael, AM, MB BS, MD, FRANZCP, Professor3,4 Sally Redman, BPsych(Hons), PhD, Chief Executive Officer2 John Daniels, MB BS, FACRRM, Director of Health Services and Research5 Sandra J Eades, BMed, PhD, Head6 Naomi Mayers, Chief Executive Officer5 1 School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW. 2 Sax Institute, Sydney, NSW. 3 School of Medicine, University of Western Sydney, Sydney, NSW. 4 Psychological and Addiction Medicine Unit, Australian National University, Canberra, ACT. 5 Aboriginal Medical Service Cooperative Limited, Sydney, NSW. 6 Indigenous Maternal and child health
Group, Baker IDI Heart and Diabetes Institute, Melbourne, VIC. Correspondence: [email protected]
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: APA, 1994. 13 Sawyer MG, Miller-Lewis LR, Clark JJ. The mental health of 1317 year-olds in Australia: findings from the National Survey of Mental Health and Well-Being. J Youth Adolesc 2007; 36: 185194. 14 Social Health Reference Group for National Aboriginal and Torres Strait Islander Health Council and National Mental Health Working Group. A national strategic framework for Aboriginal and Torres Strait Islander peoples' mental health and social and emotional well being 20042009. Canberra: Department of Health
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(Received 4 Jan 2010, accepted 30 Mar 2010)
MJA · Volume 192 Number 10 · 17 May 2010
AB Williamson, B Raphael, S Redman