Timeliness of child health and development services

Submission to the Select Committee established to examine child development services in Western Australia.

When a flower doesn’t bloom you fix the environment in which it grows, not the flower.

Alexander Den Heifer

1

Author Profile

Employed by Princess Margaret Hospital for Children as a paediatric registrar and later as a Community Child Health Medical Officer in a suburban Child Development Centre for about 7 years. Established Community Link and Network Inc - a volunteer scheme to provide peer support to parents of young children.1 Trialled the Canadian Early Development Index (EDI) for potential use in Australia as a public health physician

in a North Metropolitan Public Health Program which included Community Health Staff. 2–4 The Australianised

EDI became the triennial Australian Child Development Census (AEDC)5 which provides evidence to support policy, planning and action for health, education and community support. The AEDC can assist governments to develop flexible approaches to policy and planning that address the evolving needs of children and families in the future. It also supports community-led action for improving children’s development.6 Led a team of physicians to develop Health in all Policies Position Statement for the Royal Australasian College of Physicians (RACP).7 Faculty of Public Health Medicine representative on the Early Childhood and Inequities in Child Health

Working Groups and member of the RACP Chapter of Community Child Health. Currently Independent Board

Director Puntukurnu Aboriginal Medical Service and Adjunct Clinical Associate Professor Curtin Medical School. The views expressed in this submission do not necessarily represent the views of the organisations mentioned above.

Introduction

A person goes into a garage to book her car in for a service. The receptionist indicates the earliest the car can be serviced is in about 18 months. “What am I supposed to do in the meantime?” the driver exclaimed. The receptionist responded by suggesting DIY*.8 This is the where the analogy of waiting for an appointment for a child developmental assessment is not applicable as vehicles don’t have critical and sensitive periods – children do - as indicated by ‘Time’ in the diagram. Despite this knowledge of neurodevelopment known for many years,9 many children have not received the child health and development services they need for decades. Waiting 18 months – 2 years for a car service would be considered totally unacceptable. Why has this been tolerated for child development services until now?

Gratton Institute CEO

Danielle Wood also made an analogy in her Jobs and Skills Summit address. Here is a modification of her quote which is just as applicable as the original,10 “I can’t help but reflect that if children’s development potential for productivity was a massive ore deposit, we would have governments lining up to give tax concessions to get it out of the ground.”

• The reality is that the recommendations in this Inquiry will not be considered for a year or more with the potential for implementation to take even longer. Meanwhile, parents and child health services should consider implementing the suggestions made by Emerging Minds - weblink available in reference 7.

2

Table of Contents

• Author Profile

• Introduction

• (a) The role of child development services on a child’s overall development, health and wellbeing.

• Health Repair Shops

• Stop Punishing Children for Missed Diagnoses.

• Failure Demand

• (b) the delivery of child development services in both metropolitan and regional Western Australia, including paediatric and allied health services

• Leadership lacking

• Nifty Idea

• Where is Society’s Soul?

• Destined to fail and abandoned by the State

• Bare Bones

• (c) the role of specialist medical colleges, universities and other training bodies in establishing sufficient workforce pathways

• (d) opportunities to increase engagement in the primary care sector including improved collaboration across both government and non-government child development services including Aboriginal Community Controlled Organisations;

• Visionary Leadership

• Child and Parent Centres

• Closing the gap from the start

• Parting the Dark Cloud

• (e) other government child development service models and programs operating outside of Western Australia and the applicability of those programs to the State.

• Guarantee for young Children & Families

3

• Lessons from overseas

• Conclusions

• Recommendations

• References

• Appendix

(a) The role of child development services on a child’s overall development, health and wellbeing.

The role of WA Child Development Services (CDS) is to respond to referrals from Community Child or School Health Nurses, other health practitioners and parents. According to their website, the CDS provides “…a range of assessment, early intervention and treatment services to children with developmental delay or difficulty that impact on function, participation and/or parent-child relationship.” 11 An intake team assesses the suitability or otherwise of being accepted into the service. “This model of service delivery has not altered in the metropolitan area since the 1960s” commented the Auditor General in his 2010

Universal Child Health

Checks report.12 Since the sixties the neuroscience of early child development has greatly expanded13 and so has understanding of a child’s environmental exposure (exposome)14,15 and experiences interacting with the child’s genetic endowment leading to a host of biological changes across multiple levels16 as indicated in on page 6. Whilst it would be impossible to encompass the wealth of literature on child development in this submission, it is important to appreciate the range of issues that confront CDS. The commonest problem is said to be ‘intellectual

4

disability’ 17 with underlying causes depicted in the diagram from an information guide for parents on developmental delay produced by Melbourne’s Centre for Community Child Health.18 (There does not appear to be an equivalent publication in WA but the NGO, Developmental Disability WA, provides links to a range of publications.)19 As indicated in the diagram, it is understandable why a neurodevelopmental behavioural (DB) paediatrician is necessary to investigate and manage the underlying cause of an intellectual disability such as a genetic anomaly. DB paediatrics is defined as “…the provision of paediatric care to children whose developmental and behavioural trajectories vary substantially from neurotypical peers, who have functional impairment due to these variations and who are likely to have multifactorial aetiological processes contributing to their presentations. The purpose of the clinical interaction with the child and family varies depending on the child’s age, the stage of clinical interaction (assessment vs. long term care) and context – including family, child and societal expectation. The initial assessment period should focus on understanding the child, exploring a medical diagnosis or co-morbidity, considering functional skills, documenting developmental level or difficulties and arranging investigations. It may also involve pragmatic support such as facilitating access to funding and providing help with minimising symptoms causing distress to the child or their carers. In all clinical interactions, the overarching goal should be optimising the child or young person’s overall quality of life and long term outcome.” 20 [Bold emphasis added] To fully appreciate the role of paediatrics in child development, readers are encouraged to read

the RACP Paediatric and Child Health Division Position Statement, ‘Early Intervention for Children

with Developmental Disabilities’ via the web address provided in the reference.21 One of the overarching principles (which may be compromised as suggested by Dr Chadwick below) is that, “it is important that children with disabilities experience equity of access to intervention and other services, and are not discriminated against through requirements of programs for the child to have a medical diagnosis.” Nevertheless, making a diagnosis is critical as indicated by the Canadian paediatricians with their more recent and prescriptive position statement22 which argues that by making a diagnosis this allows for:  timely initiation of causal treatment or supportive management,  prevention of complications,  improved prognostication,  accurate genetic counselling regarding recurrence risk and prenatal/preimplantation genetic diagnosis when indicated,  better access to services in the community, and  resolution of a diagnostic odyssey or (better still) avoidance of inappropriate, costly and traumatising tests. [ An example of Quaternary prevention23]

Parents needing a diagnostic label in order to satisfy the criteria when applying for funding is contributing to growing CDS waiting lists as explained in a recent podcast by WA developmental paediatrician, Dr Lynda Chadwick. She indicated the notion of labelling emerged in the last decade when funding for school education disability assistance was limited to children with specific diagnostic labels including intellectual disability, global developmental delay, autism or significant mental health issues which require a mental health professional to diagnose. Dr Chadwick indicated there were more referrals for autism. This was, in part, due to not only more knowledge of the disorder but also because schools are making parents aware of the possibility of this cause of behavioural issues. This may reflect a school’s genuine concern or schools can be assertive in encouraging parents to consider a diagnosis of autism to facilitate access to funding to support the child’s behavioural difficulties in the school setting. Whatever the diagnosis, it is highly likely that therapy will be required from one or all of the CDS allied health team as in most instances the ability to prevent or treat the causes of the intellectual

5

disability are limited. The following would reduce the incidence of intellectual disability but the measures required are currently not within the role or scope of CDS. These include addressing the perinatal factors mentioned in the diagram - especially low expected birth weight, prematurity and strategies to prevent Foetal Alcohol Spectrum Disorder (FASD).24

As indicated in the beginning and last sentence on the diagram on page 4, the cause of intellectual disability is often not known. It is surprising there is no reference to recent studies of adversity in childhood influencing development and mental and physical health in later life. The diagram demonstrates some of the pathways that mediate exposure to early adversity which interacts with a child’s genetic endowment which in turn leads to a host of biological changes with lifelong consequences. Many studies have identified structural and functional differences in brain development associated with environmental stressors, such as low socioeconomic status, physical abuse, and care giving neglect. For example, exposure to maternal stress in infancy has been associated with reduced brain activity, as inferred from electroencephalogram testing, and profound psychosocial deprivation has been associated with differences in overall brain volume. Researchers Hansen et al analysed

repeated Magnetic Resonance Imaging

(MRI) scans of the brains of young children between five months and four years of age from economically diverse backgrounds. Infants from low-income families had lower volumes of grey matter, tissue critical for processing of information and execution of actions. This is illustrated in the graph of total grey matter volume on the y axis in relation to socioeconomic status (SES) relative to age in months on the x axis. In addition, they found differences in brain growth varied with SES, children from lower-income households having slower trajectories of growth during infancy and early

6

childhood. They also found brain volume differences were associated with the emergence of disruptive behavioural problems. The authors concluded that this scientific evidence of economic disparities affecting human brain development and behaviour “…should lead to public policy initiatives directed at improving and decreasing disparities in human capital.” 25

Health Repair Shops

As CDS do not have a mandate to ‘improve and decrease disparities’, their role would be more accurately described as being akin to ‘repair shops’. Sadly, this a generous term because for many children it is not possible to repair the damage caused by many of the factors listed in the diagram on page 4. The concept of repair shops was described in an article by American paediatrician Don Berwick, President Emeritus and Senior Fellow, Institute for Healthcare Improvement and previous Administrator of the Centers for Medicare & Medicaid Services. He said, “… most hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted ‘social determinants of health.’” 26 Professor Sir Michael Marmot is credited as the figurehead driving the social determinants of health (SDoH) agenda globally.27 He defines SDoH as the social and environmental conditions in which people are born, grow, live, work, and age which shape and drive health outcomes. Factors that determine how SDoH conditions are experienced across societies include the distribution of power, money and resources. Unfair distribution creates avoidable health inequalities, known as ‘health inequities. Therefore, social, economic, and environmental factors, as well as political and cultural factors, constitute the social determinants of health.28 He suggested the ‘levelling up’ strategy is a missed opportunity in addressing inequality which is the main driver of child health. “Levelling up through places and people, focusing on the youngest, could be a powerful recipe for a more equal society”.29

Stop Punishing Children for Missed Diagnoses.

Early this decade, the World Health Organisation (WHO) invited Marmot to establish a SDoH Commission to marshal the evidence on what can be done to promote health equity and to foster a global movement to achieve it. In the subsequent report, ‘Closing the gap within a generation’, emphasis was given to the importance of early child development, including not only physical and cognitive or linguistic development but also, crucially, social and emotional development. “Early child development affects subsequent life chances through skills development, education, and occupational opportunities; it also affects the risks of obesity, malnutrition, mental-health problems, heart disease, and criminality”.30 ‘Criminality’ is a topical issue in WA in relation to children and adolescents in detention. They have an elevated frequency of health problems when compared to young people not in detention. This was confirmed locally in a study published this year of just over 100 young people (40% aged less than 16) at the Banksia Hill Detention Centre. This revealed 36% had FASD, 20 had hearing problems and 15 with visual problems.31 89% young participants completing a full multidisciplinary assessment were found to have one or two domains of severe neurodevelopmental impairment and 65% had three or more domains of severe impairment. Over half of the young people were found having impaired attention (55%), impaired executive function (54%), and also language impairment (45%). About 73% of the 103 study participants were Aboriginal and Torres Strait Islander young people. Of the 36 children diagnosed with FASD, only 2 had been diagnosed previously and this was because they were participants in previous research being conducted on FASD. None had been

7

identified through prior routine health, education and child protection services. Similarly, interviews of the young participants and their carers revealed few had obtained contemporary referrals for a comprehensive assessment to determine their education and rehabilitation vulnerabilities. 42% were found to be two years or more behind their expected schooling year of their chronic chronological age and 89% of participants were suspended from school at least once and 59% had disengaged from school by the end of nine years of age. This has major implications knowing that educational success is such a major determinant of health and lifespan. 32–35 The study by Mutch et al revealed significant morbidity amongst the cohort of young people incarcerated at Banksia Hill Detention Centre. It also exposed the failure of Child and Adolescent Health Services (CAHS) and other human services that interact with children, to identify children early who would benefit from assessment and therapy. This study revealed the value of and argument for the comprehensive Multidisciplinary Team Assessment of incarcerated young people. Whilst achieving this as standard practice might be considered expensive, the cost needs to be compared with how much money it takes to incarcerate children and young people - reported to be about $1,350 per day.36 Not factored into this cost benefit analysis is the ongoing benefits of providing more appropriate therapy than the health harming experience of captivity - especially in adult maximum security – without access to Medicare (see page 25 for an estimate). It would be preferable to detect children who would benefit from assessment and therapy before the behavioural signs of their undiagnosed developmental disorder bring them to the attention of law enforcement. The process of detection of developmental issues in children who appear to be functioning normally can be described as ‘secondary prevention’. This is defined in the RACP Position Statement as “actions to detect and minimise a health problem at an early stage).” While secondary prevention seeks to prevent the onset of illness, ‘tertiary prevention’ aims to reduce the effects of the disease once established in an individual. Tertiary prevention is defined as “actions to reduce the impact of an already established disease by restoring function and reducing disease-related complications.” The role of CDS on a child’s overall development, health and wellbeing could best be described as a tertiary prevention service. By improving secondary prevention services, the demand on the already stretched child development services would increase unless there is an improvement in primary prevention. Primary prevention is defined as “population-wide approaches to remove or reduce the cause of a health problem before it arises.” Often overlooked (which is the case with the RACP Position Statement) is ‘Primordial Prevention.’ This “…consists of risk factor reduction targeted towards the entire population through a focus on social and environmental conditions. Such measures typically get promoted through laws and national policy. Because primordial prevention is the earliest prevention modality, it is often aimed at children to decrease as much risk exposure as possible. Primordial prevention targets the underlying stage of natural disease by targeting the underlying social conditions that promote disease onset.”37

Failure Demand

Whilst primary and primordial prevention may appear outside the terms of reference of this inquiry, failure to address these upstream levels of prevention will inevitably lead to the reason for this inquiry in the first place - namely the growing and unacceptable waiting list for children to be assessed and to be provided appropriate therapy and support. It is therefore important to act on some of the policy suggestions already mentioned in this submission and also to address the following challenges which could be described as primordial and primary prevention strategies. Despite the evidence of investment during the early years of life has some of the greatest potential to reduce health inequities, the Australian government failed to act on the recommendations of its own Senate Inquiry into Australia’s domestic response to the WHO’s Closing the Gap in the Generation report.38 The cost of ignoring the Senate Inquiry was estimated to be

8

billions of dollars that would be saved in health and welfare costs, whilst increasing employment levels and improving productivity.39 This is not only an example of false economy but also could be an illustration of policy makers having the “licence to be bad” - the title of Aldred’s book on “how economics corrupted us”.40 In the absence of previous national leadership on the social determinants of health, it behoves State and Territory governments to compensate. The WA Sustainable Health Review made many references to SDoH in response to their consultations and submissions as described in the WACOSS document, ‘Social determinants of health and the Sustainable Health Review’ 41 but the need to turn rhetoric into action remains. Fortunately, some of the range of actions required has been formulated by Professor Timothy Moore and colleagues in their journal article on early childhood development and the social determinants of health inequities. This is highly commended reading and is available for download via the reference.42 Because the policy recommendations are so vital they are summarised verbatim as follows but not including references to the evidence that informs the proposed actions:

Socio economic, political and cultural context

1. because traditional governance and leadership approaches are not an appropriate or effective means for addressing the complex problems that lead to inequity, decision makers (for example government, non-government organisations) need to ask questions of and engage communities, service providers and institutions. [A similar suggestion to one made in WA in 1991 as indicated on page 7 and again in 2010 in the Health

Administrative Review Committee report].43

2. because all children benefit from high quality early childhood education and care (ECEC), especially children experiencing disadvantage, the quality agenda in early childhood education and care needs to be maintained.

3. because families with young children experiencing disadvantage are less likely to utilise ECEC we need to implement policies that make it easy for families with young children experiencing disadvantage to access high quality ECEC.

4. because for young children the key to developmental environments is relational, we need to implement policies that enable greater workforce flexibility for all parents and caregivers so they can spend more time with their children during the early years.

5. because employment for parents at any cost could increase in equity (those in the most disadvantaged groups are likely to be employed in the most insecure and instable jobs, and insecure, unstable employment can have a negative impact upon children) we need to implement policies that ensure secure and stable employment for primary caregivers.

 An example of the Inverse Care Law which states the availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources. 44

9

6. because public perceptions of early childhood can impact upon public support for strategies that aim to support young children’s learning and development, and because a number of misconceptions about early childhood and ECEC exist among Australia’s general public (e.g., young children are passive absorbers of content and ECEC is a child minding service) we need to improve public understanding of the importance of the early years and the role of ECEC.

Daily living conditions

7. because most Australian families are doing well (and will continue to do well if any risks or problems are identified early) and because all families will struggle at some point (and some will struggle more than others) we need a service system that reflects these realities of family life. Proportionate universalism reflects these realities because it provides a baseline of universal services for all families (i.e., those who are doing well) and additional services according to need (for those who are struggling, including those who are struggling the most).

8. because there is some evidence to indicate that children in more affluent neighbourhoods of Australia are receiving a higher quality of ECEC than children in less affluent neighbourhoods and because this has the potential to increase in inequities among children (i.e., those who are already worse off receiver poorer quality of care) we need to ensure universal high quality early childhood education and care in all neighbourhoods.

9. because the prenatal period plays a critical role in biological and neurological development and inequities during the prenatal period have the potential to lead to inequities in children’s development, and subsequent long-term outcomes we need universal high quality antenatal services.

10. because the type of problems that cause inequity during early childhood are characterised by complexity and no single organisation or sector can resolve these problems alone, we need service systems that enable collaboration between professionals, between services, between sectors and with communities.

11. because we need to ensure that the programmes we invest in will have the best chance of achieving the desired outcomes in the most efficient way we need evidence based programmes.

12. because how services are provided is as important as what services are provided (i.e., the characteristics of the service environment will strongly influence the extent to which families engage in the programme services have to offer) we need welcoming inclusive services that employ a strength-based partnership-based approach.

 ‘Proportionate universalism’ suggests that health actions must be universal, not targeted, but with a scale and intensity that is proportionate to the level of disadvantage.45

 Another example of the Inverse Care Law

10

13. because informal support from extended family, friends, neighbours and colleagues can benefit families with young children by providing a form of flexible and sustainable assistance as well as promoting a sense of belonging and reducing the potential for social isolation, we need more supportive communities.

14. because not all communities will have the resources to participate in new forms of governance and community participation, … communities need support to engage in decision making and collaborative processes.

15. because knowing what services exist and what they provide is a key facilitator of families’ engagement with services, families need information about services and child development in a range of different languages tailored to differing circumstances and via a range of mediums.

Individual health-related context

16. because parents need to be able to get support for themselves, their child and their family when it is needed, parents need to know what services are available, what type of support is offered by those services and feel confident to approach those services. For some families the confidence to approach services will rely upon the ‘approachability’ of those services (strategy 12).

17. because knowledge of child development helps parents understand their child and their child’s behaviour, parents need to know about child development, the factors that promote positive health and development, and have the capacity to support their child’s development.

18. because of parents’ attitudes about parenting mediate how they behave towards their children; parents need to feel confident and supported in their role as parents. Some parents will be confident in their parenting role, some will require reassurance and others may require more intensive support.

If there are no and/or inadequate public policy initiatives to reduce the inequity gap, then the demand for CDS to deliver more services will continue to increase. This is an example of Failure

Demand.46,47

(b) the delivery of child development services in both metropolitan and regional Western Australia, including paediatric and allied health services

It seems likely that the publicity associated with long waits for children to be assessed and to receive therapy services there will be a clarion call for more resources and for the recruitment of more neurodevelopmental paediatricians and allied health practitioners. This is appropriate especially with neurons atrophying whilst awaiting therapy - but the ability to recruit staff in the short term will be more that challenging when there is a shortage of practitioners available. Also, in the long term this will not solve the problem of growing demand as there are insufficient ‘upstream’ strategies such as those already mentioned – to improve and decrease inequities. Upstream interventions and strategies have been defined as focusing on ‘improving fundamental social and economic structures in order to decrease barriers and improve supports that allow people to achieve their full health potential’.48

11

Barriers to children receiving the services that The ‘drowning man story’ was used by a doctor would help ensure they achieve their full to explain the dilemmas of the modern practice potential have been built over several decades in of medicine: “You know,“ he said, “sometimes it WA. Multiple reviews and inquiries describing feels like this. There I am standing by the shore of these barriers are worth reviewing as many a swiftly flowing river and I hear the cry of a include recommendations which are still relevant drowning man. So I jump into the river, put my and overdue being implemented. This might also arms around him, pull him to shore and apply artificial respiration. Just when he begins togo some way to compensate for the time, energy breathe, there is another cry for help. So I jump and vast expense to the taxpayer of conducting into the river, reach him, pull him to shore, apply these inquiries, reports and reviews but did not artificial respiration, and then just as he begins to prevent the need for this parliamentary inquiry. breathe, another cry for help. So back in the river The delivery of CDS becomes more challenging again, reaching, pulling, applying, breathing and when the demand for services increases without then another yell. Again and again, without end, a corresponding increase in supply. Whilst the goes the sequence. You know, I am so busy logical response is to increase the number CDS jumping in, pulling them to shore, applying centres and staff this strategy alone is not artificial respiration, that I have no time to see sustainable without also tackling the reason for who the hell is upstream pushing them all in.” the growing demand. The analogy was made by a cardiologist speaking at the Proceedings of American Heart Association Conference on Applying Behavioural Science to Cardiovascular Risk in 1974.49 He relates the story of the drowning man to highlight the fact that a majority of resources and activities in the health field are devoted to what he termed “…‘downstream endeavours’ in the form of superficial, categorical tinkering—in response to almost perennial shifts from one health issue to the next, without really solving anything.” He indicated there was a need to “…begin focusing our attention upstream, where the real problems lie.” It is story modified by other physicians to explain the emerging field of ‘Upstream Medicine’.50 The drowning man story is quite useful in also explaining the differences between the prevention levels discussed previously. For example, primordial and primary prevention focuses on strategies to stop being pushed into the river. Secondary prevention is identifying people who are risk of drowning. Swimming CDS repair shop lessons is an example of a secondary prevention intervention and, as indicated previously, tertiary prevention is providing therapy to those who have inherited challenges and/or suffered ill effects from their experiences equivalent to the role of CDS. The potential for CDS to be overly challenged to deliver services in response to growing demand was predicted in 1990. During that year Professor D’Arcy Holman interviewed about 2000 Community and Child Health Services staff across the State which included CDS in his review of Community and Child Health Services.51 He found staff “…under siege from community demand for pastoral care, counselling and social welfare services” because people were suffering from “a state of human distress resulting from personal conflict within an individual, and/or from an adverse social environment.”

12

He described this phenomenon as ‘psychosocial morbidity’ with an analysis of how it had arisen. Holman suggested the Office of the Family should promote “community debate on ‘family, work and personal well-being’” as he was concerned about “…the low level of community debate on the real issues surrounding the family, work, and other standards of material and emotional well-being.” In other words, he was describing “stress” but at the time that might have been considered too colloquial. Now, however, stress is included in the scientific literature as a major factor in influencing children’s neurobiology in ways that undermine their health, their social competence, and their ability to succeed in school and in life.16,52–60 He estimated that almost 12% of Community and Child Health Service were allocated to ‘psychosocial services’. The Health Department’s executive did not endorse such services being provided other than for developmental disorders. Nevertheless, one of Holman’s recommendations was to develop a ‘social health program’ to make a contribution to a whole-of-government response to psychosocial problems in the community. WA would have been Way Ahead of the world had this suggestion been implemented. Instead, the Health Department’s executive suggested “…examining the costs and potential benefits of ‘mental health promotion,’ the need for a specific programme to address the area, and to define the limits of the Department’s responsibilities. A decade later, the author of this submission co-chaired a multidisciplinary group to develop a Mental Health Promotion and Illness Prevention Policy for the Office of Mental Health which was within the Department of Health. Whilst the policy was ignored, at least in a regional area one mental health promotion officer was established for a few years until the position was abolished when he retired.61 Holman’s review with its 172 recommendations was not endorsed. Some of these recommendations specifically related to CDS. In the 90s the average time to see an allied health professional was about 4 weeks with around 70 people on the waiting list to see a speech pathologist. In the absence of implementing his recommendations he presciently warned that Community and Child Health Services would become “a grossly overstretched and under resourced public sector”. He made the analogy with public hospitals that were under pressure even then. His solution was to introduce a three-part scale of fees for the provision of CDS. It seems even more unlikely that such a recommendation would be acceptable today with the current economic challenges facing WA families with young children. However, the suggestion that there should be community debate on ‘family, work and personal well-being’ is long overdue and likely to be well received as will be discussed in TOR (e).

Leadership lacking

Leadership is an elusive concept, hard to describe and impossible to prescribe. It is more evident in its absence, so that when leadership is needed, its lack is sorely felt. Patrick Dodson

In his review, Holman was confronted by ‘orchestras without conductors’ and he was convinced that “…the performance of, and harmony within, the service would benefit from a greater emphasis on leadership.” He said at head office level, leadership was needed especially with respect to the content of the public health programs delivered by Community and Child Health Services which included CDS. He proposed the mandate to lead should be located in Public Health. Leadership is a major factor in the history of CDS and will also determine its future. The lack of leadership led inevitably to further reviews after Holman’s such as the “New Vision for Community Health Services for the Future” in 2000. It is catalogued in the National Library.62 In 2001, an independent review of the State health system recommended an overhaul of health administration to deliver a more transparent and accountable service to Western Australians. This led to the Health Administrative Review Committee (HARC).43 Whilst most recommendations were

13

implemented, the following suggestion in the HARC report which is not too dissimilar to the one made by Holman a decade earlier was ignored;

Extract from HARC

The Committee felt that despite all the various pressures, there is also a growing recognition amongst opinion-leaders and others in the community that the health dollar is finite, and that the time is opportune for serious discussion with the community about the level of health services and care Western Australians can and should expect. It is a reality of the present and the future that there will be a level of unmet health need in the community. It is the belief of this Committee that the level and type of unmet need should be explicit, and that the community should be involved in informed discussion on this important topic. It is noteworthy that The West Australian newspaper has called for an informed community debate on health funding and related matters. In discussion with the Committee, it was made clear that there would be bipartisan support for such an approach. The Committee recognises the limitations of such a debate – not least that it will not address a range of short-term problems - nor is it intended to preclude normal political argument. The Committee did, however, feel that there would be genuine support for a community debate of the nature envisaged by The West Australian. This can provide some clear short, medium and long-term benefits including building a sense of ownership within the Western Australian community of decisions being taken, and an understanding of the constraints on both administrators and practitioners in the health system. During the 1980s, the state of Oregon in the US established a process for defining priorities for health care services, including discussion papers, several hundred community meetings, a Citizens’ Health Care Parliament, focus groups and development of both informed discussion and priority lists to inform decision making by Government. The Committee believes that there is much to learn from this and other processes (including some in Australia) to create a climate in which there is informed debate, community participation in health service planning and a climate in which sectional interests take second place to the broader interest of the community. Within Western Australia, some work has been developed by the Medical Council to work with Citizens’ Juries about priorities in health. The Committee recommends that the Minister for Health and Health Department initiate a continuing, informed, bipartisan community discussion as to what Western Australians can expect from their health system, and the priority issues to be addressed. The Committee felt that while such a debate can be supported by the Health Department and the health system, it must be led by the Minister and the Government. The Committee proposes the following as guidelines:  Debate to be led by the Minister and Government,  Emphasis on a bipartisan approach,  The debates and discussions to be continuing, not “one-off”,  Discussions to engage the entire community as far as is possible,  Careful thought given to means of ensuring that the community is well informed over time about areas in which discussion is to focus,  Plans for community discussion to be developed in association with the proposed Health Advisory Council and Consumer Advisory Council and to be informed by experience within Western Australia and overseas.

14

Nifty Idea

In 2003, the National Initiative for the Early Years (Niftey) developed a strategy for Western Australia. As past member of the late Dr Trevor Parry’s Niftey group, a draft working document is able to be included in the appendix. The strategies are still applicable today. During the mining boom between 2005 and 2012, Premier Alan Carpenter said on ABC radio in 2007, “Fiona Stanley and people in the State Health Review team have been looking at what we can do to ease the pressure on the public health system and their strong advice was more money needs to go into public health education programmes, medical research and so on so that we reduce the level… the number of people who are attending … coming to hospital with things like obesity diabetes and so on and they acknowledged … and my point to them was - yes we would love to do that but and we are trying to do that - but there are huge immediate demands now every day of the week for us to spend more money, not just not so much on the preventative side - we understand that - but on responding to circumstance that people are facing every day and we are spending more money… it is already a big big budget challenge for us at State Government level. It’s a massive challenge for us.” Exactly the same response could occur today except that the wording would need to be changed slightly to reflect a crisis prompting a call for a Royal Commission.63 The suggested word changes are from “huge immediate demands” to “overwhelming demands” and from “massive challenge” to “insurmountable challenge” in view of the ignoring the expertise of well-respected health practitioners on how to prevent the pressure on the health system. Perhaps the advocacy of Fiona Stanley and others led to the Health Department developing ‘A Framework for Child and Youth Health Services in Western Australia 2008–2012’. Access to this document is no longer available online. However, it was rescued from the cache with the apposite heading, ‘Children: Obsolete – for reference use only.’ It is included in the appendix as the framework is not obsolete but remains relevant - especially the red text. However, a framework is defined in the Cambridge Dictionary as a ‘supporting structure around which something can be built’. It is not a costed strategic plan that specifies the crucial answers to, who is going to do what, by when, how much will it cost and how will we know it’s been done? Perhaps the lack of progress contributing to the growing CDS waiting lists precipitated the 2009 Inquiry into the ‘Adequacy of Services to meet the Developmental Needs of Western Australia’s Children’ with its 30 well considered recommendations.64 They need to be more than considered now. As the late Dr Trevor Parry had the most experience as a developmental paediatrician and director of the State Child Development Centre, his perspective is important. A copy of his comments submitted to the 2009 Inquiry follows: For many years Western Australia has had a comprehensive early health and developmental surveillance and screening program offered through Community Child Health and School Health Nurses of the Department of Health. Surveillance: was the availability for monitoring the health and developmental status of children and offering advice and support to parents at Child Health Centres. Screening: was the routine use of tests to check specific aspects of health development at specified times. When concerns arose, referral was encouraged to General Practitioners, and for developmental concern; referral could also be made for team assessment to the Child Development Centres in various districts, or to the State Child Development Centre for more complex problems, latterly in particular for suspected autistic spectrum disorders (ASD).These centres staffed with specialised allied health and paediatric professionals could provide initial and ongoing assessment as initial and sometimes ongoing management – or arrange referral to other intervention and management agencies. However, over time the population increase and the changing complexity of developmental

15

concerns outstripped the resources of these services leading to a reduction in availability of access to Community Child Health Nurses, a pruning of the Screening schedule, a closure of the central Health Department Preparation for Parenting program, a restriction of Allied Health services to those up to age six only in most Child Development Centres, as a way of managing the increasing waiting list time. Even so it can for example be a six to nine month wait for Speech Pathology, up to 12 months for clinical psychology, and a 12-month wait for a primary school age assessment for ASD. At the time of the 2009 ‘Adequacy of Services to meet the Developmental Needs of Western Australia’s Children’ Inquiry, community child health achieved savings of $560,000 by reducing five Full Time Equivalent (FTE) staff in 2008-09, with projected savings of $1.75 million and a further reduction of 22.5 FTE for the whole of 2009-10 demonstrating that the Government did not quarantine money for community child health from the health repair shop budget. This also illustrates the lack of power of children in advocating for their health as opposed to the vocal majority who have a vote. Whilst the cartoon is meant to amuse, ‘there is never a truer word said in jest.’

Where is Society’s Soul?

There can be no keener revelation of a society’s soul than the way in which it treats its children. Nelson Mandela

Around the time of the proliferation of reports on child and community health, a senior paediatrician advocated for more CDS staff at a large meeting between front line staff and the executive of an area health service. The response from the CEO was to ask if he would explain to somebody on a waiting list for hip surgery that they would have to wait even longer because resources had been reallocated to child health. This is an illustration of the challenge of being part of an acute care system where the clinical imperative always outweighs the argument for more preventative child health services with longer term health benefits. Another example of the vulnerability of child health is when an efficiency dividend – euphonism for funding cuts - was imposed on an Area Health Service. The executive had to come up with ideas on how they were going to achieve budget savings. A senior hospital nursing executive privately indicated that public and community health (which included CDS) could help the most with the dilemma by being the “soft underbelly”. This aside exposed the elephant in the room that has undermined children’s health services for decades. It might seem strange that there would be interest in the comparatively minimal budget of Public and Community Child Health Services when compared with the 98.5% of the health budget allocated downstream to hospital treatment.65,66 Nevertheless, in the minutes of a meeting discussing the budget challenge, the amount allocated to public and community child health services was described as a ‘cash cow’. The reason for this is that there is no discretionary funding available as all the budget is apportioned to hospitals. For example, proposals for a preventive intervention were responded to by asking the question, “what activity or program are you willing to cease so that funding can be reallocated to this new proposal?” Another question often asked is, “what evidence is there that your proposal will bring benefit?”. It’s a question not asked about the comparatively massive allocation to hospitals as it goes without saying that the money is necessary because of community demand and the clinical and political imperatives. Hence the response to the senior paediatrician’s appeal described above. This

16

constrictive financial culture within the health repair shop system may contribute to the lack of response to reports on improving child health with its budget lacking a ring-fence. In 2009, another report was published by the Education and Health Standing Committee “Healthy

Child – Healthy State: Improving Western Australia’s Child Health Screening Programs.” The

committee chair recognised that “…if a child’s development falls behind because of health issues that could be detected and rectified, their development will be delayed and the process of resolving the problem will become progressively more costly the later it is attempted in a child’s life.” The growing numbers of births in Western Australia (an additional 4,000 births a year) [in 2009] and an escalation in migration to the State by young families as a result of the mining was blamed for the large increase in demand for child health services. The magnitude of the resource shortfall over a decade ago was revealed as quoted below:

 The ratio of School Health Nurses to students in metropolitan primary schools was one-third of the government target that is required to provide appropriate services.  The status of the Community Health Nursing sector was [and still is] dire. The average age of the current Community Health Nurse was 54. Already under-resourced, this ageing workforce increasingly dispirited by the growing demands being placed upon its members.  DOH future projections estimate that there will be a 10% shortfall of general nurses and midwives, based on current levels, by 2015-2016.  DOH conceded to the Committee that, without redress, “there will remain a problem of demand for services exceeding capacity of the Child Development Service (CDS) to provide”. A number of submissions confirmed the impact of these shortfalls, suggesting that waiting times of between nine and 12 months were ‘commonplace’ amongst the CDS.  Speech and Language services provide a stark example of current inadequacies. For the 14,500 children in K-12 years suffering from an impairment or difficulty, only 1,000 places are available in the DET Language Development Centres, and all of these are located in the metropolitan area.

The report indicated that permanent under-resourcing under previous governments forced agencies into implementing ‘waitlist management’ strategies. These included; Prioritising services on the perceived urgency of individual cases; Offering group therapies instead of individual consultations; and conveying written information to parents and carers. [This may have proved to be successful in that the guides provided by a Child Development Centre led to some children no longer requiring speech therapy possible as a result of the DIY suggestions provided. Unfortunately, this is anecdotal evidence as no formal evaluation was conducted. However, since then, a systematic review of parent-implemented home therapy programs for speech and language revealed they are a potentially useful service delivery model, but caution was advised in considering their use to address broader service delivery challenges. Further high-level evidence is needed across all facets of this service delivery model.67 Whilst web based information has potential,68 stakeholders are concerned months of can be wasted according to written submissions to an Australian Government Senate Inquiry69 ]. In relation to children aged eight years and over, the situation was [and presumably still is] particularly grim. The DOH originally acknowledged to the Education and Health Standing Committee that “as a result of resource restrictions, many sites have been unable to effectively manage children older than eight years of age”. Knowing this, the committee recommended additional staffing, particularly school and child health nurses; funding to ensure the standard of screening is consistent with other States and with national guidelines; and funding to ensure that services are delivered in a timely manner whenever a general health, hearing, vision, speech or motor skill problem has been identified.

17

Destined to fail and abandoned by the State

2010 was an even busier year for reports documenting the poor state of affairs. The Education and Health Steering Committee published a second volume focused on the community health sector in their report with the prophetic title ‘Destined to Fail: WA’s Health System’. It noted that “Many members of the public confuse the children’s health services provided by the Department’s Child and Adolescent Health Service (CAHS) as just the acute care paediatric services offered by Princess Margaret Hospital for Children (PMH), which also provides services for children from birth to 16 years. Under the heading (8.3) ‘Minister for early Childhood Services’, the report indicated: Both this

Committee’s Healthy Child — Healthy State: Improving Western Australia’s Child Health Screening

Programs report in May 2009 and the Community Development and Justice Standing Committee’s Inquiry into the Adequacy of Services to Meet the Developmental Needs of Western Australia’s Children report in August 2009 recommended that the Western Australian Government reform the management of early childhood health and education policies along the lines undertaken in South Australia and Victoria. As this recommendation relates to TOR (e) other government child development service models and programs operating outside of Western Australia and the applicability of those programs to the State further discussion on the comments made in the Education and Health Steering Committee will be considered in this section. Again in 2010, the Education and Health Standing Committee published another report that could have been entitled ‘Abandoned by the State: Children’s Health Care Services in WA’ according to the committee chair Janet Woolard in her forward. She also appealed for the Government to create a Minister for Early Childhood - an approach adopted by other state governments. The report formally titled Invest Now or Pay Later: Securing the Future of Western Australia’s Children resonates with Holman’s prediction two decades earlier – ‘Community and Child Health Services would become “a grossly overstretched and under resourced public sector”.’ Meanwhile, in late 2010, the Auditor General reported on Universal Child Health Checks and referenced The Education and Health Standing Committee’s Reports that had uncovered inadequate funding for child health nurses for many years and that “…many children were missing out on key health checks between birth and school entry. As a result, some developmental problems were not being detected and intervention was being delayed. This has a significant impact on children’s development and school readiness.” The auditor recommended that in order to demonstrate that it is delivering best value for money, Health should:

 set performance targets for each child health check and report its performance against these in its annual report  improve its patient management system and financial reporting to provide better business information for service management and planning, and performance monitoring  use its existing information system (HCARe) more effectively as a stop gap until an improved system is in place  undertake analysis to demonstrate that its current practice gives the best value for money

To increase the number of children receiving checks, Health should  better promote to parents the importance of all the child health checks and particularly the 18 month and 3-year-old checks, which rely to a greater extent on parent engagement  implement different models of service delivery to improve accessibility of services in response to changing community needs

18

To improve consistency of services and support offered to families wherever they live, Health should:  put in place monitoring mechanisms to support nurses in delivering services in keeping with the core business framework  consider partnering with other agencies to make better use of other government and non government services that are funded and set up to deliver relevant complementary services, such as parenting information and toddlers groups.

To better support child health and school nurses so they can reach more children, Health should:  ensure adequate information technology support for all child health and school nurses  review its approach to administrative tasks such as booking appointments and collating data to free-up nurses to deliver services  review its management of child health facilities to coordinate leasing and maintenance to ensure that buildings are safe, ‘fit for purpose’ and located in the right place.12

The following year in April 2011, the Commissioner for Children and Young People’s Inquiry into the Mental Health and Wellbeing of Children and Young People in Western Australia recommended that ‘The number of community child health nurses be increased to provide a comprehensive universal health service to parents and children across Western Australia.’ The government partially responded by addressing the CDS waitlists. The 2010/11 budget committed $49.68 million over 4 years to improve timely access to CDS. While this money was very welcome and resulted in significant reductions in the waiting lists for CDS such as speech pathology and physiotherapy, it did not solve the problem of children missing out altogether on assessments. “More money must be invested at the start of the process, i.e., into funding child health nurses, to open the door to all those who need it.”

Bare Bones

In 2012 another legislative council report suggested limited progress. This is reflected in the following quote from the chair of the Education and Health Standing Committee’s Education and Health Standing Committee Child Health - Child Development: the first 3 years, “There is a growing population in Western Australia. This is placing pressure on child health nurses to see more and more infants and children. This results in an overstretched workforce struggling to provide a ‘bare bones’ service.” The terms of reference (TOR) of the Education and Health Standing Committee Child Health Child Development: the first 3 years70 were as follows:

1. Current and future resourcing of new methods and activities to improve educational outcomes such as e-learning and school partnerships;

2. Factors influencing positive or negative childhood development from birth to year 12;

3. Facilitating greater opportunities to engage all students in year 11 and 12;

4. Improving access and opportunities for adult learning in regional and remote WA; and

5. Foetal Alcohol Syndrome: prevalence, prevention, identification, funding and treatment to improve education, social and economic outcomes. Strangely, the report ignored most of these important issues apart from some of TOR 2 as reflected in the following recommendations:

6. The Minister for Health ensures that funding is provided for the addition of 151 child health nurse full time equivalent positions in the 2012 state budget.

7. The Minister for Health should direct the Department of Health to secure and collate data from relevant Commonwealth Departments to help identify children in the 0-5 age group who migrate to

19

Western Australia each year. This data should then be used to: Advise parents of the child health services available, in particular child health nurses; and Supplement birth notification data in staffing and workforce planning calculations for child health nurses.

3. The Minister of Health provide funding in the 2012 budget for the infrastructure required to support current and additional child health nurses to improve service delivery. This should include funding for: Improved information technology for all child health nurses; Administrative support; Significant improvements to the physical infrastructure of child health centres; and better access to pool cars for metropolitan child health nurses.

4. The Department of Health be funded to enable more flexible service delivery by child health nurses, particularly through such mechanisms as: The provision of assertive outreach activities to locate and assess vulnerable children, and the development of more accessible services with flexible/extended opening hours for child health clinics and the provision of mobile services to childcare centres, shopping centres, etc.

5. That the Department of Health be funded to extend the current capacity of child health nurses to have ante-natal contact with a family.

Following the plethora of reports in the early part of the previous decade, there appear to be few signs that much has changed judging by the sporadic articles in the press regarding CDS and access to paediatricians.71 For example, the previous coach of the Wildcats had to travel to the Eastern States to obtain an autism diagnosis for his son.72

The Commissioner for Children and Youth is monitoring progress with child development and identifies and publishes areas of concern with policy implications.73

The delivery of CDS used to include salaried community child health medical officers (CCHMOs). They were Included in the multidisciplinary teams of the suburban-based CDS. These doctors were trained in conducting Griffiths Developmental assessments and they referred children to relevant allied health staff via team meetings. Despite the fact that it was developed in the 1950s, the Griffiths remains one of the most popular developmental tests.74 The CCHMOs and the allied health teams acted as triage deciding if a child required a paediatric assessment. But this changed with the apparent emergence of hyperactivity in the 1980s.75 In 1980 the American Psychological Association released the third edition of the Diagnostic & Statistical Manual of mental disorders (DSM-III) in 1980. They changed the name of a disorder previously called ‘hyperkinetic reaction of childhood’ to attention deficit disorder (ADD) with two subtypes: ADD with hyperactivity, and ADD without hyperactivity. Even though ADD was described by Scottish physician Sir Alexander Crichton in 1798, many ascribe ‘modern day living’ to its occurrence.76 But it was the discovery of the benefit of methylphenidate (Ritalin) in controlling ADD symptoms that spurred interest in seeking diagnosis and treatment.77 Being a Schedule 8 controlled drug it can only be prescribed by a specialist so one of the most common reasons for referral to a paediatrician became making a diagnosis and managing ADD or ADHD. The launch of guidelines on managing ADHD in October 2022 may add impetus to the argument for GPs to relieve pressure off paediatricians by GPs being able to prescribe medications for ADHD.78,79 Despite the debate about the value of CCHMOs,80 when they moved on or retired the opportunity was taken by management to not fill the positions and instead to engage paediatricians on a sessional basis. The extinction of CCHMOs removed their ‘gatekeeper’ role thereby adding to CDS wait lists. But this anecdote is hard to prove. Meanwhile the role of GPs to assist is being mooted which will be discussed in TOR (c). Another role of CCHMOs was to visit rural areas to review children referred by community, school and child health nurses when they had concerns as a result of their screening. The value of this service was questionable in view of the sporadic nature of the visits. It is better to have child development services located in rural areas which has in fact occurred thanks to Western Australia

20

Country Health Services (WACHS).81 However, a review of child development services in the Kimberly revealed the services are fragmented and variable and would benefit from a coordinated approach between government, community-controlled agencies, health and education sectors. The review recommended a unifying model of care with emphasis on capacity-building with Aboriginal community members. Also training and support for Aboriginal Health Workers and other health professionals is required but must be developed in consultation with communities. The researchers also suggested a prospective audit of child health services is needed to inform improved planning of child health services with a focus on identifying service gaps and training needs and better coordinating existing services to improve efficiency and potentially also efficacy.82 It is likely these findings and suggestions would apply in other areas of the State and, in fact, also are applicable in the metro area according to reports on child services in the Midland area.83–85 For example many of the local families and service providers found the local early years system complex, with unclear entry points and access criteria, and that this complexity was a barrier to service usage despite potential benefits. Whilst it is great that WACHS has increased access to CDS in country areas, it is concerning to learn from anecdotes that the policies, procedures and IT systems apparently differ from metropolitan based CDSs. If these differences are driven by variations in local needs this is a worthy justification. However, anecdotal evidence suggests that the differences between WACHS and CAHS relate to governance arrangements. Also the Inverse Care Law still applies as CDS resources are greater in Perth and are less where the need is greatest – in rural, remote and very remote locations – and for disadvantaged children who attend CDS less than non-disadvantaged children.86 It is likely that the delivery of CDS will vary in accordance with changes in the Australian Early Development Census (AEDC). A study found reductions in the adjusted prevalence of developmental vulnerability between 2009 and 2018 in various Territories and States including Western Australia (26% to 20%). The “…results provide an opportunity for jurisdictions to reflect upon how their policies and mix of services may be affecting children’s development and inform future government policies and practices for closing gaps in developmental outcomes.”87

(c) the role of specialist medical colleges, universities and other training bodies in establishing sufficient workforce pathways

Being very familiar with the intake process within a child development service, it was enlightening to be invited to the intake meeting of a child and adolescent mental health service. The differences in the range of symptoms that precipitated children being referred were marginal. Recollection of this experience introduces implications for the specialist medical colleges as indicated in the following paragraph in a recent paper in the Journal of Paediatrics and Child Health88: Current training programs for general and community paediatrics do not require formal training in mental health, despite its prevalence in paediatric practice. This deficit may increase the risk of poor outcomes for children, and stress and burnout for practitioners. For child psychiatry trainees, helpful training may include screening, assessment, investigation for developmental disorders and associated learning difficulties. Current staff in both clinics include allied health, nursing, and medical staff, who are likely to benefit from cross-disciplinary training, which may include joint training opportunities such as didactic learning, case review and cross-discipline placements. Also having implications for several colleges is Dr Andrew Leech’s idea89 of an integrated GP paediatrician model with a new Medicare item number.79 This option is supported by Professor Harriet Hiscock, a consultant paediatrician at CCCH. She said having multidisciplinary, coordinated care on one site is the way to go because there’s never going to be enough specialists to service the population growth. She said this could take some of that pressure off the crisis point that has been reached’.79 21

However, GPs have a crisis of their own that needs fixing.90–92 Medical Schools can assist with this crisis by encouraging their students to specialise in general practice. The Paediatrics & Child Health Division (PCHD) of the Royal Australasian College of Physicians (RACP) represents 5400 Fellows and trainees. The PCHD aim is to improve the health and wellbeing of neonates, infants and children as well as adolescents and young people through education and training, research, and through their policy and advocacy branch.7 The latter has a wealth of policy documents and position statements of relevance to this Inquiry. There is also a Chapter of Community Child Health a branch of paediatric medicine focused on the health and development of children in the broader community. It conducts Advanced Training in Community Child Health over 3 years which includes in-depth specialty training in the understanding of the complex interplay between physical, social and environmental factors, and human biology that affects the growth and development of all young people. The training occurs under supervision in preparation for independent practice as a consultant. The program builds skills through work based learning and assessment tools. The RACP’s current campaign is to appoint a Chief Paediatrician for Australia as indicated in the media release of May 2022: Paediatricians say kids have fallen behind – taskforce and Chief Paediatrician needed to address setbacks Paediatricians and physicians from the Royal Australasian College of Physicians (RACP) say children face enormous setbacks from the COVID-19 pandemic and are urging political parties to commit to addressing them. The RACP says it has been positive to see some commitments made to specific mental health initiatives for young people. But without a national coordinated approach to helping children and young people recover from the pandemic, many will fall through the cracks. RACP President and Paediatrician, Dr Jacqueline Small says “We’re losing the opportunity to help this generation of young people catch up from the setbacks of the pandemic. “Whether it’s the loss of learning from missed face-to-face teaching, the emotional impact of reduced social connection with their peers, or the lack of access to sport, recreational, and cultural activities, the pandemic has overturned many parts of children’s lives. “There is an urgent need for a national recovery plan to help the nation’s children catch up from the setbacks of the COVID-19 pandemic. “As a developmental paediatrician I see this in my work every day. Children have faced so many challenges and hurdles for over two years and some of those impacts are yet to be realised. “This is why we need a National Chief Paediatrician to lead the way and be an important clinical voice for the health and wellbeing of young people in Australia.” The Kids COVID Catch Up campaign has brought together medical specialists, healthcare professionals, families, and young people from across the country to call on all parties to commit to:  Establish a National COVID-19 taskforce to lead a recovery plan  Appoint and fund a National Chief Paediatrician  Fund and implement the National Children’s Mental Health and Wellbeing Strategy  Increase Commonwealth funding for evidence-based school support, such as tutoring, for students with disability or learning difficulties  Implement universal access to early education programs for all three-year olds  Restrict marketing of unhealthy diets to children and young people through regulation The College is concerned that reports that children in Australia who were developmentally “on track” across five key areas in 2021 had decreased from 2018. This is the first national fall since 2009 and highlights the need to help our kids catch up. Find out more about the RACP’s Kids COVID Catch Up Campaign: https://kidscatchup.org.au/

The AMA also has several relevant position papers and is an advocate for child health.93

22

(d) opportunities to increase engagement in the primary care sector including improved collaboration across both government and non-government child development services including Aboriginal Community Controlled Organisations;

Australian Health repair shops have been declared ‘not fit for purpose’ so they are themselves in need of repair.94 In WA, the Sustainable Health Review was conducted because, to quote the chair, Robyn Kruk, “Business as usual is not an option, the rate of growth is not sustainable.” 95 That was 4 years ago. Anecdotally it appears that the health repair shop model is continuing with business as usual. CDS is administered by the WA Department of Health Child and Adolescent Services (CAHS) which has had much publicity in recent years for all the wrong reasons. This precipitated CAHS to engage a management consultancy firm to conduct a three-year strategic review. The secret report revealed an overloaded, burnt out, frustrated, underappreciated and overstretched workforce, challenged by a lack of resources, and concerns from staff about leadership. A media report indicated issues relating to CAHS’ leadership and governance had negatively impacted the experience of staff with leadership becoming progressively less visible with staff feeling disconnected.96 Leadership was chosen as the first of a five-phase model for an Early Childhood Development (ECD) system reform based on available evidence. (You may recall leadership was identified as lacking in 1991). The other phases include exploration, preparation, implementation, and continuation. The report was compiled this year by Kevin Runions and colleagues from the Telethon Kids Institute for the Life Course Centre.97 They begin by claiming that governments are increasingly mindful of the role of early childhood development in determining the health and wealth of nations. They also think that governments appreciate that many of society’s most challenging contemporary issues among adults have their roots in early childhood which is when they are best addressed. Hopefully this can be demonstrated in future with practical action. Runions specifies that for a ECD service to benefit children and families, a whole of government multi-sectoral coordinated and integrated response is required. This approach is consistent with the aim of the global Children in All Policies (CAP-2030) movement which aims to implement the recommendations of the WHO-UNICEF-Lancet Commission by promoting children’s rights and protecting their health through science, advocacy and coalition-building.98 Currently Australia is not represented on the www.CAP-2030.org world map as having any CAP-30 initiatives. WA is well placed to get on the map as it is one of the few regions to have guidelines on how to conduct child impact assessments – an essential process for the Child in All Policies process.99 Leadership will be required to adopt CAP-2030 in WA whilst incorporating a new CDS model. The section on leadership from Runions’s report follows in italics without references.

Visionary Leadership

Successful implementation is dependent upon leaders who are persistent, well connected, credible, able to mobilise resources and can articulate a clear vision. Leadership needs to exist at multiple levels, including the political as well as at the level(s) of the specific agencies involved in the system. Within the political hierarchy, this includes recognition and promotion of the initiative at the highest levels of government, for example via a national plan of action [in this instance a State plan]. Sectoral leadership is also needed to interpret whether existing services have the collective scope and effectiveness to implement such a plan. [The track record documented in TOR (b) makes these criteria highly questionable]. This can be a long and hard process, and one which is vulnerable to electoral cycles and oscillating ideological priorities. Leadership in the ECD sector needs to be sensitive to the disruption that will arise as changes are introduced down the line to people already doing their best. Thus, models of leadership should emphasise humility and recognition of the

23

expertise of followers, creating a climate of trust and fairness as sectoral hallmarks. Servant leadership for instance, may provide a useful leadership philosophy for orchestrating the complex changes needed to achieve a comprehensive ECD system.

The greatest leaders mobilize others by coalescing people around a shared vision. (Ken Blanchard).

One of the challenges to advancing ECD is ensuring a shared vision as to “how early childhood development is understood and conceptualised, including the definition of early childhood development, reliable and valid measures, and effective intervention strategy” A shared view should not only include what parties are required ‘at the table’, but also how effectiveness can be determined, equity can be assured, and successes sustained. The need for a shared vision also extends to the domains/elements to focus energy on, and whether the interventions within or across the particular sectors should be targeted or universal. Targeting services depends upon an understanding of the prevalence of key outcomes, as well as key risk and protective factors, and a clear delineation of whom and what is to be targeted. Ideally, deep population-level data should be available to inform such decisions. Thus, a priority in achieving a shared view will be groundwork on data availability, systems for exchange of data, and data literacy. Establishing of a systems level Theory of Change (TOC) may also be a useful foundation for ECD systems establishment. A TOC describes how and why a set of actions are expected to lead to desired changes and this can help to make sense and harmonise collective programs of work with children, families and communities. Runions concludes by saying, “For those seeking to institute ECD systems reform, this framework offers some of the key signposts. Change, however, is always more complex than such models suggest, requiring a relentless persistence, enduring patience, and a commitment beyond the usual 3–4-year terms of government. Notwithstanding this, the potential payoff is great – both in terms of the positive gains to the lives of the children and families involved and of the ‘bottom line’ of investment-return ratios, so that the effort required is more than justified.”

The catalogue of previous inquiries, reports, and reviews summarised under TOR (b) have tended to focus on increasing and/or improving service provision with limited attention to influence the home learning environment (HLE). A review of the literature on early childhood development and the role of neighbourhood hubs was published this year indicating the HLE is the strongest predictor of a child’s long-term learning and development outcomes.100 The authors of the review, Clark et al found evidence that sustained, community-level actions which seek to enhance early child development can lead to significant gains, especially for children with elevated risk of being developmentally vulnerable at school entry. Ipso facto, there is the potential to reduce demand on CDS by implementing these ‘community-level actions.’ For example, a study has found a strong association between playgroup participation and reduced developmental vulnerability evident in AEDC data. Children who did not attend playgroup were 1.71 times more likely to be developmentally vulnerable on the AEDC at school entry. The study authors indicated that, “Playgroups are a low-cost, two-generational early learning opportunity for children and offer an entry-point service option that most schools can accommodate on-site.” 101 In Clark’s review he cites evidence that primary schools are the preferred settings for all early years services especially in low SES neighbourhoods. He promotes the idea of local primary school hubs as they resonate with the interconnected nature of neighbourhoods and homes, which encourage relational, flexible responses that are capable of partnering with families in their efforts to scaffold their children’s development and learning. Flexibility is not a characteristic of formal child services and CDS being “… constrained from early intervention in this regard because they have policies and guidelines that require certain thresholds of need to be reached before support may be provided. These thresholds tend to be set at points

24

when families are approaching a state of crisis. … Waiting until issues approach crisis also means that options for remediation narrow, predisposing heavy-handed interventions which create the potential for deeper ‘scars’ to be left on children and families, including the potential for enduring intergenerational problems. The avoidable cost of this approach to policy in Australia has been estimated to be $15.2 billion annually.” Clark et al also found a study comparing the trajectories of ‘rich’ and ‘poor’ cohorts. The costs associated with elevated welfare, crime, and poor health for those who got an impoverished start in life were in the order of 20:1. As well as a moral duty, there is a financial incentive to act on the research that shows that candidates for high later-life health and social service costs are identifiable early in life, long before they start school. “When this is combined with evidence that those likely to experience disadvantage in the early years are much more likely to live in lower socioeconomic areas a strong argument is established for neighbourhood policies that more effectively support families in these communities with responsive and culturally secure early childhood and parenting support initiatives.”

Child and Parent Centres

Clark cited in his review a discussion paper on integrated care which has proved challenging because of rigid institutional and professional cultures, arguing that responsiveness to client perspectives and priorities in larger organisations can easily become secondary concerns to operational efficiency and become invisible to those working in the centres and services. Changing such cultures is complex and costly, and efforts in this area often have limited success. With this information it would be unwise to consider reorganising CDS whilst it is located within a much larger health repair shop which is harder to reorientate. Re-orienting health services was proposed in 1986 in the Ottawa Charter to achieve a better balance in investment between prevention and treatment, and to include a focus on population health outcomes alongside the focus on individual health outcomes. However, there is little evidence that a re-orientation of health services in these terms has occurred systematically anywhere in the world.102 As indicated in Clark’s review, large service centres operate with attractive economies of scale but their bureaucracy struggles to achieve the flexibility required to address access barriers for disadvantaged families. This is one of several advantages of locally tailored neighbourhood hubs that can by-pass some of these impediments. Clark’s paper demonstrates growing evidence in support of neighbourhood public primary school hubs is growing, with a coherent base of theory and empirical support to recommend their more widespread establishment. The hubs are readily justified as a key pillar of early years policy, allowing interventions at a point in the life course where the economic evidence suggests it is most cost efficient to do so. Clark concludes by saying that the evidence is clear that “…hubs offer a fit-for purpose and ‘shovel-ready’ policy opportunity to address the key performance gaps that were identified more than a decade ago by Australia’s Education Ministers’ in the Melbourne Declaration

on Educational Goals for Young Australians.”

Clark’s reference to Primary School Hubs in his review applies to WA’s Child and Parent Centres (CaPCs). These purpose-built centres are located in or near a Primary school and bring together the

Departments of Education, Health, Local Government and Communities, Child Protection and Family

Support, and the Department of the Premier and Cabinet working together to support families with young children. Each centre is managed by a non-government organisation (NGO) thereby increasing opportunities to engage with the primary care sector including improved collaboration across both government and NGO child development services. With interest from GPs to be more involved in child development as mentioned previously, they would be a welcome addition to the list of resources accessible via CaPCs shown in the following table.

25

maternal and child health services speech therapy support paediatric services and paediatric

referrals

family psychological services                     counselling services           antenatal classes

early learning programs                           early literacy/numeracy         cultural programs

programs

child support activities                          playgroups, including          school holiday programs

other child support programs, for example       parenting and family          parent literacy support

Rhyme Time, Aboriginal Story Time support

parent workshops and groups,                     transition schooling            multicultural programs and services

activities

referrals to other services.                       protective behaviour        new parent and baby groups

workshops,

Positive Parenting Program (Triple P),            Best Start Aboriginal         managing behaviour workshops

playgroups

CDS are more aligned with the positive ethos of CaPCs than within the restraints of the acute care system with a history of being unable to meet all the health and development needs of children. Building more CaPCs is clearly a wise investment not only for children’s development but also for development of the WA especially in areas where the need is greatest. Options for integrating CDS and their governance should be explored in consultation with children, their parents and stakeholders in their local communities utilising Runions’ framework. Providing more CaPCs will be insufficient in themselves to reduce the burden on parents and children. For example, despite the presence of CaPCs in the Midland area as mentioned previously, there is still a need to assist families to navigate the complex array of services that could provide benefit. Navigators are essential to make the most of existing children’s services including CDS. There is now gold standard evidence to support this assertion as demonstrated by a randomized clinical trial (RCT). The health outcomes of a paediatric social-needs navigation program were evaluated using for the first time a RCT. The researchers recruited volunteers from local universities and they were trained to recruit caregivers, conduct social screening, and serve as navigators. They received 8 hours of training covering intervention procedures, cultural accountability, and community, hospital, and government social service resources, as well as motivational interviewing. They also received ongoing, on-site training from supervisors who observed volunteer-patient interactions, with feedback for quality improvement. Compared with an active control at 4 months after enrolment, the intervention significantly decreased families’ reports of social needs and significantly improved children’s overall health status as reported by caregivers.103 Although the RCT did not refer to the problem of children not attending their paediatric appointments, it is likely the navigators would reduce the likelihood of non-attendance. A review of patients in Victoria not attending their appointments revealed over half said that they would agree to a “buddy” system whereby the appointment reminder was sent to the patient but also a nominated friend or relative.104 Sending the appointment to the navigator is likely to overcome the commonest reason for not attending – forgetting.105 As CDS appointments are valuable hard to obtain it is important to reduce waiting lists by exploring ways to reduce the non-attendance rate.

Closing the gap from the start

Aboriginal community controlled health organisations (ACCHOs) are not only downstream health repair shops but also try to address health equity through action on the social determinants of health.106 There is the potential to significantly improve child health and thereby help reduce the gap by resourcing ACCHOs with CaPCs and caregiver navigators. This is consistent with the Close the Gap agreement (Coalition of Peaks 2020) which recommends prioritising the support of child development using community-led initiatives such as the ‘Share and Care Check.’ This optimised 26

child health check was co-designed with a remote ACCHO and led by Aboriginal Health Practitioners. A study of Share and Care Check published this year outlined the 80 minute process as follows: (1) informed consent; (2) demographic details; (3) cultural connections; (4) developmental, medical and social history; (5) educational history; (6) prenatal history; (7) developmental screening utilising the Rapid Neurodevelopmental Assessment (8) clinical observations (9) body systems review; (10) physical examination; (11) mental health review (including mental state examination); (12) formulation; and (13) care planning and referrals. Some participants in the Share and Care Check complained about the length of time the check takes. In response, an alternative stepped-care approach was revised to an entry-level shorter health check, which includes a basic medical check and a rapid assessment of developmental concerns,107,108 as well as questions pertaining to cultural connections. Based on the findings of the entry-level health check, those who required a more in-depth health check then continued onto the Share and Care Check, which covers a more detailed developmental history. The collection of the initial health check data informed further development of a more comprehensive referral process that utilises the information collected (e.g., prenatal history, developmental concerns, cultural connections) to provide more targeted and holistic pathways of care for children and their families. It is not difficult to conject that by incorporating cultural information in referral of children who have been through the Share and Care Check process would provide CDS with vital information on which to inform a management plan for children who need ongoing allied health services and social support. It is also another argument for resourcing ACCHOs with CDS staff to provide culturally appropriate seamless care. The study revealed that ACCHO practitioners were provided with valuable information and an opportunity to connect families with appropriate community members and Elders who could work with families to enhance their cultural connections. Nearly 70% of the 49 children participating in the study had one or more developmental concerns which had not been previously detected. The process of combining the collection of a range of prenatal (e.g. nutrition, stress, substance use) and postnatal (e.g. childhood adverse experiences) factors with a developmental screener during a health check, provided ACCHO practitioners with information they needed to guide the following interventions: (1) offer education regarding factors that influence child development; (2) identify children who are at risk of future developmental concerns; and (3) to prioritise early, strengths-based interventions that support children and families in their community, close to home. This focus on education and prevention from valued members within local communities such as Aboriginal Health Practitioners reduced stigma. The researchers suggested this process, given the ongoing staffing challenges in remote communities, utilising Aboriginal Health Practitioners was key to not only providing culturally appropriate care but also cost-effective continuity of care. The study authors surmised that Share and Care Check could help to close the gap between the health of First Nations Australians and other Australians.109 As indicated on page 5, FASD is often missed as an underlying cause of developmental delay and being preventable warrants particular attention. The National Aboriginal Community Controlled Health Organisation has recommended that the Australian government:

 allocate dedicated funding for ACCHOs to facilitate regular health checks and the delivery of home visits in all rural and remote communities.  invest in culturally sensitive awareness raising, targeted to Aboriginal and Torres Strait Islander women, men and communities via mainstream media, school curriculum, and in ACCHOs’ and mainstream health service delivery, about:  the risk of alcohol consumption during contraception and pregnancy;  supporting your partner, sister, aunty, mother, daughter etc. to make healthy choices in pregnancy; and

27

 the size of a standard alcoholic drink.  allocate dedicated funding to bolster ACCHO’s workforce to deliver comprehensive screening and assessment of FASD and other developmental disorders;  co-produce with ACCHOs and other Aboriginal health service providers a comprehensive, common screening and assessment tool for diagnosing FASD and other developmental disorders.  allocate dedicated funding to enable ACCHOs to employ Child Health Nurses, Occupational Therapists and Speech Pathologists.  in negotiation with NACCHO affiliates and ACCHOs, adopt key aspects of the WA model for NDIS services for Aboriginal and Torres Strait Islander people with a disability that will work in other jurisdictions across Australia, funded through the redirection of the NDIA operational budget.  allocate dedicated funding to enable ACCHOs to deliver paediatric and community child health services, and to develop and implement integrated care pathway and individual care plans for all children diagnosed with FASD.  allocate dedicated funding to bolster training opportunities for ACCHO staff, including increasing their know-how of FASD diagnostic criteria, evidence-based treatments and FASD management.  allocate dedicated funding to research and collection of data, toward identifying service gaps and best approaches to prevent, diagnose and treat FASD and support people with the disorder.

Whilst these recommendations are aimed at the Federal Government, they are also applicable for the State Government to negotiate a funding agreement with the Australian Government.

Parting the Dark Cloud

The first Indigenous person elected to the WA Parliament and the first to serve as a state government minister in Australia, the late Hon Ernie Bridge was told by a community member that her children’s limited prospects were like a “dark cloud” hanging over their future.110 This month’s article in MJA-insight suggests the cloud is even more menacing. All the previous reports, inquiries and reviews have given insufficient attention to the development of First Nations children. This is one of many reasons that particular attention needs to be given to this article authored by nine experts in the field.111 Readers are encouraged consider the references and guiding documents which include the National Aboriginal and Torres Strait Islander Health Plan 2021–2031, the National Aboriginal and Torres Strait Islander Early Childhood Strategy, and the revised Closing the Gap Report 2020. The article includes the following recommendations of particular relevance to child development:

In terms of health services, priority should be given to preventive care, including maternal and child health care, parenting programs, early infancy and childhood programs, primary care, and vaccination. Empowering Indigenous leadership and knowledge sharing are key to improving child health. Consulting young people about service development will increase health service access by adolescents. Increasing funding, training, employment opportunities, and accommodation for Aboriginal health workers, paediatric nurses and allied health practitioners is needed to improve child health. These professional groups play an important role in facilitating access to health services in remote communities yet are seldom discussed.

Strategies to improve health care for Indigenous children must include service plans that are led by, or developed and implemented in partnership with, community leaders. 28

Implementing systems-wide, formal developmental assessments for all children will enable early identification of children’s need for services and support. For Indigenous children, use of culturally appropriate assessment tools and availability of culturally competent staff will facilitate acceptable service delivery. Increasing the number of trained Indigenous health care workers and culturally informed services in remote communities is crucial.

(e) other government child development service models and programs operating outside of Western Australia and the applicability of those programs to the State.

It was suggested in the 2009 Healthy Child-Healthy State report that the Minster for Education should communicate with the reference group in South Australia that authored the report on SA’s Ministerial Inquiry into Early Childhood Service. This was in order to learn how they established a dedicated Office of Early Childhood Development and Learning that reports to the Minister for Education and Early Childhood Development in that State. The communication did not happen. South Australia provided an example of a whole of government approach with their Departments of Health and Education receiving Federal government funding to develop a childhood centre based at a primary school managed by staff from the Departments of Health, Education and Families SA. An important aspect of the approach is the presence of family support coordinators whose role is to link the programs of all agencies. The status of those initiatives is unclear. However, SA’s 2021/22 Budget made a broad and significant commitment to the early years with a range of new initiatives including the creation of an Office for the Early Years to lead the universal early years system as part of a broader Early Learning Strategy. Victoria has a Children’s Services Coordination Board which brings together key decision-makers across departments to lead coordination of activities impacting on children and young people. It is established under the Child Wellbeing and Safety Act 2005. The Board comprises the Chief Commissioner of Victoria Police and the Secretaries of the

Departments of Premier and Cabinet, Treasury and Finance, Health, Families, Fairness and Housing,

Justice and Community Safety, and Education and Training. The Board is chaired by the Secretary, Department of Education and Training. The role of the Board is to sponsor and oversee coordination of effort across different Victorian Government programs and policies where this is needed to improve outcomes for children and young people, particularly those vulnerable to harm, disadvantage or social exclusion. Consistent with its functions under the Child Wellbeing and Safety Act 2005, the Board:  Receives an annual report of The State of Victoria’s Children, which investigates outcomes for children and young people in Victoria, drawing on available data and research, with information included on relevant Victorian Government policies and programs.  Reviews and reports the findings to the Ministers, including any recommendations for improvement. The Board is supported by the Children’s Services Coordination Steering Group. Their secretariat support is provided by the Department of Education and Training.112 Victoria also has the Centre for Community Child Health (CCCH) which is a department of The Royal Children’s Hospital. The Centre is also integrated with a research group of Murdoch Children’s Research Institute. The author has bolded ‘integrated’ as this bridge across the knowledge gap is a stand out difference with the equivalent entities in WA. The Centre’s strength lies in its unique structure as shown on their comprehensive website.113 Another strength not mentioned underpinning its development is leadership. Just this month CCCH launched a resource very relevant to this Inquiry: A new evidence-based resource from raisingchildren.net.au helps parents understand neurodiversity in children and gives tips on embracing neurodiversity in family life, communities and schools.114

29

Providing CDS is just one of a suite of services, programs and initiatives that CCCH provides encompassing primary, secondary and tertiary prevention. CCCH evaluated Tasmania’s dozen Child and Learning Family Centres which were established to improve the health and well-being, education and care of Tasmania’s very young children by supporting parents and enhancing accessibility of services in the local community. CCCH indicated “the Tasmanian Child and Family Centre Project is now recognised by national and international early years leaders as leading the way in engaging communities of disadvantage in the co-production of local service models.” It is important to access and read the overview of the Child and Family Centres as they are not governed within a health repair shop paradigm but by the Department of Education115 which includes an early intervention service.116 NSW has a website about the provision of child development service within NSW Health.117 In the ACT, CDS is provided by their government’s Community Services.118 The NT had no website for their child development team but their child health website provided phone numbers.119

Guarantee for young Children & Families

The Centre for Policy Development recently spelt out what Australia should do - provide a ‘Guarantee for Young Children and Families’ - a new pillar of Australia’s social deal that entitles every child in Australia and their family to:  Three days free or low-cost quality early education from birth until school, with more days available at minimal cost. This begins as soon as families need it. This means all children will experience the lifelong benefits of quality early education  More paid parental leave, shared between partners. This will give babies time with their parents in the crucial first year of life, and it will give families the confidence to balance work and home more easily and equally  Support for children and parents from within their community, including up to 25 visits from maternal and child health nurses The Guarantee will simplify and integrate a currently confusing and expensive array of services and schemes, sharing information, tracking progress, and putting the needs of children and their families at the centre of Australia’s early childhood system. This ambitious but deeply necessary suite of reforms will take place over a transformative decade, and will involve every level of government, as well as business, unions and civil society. Delivering the Guarantee for Young Children and Families will build a generation of national prosperity, with lower health and crime bills, rewarding and secure jobs in early childhood education, and greater tax receipts from a smarter, healthier and more capable nation.120

Lessons from overseas

The World’s Best Countries for Raising Kids report by Ceoworld evaluated 159 countries across 12 different metrics. They surveyed more than 260,000 people in the Americas, Asia, Europe, Oceania, the Middle East, and Africa. Sweden took the blue ribbon as Best Country for the second year in a row.121 This seems to be a good enough justification for examining and potentially emulating their child development services. However, there is a very different political history and infrastructure compared to Australia with double Sweden’s population. For example, schools and other social services are managed by 290 semi-independent municipalities.122 The following is a summary of Swedish Child Health Services (SCHS) which are voluntary, free-of charge primary healthcare services offered to all children aged 0–5 years. The attendance rate is 97%. SCHS offer a tiered well-child surveillance programme, which aims to promote health and development, prevent negative health outcomes and identify children who need targeted interventions. By partnering with parents, the programme aims to support their parental roles and

30

make them feel confident in raising and caring for their children. They also provide them with tools to make independent decisions about their children based on their own values. This includes health guidance, parental support and providing parents with information and skills that promote their child’s development. The primary healthcare providers in CHS are child healthcare nurses, who are specialists in either paediatric care or primary health care. Within the primary care sector, most children receive care from family physicians. The majority of family physicians have completed 3 months of paediatrics in their basic training program. In the more densely populated areas, there are also paediatric ambulatory care centres working mostly with referrals from the family physicians. Preventive care is carried out at midwife-led maternity health centres, nurse-led Child Health Centres, and nurse-led school health care settings and reach almost everyone (99%). All health care for children and adolescents is free of charge up to 18 years of age.123 Although SCHS have implemented an approach that emphasises health promotion and prevention, health monitoring is still a central task. During the first 18 months of a child’s life, the families have at least 11 scheduled routine health visits. The nurses participate in all the visits and the physicians participate in three. The children undergo five developmental check-ups, performed by either the nurse or the physician, and three medical examinations performed by the physician. The developmental check-ups include an assessment of the child’s motor development. To ensure that SCHS provides equal, equitable and high-quality services to all children, national guidelines have been developed. The Rikshandboken is an open-access website that offers knowledge and methodological guidance to child healthcare professionals across Sweden.124 Sweden theoretically has a “healthcare guarantee” limiting the wait to see a GP to three days, and to see a consultant to three months. However, it is not and cannot be enforced. However, it is better to have a target or goal than none which may apply to CDS. This could be rectified by exploring how participants in the Origin project can be developmentally assessed and begin therapy within a short time frame.125

Conclusions

Child development services and related programs delivered in Western Australia are inadequate hence the need for this inquiry. This submission summarises the history of how this inadequacy has increased over previous decades with many reviews, inquiries and reports with recommendations designed to tackle the problem. Had the recommendations been implemented they are likely to have increased the adequacy of CDS. In reviewing material which is in the public domain it was impossible to determine who was responsible for and reasons behind ignoring, dismissing or refusing to act on the recommendations. There is one exception with a recording in 2007 of an interview with the then WA Premier (see page). This revealed an affliction which is common to many politicians: presentism – defined as a bias in the laws in favour of present over future generations.126 The cure is to teach politicians anticipatory governance127,128 and to make government departments accountable for their impact on future generations. To achieve the latter, Wales was the first county in the world to enact a Wellbeing and Future Generations Act. They also have a Future Generations Commissioner who works in collaboration with the Welsh Commissioner for Children to ensure that departments comply with the Act.129 Since the Act was passed in the Welsh Parliament in 2015, CAP 30 was launched as mentioned on page 23. By WA incorporating child in all policies in its Wellbeing in Future Generations Act would give added strength.128 WA is also well placed to adopt CAP-30 having a child impact assessment tool developed by the Commissioner for Children and Youth.130 It would have been be a useful tool to assess the impact of no action taken on the recommendations of the reviews, inquiries and reports - especially if those responsible were held to account. Another affliction of many politicians and managers is the obsession with the bottom line. This seemed to be the predominant concern judging by the Premier’s response to the delegation of Fiona Stanley and other experts in the State Health Review team. It was disrespectful and injudicious to

31

ignore the expertise of the delegation citing the challenge of managing an unsustainable health budget as an excuse. Even though Nobel laureate economist James Heckman had yet to complete formulating his equation131 at the time, Fiona Stanley and others would have been well aware of the basis for his calculations with his following quotation; “The highest rate of return in early childhood development comes from investing as early as possible, from birth through age five, in disadvantaged families. Starting at age three or four is too little too late, as it fails to recognize that skills beget skills in a complementary and dynamic way. Efforts should focus on the first years for the greatest efficiency and effectiveness. The best investment is in quality early childhood development from birth to five for disadvantaged children and their families.” 131 Since then there is even more evidence to suggest there is a greater return on investment despite the challenges in estimating the broader societal benefits.132 If the dollar bottom line is the dominant concern, politicians, managers and bureaucrats need to take into account and be accountable for their decisions against the following key messages quoted from the prestigious Lancet’s ‘Advancing Early Childhood Development Series’: 133

 The burden and cost of inaction is high  A poor start in life limits children’s abilities to benefit from education leading to lower productivity and social tensions in the long term.  Consequences affect not only present but also future generations. For individuals, it predicts a loss of about a quarter of average adult income per year while countries may forfeit up to two times their current gross domestic product expenditure on health.  Many countries already feel the drag on their economies of poor human development  Child development starts at conception and the development of the young child’s brain is dependent on good nutrition and on certain types of experiences. o Most families provide these experiences for their young children, but many cannot because of stresses and conditions that interfere with their ability to parent. The influence of some of these factors starts during the preconception period. Families must be supported to provide nurturing care; they need material and financial resources, and the knowledge, time, and skilled assistance when required. Families can be supported through the adoption of national policies, affordable quality childcare, and provision of population-based services. o A start can be made through health [attempts over many years to make this start in WA have proven that CDS being part of a health repair shop is not suitable for children hence the alternate suggestion; a start can be made through Early

Childhood Education]

 Scale up what we know works - The Lancet series shows that it is possible to move from small-scale civil society initiatives to nationwide programmes that are effective and sustainable. o Government leadership and political prioritisation are a prerequisite. Governments may choose different pathways for achieving early childhood development goals and targets, from introducing transformative whole-of government initiatives to enhancing existing services progressively.

32

Recommendations

1. The WA State Government should, on behalf of the bureaucrats and politicians who opposed previous recommendations to improve Child Health Services and CDS, say sorry to the people whose physical and mental health and longevity has been compromised from not being detected and referred to child development services when they were children. In addition, apologise to those who are homeless and/or have been fined and incarcerated as a result of developmental health problems not being identified and treated. And apologise to the many concerned West Australians who spent time and effort in responding to calls for submissions to previous inquiries, reviews and reports and to taxpayers who funded these expensive fruitless endeavours. In addition, acknowledge the disappointment felt by authors, chairs and committee members contributing to past reviews, inquiries and reports.

2. Rectify the situation by considering all the recommendations that have been made in previous reviews, inquiries and reports with a view to implementation of the recommendations and strategies in the appendix which are still relevant.

3. Appoint a child health and wellbeing leader whose first task will be to oversee the implementation of the recommendations including the transfer of community child health and child development services to the Early Childhood Services of the Department of Education.

4. Conduct a Statewide consultation with the community along the lines of the suggestion made in the Holman report of 1991 and HARC report of 2001. This should include discussing the implications of the global child in all policies movement with child impact assessments of all government policies. This consultation can follow the example of Wales in asking West Australians, especially children and youth, what WA they want as a basis for implementing a WA Wellbeing and Future Generations Act.

5. Implement all the underlined suggestions and recommendations included throughout this Inquiry submission.

6. Refer recommendations that might be considered out of scope of the TOR of this Inquiry to the Child Health and Wellbeing leader to convene a WA Child Health Task force for implementation. This will help ensure that the demand for CDS will become more sustainable.

A politician thinks of the next election. A statesman, thinks of the next generation. (James Freman

Clarke)

References

1. CLAN History [Internet]. Clan Midland. [cited 2022 Sep 18]. Available from: https://clanmidland.org/about/clan-history

2. Hart B, Brinkman S, Blackmore S. How well are we raising our children in the north metropolitan area? Early development index. Population Health Program, North Metropolitan Health Service; 2003.

3. Andrich D, Styles I. Final report on the psychometric analysis of the Early Development Instrument EDI) using the Rasch model: a technical paper commissioned for the development of the Australian Early Development Instrument (AEDI). Citeseer; 2004.

33

Brinkman S, Hart B, Blackmore S. Support for the Early Years and Australia’s Future Health: The Australian Early Development Index. In 2004.

Development of the AEDC [Internet]. [cited 2022 Sep 10]. Available from: https://www.aedc.gov.au/about-the-aedc/history/development-of-the-aedc

Why the AEDC is important [Internet]. [cited 2022 Sep 16]. Available from: https://www.aedc.gov.au/about-the-aedc/why-the-aedc-is-important

Physicians TRAC of. The Royal Australasian College of Physicians [Internet]. The Royal

Australasian College of Physicians; [cited 2022 Oct 1]. Available from: https://www.racp.edu.au/about/college-structure/paediatrics-child-health-division

While you wait: Suggestions for service providers to support children and their families who are on waiting lists [Internet]. Emerging Minds. [cited 2022 Sep 29]. Available from: https://emergingminds.com.au/resources/while-you-wait-suggestions-for-service-providers-to support-children-and-their-families-who-are-on-waiting-lists/

Boyce WT, Levitt P, Martinez FD, McEwen BS, Shonkoff JP. Genes, Environments, and Time: The Biology of Adversity and Resilience. Pediatrics. 2021 Feb 1;147(2):e20201651.

Think big: a new mission statement for Australia [Internet]. Grattan Institute. [cited 2022 Sep 25]. Available from: https://grattan.edu.au/news/think-big-a-new-mission-statement-for australia/

Child and Adolescent Health Service | CAHS - Child Development Service [Internet]. [cited 2022

Sep 10]. Available from: https://cahs.health.wa.gov.au/Our-services/Community-Health/Child

Development-Service

Universal Child Health Checks [Internet]. Office of the Auditor General. 2010 [cited 2022 Sep 21]. Available from: https://audit.wa.gov.au/reports-and-publications/reports/universal-child health-checks/

In Brief: The Science of Early Childhood Development [Internet]. Center on the Developing Child

at Harvard University. [cited 2022 Sep 11]. Available from: https://developingchild.harvard.edu/resources/inbrief-science-of-ecd/

Maitre L, Julvez J, L6pez-Vicente M, Warembourg C, Tamayo-Uria I, Philippat C, et al. Early-life environmental exposure determinants of child behavior in Europe: A longitudinal, population based study. Environ Int. 2021 Aug 1;153:106523.

Vineis P, Barouki R. The exposome as the science of social-to-biological transitions. Environ Int. 2022 Jul;165:107312.

Nelson CA, Bhutta ZA, Burke Harris N, Danese A, Samara M. Adversity in childhood is linked to mental and physical health throughout life. BMJ. 2020 Oct 28;371:m3048.

Lee K, Cascella M, Marwaha R. Intellectual Disability. In: StatPearls [Internet]. Treasure Island

(FL): StatPearls Publishing; 2022 [cited 2022 Sep 10]. Available from: http://www.ncbi.nim.nih.gov/books/NBK547654/

34

18. Reddihough D, Marraffa C, Rowell M, Carne R, Ferguson L. Developmental delay-An information guide for parents. 2009;

19. DDWA - Developmental Disability WA [Internet]. Developmental Disability WA - DDWA. [cited 2022 Sep 11]. Available from: https://ddwa.org.au/

20. Jongeling B, Roberts G. Models of care in neurodevelopmental–behavioural paediatrics. J Paediatr Child Health. 2018;54(10):1100–3.

21. Early Intervention for Children with Developmental Disabilities [Internet]. Sydney, Australia: The

Royal Australasian College of Physicians Paediatric & Child Health Division; 2013 Aug. Available

from: https://www.racp.edu.au/docs/default-source/advocacy-library/early-intervention-for children-with-developmental-disabilities.pdf

22. Bélanger SA, Caron J. Evaluation of the child with global developmental delay and intellectual disability. Paediatr Child Health. 2018 Aug 16;23(6):403–10.

23. Martins C, Godycki-Cwirko M, Heleno B, Brodersen J. Quaternary prevention: reviewing the concept. Eur J Gen Pract. 2018 Jan 31;24(1):106–11.

24. Pettigrew S, Booth L, McCausland T, Kennington K, Miller M, Bowden J, et al. Evaluation outcomes of an alcohol and pregnancy campaign targeting multiple audiences. Drug Alcohol Rev [Internet]. [cited 2022 Sep 11];n/a(n/a). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.13541

25. Hanson JL, Hair N, Shen DG, Shi F, Gilmore JH, Wolfe BL, et al. Family Poverty Affects the Rate of Human Infant Brain Growth. PLOS ONE. 2013 Dec 11;8(12):e80954.

26. Berwick DM. The Moral Determinants of Health. JAMA. 2020 Jul 21;324(3):225–6.

27. Boseley S. Michael Marmot: leader in the social determinants of health. The Lancet. 2008;372(9650):1625.

28. Action on the Social Determinants of Health [Internet]. Institute of Health Equity. [cited 2022 Sep 15]. Available from: https://www.instituteofhealthequity.org/about-our-work/action-on the-social-determinants-of-health

29. Black M, Taylor-Robinson D, Lee ACK, Morling JR. ‘Levelling up’ in the UK must involve a reduction in inequalities in children’s life chances. Public Health Pract. 2022 Mar 17;3:100246.

30. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health. World Health Organization; 2008.

31. Mutch R, Freeman J, Kippin N, Safe B, Pestell C, Passmore H, et al. Comprehensive Clinical Paediatric Assessment of Children and Adolescents Sentenced to Detention in Western Australia. J Fetal Alcohol Spectr Disord. 2022 Jul 2;4(1):e16–31.

32. Health TLP. Education: a neglected social determinant of health. Lancet Public Health. 2020 Jul 1;5(7):e361. 35

4A.

Albert C, Davia MA. Education is a key determinant of health in Europe: a comparative analysis of 11 countries. Health Promot Int. 2011 Jun 1;26(2):163-70.

Fiske ST, Kaplan RM, Spittel ML, Zeno TL. Educational Attainment and Life Expectancy. Policy Insights Behav Brain Sci. 2014 Oct 1;1(1):189-94.

Cohen AK, Syme SL. Education: A Missed Opportunity for Public Health Intervention. Am J Public

Health. 2013 Jun;103(6):997—1001.

Outrage as boys moved from Western Australian juvenile detention centre to maximum security

adult prison | Western Australia | The Guardian [Internet]. [cited 2022 Sep 17]. Available from:

https://www.theguardian.com/australia-news/2022/jul/06/outrage-as-boys-moved-from western-australian-juvenile-detention-centre-to-maximum-security-adult-prison

Kisling LA, M Das J. Prevention Strategies. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Sep 17]. Available from: http://www.ncbi.nim.nih.gov/books/NBK537222/

Australia’s domestic response to the World Health Organization’s (WHO) Commission on Social Determinants of Health report “Closing the gap within a generation” [Internet]. Canberra: Commonwealth of Australia, Senate Standing Committees on Community Affairs; 2013 [cited 2017 Mar 10]. Available from: http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Comp leted_inquiries/2010-13/socialdeterminantsofhealth/report/index

Brown L, Thurecht L, Nepal B. The Cost of Inaction on the Social Determinants of Health. The National Centre for Social and Economic Modelling; 2012 p. 54. (CHA-NATSEM Second Report on Health Inequalities). Report No.: 2/2012.

Licence to be Bad by Jonathan Aldred [Internet]. [cited 2022 Sep 15]. Available from: https://www.penguin.com.au/books/licence-to-be-bad-9780141986951

WACOSS Library — WACOSS [Internet]. [cited 2022 Sep 15]. Available from: https://www.wacoss.org.au/category/resources/?post_type=library

Moore TG, McDonald M, Carlon L, O’Rourke K. Early childhood development and the social determinants of health inequities. Health Promot Int. 2015 Sep 1;30(suppl_2):ii102—15.

Media Statements - Review paves the way for changes to the State health system [Internet]. [cited 2022 Sep 21]. Available from: https://www.mediastatements.wa.gov.au/Pages/Gallop/2001/07/Review-paves-the-way-for changes-to-the-State-health-system.aspx

Hart JT. The inverse care law. The Lancet. 1971;297(7696):405-12.

Carey G, Crammond B, De Leeuw E. Towards health equity: a framework for the application of proportionate universalism. Int J Equity Health. 2015;14(1):81.

Walley P, Found P, Williams S. Failure demand: a concept evaluation in UK primary care. Int J Health Care Qual Assur. 2019 Jan 1;32(1):21-33. 36

47. Failure Demand [Internet]. Vanguard Consulting Ltd. 2019 [cited 2022 Oct 10]. Available from: https://beyondcommandandcontrol.com/failure-demand/

48. National Collaborating Centre for Determinants of Health [Internet]. [cited 2022 Sep 12]. Available from: https://nccdh.ca/search/eyJyZXN1bHRfcGFnZSI6InNlYXJjaCIsImtleXdvcmRzIjoidXBzdHJlYW0ifQ

49. McKinley JB. A Case for Refocusing Upstream: The Political Economy of Illness [Internet]. 1975 [cited 2020 Aug 17]. Available from: https://iaphs.org/wp-content/uploads/2019/11/IAPHS

McKinlay-Article.pdf

50. Manchanda R. Practice and Power: Community Health Workers and the Promise of Moving Health Care Upstream. J Ambulatory Care Manage. 2015;38(3).

51. Holman CDJ. Report of the Special Consultant on Community and Child Health Services,

Executive Overview and Recommendations. Perth: Epidemiology and Research Branch, Health

Department of WA; 1991.

52. Thompson RA. Stress and Child Development. Future Child. 2014;24(1):41–59.
53. Garbarino J, editor. The Right to a Healthy Social Environment: Protecting Children from Social

Toxicity. In: Children and the Dark Side of Human Experience: Confronting Global Realities and

Rethinking Child Development [Internet]. New York, NY: Springer; 2008 [cited 2019 Nov 18]. p. 29–41. Available from: https://doi.org/10.1007/978-0-387-75626-4_3

54. McNamara BJ, Banks E, Gubhaju L, Joshy G, Williamson A, Raphael B, et al. Factors relating to high psychological distress in Indigenous Australians and their contribution to Indigenous–non Indigenous disparities. Aust N Z J Public Health. 2018;42(2):145–52.

55. McEwen BS, Gianaros PJ. Stress- and Allostasis-Induced Brain Plasticity. Annu Rev Med. 2011 Feb 18;62(1):431–45.

56. de Oliveira DM, Ferreira Lima RM, El-Bachá RS. Brain rust: Recent discoveries on the role of oxidative stress in neurodegenerative diseases. Nutr Neurosci. 2012 May 1;15(3):94–102.

57. Biochemistry WO. World of Biochemistry (blog about biochemistry): Oxidative Stress and aging [Internet]. World of Biochemistry (blog about biochemistry). 2017 [cited 2022 Apr 7]. Available from: http://worldofbiochemistry.blogspot.com/2017/04/oxidative-stress-and-aging.html

58. Luby J, Belden A, Botteron K, Marrus N, Harms MP, Babb C, et al. The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Caregiving and Stressful Life Events. JAMA Pediatr. 2013 Dec 1;167(12):1135.

59. Magalhães-Barbosa MC de, Prata-Barbosa A, Cunha AJLA da. Toxic stress, epigenetics and child development. J Pediatr (Rio J). 2022;98:13–8.

60. Hughes V. Stress: The roots of resilience. Nature. 2012 Oct;490(7419):165–7.

61. Sylwestrzak J, Hart B. Pioneering mental health promotion within a public health framework. Health Promot J Aust Off J Aust Assoc Health Promot Prof. 1999;9(2). 37

New vision : community health services for the future / Health Department of Western

Australia ; [Ja... | National Library of Australia [Internet]. [cited 2022 Sep 17]. Available from:

https://catalogue.nla.gov.au/Record/2343459

WA health royal commission would be ‘line in the sand’ [Internet]. The West Australian. 2022 [cited 2022 Sep 17]. Available from: https://thewest.com.au/news/health/wa-health-crisis opposition-backs-calls-for-a-royal-commission-saying-it-would-be-a-line-in-the-sand-c-8095048

Committee Details - Inquiry [Internet]. [cited 2022 Sep 17]. Available from: https://parliament.wa.gov.au/parliament/commit.nsf/(InqByName)/Inquiryt+into+the+Adequacy +of+Servicestto+Meett+the+Developmental+Needs+of+Western+Australia’s+Children#Report

Jackson H, Shiell A. How much does Australia spend and is it enough. Canberra Found Alcohol Res Educ. 2017;

Shiell A, Jackson H. How much does Australia spend on prevention and how would we know whether it is enough? Health Promot J Austr. 2018;29(S1):7-9.

Tosh R, Arnott W, Scarinci N. Parent-implemented home therapy programmes for speech and language: a systematic review. Int J Lang Commun Disord. 2017;52(3):253-69.

McGill N, McLeod S. Aspirations for a website to support families’ active waiting for speech language pathology. Int J Soeech Lang Pathol. 2019 Jun;21(3):263-74.

McGill N, Crowe K, Mcleod S. “Many wasted months”: Stakeholders’ perspectives about waiting for speech-language pathology services. Int J Soeech Lang Pathol. 2020 May 3;22(3):313-26.

Education and Health Standing Committee Child Health - Child Development: the first 3 years [Internet]. Perth, Western Australia: Parliament of Western Australia; 2012. Available from: https://www.parliament.wa.gov.au/parliament%5Ccommit.nsf/(Report+Lookupt+by+Com+ID)/5 D835C076D06D025482579B400070FB5/%24file/EHSC+Report+No+deleted+pages.pdf

WA public health system: Young children suffering in long wait to see paediatrician | The West

Australian [Internet]. [cited 2022 Oct 16]. Available from: https://thewest.com.au/news/public health/wa-public-health-system-young-children-suffering-in-long-wait-to-see-paediatrician–c 6172431

Why | quit: Ex-Wildcats coach reveals child anguish [Internet]. The West Australian. 2022 [cited

2022 Sep 25]. Available from: https://thewest.com.au/sport/perth-wildcats/dribble-podcast former-perth-wildcats-coach-scott-morrison-opens-up-about-son-maxs-autism-diagnosis-c 7633342

Developmental screening [Internet]. Commissioner for Children and Young People, Western Australia. [cited 2022 Sep 25]. Available from: https://www.ccyp.wa.gov.au/our work/indicators-of-wellbeing/age-group-0-to-5-years/developmental-screening

Johnson S, Marlow N. Developmental screen or developmental testing? Early Hum Dev. 2006

Mar 1;82(3):173-83.

38

75. Martinez-Badía J, Martinez-Raga J. Who says this is a modern disorder? The early history of attention deficit hyperactivity disorder. World J Psychiatry. 2015 Dec 22;5(4):379–86.

76. Lange KW, Reichl S, Lange KM, Tucha L, Tucha O. The history of attention deficit hyperactivity disorder. Atten Deficit Hyperact Disord. 2010;2(4):241–55.

77. Morton WA, Stockton GG. Methylphenidate abuse and psychiatric side effects. Prim Care Companion J Clin Psychiatry. 2000;2(5):159.

78. Fuller K. Australian Evidence-Based ADHD Clinical Guideline [Internet]. AADPA. 2021 [cited 2022 Oct 7]. Available from: https://aadpa.com.au/guideline/

79. newsGP - Paediatricians float solutions for deteriorating access problems [Internet]. NewsGP. [cited 2022 Sep 27]. Available from: https://www1.racgp.org.au/newsgp/clinical/paediatricians float-solutions-for-deteriorating-a

80. Vimpani G. Pragmatism and idealism in community child health. J Paediatr Child Health. 2006;42(5):306–8.

81. WA Country Health Service - Child Development Services [Internet]. [cited 2022 Sep 25]. Available from: https://www.wacountry.health.wa.gov.au/Our-patients/Health-programs/Child health/Child-Development-Services

82. Dossetor PJ, Thorburn K, Oscar J, Carter M, Fitzpatrick J, Bower C, et al. Review of Aboriginal child health services in remote Western Australia identifies challenges and informs solutions. BMC Health Serv Res. 2019 Oct 26;19(1):758.

83. Saavedra K, Clarke K, McAllister R, Bill M, Richer K, Golat N, et al. Midland Early Years Services Consultation Project. Perth: Telethon Kids Institute; 2018.

84. Kids First Midland: creating a community that hums. Research Report [Internet]. Midland, WA: We the People (WA) Inc 2020; 2020. Available from: https://static1.squarespace.com/static/5e537917ec1e4d2bc3f759fa/t/60053ba06909e922ff3c3 0c4/1610955689710/Research+Report+Kids+First+Midland.pdf

85. Research [Internet]. We the People (WA) Limited. [cited 2022 Sep 26]. Available from: https://www.wethepeoplewa.org.au/research

86. Woolfenden S, Galea C, Badland H, Sheedy HS, Williams K, Kavanagh AM, et al. Use of health services by preschool-aged children who are developmentally vulnerable and socioeconomically disadvantaged: testing the inverse care law. J Epidemiol Community Health. 2020 Jun 1;74(6):495–501.

87. Collier LR, Gregory T, Harman-Smith Y, Gialamas A, Brinkman SA. Inequalities in child development at school entry: A repeated cross-sectional analysis of the Australian Early Development Census 2009–2018. Lancet Reg Health - West Pac. 2020;4:100057.

88. Butler L, Harris A, Rapaic T, Heussler H, Bor W. Specialist care of children with complex needs: Insights from comparison of child development and child mental health clinics. J Paediatr Child

39

Health [Internet]. 2022 Sep 7 [cited 2022 Sep 26];n/a(n/a). Available from: https://doi.org/10.1111/jpc.16161

newsGP - GP lobbies Health Minister as paediatrics access reaches ‘tipping point’ [Internet]. NewsGP. [cited 2022 Sep 29]. Available from: https://www1.racgp.org.au/newsgp/clinical/gp lobbies-health-minister-as-paediatrics-access-r

newsGP - Health of the Nation: Investment needed to secure the future of general practice [Internet]. NewsGP. [cited 2022 Sep 29]. Available from: https://www1.racgp.org.au/newsgp/racgp/health-of-the-nation-investment-needed-to-secure-t Doctor’s plea to keep GP visits affordable as “the poor, chronically ill” ABC News [Internet]. 2022 Sep 26 [cited 2022 Sep 29]; Available from: https://www.abc.net.au/news/2022-09-26/gp-mariam-tokhi-warns-medicare-failures-leave vulnerable-at-risk/101447950

go without quality care.

Halting the slow demise of general practice in Australia [Internet]. InSight+. [cited 2022 Oct 10]. Available from: https://insightplus.mja.com.au/2022/34/halting-the-slow-demise-of-general practice-in-australia/

AMA calls for Child Health Taskforce [Internet]. Australian Medical Association. 2022 [cited 2022 Oct 4]. Available from: https://www.ama.com.au/gpnn/issue-22-number-7/articles/ama-calls child-health-taskforce

Leonardi G. Discussion paper on the future of primary care leaves much to be discussed [Internet]. Croakey Health Media. 2021 [cited 2022 Sep 30]. Available from: https://www.croakey.org/discussion-paper-on-the-future-of-primary-care-leaves-much-to-be discussed/

Rise is WA health costs scary: report | SBS News [Internet]. [cited 2022 Sep 30]. Available from:

https://www.sbs.com.au/news/article/rise-is-wa-health-costs-scary-report/Imne9t03y

Head honchos escape public scrutiny over PCH problems [Internet]. The West Australian. 2022 [cited 2022 Sep 30]. Available from: https://thewest.com.au/opinion/joe-spagnolo/head honchos-escape-public-scrutiny-over-pch-problems–c-5847283

Runions K, Cahill R, Markham R. Toward a Comprehensive Early Childhood Development System: Evidence-Based Strategies for Implementation [Internet]. Rochester, NY; 2022 [cited 2022 Sep 30]. Available from: https://papers.ssrn.com/abstract=4193254

Dalglish SL, Costello A, Clark H, Coll-Seck A. Children in All Policies 2030: a new initiative to implement the recommendations of the WHO—UNICEF—Lancet Commission. The Lancet. 2021 May 1;397(10285):1605-7.

Child Impact Assesment Guidelines; Considering children and young people in decision-making [Internet]. Perth, WA: Commissioner for Children and Young People WA; 2020. Available from: https://www.ccyp.wa.gov.au/media/4338/ccyp-child-impact-assessment-g-web-enabled-file june-2020.pdf

40

100. Clark, K., Cahill, R. & Ansell, D. (sland. Early Childhood Development and the Role of

Neighbourhood Hubs for Supporting Children’s Development and Wellbeing in Disadvantaged

Communities: A Review of the Literature [Internet]. Institute for Social Science Research, The University of Queensland.; 2022. (Life Course Centre Working Paper Series). Report No.: 11. Available from: https://lifecoursecentre.org.au/wp-content/uploads/2022/05/LCC-Working

Paper-2022-11-Clark-et-al.pdf

101. Sincovich A, Gregory T, Harman-Smith Y, Brinkman SA. Exploring Associations Between

Playgroup Attendance and Early Childhood Development at School Entry in Australia: A Cross-

Sectional Population-Level Study. Am Educ Res J. 2020 Apr 1;57(2):475–503.

102. Wise M, Nutbeam D. Enabling health systems transformation: What progress has been made in re-orienting health services? Promot Educ. 2007 Feb 1;Suppl 2:23–7.

103. Gottlieb LM, Hessler D, Long D, Laves E, Burns AR, Amaya A, et al. Effects of Social Needs

Screening and In-Person Service Navigation on Child Health: A Randomized Clinical Trial. JAMA

Pediatr. 2016 Nov 7;170(11):e162521–e162521.

104. Roberts K, Callanan I, Tubridy N. Failure to attend out‐patient clinics: is it in our DNA? Int J Health Care Qual Assur. 2011;

105. Wolthers OD. Non-attendance in a secondary paediatric referral centre. Dan Med J. 2018;65(11):A5515.

106. Pearson O, Schwartzkopff K, Dawson A, Hagger C, Karagi A, Davy C, et al. Aboriginal community controlled health organisations address health equity through action on the social determinants of health of Aboriginal and Torres Strait Islander peoples in Australia. BMC Public Health. 2020 Dec 4;20(1):1859.

107. Khan NZ, Muslima H, Begum D, Shilpi AB, Akhter S, Bilkis K, et al. Validation of Rapid Neurodevelopmental Assessment Instrument for Under-Two-Year-Old Children in Bangladesh. Pediatrics. 2010 Apr 1;125(4):e755–62.

108. Khan NZ, Muslima H, Arifeen SE, McConachie H, Shilpi AB, Ferdous S, et al. Validation of a Rapid Neurodevelopmental Assessment Tool for 5 to 9 Year-Old Children in Bangladesh. J Pediatr. 2014 May 1;164(5):1165-1170.e6.

109. Reid N, Page M, McDonald T, Hawkins E, Liu W, Webster H, et al. Integrating cultural considerations and developmental screening into an Australian First Nations child health check. Aust J Prim Health. 2022;28(3):207–14.

110. Hart B. Parting dark clouds [Internet]. InSight+. [cited 2022 Oct 18]. Available from: https://insightplus.mja.com.au/2014/21/bret-hart-parting-dark-clouds/

111. Needs and strengths: supporting child health in remote Australia [Internet]. InSight+. [cited 2022 Oct 18]. Available from: https://insightplus.mja.com.au/2022/40/needs-strengths supporting-child-health-in-remote-australia/

41

112. Statutory authorities: Department of Education and Training | Victorian Government

[Internet]. [cited 2022 Sep 26]. Available from: http://www.vic.gov.au/statutory-authorities department-education-and-training

113. Centre for Community Child Health : Centre for Community Child Health (CCCH) [Internet]. [cited 2022 Sep 11]. Available from: https://www.rch.org.au/ccch/

114. Neurodiversity, neurodivergence & children | Raising Children Network [Internet]. [cited

2022 Sep 26]. Available from: https://raisingchildren.net.au/guides/a-z-health reference/neurodiversity-neurodivergence-guide-for-families

115. Anoverview of child and family centres. Department of Education, Tasmanian Government;

117. Great Start - Early Childhood Intervention Service [Internet]. Great Start. [cited 2022 Sep 26]. Available from: https://greatstart.tas.gov.au/extra-support-for-your-child/early-childhood intervention-service/

118. Child Development Service - Our services - Northern Sydney Local Health District [Internet]. [cited 2022 Sep 26]. Available from: https://www.nslhd.health.nsw.gov.au/CYFH/services/Pages/ChildDevelopmentalService.aspx#

119. Services AGPS and CC. Child Development [Internet]. Community Services; 2022 [cited 2022 Sep 26]. Available from: https://www.communityservices.act.gov.au/childdevelopmentservice

120. Government NT. Child health [Internet]. https://nt.gov.au; 2022 [cited 2022 Sep 26]. Available from: https://nt.gov.au/community/parents-and-families/support-services/child health

121. Starting Better - Centre For Policy Development - Early Childhood Initiative [Internet]. Centre for Policy Development. 2021 [cited 2022 Sep 26]. Available from: https://cpd.org.au/2021/11/starting-better-centre-for-policy-development/

122. Ireland S. The World’s Best Countries For Raising Kids, 2021 [Internet]. CEOWORLD magazine. 2021 [cited 2022 Sep 26]. Available from: https://ceoworld.biz/2021/02/01/the worlds-best-countries-for-raising-kids-2021/

123. Bremberg S. A perfect 10: Why Sweden comes out on top in early child development programming. Paediatr Child Health. 2009 Dec 1;14(10):677-80.

124. Wettergren B, Blennow M, Hjern A, Sdder O, Ludvigsson JF. Child Health Systems in Sweden. J Pediatr. 2016 Oct 1;177:S187-202.

125. The national handbook in child health care [Internet]. [cited 2022 Sep 26]. Available from: https://www-rikshandboken--bhv se.translate.goog/?_x_tr_sl=sv&_x_tr_tl=en&_x_tr_hl=en&_x_tr_pto=sc

126. Hagemann E, Colvin L, Gibson LY, Miller SJ, Palmer DJ, Srinivas Jois R, et al. The ORIGINS

Project. In: Sata F, Fukuoka H, Hanson M, editors. Pre-emptive Medicine: Public Health Aspects

42

of Developmental Origins of Health and Disease [Internet]. Singapore: Springer Singapore; 2019.

p. 99–116. Available from: https://doi.org/10.1007/978-981-13-2194-8_6 126. Thompson DF. Representing future generations: political presentism and democratic trusteeship. Crit Rev Int Soc Polit Philos. 2010 Mar 1;13(1):17–37.

127. Boston J. Enhancing anticipatory governance: Strategies for mitigating political myopia in environmental planning and policy making. In: The Routledge companion to environmental planning. Routledge; 2019. p. 130–40.

128. Sindall C, Lo S, Capon T. Governance for the well‐being of future generations. J Paediatr Child Health. 2021;57(11):1749–53.

129. The Right Way: A Wales future fit for children – The Future Generations Commissioner for Wales [Internet]. [cited 2022 Oct 9]. Available from: https://www.futuregenerations.wales/resources_posts/the-right-way-a-wales-future-fit-for children/

130. Assessing impact of decisions on children and young people [Internet]. Commissioner for Children and Young People, Western Australia. [cited 2022 Oct 9]. Available from: https://www.ccyp.wa.gov.au/news/assessing-impact-of-decisions-on-children-and-young people/

131. jim. Invest in Early Childhood Development: Reduce Deficits, Strengthen the Economy [Internet]. The Heckman Equation. 2013 [cited 2022 Oct 9]. Available from: https://heckmanequation.org/resource/invest-in-early-childhood-development-reduce-deficits strengthen-the-economy/

132. Geelhoed EA, Bloom DE, Bock C, Flatau P, Mandzufas J, Li I, et al. Informing Resource Allocation for Investment in Early Childhood: A Review of the International Peer-Reviewed Evidence. Aust Econ Rev. 2022 Jun 1;55(2):215–31.

133. Richter LM, Daelmans B, Lombardi J, Heymann J, Boo FL, Behrman JR, et al. Investing in the foundation of sustainable development: pathways to scale up for early childhood development. The Lancet. 2017 Jan 7;389(10064):103–18.

Appendix

Children: Obsolete – for reference use only

Our children Our future: A framework for child and Youth Health Services in Western Australia 2008–2012

HP10703 JUNE’08 22832

Message from the Minister

43

Improving the health and wellbeing of children and youth in Western Australia is a key priority for the State Government, so it is with great pleasure that I present to you the Our Children Our Future – A framework for Child and Youth Health Services in WA 2008 – 2012 (Framework). This new Framework provides an exciting blueprint for guiding the development and delivery of health services across the State for all children and youth for the next five years, with a particular focus on Indigenous groups and socioeconomically disadvantaged populations. It provides a range of strategies that will help to improve the health experiences and outcomes of these groups. The Framework provides a vision that will assist WA Health, service providers and communities to develop local strategies to achieve the best possible future and opportunities for the children and youth in every part of Western Australia. We know that the health of children and youth must be viewed within the context of their surroundings and so the Framework proposes strategies that take into account social and environmental determinants of health such as lifestyle, housing, unemployment and family functioning. By empowering individuals and communities to address these factors, we can all contribute to improving the overall health and wellbeing of our children and young people. This Framework is an important addition to the extensive reforms being made across WA Health and will continue to ensure that high-quality and accessible health care is made available to all Western Australians and helps to improve the health and wellbeing of our future generations.

The Hon Jim A McGinty

Minister For Health

foreword Over the past fifty years there have been major demographic, social, and economic changes in Australia that have had a significant impact on the health and wellbeing of our children and young people. Positively, we have seen rates of serious morbidity and mortality from infectious disease decline, and the rates of survival after pre-term birth and childhood cancers improve. However, there are growing health risks in other areas, such as the increasing prevalence of mental health problems, and an alarming increase in the rates of sexually transmitted infections and child and adolescent risk-taking behaviours such as binge drinking. The rise in the rate of overweight and obesity in children also has a significant impact on increasing the risk of chronic health problems such as diabetes and cardiovascular disease. The health of Aboriginal and Torres Strait Islander children continues to pose challenges, with overall health outcomes poorer than other Australian children. Social, cultural, and economic differences impact on the health of Aboriginal people, and these factors must be taken into account when developing, implementing, and evaluating health policies and programs aimed at improving the health of Indigenous children and youth. Our Children Our Future – A framework for Child and Youth Health Services in WA 2008 – 2012 (Framework) provides an important basis for future health service planning for Western Australia’s children and youth, and will help to guide the development of locally relevant strategies to address health service delivery and child and youth health priorities at local and regional levels. The Framework identifies five key objectives for improving the health and wellbeing of Western Australia’s children and young people:

1. Improve the health and wellbeing of all children and youth through perinatal and early childhood intervention and prevention strategies which address the determinants of health

2. Improve child and youth health and wellbeing through the early diagnosis, acute care and ongoing treatment of current key health issues

3. Improve child and youth health and wellbeing by encouraging self-management and addressing key health-related and risk-taking behaviours

4. Improve the health and wellbeing of specific population groups through improved access and cultural sensitivity

5. Improve child and youth health and wellbeing by improving child and youth health service provision.

The strategies proposed for each of these priority areas aims to enhance current efforts being made across the health system, as well as present new approaches to improve the physical and mental health, development, and wellbeing of all Western Australian children and young people. The Framework is an important contribution to the ongoing work being delivered by WA Health, and continues to enable the health system to develop equitable and sustainable health services for all children and young people in Western Australia.

44

I would like to acknowledge and thank the WA Child and Youth Health Network Advisory Group for driving the development of this new strategic agenda for improving child and youth health and wellbeing in this State.

Dr Peter Flett

Acting Director General

Executive Summary

Background

One of the most significant developments in health over the past three decades has been the increasing recognition of the need to broaden the response to health to include a more holistic approach. The World Health Organisation’s 1986 Ottawa Charter broadened the definition of health stating that “Health is a positive concept emphasizing social and personal resources, as well as physical capacities”.1 The promotion of health and wellbeing is attained through enabling individuals and communities to address the determinants of health, which directly and indirectly impact on their health and wellbeing. There are many aspects of the health and wellbeing of Australian children and youth that indicate the need to more effectively address their health-related issues in this country. The rate of overweight and obesity has increased in children and adults in Australia, increasing the risk of chronic health problems such as diabetes and cardiovascular disease. The prevalence of mental health problems,2 rate of sexually transmitted infections3 and child and adolescent risk-taking behaviours such as binge drinking4 are also increasing at an alarming rate. In Western Australia particularly, there are inequities in the health status of children and young people. There are also a number of groups who do not have equal access to health care, such as people living in rural and remote areas; the socioeconomically disadvantaged; Aboriginal and Torres Strait Islander people; people with mental health problems; those with disabilities; and the Culturally and Linguistically Diverse (CaLD) population.5 Reducing social inequality needs to be viewed as a key strategy for promoting health. This will require particular attention and specific strategies since addressing health determinants and health problems will not necessarily reduce health inequalities.6 Our Children Our Future – A framework for Child and Youth Health Services in WA 2008 – 2012 (Framework), highlights the issues affecting children and youth and proposes strategies to improve the physical and mental health, development, and wellbeing of all Western Australian children and young people.

Scope

The Framework is designed to guide stakeholder efforts to achieve improvements in the health and wellbeing of children and youth in Western Australia across the continuum of care. Stakeholders of child and youth health in Western Australia include: Clinicians; Planners and designers. Policy makers, funders and providers; Professionals and managers; Other government agencies and non-government health service providers; Consumers. The Framework is also intended to guide the development of locally relevant strategies to address health service delivery and child and youth health priorities at local and regional levels. It aims to provide sufficient information to enable the reader to understand the context and basis of key strategies and recommendations made.

Our children Our Future

The Framework recognises the benefits of appropriately formulated population health and early intervention and prevention actions, and attempts to offer strategies that enhance current and earlier efforts in Western Australia. The Framework has been developed under the auspices of the Western Australian Child and Youth Health Network (WACYHN) Advisory Group for WA Health, to provide a new strategic agenda for improving child and youth health and wellbeing.

A/Professor David Forbes

Dr Gervase chaney

Network co-Leads

Introduction

The WA Health reform agenda emphasises the need to rethink approaches to improving the health and wellbeing of all Western Australians by improving the interface between general practice and the public health system; improving clinical practices; reducing length of stay; increasing same day surgery and other procedures; and augmenting primary and community care services. With all sectors working together in partnership to improve the health and wellbeing of Western Australian children and youth, this can be achieved.

WA child and Youth Health Network

In November 2005 the WA Health Networks were launched at a major stakeholder meeting by the Health Networks Branch (then Clinical Network Development Unit). Child and youth health was represented at this forum, and at this time Dr Simon Towler, Executive Director Health Policy and Clinical Reform appointed

45

Associate Professor David Forbes and Dr Gervase Chaney as the Co-leads for the WA Child and Youth Health

Network. The WA Child and Youth Health Network was formally established in April 2006 with the first meeting of the Network Advisory Group in May 2006. The WA Child and Youth Health Network is supported by an Advisory Group comprising clinical leaders, organisational representatives, health professionals and consumer representatives. The Framework has been developed under the auspices of the Western Australian Child and Youth Health Network (WACYHN) Advisory Group.

Framework Design

The objectives and strategies outlined in the Framework are presented using a Continuum of Care Model 7 This model demonstrates the provision of health care across the lifespan utilising all essential components of the health care system ranging from population based strategies such as health promotion and prevention services, early diagnosis and intervention, through to individual treatment, rehabilitation, and palliation services. In this model, primary, secondary and tertiary care generalists and specialists are fundamental components of the health care system and should not be viewed as mutually exclusive.8 All parts of the Continuum of Care Model are seen as essential for ensuring the health and wellbeing of the population, and together they aim to seamlessly provide the right care at the right time, in the right place and by the right people. Over the past two decades there has been a growing body of evidence indicating that population health is influenced more by the determinants of health such as socio-economic, community, lifestyle and behavioural factors than by the provision of health care services.9 Current evidence emphasises the need for health services to develop effective strategies for early identification and intervention of health and developmental problems, not only in the early years but whenever problems arise across the life course, and to better address issues around the uptake of health resources. It is now well accepted that children and youth need to be viewed within the context of the multiple influences within their lives. These include social determinants such as economic, lifestyle, poverty and social exclusion; and environmental factors such as housing, unemployment and family functioning. By enabling individuals and communities to address these determinants, improvements in their overall health and wellbeing can be effected. Therefore, underpinning the Continuum of Care Model is the concept of a health determinants approach to more effectively address the needs of children and youth. This concept has evolved across Australia to complement the traditional biomedical approach to health care, health interventions, and service delivery, highlighting the need to shift the emphasis away from the provision of acute services towards population health prevention strategies.5 By shifting focus away from the provision of health care services aimed at treating the individual who is acutely ill or at high risk of disease, to a Continuum of Care Model underpinned by a population-based approach, we may more effectively address the determinants of health. This approach seeks to alter the underlying causes of disease thereby reducing the risk factors that make disease common.10 In recognition of this, the Framework places particular emphasis on an early life course approach, that utilises health promotion and prevention, community development, universal access, and strategies that address health-related and risk-taking behaviours, to address the social determinants of child and youth health.

Contributing Literature

A number of local, national and international policies were reviewed during development of the Framework. The Commonwealth Government and most States and Territories have published a number of policies and key documents relating to child and youth health over recent years. These documents address issues pertaining to the health and wellbeing of children and young people and there are many lessons to be learned from reviewing the directions, priorities and key strategies identified by each jurisdiction. The State and Territory policies have a strong focus on service delivery and policy development,11-16 while at a national level the focus has been on health outcomes.17,18-20 Both levels of government have addressed the issues of health determinants and early intervention and prevention.16,21-27 Other relevant documents such as those generated by the National Public Health Partnership through the Child and Youth Health Intergovernmental Partnership (CHIP)28-31 and a range of indicators of child and youth health,32-35 identify future directions in child and youth health by highlighting the man factors that influence their health and wellbeing. There are currently two policy documents underpinning statewide child and youth health policy and planning in Western Australia. The WA State Health Plan for Children and Adolescents (1994),36 which focussed on service delivery and health outcomes, and the policy New Vision for Community Health Services for the Future report (2000),37 which encompassed a health determinants model with a focus on early intervention and prevention.

46

These documents informed the development of the Framework and served to advance the understanding of key priorities for children and youth and how to apply the evidence in the development of effective policies and strategies for improving child and youth health. Reference was also made to the Western Australian Department of Health Youth Health Strategy 2008 – 2013, currently under development by the Child and Adolescent Health Service Child and Adolescent Community Health Policy Unit (Statewide).

Guiding Principles

Demand for health care and health services is increasing. Total spending on health in Australia has increased over the last decade and in 2003 it was greater than the Organisation for Economic Co-operation and Development (OECD) average. Spending on pharmaceuticals has also increased at double the rate of total health spending.38 Of the total 2004-05 Western Australian health care budget however, only 2.69% was spent on public health and prevention, substantially less than the 8.57% spent in the Northern Territory39 and the 8% spent in Canada.9 Yet in spite of the increased spending in Australia, health services are struggling to cope. Better and more cost-effective ways to deliver health services with improved coordination across government, private, and community health services are required in order to keep up with the growing demand and consumer expectations.

The following guiding principles direct the focus of the Framework towards achieving the development of locally relevant strategies to address health service delivery and child and youth health priorities at local and regional levels. Principle 1 Population Health Approach: A robust and well-resourced population health approach to maintain and improve the health of the entire population, with particular focus on addressing the determinants of health and child and youth health-related and risk- taking behaviours. Principle 2 Early Intervention and Prevention: Develop an early life course approach emphasising the role of health promotion, prevention and early intervention and community development to more effectively address the needs of children and youth. Principle 3 Access and Equity: Address inequities in child and youth health status by providing universal access to public health, community health and health promotion and acute health services, especially for Indigenous, Culturally and Linguistically Diverse (CaLD) and socially and economically disadvantaged children and youth. Principle 4 child and Youth Focussed and Family centred: Emphasis on promoting a patient focussed philosophy that recognises children and youth as the most important component of paediatric health care services, and the involvement, support and education of families as fundamental to improving patient health outcomes.

Population Health Approach

Documents reviewed during the development of the Framework contained common themes, with health policies all focusing on a health development model built on a population-based approach that aims to address the relationship between risk and protective factors and the developmental outcome. Children and youth need to be viewed within the context of the multiple influences within their lives .These include family, school, and the community and the interaction between them. The impact of one cannot be viewed independently. Government policy both directly and indirectly affects social institutions and the social and economic environment, which in turn affects the resources available to families and subsequently impacts upon the ability of families to perform their functions.40 Research has also identified factors that contribute to the development of the child and play a role in determining whether a child’s development results in positive or negative health and wellbeing. These risk and protective factors include genetic, biological, behavioural, socio-cultural and demographic conditions or characteristics. The impact of these factors may occur directly, indirectly, or by mediation through another factor and should be viewed within a larger causal network rather than necessarily as a direct cause of the outcome. A strong link exists between the number of risk and protective factors an individual is exposed to and their health, academic competence, behaviour, and social and emotional wellbeing.26,41-43 The presence of multiple risk factors severely undermines the ability of the individual to develop their innate talents. Protective factors are most important when there are a high number of risk factors and it is the total number and balance of risk and protective factors that account for variation in outcome. 47

There are many widespread and systematic barriers which often limit the ability of individuals to choose health-promoting lifestyles.44 Individuals and the community require supportive environments for the achievement of good health. The Framework recognises that these supportive environments are attained through intersectorial initiatives addressing physical, social, spiritual, economic and political factors (factors which are linked and have a dynamic interaction), and with sustainable solutions requiring action at local state and national levels.45

Early Intervention and Prevention

There is a strong consensus amongst experts that intervening early in the lives of socially and economically disadvantaged children, or other children at risk of negative outcomes, can improve the health and wellbeing of many of these children. Early intervention is aimed at reducing the signs and symptoms of a disorder thereby preventing the onset of a diagnosable disorder through reducing a person’s risk factors, or minimising their effect, and enhancing their protective factors. Early intervention programs assist children and their parents through the provision of information and resources, crisis intervention services, and transitional support to help stabilise children and families over the longer term.46 There is increasing evidence highlighting the importance of early brain development on health and wellbeing. Good parent-child attachment directly affects brain development and has been shown to be one of the most important determinants of this. The evidence emphasises the need for health services to develop effective strategies for early identification of and intervention into health and developmental problems, not only in the early years but whenever problems arise across the life course, if we wish to address the issues around the uptake of health resources. Early and appropriate intervention maximises the benefit to children with developmental delay. Delaying interventions or delivering the wrong intervention for the age and circumstances of the child can have a profound and adverse impact on the effectiveness of the intervention and the child’s development, compounding the initial problem.47 This then requires a greater volume of resources, therapies and time to overcome and eventually will impact negatively on other government departments such as education services and justice. From a family’s perspective, the stress, disruption to life and functioning of the child within the family unit and community, ripples out to affect those directly and indirectly involved. The more delayed the intervention is, the more costly it becomes in every way.47 Early intervention programs are therefore likely to be more successful when they are responsive to local needs, build community capacity, have an holistic approach, build on family strengths, are accessible and inclusive, intervene early, have a prevention focus and are informed by the evidence.46 The Framework recognises the benefits of appropriately formulated early intervention and prevention actions and attempts to offer strategies that enhance current and earlier efforts in Western Australia.

Access and Equity

In Western Australia, there are inequities in the health status of children and young people, as well as a number of groups who do not have equal access to health care. These include Aboriginal and Torres Strait Islander people; people living in rural and remote areas; the socially and economically disadvantaged; Culturally and Linguistically Diverse (CaLD) communities; people with mental health problems; and those with disabilities.5 It is important however to recognise that inequalities in health extend across the whole of society, with those at the top of the socioeconomic gradient having the highest level of health, with decreasing health outcomes experienced across the whole of the population, and those at the bottom having the poorest level of health. Reducing social inequality is hence viewed within the Framework as integral for promoting the overall health and wellbeing of all Western Australian children and youth. This has been given particular attention since strategies to address health determinants and health problems will not necessarily reduce health inequalities.6 Child and Youth Focussed and Family centred When the person is placed at the centre of interactions, the ‘patient journey’ improves, people are empowered to self-manage their condition and their wellbeing and quality of life is enhanced. The Framework highlights the importance of educating, supporting and empowering people, especially children, youth and their families, to undertake actions that minimise risk factors and risk-taking behaviours and improve patient or population health outcomes.

Key Objectives for Child and Youth Health

There are many aspects of the health and wellbeing of Australian children that indicate the need to more effectively address their health-related issues. The Framework highlights the key priorities for Western Australian children and youth and proposes strategies to improve their overall physical and mental health, development, and wellbeing. Objective 1 Improve the health and wellbeing of all children and youth through perinatal and early childhood intervention and prevention strategies which address the determinants of health.

48

Objective 2 Improve child and youth health and wellbeing through the early diagnosis, acute care and ongoing treatment of current key health issues. Objective 3 Improve child and youth health and wellbeing by encouraging self-management and addressing key health-related and risk-taking behaviours. Objective 4 Improve the health and wellbeing of specific population groups through improved access and cultural sensitivity. Objective 5 Improve child and youth health and wellbeing by improving child and youth health service provision. Improve child and youth health and wellbeing through perinatal and early childhood intervention and prevention strategies which address the determinants of health.

Priorities

Mortality

The risk of infant and childhood death is highest from birth through to the fifth year of life. Many of the causes of infant and childhood mortality are preventable due to social and economic factors and inequality, so the rate of infant mortality is an indicator of the social progress of society.48 Conditions originating in the perinatal period, such as pre-term birth, fetal growth, birth trauma, respiratory and cardiovascular problems, account for 36% of all hospitalisations for infants.17 Two health issues arising in the antenatal period, pre-term birth and low birth weight, account for 5.6% of all hospitalisations for children 0 4 years.19 The cumulative mortality rate in Western Australia for infants (deaths of live born infants prior to their first birthday), has decreased over the past two decades from 8.4 per 1,000 live births in 1980 to 3.7 per 1,000 live births in 2002. While Indigenous infant mortality decreased over this period it remains significantly higher than the overall rate and in 1998-2001 it was 16.1 per 1,000 live births. The main causes for infant mortality in the general community were prematurity (27%), birth defects (27%), sudden infant death syndrome (SIDS) (19%) and infection (11%), while for Indigenous infants it was infection (29%), SIDS (27%), prematurity (16%) and birth defects (15%). The rate of Indigenous infant death attributable to infection was nine times higher than in the general community and eight times higher for deaths due to SIDS48 (refer to figure 3). The highest rates of infant mortality occurred in rural and remote locations and there has been an increase in recent years in the rate of non-Indigenous mortality in remote locations.48 Injury is the leading cause of death in children over one year of age. The leading cause of injury- related death in pre-primary children is drowning, closely followed by road trauma. In Indigenous pre-primary aged children, infections, primarily respiratory, accounted for 28% of deaths. Cancer caused 25% of deaths in children of primary-school age and older.48 furthermore, the incidence of some adult onset cancers can be associated with risk factors stemming from childhood such as sun exposure, obesity and exposure to tobacco smoke.

Parental Behaviours and Family Functioning

There are a number of basic needs that children require for their development, which transcend cultural differences and changes in parenting behaviour across time.49 While physical care, nutrition, and protection are basic requirements, the importance of meeting the emotional needs of infants and children should not be underestimated. Children require love, care, commitment, consistency, guidance, and facilitation of their social and emotional development, which is provided through good parent-child attachment, stimulation, involvement, and support. Family and domestic violence is thought to be more damaging and more closely associated with child behaviour problems than non-aggressive forms of conflict.50 Children exposed to parental violence are more likely to use violence to resolve conflict than non-exposed children; to believe that their behaviour was in some way responsible for the violent behaviour within the family;51 and to continue the violence through adolescence and into adulthood.52 family and domestic violence sets the foundation for the intergenerational transmission of violence.52,53 Children of parents affected by a mental illness are at increased risk of developing emotional and behavioural problems and mental health disorders, but parents accessing mental health services may not disclose that they have children for fear of losing care of them. Many parents with mental health problems are also compromised by substance use/misuse.54 Parental alcohol and other drug use/misuse can affect children in a number of ways. In-utero exposure to alcohol and other drugs increases the risk of fetal harm and poor birth outcomes. Exposure to alcohol during pregnancy can result in permanent damage to the fetus resulting in fetal Alcohol Spectrum Disorders (fASD).55

49

Tobacco smoking is associated with low birth weight, preterm birth, birth anomalies, and perinatal death,17 while the impact of illicit drugs will vary according to the type of drug. The use of narcotics can result in Neonatal Narcotic Abstinence Syndrome, which includes neurological excitability, gastrointestinal dysfunction, and autonomic dysfunction, while the effects of cocaine and non-narcotic drugs appear to be due to the toxic effect of the drug rather than withdrawal. Infants exposed in-utero to these drugs show a range of signs and symptoms that vary with the type of drug used.56 Children of parents with a mental illness and those whose parents misuse alcohol and other drugs are exposed to a number of interacting risk factors stemming from their environment and family factors such as poverty, poor antenatal care, a less stimulating home environment, domestic violence and poor parenting.54,57-60 These negative factors increase the risk of the child developing adverse cognitive, behavioural, and psychosocial problems.54,59,61,62 Parents with mental health or substance use issues often access the services of a range of health-care professionals, highlighting the importance of an intersectorial, collaborative approach to service provision for both the drug user and their family.63 Services need to be coordinated to ensure the transition between services for pregnancy, delivery, and thereafter is smooth and that the potential risk for the child is accurately assessed and monitored. Home-based clinical intervention programs have been found to assist in improving the parenting skills of high-risk parents resulting in improvements in child behaviour and developmental skills.64 Breastfeeding and Early childhood Nutrition Normal growth and development requires appropriate energy and nutrients. Not only is a good dietary intake of nutrients essential for the growth and development of children and adolescents, it is also proven to be equally important during pregnancy and infancy. The rate of growth is highest during infancy and adolescence, making these age groups nutritionally vulnerable. However, although the rate of growth is slower in young children they also require appropriately balanced nutrient and energy intake.65 All mothers should be encouraged and supported to breastfeed their infants. In Australia, although 83% of women are breastfeeding their infants upon discharge from hospital following delivery, the rate of breastfeeding declines rapidly thereafter and by 6 months, less than two-thirds of infants are breastfed.66 Demographic, social, and economic factors impact on the rate of breastfeeding, indicating the need for a comprehensive public health strategy and community engagement to support and encourage maintenance of breastfeeding.67

Immunisation and Transmissible Disease

The National Health and Medical Research Council (NHMRC) recommend greater than 90% immunisation coverage for children 2 years of age and almost 100% coverage at school entry.17 Immunisation rates in Western Australian children are below the levels recommended by the NHMRC with 90.6% of children fully immunised at 2 years of age and only 81.1% fully immunised at 6 years in 2004. This is of considerable concern since vaccine coverage needs to be greater than 90% in order to interrupt transmission of vaccine-preventable diseases. There has also been a steady addition of new vaccines to the immunisation schedule, particularly since 2000. These additions include vaccines for Hepatitis B, Meningococcal C, Pneumococcus, Rotavirus and Human Papilloma Virus. Despite the current use of more conjugate vaccines, this has led to an immunisation schedule that is more complex, involving a larger number of injections which carries a potential risk of increased immunisation avoidance or error.

Early childhood Development

Early Childhood Development (ECD) programs typically intervene in the early years until at least the beginning of primary school, providing assistance primarily to the child but also to the parents. for children at risk of developmental, behavioural or emotional delays/disorders as a result of social determinants, such as teenage pregnancy or parental mental health or substance misuse issues, intervention services need to be provided at the earliest possible age. There are substantial benefits to the individual child, their families and society, as well as substantial financial benefits to governments far in excess of the costs of such programs. Economic evaluations indicate cost-benefit ratios ranging from AUD$4.00 for every dollar spent68 up to a high of

AUD$12.90.69

It is important to recognise that early intervention strategies should not be confined to the first five years of life. Problem pathways begin not only in early childhood but also across the lifespan with many problems appearing during adolescence. “Early in the pathway” is not necessarily the same as “early in life”.70

Critical or Sensitive Periods

There is rapid growth and development of the brain from conception until pre-school age and by the age of three years the brain has achieved 90% of its adult size. Brain development and restructuring is influenced by physical, social and emotional, cognitive, and nutritional conditions and undergoes structural development at regular intervals during childhood, reaching full size in adolescence.71

50

During the early years the child’s brain is responsive to the environment and this period of a child’s life is critical to their development. The experiences of the infant and young child provide the foundation for cognitive development and long-term physical and mental health. Research has clearly demonstrated a significant negative relationship between adverse childhood experiences (such as abuse and household dysfunction), and adult health and wellbeing.72 There are key developmental stages when children are particularly sensitive to environmental circumstances. These ‘critical or sensitive periods’ require specific information from the physical and social environment in addition to their genes, to develop brain structures and processes ultimately responsible for social recognition, growth, behaviour and bonding. Successful negotiation of critical and sensitive periods enhances the likelihood of children and young people developing positive health and wellbeing.73 Transition periods in a person’s life, such as the transition to preschool or from primary school to high school, are times of particular risk. During these transition periods, exposure to a complex array of risk factors has the potential to undermine individual development. for that reason, the most effective interventions are targeted to the appropriate life phase, whether this is during early or middle childhood or adolescence.70 This is referred to as a ‘life course approach’. Therefore, childhood and adolescence provide both an opportunity for optimal development and a vulnerable period sensitive to negative influences, and it is the balance of these which will determine health outcomes.71,74

Strategies

Mortality

 Develop an education campaign to reduce the rate of Sudden Infant Death Syndrome, especially in Indigenous communities.  Support programs that improve public knowledge of prevention and first aid treatment for drowning, burns and scalds, poisoning, and other childhood injuries.  Promote child-rearing and supervision skills of new parents, with advice on home modifications to improve child safety through home-visiting programs.  Lobby for the establishment of a system of free, low-cost or loaned home safety equipment, such as child resistant closures, car seats, and smoke alarms for socially and economically disadvantaged families.  Support population-based public health programs that aim to reduce the incidence of, and mortality, from cancer including programs that target risk factors stemming from childhood such as sun exposure, obesity and exposure to tobacco smoke.  Support strategies that promote equitable access to cancer and palliative care clinical and support services for all children and youth, especially those living in rural and remote locations.

Parental Behaviours and Family Functioning

 Reduce the prevalence of maternal alcohol, tobacco, and illicit drug use and periodontal disease during pregnancy through the development of: o Guidelines for routine antenatal screening for risk factors o Policies and guidelines for the routine use of brief interventions o Referral pathways to ensure timely access to appropriate services.  Develop programs and strategies to ensure equity and access to health care, prevention, and early intervention programs for children ‘at risk’ due to parental behaviours such as substance misuse or mental health, child abuse, homelessness, especially for Indigenous, CaLD and socially and economically disadvantaged families.  Undertake economic and outcome based evaluations of current home-visiting programs for high risk new mothers.  Provide antenatal and postnatal home visiting to all new mothers.  Provide intensive postnatal home visiting programs (such as Best Beginnings) for all high risk mothers and their infants across all of WA.  Screen all new mothers for postnatal depression and provide appropriate referral and intervention strategies.  Develop and disseminate programs to improve family functioning and parenting.  Provide parenting programs in a variety of settings to: o All new parents with an emphasis on providing services to those families identified at high risk of poor outcomes

51

o Parents of children entering school and in transition to high school. o

Breastfeeding and Early Childhood Nutrition

 Develop health promotion programs to educate pregnant women about the key dietary requirements for a healthy pregnancy.  Support current programs, and develop and disseminate breastfeeding support policies and programs to increase the percentage of infants fully breastfed at 4 and 6 months.  Develop health promotion programs to increase the knowledge of good nutrition and to promote the early adoption of healthy eating patterns by parents, children and youth.

Immunisation and Transmissible Disease

 Increase the percentage of children fully immunised at 1, 2, and 6 years to 95% by working with primary care providers and the Department of Education to promote current immunisation programs, as well as immunisation using newer vaccines as they are introduced.  Encourage the adoption of opportunistic immunisation in the hospital and other health care settings.

Early Childhood Development

 Provide assessment for health and developmental problems for all children, especially children in care.  Develop evidence-based programs for infants and children who are showing signs of delayed speech and other developmental problems.  Develop guidelines to ensure quality educational programs are implemented in all childcare settings. Extend the availability of play therapy programs for children with severe behavioural problems.  Implement universal neonatal hearing screening in WA.

Critical or Sensitive Periods

Promote the development of programs and strategies to enhance transition into pre-primary, primary and high school. Improve child and youth health and wellbeing through the early diagnosis, acute care and ongoing treatment of current key health issues.

Priorities

Child Abuse

Child abuse and neglect can have a profound negative impact on the health and wellbeing of children and young people, both in the short term and long term. There is no reliable data in Australia to determine the extent of child abuse. Child protection substantiations, which are an underestimate of the true prevalence of child abuse and neglect, are used as a proxy measure. Rates of protection substantiations are highest in children under one year of age, decreasing thereafter with age. There has been an increase in rates of child protection substantiations across Australia from 5.1 per 1,000 children 0-14 years in 1997-98, to 7.2 per 1,000 in 2002-03. The rate of substantiations in most States and Territories is around 2.5 times higher than in WA where the rate is 2.3 substantiations per 1,000 children. In the ACT and Queensland the rate is 5-6 times higher.75,76 Physical abuse and neglect account for over two-thirds of all substantiations in WA.75 It is however, difficult to determine the true extent of the trend as changes in child protection policies and practices are thought to have contributed to some of the changes in these rates.17 Western Australia is the only state in Australia that does not have universally applicable mandatory reporting of child abuse. Only family Court personnel, counsellors, mediators and licensed providers of child care and outside school hours care services are required by legislation to report allegations or suspicions of child abuse. A recent review of the Department for Community Development, now called the Department for Child Protection (DCP),77 recommended better implementation of policy, improved interdepartmental cooperation and accountability and improving service provision for vulnerable children and young people. Under recommendations in the review report, mandatory reporting by doctors and nurses of evidence of child sexual abuse is to become mandatory from 2008. 52

There are a number of factors which increase the risk of child abuse and neglect, such as poverty, family disruption, domestic violence and substance abuse.17 Effective parenting is necessary for the social and emotional wellbeing of the developing child,78 and the quality of parenting and child development can be severely hampered by family stress and negative life experiences.79-82 Marital distress impacts negatively on parent-child relationships83 with parents in conflict more likely to portray inconsistent, harsh parenting84,85 and to have negative views of the child’s behaviour.84 These features of marital discord can negatively impact on the child’s behaviour and mental health.86 Prevention of child abuse and neglect is a key issue for every jurisdiction and strategies need to be implemented which decrease the risk of child abuse and neglect, and enhance the number and range of protective factors within a child’s life.

Mental Health and Behaviour

Although 80-90% of adolescents will develop into healthy young adults, the remaining adolescents will develop serious problem behaviours between 12 to 18 years of age. Many of these problems are not new but they are increasing in prevalence, burden, and complexity, particularly in association with socioeconomic inequality. Although data is limited, the evidence indicates that between 7% and 14% of children aged 4-14 years have psychological and behavioural/emotional problems, with the three most frequently recorded disorders being attention-deficit hyperactivity disorder (ADHD), depressive disorder and conduct disorder. Mental health problems are directly associated with physical health, quality of life, poor academic achievement, and risk-taking behaviours.17,19 Almost one-third of young people will have an episode of mental illness and over 75% of all serious mental health and substance use disorders commence prior to 25 years of age.41 Around 10% of young people 15-24 years of age report long-term mental health and behavioural disorders however this rate is higher in Indigenous children. The Western Australian Aboriginal Child Health Survey (2005) indicated that 24% of Indigenous children aged 4-17 years had clinically significant emotional or behavioural problems compared with 15% of all children in WA.87 Social and emotional problems result from an interaction between the social environment and human biology, and are compounded by intergenerational transmission of risk. The rate of mental health and behavioural problems in children is not uniformly distributed across the population a number of demographic factors have been found to be associated with child mental health problems. The rates of externalising and internalising problems, for example, are higher in children who live in step/blended families, single parent families and households with a low income, than in two-parent households and households in the higher socioeconomic groups.17 Data from the Australian Institute of Health and Welfare indicates that mental health and behavioural disorders are the fourth most common reason for hospitalisation of young people 12-24 years of age with a rate of 1,265 hospitalisations per 100,000 young people.18 It is considered however, that these rates underestimate the true prevalence of mental health problems in young people.

Diet and Nutrition

Good eating patterns need to be established early in childhood to help prevent the development of weight problems and disordered eating patterns. Early dieting is a predictor of the development of disordered eating and a range of disordered eating patterns such as dieting, binge eating, with purging and concerns about body size and image being relatively common in adolescents.65

Overweight and Obesity

There has been a dramatic rise in the rates of overweight and obesity in children and young people in Australia over the past two decades.88 In 1985 around 10% of boys and girls 7-15 years of age were overweight and the prevalence of obesity was 1.4% for boys and 1.2% for girls. By 1995, 15% of boys and 16% girls were overweight while the prevalence of obesity had tripled in boys and increased four-fold in girls.89 More recent data from New South Wales indicates a worsening of this trend with 16% of boys and 21% of girls aged 7-11 years overweight while the prevalence of obesity was 10% and 7% respectively90 (refer to figure 4). South Australian data also indicates that the same trends are occurring in preschool children with 21% of four year old girls and 17% of four year old boys being either overweight or obese in 2002; a significant increase from 1995.91 Individuals who are obese are at increased risk of poor health outcomes, in particular Type 2 diabetes, cardiovascular disease, osteoarthritis, cancer and mortality. In 2006 the cost of obesity in Australia was estimated to be almost $3.8 billion in health, productivity, and other costs. These costs are carried primarily by individuals, their family and carers, and the federal and State Governments, however, obesity is a major concern for the whole community.92 Obesity is difficult to treat and the associated physical and psychological problems and the high risk of overweight children becoming obese adults make prevention of overweight and obesity in children and young people a key priority area.65

53

Physical Activity

Physical activity is also an essential part of life contributing to physical growth, the development of skills, and helping to balance energy intake and output. Low levels of physical activity are associated with higher rates of overweight and obesity. Physical activity decreases through adolescence and with increasing television viewing and use of computers and electronic games. Television viewing also exposes children and young people to a large array of food advertisements, which have been shown to influence food choices.65 The Royal Australasian College of Physicians (RACP) highlight research findings that indicate Australian children’s television has one of the highest rates of advertising in the world. They recommend that parents and carers take an active role in supervising children’s television viewing habits.93

Chronic Conditions

Chronic health conditions are a significant contributor to the disease burden among Australian children and young people. Diseases of the respiratory system are the most common long-term conditions in children and youth, with around 13% of children 0-14 years reporting asthma as a long-term condition and around one-third of young people 15-24 years of age having a respiratory condition, primarily asthma (12%) and hay fever.17,18,94 The increasing incidence of Type 2 diabetes is another major contributor to the chronic disease burden in Australia, and is shown to be linked closely to the prevalence of childhood overweight and obesity.

Respiratory

Respiratory conditions contribute the greatest health burden for health services with 11% of hospital admissions for children 0-4 years of age due to bronchiolitis, otitis media, and asthma, while in the 5-9 year age group 15.7% of hospital admissions are due to tonsils and adenoids, otitis media, and asthma. In young people aged 12-24 years respiratory conditions are the sixth most recorded reason for admission with a rate of 1,129 hospitalisations per 100,000 young people. The rate of hospitalisation for asthma is higher than for any other chronic condition.95 Respiratory conditions make up five of the top six most commonly managed problems by GPs, accounting for 29.8% of all problems managed.25 Of chronic health conditions, asthma is the most frequent presenting problem accounting for 47.9% of all presentations to GPs for chronic disease conditions.95

Diabetes

There is evidence to indicate that the rate of diabetes mellitus is increasing in children and youth. The incidence of Type 2 diabetes, previously uncommon in children, has increased as the prevalence of overweight and obesity has increased,96 and this increases the risk of health problems such as heart disease, stroke and blindness.88 The rate of Type 1 diabetes is 20.3 per 100,000 for boys and 18.9 per 100,000 for girls and the rate increases with age; this too has been steadily increasing over time.17 The hospitalisation rate for diabetes is 37.6 per 100,000 children 0-14 years, with the highest rate seen in boys (93.4 per 100,000) and girls (45.7 per 100,000) aged 10-14 years.95

Dental

Dental health issues contribute a high proportion of hospital admissions for 5-9 year olds, with dental caries accounting for 6.7% of admissions and impacted teeth accounting for just over 3% of hospitalisations for 10-14 year olds.97

Strategies

Child Abuse

 Encourage and support parents, families and communities in safeguarding and promoting the wellbeing of children.  Develop prevention and early intervention responses to child abuse that support families and communities most at risk.  Utilise guidelines for all staff working with children to delineate responsibilities for issues relating to child protection.  Develop therapeutic support programs for children-in-care who have been exposed to domestic violence and abuse and their foster-carers.

54

Mental Health and Behaviour

 Develop programs to enhance positive mental health in all children and youth across Western Australia with targeted strategies for high risk groups, such as Indigenous children and youth and refugees from war-torn countries.  Promote collaboration between policymakers in the mental health, alcohol and other drugs and child protection areas to develop policies for routine health screening and appropriate referral to health services of children who are in high risk settings where there is concern about their health, including their mental health and development.  Increase the number and accessibility of culturally appropriate mental health services for children and youth, particularly Indigenous, CaLD and socially and economically disadvantaged populations.

Diet and Nutrition

 Develop evidence based programs to promote the uptake of healthy eating and the maintenance of healthy weight.  Develop training strategies and health promotion programs for childcare workers to increase their knowledge of best practice and their ability to educate parents about healthy eating and active play.  Develop strategies to improve the skills of staff working in the health sectors including hospitals, community health services, and primary care service providers to routinely educate parents about good nutrition and physical activity for their children.  Develop guidelines for the treatment and referral of children and young people who are overweight or who may have an eating disorder to programs and clinical management services in consultation with key stakeholders.  Improve access to nutritious, reasonably priced food for people in remote areas and socially and economically disadvantaged groups.  Develop guidelines promoting healthy eating and active play in all childcare settings.  Support and develop programs for healthy eating and increased physical activity at schools.

Chronic conditions

 Support the implementation and ongoing monitoring of key current national chronic disease prevention strategies, including: o National Public Health Strategic framework for Children 2005 – 2008 o Healthy Weight 2008 – Australia’s future: The National Action Agenda for Children and o Young People and Their families o National Service Improvement framework for Asthma o National Service Improvement framework for Diabetes  Support consistent health messages that address the common behavioural risk factors for chronic disease, especially respiratory conditions and diabetes.  Provide support to families to allow them to care for children who have a chronic health condition in their own home.  Support children, youth and their families to participate in developmentally and culturally appropriate chronic disease self-management activities, especially Indigenous, CaLD and socially and economically disadvantaged families.

Dental

Promote good oral health promotion messages directed towards parents and focusing on twice daily brushing of teeth with fluoride toothpaste and reducing frequent exposure to sugars. Support school based oral health promotion and education programs across Western Australia. Improve access to dental services for all children and youth, especially pre-school children and school-leaving age youth of Indigenous, CaLD and lower socioeconomic status.

55

Improve child and youth health and wellbeing by encouraging self-management and addressing key health-related and risk-taking behaviours.

Priorities

Self-Management

Self-management is the active participation by people in their own health care. Self-management incorporates health promotion and risk reduction, informed decision making, care planning, medication management, and working with health care providers to attain the best possible care and to effectively negotiate the often complex health system.98 There has been a recent surge in interest in patient self-management as a result of a number of converging influences: new ideas about clinical care, universal concern about costs, shifting consumer habits and expectations of health services, and an explosion of technological innovation.99 Optimising self-management is essential to achieving person-centred care and needs to be supported at all levels of the health system. Self-management enhances people’s capacity to take responsibility for their own health, and with the support of health care providers, make informed decisions and undertake responsible health service utilisation and health-related behaviours that maximise their wellbeing and quality of life.98 The involvement of children, youth and their families in self-management activities, is integral to the early initiation and maintenance of these behaviours into adulthood. The ability of health care professionals to facilitate the flexible delivery and content of self management education programs to children, youth and their families has been shown to be more successful at raising awareness and participation in self-management than reliance on social marketing alone. furthermore, social marketing approaches to improving patient participation in self-management activities do not sufficiently engage marginalised sectors of the community, leading to concerns that inappropriate promotion and implementation of self-management activities can in fact increase social inequities, as people with limited education and low economic resources are not being reached.100 Support for self-management should be put in place at the earliest opportunity as the ability of individuals to self-manage is likely to be enhanced the earlier it is started. General practice and other primary health care settings are particularly well suited to encouraging the appropriate early adoption of self-management practices by children, youth and their families.98 In recognition of this, the Australian Government has made an unprecedented provision for the implementation of chronic disease self-management education and training activities for both patients and clinicians over the next five years through the National Chronic Disease Strategy,98 National Service Improvement frameworks and the Blueprint for Chronic Disease Surveillance.101

Health–Related and Risk-Taking Behaviours

Behaviours adopted during childhood and adolescence influence attitudes and behaviours throughout life, and establishing responsible patterns of behaviour early in life helps to reduce the negative impact on health, both in the short-term and long-term.17 Alcohol and other illicit drug use also affects the incidence of other child and youth health-related and risk-taking behaviours such as drunk/drug driving, risky sexual health practices, anti-social and aggressive behaviours and intentional self-harm and suicide. In 1999-2000, alcohol-attributable injury and disease accounted for over 3,300 14-17 year olds being hospitalised.102

Alcohol Use

The contribution of alcohol to preventable harm in Australia is second only to tobacco.103 Over two-thirds (71%) of young Australians aged 14-19 years report that they consume alcohol.104 While the proportion of young people 12-17 years of age drinking alcohol has not changed over the past two decades, the proportion drinking at risky/high risk levels has increased. In the 16-17 year olds currently drinking alcohol, binge drinking has increased from around 34% in 1984 to 41% in 2002 for both boys and girls. The same pattern can be seen for 12-15 year olds with the percentage of girls binge drinking increasing more rapidly over this period from 14% in 1984 to 21% in 2002 compared with 11% and 16% (respectively) for boys of this age.4 It has been estimated that over 80% of alcohol consumed by young people in Australia is consumed at levels that place them at risk or high risk of acute harm.102 Excessive and/or risky patterns of alcohol consumption not only place young people at risk of short-term harm, it also increases the risk of harmful drinking patterns continuing in later life.105,106 Conversely, those using alcohol less than once per week are more likely to maintain this pattern into adulthood.107 The age of initiation of the use of alcohol and other drugs has decreased over the past 50 years.

56

While only 16% of people born between 1940-44 used alcohol by the age of 15 years, this increased to 56% for people born between 1980-84.108,109 Parenting behaviours, parental characteristics, and the quality of the parent-adolescent relationship have been demonstrated to influence adolescent alcohol use, problematic use, and chronic misuse.106 There is some evidence to indicate that delaying the uptake of alcohol during adolescence reduces the likelihood of alcohol problems in later life. Teenagers who start drinking by 14 years of age are four times more likely to develop alcohol dependence than young people who start drinking at 20 years of age or older.106

Tobacco Use

Tobacco use is estimated to be the greatest contributor to preventable health and social costs,107 contributing almost 10% of the total burden of disease in Australia.17 Prevention of smoking by young people is an important public health goal since people who do not commence smoking when they are young are unlikely to begin at all. There has been a decreasing trend since 1984 for young people to smoke,17 however there is still a substantial minority of young people using tobacco. The 2004 National Drug Strategy Household Survey findings indicate that almost 13% of 14-19 year olds use tobacco, with 9.5% using on a daily basis, 2% weekly and 1.3% less than weekly.108 These data show that the rate of smoking in young people increases with age from around 3% of 12-15 year olds, 12% at 16-17 years of age and increasing to 21% at 18-19 years of age with the rate peaking in the 20-29 year old age group at almost 30%.

Illicit Drug Use

Almost 30% of young people 14-19 years of age have used illicit drugs at least once, with 21% reporting use within the past year. This increases to 58% of 20-29 year olds reporting use at least once in their lifetime, of which 31.5% report recent use. The most commonly used illicit drug is marijuana/cannabis, with 5.2% of 12-15 year olds reporting recent use, increasing to 26.5% of 18-19 year olds.108 Cannabis use is associated with both short-term harms such as impaired cognition and mental health problems, and long-term harms such as cognitive and memory deficits, low academic performance, respiratory damage, and dependence. Adolescent cannabis use increases the likelihood of other illicit drug use.107 The percentage of young people 12-19 years reporting recent use of other illicit drugs is low with around 3% reporting the use of methamphetamines, ecstasy, and analgesics for non-medical purposes108. The use of more than one substance in a single occasion, known as poly drug use, increases the risk or later substance use problems with early poly drugs use an important predictor of adult poly drug use.108

Intentional Self-Harm and Suicide

In young people aged 17-23 years, death attributable to suicide accounts for 26% of all deaths, and 41% for Indigenous young people of the same age. The rate of intentional self-harm and suicide also increases with age and with the use of alcohol and/or illicit drugs and is five times higher in Indigenous youth than in the general community.109

Sexual Health and Practices

Adolescents and young adults have the highest rates of sexually transmitted infections (STIs) in Australia. STIs are a cause of morbidity, infertility, pelvic inflammatory disease, ectopic pregnancy, complications in pregnancy, disability, premature mortality and increase the risk of HIV transmission three- to five-fold.3,110 Chlamydia and gonorrhoea are the most commonly notified STIs8 and since 1993, the rate of chlamydia has increased six-fold and the rate of gonorrhoea has doubled.111 The highest rates of notifications for chlamydia are found in 20-24 year olds (36% of notifications) and 15-19 year olds (30% of notifications) while for gonorrhoea the percentages are 23% and 30% respectively. Syphilis notifications are low across the general community, however the rates are twenty-eight times higher among Indigenous people.111 The birth rate for 15-19 year olds in WA and SA is around 21 per 1,000,112,113 with rates much higher for Indigenous females.19 The abortion rate for 15-19 year olds in 2005 in WA was 21 per 1,000, giving a pregnancy rate of 42 per 1,000.113 While there is evidence to indicate that school sex and relationship education (SRE) programs improve knowledge of sexual health,114 there is a wide gap between knowledge of sexual health and delaying sexual initiation, safer-sex practices and pregnancy prevention.115-123 Adolescents often delay practising contraception for up to a year after becoming sexually active124 and around a third of teenagers do not use any contraception the first time they have sex125 or at their most recent intercourse.126 There is a high failure rate of individual contraceptive methods

57

indicating the need for increasing the use of dual contraceptive methods in order to prevent conception and the transmission of STIs. The use of both condoms and a female method of contraception however is not generally promoted or widely understood and practised in Australia.127 There is increasing recognition that programs focusing only on the sexual antecedents have limited success in preventing unplanned adolescent pregnancy.128,129 The evidence clearly highlights the need to adopt a range of strategies, in addition to SRE programs, targeting non-sexual factors such as individual and peer characteristics, family, school, and community features including strategies aimed at delaying initiation of sexual activity and enhancing life choices.127,128

Road Safety and Driver Behaviour

Motor vehicle accidents were the main cause of death for children and youth up to 23 years of age (54% of deaths in young people 17-23 years of age and 48% for Indigenous youth of the same ages). Alcohol and illicit drugs were present in 49% of non-Indigenous motor vehicle deaths and in 58% of Indigenous motor vehicle deaths. Over 50% of all alcohol-related crash victims are between 15-24 years of age129 and almost one-third of all alcohol-related hospital admissions for assault injuries are in this age group.130

Sun Protection

Australia has the highest rate of non-melanoma skin cancer (NMSC) in the world131,132 with the incidence rate reported to be 1,000-2,000 per 100,000 per year131. The rate of NMSC has been increasing worldwide since the 1960s due to in part to increased sun exposure through changes in behaviour and depletion of the ozone layer.131 Around 374,000 Australians are treated for NMSCs each year, almost 9,000 are diagnosed with melanoma each year and more than 1,400 die each year.132 In Australia and New Zealand, malignant melanoma ranks as the fourth most common cancer.131 Parental sun protection behaviours directly impact on the adoption of sun protection measures by children and young people. Adolescents, however, are recognised as having a low rate of using sun protection.135 Primary prevention of sun exposure and intense intermittent sun exposure in children and young people are key strategies to reduce the rates of NMSC and malignant melanoma.131,133,134

Strategies

Self-Management

 Support the integration of tailored self-management with medical management that is developmentally and culturally appropriate for children, youth and their families, especially for Indigenous, CaLD and socially and economically disadvantaged groups.  Support alternative approaches to improving appropriate participation in self-management by children, youth and their families, including: o Targeted and appropriate social marketing and health promotion o Self help and internet-based resources o Telephone counselling o Mentoring and peer-based support. o Encourage greater participation by health care professionals in formal self-management education and training to support children, youth and their families to engage in self-care.

Health-Related and Risk-Taking Behaviours

 Support prevention programs that aim to prevent the uptake of adverse health-related and risk-taking behaviours in children and youth, including alcohol, tobacco and illicit drug use, risky sexual practices, risky driving behaviours and prolonged exposure to the sun.  Develop mentoring programs for high-risk adolescents with the aim of reducing risky alcohol, tobacco and illicit drug use, behaviour problems, and risky sexual practices, and enhancing school attendance and achievement.  Support measures to identify children and youth at high risk of engaging in intentional self-harm and attempted suicide, especially Indigenous, socially and economically disadvantaged groups and refugees from war-torn countries, and provide culturally appropriate support and acute interventions.  Support a range of strategies to promote safe sex practices targeting both sexual and non-sexual factors such as individual and peer characteristics, family, school, and community features, and strategies aimed at delaying initiation of sexual activity and enhancing life choices.  Promote advanced driving skills training programs through high schools.

58

 Support family-focused and community-focused (including schools, sport and recreation and outdoor employment) strategies that increase awareness of responsible sun protection behaviours, and early uptake of sun protection behaviours by children and youth.

Improve the health and wellbeing of specific population groups through improved access and cultural sensitivity.

Priorities

Over the past fifty years there have been major demographic, social, and economic changes in Australia that have had a significant impact on the lives of Australian children and their families, often constructing systematic barriers which limit the capacity of individuals to live healthy lives. One significant barrier is the unacceptably high level of inequality within Australia. The OECD measure of inequality places Australia 15th out of 26 nations, indicating greater income inequality within Australia than in the majority of OECD countries.38 Improvements in the health of Australians during the 20th century have not been experienced equally by all members of society and in some areas the disparities have been expanding.135 People from disadvantaged backgrounds have more risk factors present in their life and are significantly more likely to experience poor health, to engage in risk-taking behaviours, and are less likely to use preventative health care services in favour of GP services, than more affluent members of society.

Indigenous

Social, cultural, and economic differences impact on the health of Aboriginal people. Overall, the health of Aboriginal and Torres Strait Islander children is much worse than for other Australian children, with higher rates of hospitalisation among Indigenous children a measure of this.17 The rate of hospitalisation of Indigenous infants is 1.7 times that of non-Indigenous infants and for children 1-14 years it is 1.4 times higher. This data clearly indicates that we would need to spend around 40% to 70% more on health care for Indigenous children compared with non-Indigenous children in order to reflect the discrepancies in health and wellbeing and address Indigenous health disadvantage. Currently though, health care expenditure for Aboriginal and Torres Strait Islander peoples is only 18% higher than for other Australians136 and at this level of funding we have not been able to reduce the disparity in health status. A serious commitment for increased funding directed at prevention and early intervention programs and early treatment services is required.137

Socially and Economically Disadvantaged

Children and young people raised in socially and economically disadvantaged families are often exposed to a myriad of risk factors such as insufficient or sub-optimal food, poor quality housing, and a lack of timely health care. They are less likely to finish high school and to be gainfully employed, and more likely to suffer from health and mental health problems and be involved in criminal activities and antisocial behaviour.64 In Australia, the mortality rate of infants living in the most disadvantaged 20% of society was twice that of the least disadvantaged 20% while for Indigenous infants the rate was three times that of other Australian infants.19 The greatest difference in rates was for injuries and poisoning with a rate of 18.5 deaths per 100,000 Indigenous children 1-14 years compared with 7.3 per 100,000 for other Australian children in the same age group.19

Culturally and Linguistically Diverse

Based on 1996 Australian Bureau of Statistics estimates, 29.3% of Western Australia’s population was born overseas (23.3% nationally). Those from non-english speaking backgrounds (NESB) constitute less than half of these. There is diversity within this group and the clusters of same language speaking groups are small and many. While most from English speaking backgrounds are from the United Kingdom, some 5% with varied cultural backgrounds come from other areas such as the African and South American continents. Not included in these statistics are those people who are Australian born but who identify with the culture and/or language of another country.138 The determinants of health status for people from Culturally and Linguistically Diverse (CaLD) backgrounds are a complex interaction of factors. These include historical exposure to disease (e.g. tuberculosis or malaria), communication (language barriers and English proficiency), cultural norms and attitudes to health issues, employment status, gender, family and community contacts, service utilisation and environmental factors.138 Refugee children and Youth Children and young people make up a significant proportion of the humanitarian refugee intake 59

in Australia and New Zealand and are arguably the most vulnerable subgroup. The health needs of refugee children and young people have been well documented and include high rates of preventable conditions including psychosocial morbidity and sequelae, due to poor access to health services. Of particular concern are those children and young people who are ‘unaccompanied minors’, who lack the protection and support of their families.139 Despite complex health needs in refugee children and young people, service delivery is fragmented and there are many barriers to providing the most effective health care. There are wide local variations in the health care provided, and preventive activities known to be highly effective, such as immunisation and early detection of infectious disease, are not routinely offered. Health care delivery is further complicated by the shifting responsibility between state and federal governments, and government and non-government organisations.139

Strategies

 Provide culturally and linguistically competent child and youth health services across the continuum of child and youth health care, with particular emphasis on: o Patient and parent support services o Child protection and safety services o family and domestic violence intervention o Acute and chronic care services.  Advocate for improved access to services for disadvantaged groups of children and youth, particularly for Indigenous, CaLD, socially and economically disadvantaged, and children and youth living in rural and remote regions of Western Australia.  Develop strategies and policies to improve access to transport for Indigenous, CaLD and socio economically-disadvantaged children and youth and their families to attend outpatient services in the metropolitan area.  Promote the use of video conferencing by health specialists for the provision of prevention, early intervention, and treatment services to people living in rural and remote regions of Western Australia.  Increase the number of culturally appropriate video conferencing services targeting the health needs of Indigenous children and youth living in rural and remote regions of Western Australia that provide prevention, early intervention, and treatment services.  Develop policies and guidelines that assist in transforming existing mainstream health promotion, and perinatal and early childhood intervention and prevention services so that they are more accessible and culturally appropriate for Indigenous, CaLD, and socio- economically disadvantaged children and youth and their families.  Encourage the involvement of Indigenous, CaLD and socially and economically disadvantaged community members in the development of culturally and linguistically responsive child and youth health policy.  Encourage the involvement of Indigenous, CaLD and socially and economically disadvantage community members in the planning and design of child and youth health services.  further raise the awareness of the particular health needs of refugee children and youth and improve methods to address these across the continuum of care.

Improve child and youth health and wellbeing by improving child and youth health service provision

Priorities

The Framework recognises that although the determinants of health and health-related behaviours have significant influence on child and youth health and wellbeing, health service provision and usage also affects the health outcomes of children and youth. In order to improve the quality of child and youth health, attention must also focus on improving health service delivery. In order to address this, a number of approaches must be utilised. Integration and coordination of Services One such approach is through the integration and coordination of services. A coordinated and integrated approach across the continuum of child and youth health care will ensure the seamless and effective provision of care using integrated care pathways and innovative models of care. It is well recognised that there is considerable fragmentation within health systems, increasing complexity of patient care, and a lack of focus on population health. The concept of community based integrated care re-orientates the focus of health systems back to the core health goals in

60

which the aim of the health system is to support and maintain health. An example model of community based integrated care based upon coordination and cooperation and driven by community health needs has been developed in The Netherlands. This model enhances community participation through qualitative research with patients to determine their health care experiences and satisfaction to inform the development of the health care system with the aim of promoting a more coordinated health care service and ultimately a more positive patient journey.140 Integrated care pathways are also increasingly being used as a tool to coordinate patient care in Australia, the United Kingdom, and the USA.141 The aim of these integrated care pathways is to improve patient care and health outcomes through increased coordination and reduced fragmentation of care142. Integrated care pathways are based on the evidence, and attempt to focus not only on ‘what should be done’ but also identify ‘who should do it, when, and where’ taking into account the organisation of the health care delivery process as experienced by the patient. The National Pathways Association (1998) has published a working definition of integrated care pathways, also known as coordinated care pathways, care maps, or anticipated recovery pathways following consultation with its membership: “An integrated care pathway determines locally agreed, multi-disciplinary practice based on guidelines and evidence, where available, for a specific patient/client group. It forms all, or part of, the clinical record, documents the care given and facilitates the evaluation of outcomes for continuous quality improvement.”141 In essence, integrated care pathways are structured, multi-disciplinary care plans. The aim of having a care plan is to improve multi-disciplinary communication and collaboration, promote standards of practice, reduce length of hospital stay and care costs, and enhance systematic collection of data to enable auditing and evaluation of clinical practice.141,143 The implementation of integrated care pathways enables the health care system to be redesigned to focus on patient groups and/or diseases. This encourages active management of the whole care process. This has been termed ‘community-based integrated health care’.140

Collaborative and Flexible Partnership Approach

Efforts to improve the health and wellbeing of children and youth may be enhanced by a collaborative and flexible partnership approach to health care delivery. This should involve a commitment to developing new partnerships among all child and youth health providers, which actively engage government and non-government organisations, the private business sector, communities, families, and children and youth. Existing partnerships also need to be strengthened and enhanced. The emphasis on a whole of Government, multi-disciplinary approach to planning and development of child and youth health services and the promotion of healthy environments is underpinned by partnership development with patients, parents and consumers. The Department of Health will have a primary focus on health gains in these partnerships, but the partner organisations may have additional objectives of which government agencies must be aware.6 It is well documented that population health is influenced by policies from sectors outside the health sphere, while in turn the health and wellbeing of the population impacts on the goals of other sectors and the economic prosperity of the community. As such, policy makers both within and outside of health should consider how their decisions, policies, and actions are likely to impact on the health and wellbeing of the population.6 The United Kingdom Government, for example, has established a requirement that government agencies must form partnerships and make a clear commitment to work collaboratively in order to be eligible to access government sources of funding.144 Partnerships are recognised as critical to achieving objectives but it is recognised that they encounter many obstacles, which often overwhelm them. In order to assist partnerships in achieving their objectives, a set of key ingredients for success have been identified:

 Clear, shared objectives defined at the outset  A realistic plan and timetable for reaching these objectives  Commitment from the partners to take the partnership’s work into account within their  mainstream activities  A clear framework of responsibilities and accountability  A high level of trust between partners  Realistic ways of measuring the partnership’s achievements.

61

Formation of the WA Health Health Networks across the clinical disciplines is an example of state level efforts to improve the integration and coordination of clinical services through improved communication between service providers and other stakeholders, and by collaborating across area health service and institutional boundaries. The strategic role of the Health Networks is to provide advice and direction on where and how services should be delivered encompassing service planning and the development of policies and protocols including new models of care, which will subsequently influence the priorities on how resources are allocated across the system.145

Workforce Development

The delivery of high-quality health services for children and youth requires a highly skilled and knowledgeable workforce. The importance of addressing workforce issues and the need to enhance and sustain the current level of quality of the WA Health workforce has been detailed in the WA Health Healthy Workforce Strategic Framework 2006 - 2016.146 There is an urgent need to increase the numbers of health professionals in the health system in order to meet the continuing growth of health services across the state. The key workforce issues for WA are workforce supply and distribution, workforce design, workforce skill development, workforce data and planning and workplace culture and environment. The Healthy Workforce Strategic Framework 2006 - 2016 should be viewed as complementary to the Framework as it identifies a comprehensive range of strategies relevant to the child and youth health workforce, including:

 Development of education and training frameworks  Attraction and retention initiatives  More effective utilisation of workforce resources including the development of new models of care  The need to identify and implement work redesign opportunities and initiatives  Initiatives to improve the clarity of roles  A broadening of approaches to address the particular issues of health services in rural and remote

Western Australia

 Regulation and recognition of Aboriginal and Torres Strait Islander health workers  The need to provide positive workplace cultures  Developing leadership and change management skills in staff  Engaging staff on workforce reform and implementation and promoting a balance between work and life for all staff.146

The specialist nature of child health services necessitates continued post-graduate education and training of health staff in order to maintain staff skills and to increase the effectiveness and efficiency of the health workforce to deliver innovative programs and treatment. Hence there is a clear recognition in the Healthy Workforce Strategic Framework 2006 - 2016 of the need to invest in workforce development and training to develop partnerships with the higher education and vocational education and training systems to promote flexibility in education and training.146 Integrated workforce planning frameworks and workforce modelling systems are also identified as key strategies in the Healthy Workforce Strategic Framework 2006 - 2016.146 Integrated workforce data collection and analysis needs to be developed across the WA child and youth health sector in order to provide the evidence base for workforce planning initiatives and monitoring and evaluation of these initiatives. In order to increase the use of health outcomes and health services data and promote monitoring and evaluation of services and programs, a wide range of health staff, including policy officers, will need to have the knowledge and skills to work with this information. Workplace culture and environment such as stability of the work situation, social support, decision latitude, work loads, resource availability and psychosocial work factors impact on staff stress levels, health, mental health and wellbeing, absenteeism and the quality of patient care.147-152 Prevention of staff burnout, absenteeism, and turnover can be achieved through the provision of mentoring programs, organisational engagement and intervention strategies,147,153 improved leadership and management practices and appropriate staffing levels.152 WA Health has commenced addressing these issues through work life balance initiatives aimed at providing a flexible and responsive workplace, which enables employees to balance work and family responsibilities and promote a positive work environment.

Strategies

Integration and coordination of Services

62

 Support qualitative research with children and youth and their families to inform the development of improved health care services and coordination of service delivery.  Identify common and/or costly treatment and clinical outcomes associated with frequent child and youth presentation and/or hospital admission or increased in-patient stay, such as perforated appendicitis, and establish clinical care pathways.  Promote these clinical care pathways to primary care providers including general practitioners, emergency care physicians and paediatricians located at hospitals outside of all hospitals caring for children, including in rural regions.  Develop models of care that streamline the patient journey across services, especially in transition from paediatric to adult health services, public to private hospitals (and vice versa), and between hospital and community-based government and non-government services.  Promote the co-location of service providers working with children and youth, such as general practitioners, child development, mental health, community health, private hospital and other non-government services in order to facilitate greater cooperation.  Promote the co-location of population health, non-government services, and community development programs such as playgroups, childcare and parenting programs to increase ease of access.  Promote joint appointments for health professionals working with children and youth across public and private hospitals and other government and non-government health services.  Promote hospital-community service interfaces such as ambulatory care services.  Promote the requirements for hospitals to have separate areas for child and youth health care, including in-patient and emergency services.  Where feasible and appropriate, extend health services into youth settings and promote a youth focus.

Collaborative and Flexible Partnership Approach

Develop links and partnerships across government and non-government agencies to enable the development of policies, early identification procedures, and programs to address the health and developmental needs of children and youth coming into contact with service providers from other sectors. Key agencies include agencies both within the health system, other government, and non-government agencies:

Child and Adolescent Health Service

Western Australian Health Networks

Mental Health Services, including child and adolescent and adult mental health services

Drug and Alcohol Office

Justice Department

Department of Education and Training

Office of Aboriginal Health

Aboriginal Health Council of Western Australia

Disability Services Commission

Department of Child Protection

Department for Communities

Department of Immigration and Multicultural Affairs

Telethon Institute for Child Health Research

Private Hospitals

Non-government community health services

General Practitioners

Promote coordination and cooperation between all child and youth health care service providers. Develop links and partnerships across all WA Health Health Networks to ensure specific issues pertaining to child and youth health are prioritised and addressed at all levels within the health system. Promote recognition within government and non-government service providers outside the health sector, including those providing services to adults, of the health and development needs of children and adolescents exposed to high-risk situations and environments. Promote child and youth health representation on committees working on legislative issues, which have an impact on child and youth health.

63

Develop links between families and paediatric and palliative and supportive care programs and strategies to support families to care for children who have a chronic health condition in their home.

Workforce Development

Promote workforce planning and research looking at job expectations, attraction and retention of staff for hospital-based and community-based child and youth health services. Promote or develop policy and frameworks that: Support clinical, nursing, and allied health placements in child and youth health services in both the public and private sectors Aim to increase the number of Aboriginal health professionals and Aboriginal health workers undertaking specialist training in child and adolescent health Increase recruitment and retention of staff and improve education and training for the rural and remote child and youth health workforce, particularly for staff working with Indigenous people Identify gaps and priority areas in the current continuing education and training programs and improve the accessibility of quality education programs to enhance workforce development in relation to child and youth health. Develop programs to educate hospital staff, primary care providers, and general practitioners about child and youth health. Promote development of youth friendly services across the community by offering training in adolescent medicine skills to general practitioners, community nurses and school health staff. Develop statewide training programs around priorities in child and youth health, for relevant public and private hospital staff, emergency department staff, general practitioners and child and community health staff. Develop information, education, and training packages on issues relating to child and youth health and development particularly for staff working in the mental health, alcohol and other drugs, and child protection. Develop the role of paediatric nurse practitioners in hospitals currently unable to provide a sufficient level of paediatric physicians. Develop education and employment policies and procedures, in conjunction with human resources and professional organisations, to support qualified health workers re-entering the child and youth health workforce. Expand post-graduate education and training to increase the number of qualified medical, nursing, allied health workers and Aboriginal health workers entering the child and youth health workforce. Strengthen the focus on issues pertaining to child and youth health in the undergraduate and postgraduate education and training sectors, particularly university schools of medicine, nursing, and allied health, and increase the number of students undertaking postgraduate training in these areas. Develop programs to educate professionals working outside the health sector who work with children and youth either directly or through contact with their parents about child and youth health.

WORKING DOCUMENT: DRAFT ONLY

21 March 2003

A STRATEGY FOR WESTERN AUSTRALIAN CHILDREN

PREPARED BY THE NATIONAL INVESTMENT FOR EARLY YEARS (NIFTEY)

WESTERN AUSTRALIA.

FOREWORD

It has been known for many years that the early years of a child’s life and the nature of family experiences are important influences on long term life outcomes. Newer evidence as to the nature of

64

brain development has provided a more urgent basis for preventive action for the developmental well being of children. How a child’s brain develops in early childhood, beginning in the womb, is the basis for development throughout life.

For children there is the mix of genetics and environmental influences that are shaped by a range of life experiences. Some of these can be assisted and some are ‘happenings’ of the human journey. The role of the family in this journey is paramount in a child’s life and the community is in partnership with the family either actively or passively to support the family in its central role.

The book “Neurons to Neighbourhoods” adds: ‘All children are wired for feelings and ready to learn… Early environments matter and nurturing relationships are essential’.

The challenge of the new evidence is for society to focus on the well-being of children and their families to bring about quality of life opportunities and co-ordinated services that will lead to positive changes in the lives of children and some times in the lives of their parents also. This involves all levels of government including local government, not- for- profit organizations, private agencies, business groups, and local communities to prepare and implement consensus policies and strategies. For this to happen the voice of children must be heard in what is planned and provided.

This Strategy for Western Australian Children prepared by NIFTEY in consultation with others,

proposes such an approach.  It is inclusive of the requirements of children.  It advocates for their best

interests, and recognises parents as partners alongside professionals and agencies. It endorses the voice of children to promote change and advocates for children to be given a positive role in their communities and in their futures.

Dr Trevor Parry FRACP DPH DCH FRACMA

[ There are many ways of growing up- Tina Bruce]

THE HISTORY OF THE STRATEGY FOR CHILDREN

In 2001 a number of conferences and seminars were held in Western Australia (WA) that highlighted the importance of the need to support families with children in the early years. It resulted in a call for greater co-operation and co-ordination between all services concerned with health, care and education of these young children and their families.

At one of these seminars Moira Raynor former Commissioner for Children in London articulated a complementary call that to improve the well being of WA’s children, a “Strategy for Children” should be developed so their voices could be heard both at a policy and at an implementation level.

Moira Raynor postulated that a “Strategy for Children” that included children having a voice in decisions that affect them, is likely to result in more effective policies for children and their families. The strategy of inclusion of children’s voices could become a template for government action and democratic relationships between citizens and their Government.

NIFTEY and WACOSS took up Moira Raynor’s challenge and invited her to develop a proposal that forms the basis of this Strategy for Western Australian Children. The guiding principles together with the strategies, outline a vision that could achieve a positive beginning for all WA children and their families. This document suggests a way forward. It advocates some short –term and some long term strategies that could progress WA’s journey toward all children having equal opportunities to live satisfying and productive lives as active and involved citizens of WA.

65

The intention is that the Strategy for Western Australian Children influences or becomes the basis of future policy development for all political parties. After the completion of the consultative process and changes made in line with the feedback received, the developed strategy could provide a framework from which action plans could be taken up by government departments, non-government agencies and not-for-profit organisations. They could include from the framework those strategies that they chose to implement. The commitment to the strategy would be voluntary. Once acceptance of an agreed strategy is gained from Western Australians, a strategic plan of the steps, processes and timeframes could be developed. Clearly designed accountability requirements could be specified, monitored and reported to the public.

To achieve this goal a state- wide consultation process and request for feedback will begin on 24 March to gain Western Australian’s endorsement for the continued development of this strategy.

Submissions on this document are welcome and the closing date for submissions is 31 May 2003. Please email or address your submissions to:

The NIFTEY Working Group

Strategy for Western Australian Children

Po Box 510, West Perth 6872

ABOUT THIS STRATEGY

This document takes the definition of children as all children 0-18 years. It is understood that a Strategy for Youth is in the process of development by a Government Department. This document therefore confines itself to children and the families of children.

Readers are reminded this is a working document. Feedback is required to move the document forward. Closer to the final stage the document will be edited and formatted.

The Strategy is divided into 3 parts. 1 Guiding Principles: Outlines the philosophy underpinning the strategy. 2 Strategies: Suggests ways that children, families, society and Government can act to improve the wellbeing of children and their families. 3 An Appendix 1 outlines the respective roles that children, families, society and the Government play in children’s lives.

GUIDING PRINCIPLES

Underlying these principles is the interactive complexity of experiences, relationships, values, and practices that shape childhood, and the culture of a community. Adults pass on their life understandings to children who carry the knowledge into the next generation. Children are a cohesive factor in the links that bind society. It is often said, “Children are our most valuable asset.” They embody the past, the present and the future.

When working with children it is their whole life and circumstance that requires attention, not just isolated issues or problems. The focus is on what children can do, not what they cannot do. The emphasis is in on their growth and development to increase their competency as human beings.

[Children have a life not a background-B.Comber University of South Australia]

Underpinning this strategy is the principle that children are entitled to be included in decisions that affect them. This includes very young children and those who are isolated for any reason such as disability, location or ethnic minority status and unable to express their views directly. It also

66

recognizes the central role played by parents in the lives of their children. In most circumstances parents have the responsibility for making the final decisions that affect their children

In countless books, films, poems, reports, research projects and records of children’s lives writers, artists, parents, childhood experts, researchers, and commentators have expanded on the central messages within the following guiding principles that:

 A child’s life is here and now

 The best interests of the child are paramount. In instances of abusive, neglectful or exploitative situations the protection and best interest of children takes precedence over the interests of adults

 Every child is entitled to nurturance, protection and sustenance.

 Families are the natural place for children to thrive

 Each child’s cultural heritage is recognized and respected

 The unique place of Indigenous children and their families as the descendants of the original people of Australia is respected and acknowledged.

 Children are entitled wherever possible to be included in decisions that affect them. All children have their own view of the world and of other people.

 All children have a right to experience childhood free from extreme anxiety, neglect, abuse, fear, hunger and lack of shelter or protection and to have opportunities to play and be playful

 Childhood should be protected from the excesses of exploitation from commercialism

 Children are interactive and powerful learners from before birth

 Children are always learning from the settings in which they live and from how they interpret these experiences into their own unique thoughts and actions.

 Children grow and develop at different rates and the variation between children is wide. This makes it difficult to distinguish maturational variations from the need for specific intervention.

 Throughout childhood children experience happenings that either help them protect themselves through resiliency or increase their vulnerability

 The course of development can be altered in early childhood by effective interventions that change the balance between the child becoming at risk or the child developing resiliency.

 The way adults resolve conflict teaches children about balancing, respecting and valuing other people’s rights

[School is a building that has four walls –with tomorrow inside.-Lon Watters]

67

STRATEGIES

Children are the centre of this strategy. The basis for a successful children’s strategy will be its capacity to fit into the structure of other strategies and responsibilities that already exist. Each agency may also develop its own strategies based on the guiding principles of the agreed Strategy for Western Australian Children. When agencies do consult children it will be important that the consultations are conducted in an appropriate way and are made relevant and of interest to the children involved.

It is intended that this Strategy for Western Australian Children influences the development of Western Australia’s strategic planning, public infrastructure, cultural, justice, education, community and economic development strategies.

To achieve implementation of this strategy, all government, non-government and not-for profit agencies that work for and with children and their families, need to agree on the necessity of a comprehensive and coherent children’s policy and strategy for Western Australia.

STRATEGIES FOR CHILDREN

 Develop skills and practise making known their opinions  To participate in decision making in relation to themselves.  To have a feeling of self-identity as a contributing Australian and world citizen and know the protocols of mainstream society as well as one’s own cultural heritage  Children take opportunities to learn about themselves and their world through learning, listening, observing, reading, asking questions, trying new activities, talking and offering their experiences and views on what is happening around them.

[We must view young people not as empty bottles to be filled, but candles to be lit.-Robert H

Shaffer]

STRATEGIES FOR FAMILIES

 Parents regard themselves as partners working alongside other agencies who work for the mutual benefit of their children.

 Develop the skill to ask for help with child rearing

 Form an ongoing coherent network of support and guidance to children throughout their lives.

 Become advocates for children and their rights

 Foster in children the abilities of self-determination, self-regulation, self responsibility, self-awareness, acceptance of self and empathy for others.

 Seek guidance, information and skills as to how to relate and support family members who are in difficulties or not coping with life.

 Seek help and support when overcoming parental or relationship difficulties in situations that are the result of experiences of neglect or emotional, physical or sexual abuse,

STRATEGIES FOR SOCIETY

68

Collaboration and Inclusion

 Non –Government stakeholders whose main interest is the well being of children form or affiliate to an organization that can speak with one voice to Government on matters of common agreement.

 Government, non-government and not-for-profit agencies establish partnerships with and investment in strategic alliances that result in improved quality of life opportunities for children by speaking with one voice on:

• the need for all policies to be scrutinized and assessed for their impact on children

• the need for new policies that affect children to be written with their best interests paramount within the policy

• working collaboratively and cohesively together in new ways to benefit children and their families.

 Provide the means whereby all Western Australian children have access to knowledge of the history and culture of Aboriginal people and have a basic understanding of their protocols

 Develop specific guidelines for improving the participation in decision-making processes for children from ethnic minorities, children with disabilities and children who have been abused.

 Become advocates to Government on the importance and benefits of an Office for Children and a Commissioner for Children.

Structures and systems  Agencies will be responsible and accountable for maintaining policies and practices that ensure the safety, protection and well being of children in their care.

 In consultation with children, local authorities develop plans for the well being of children.

Resource management  Agencies involved in children’s well-being provide funding to support cross-agency research and make and support applications for funds for initiating research

 Ensure that Government funding allocations to government departments, non-government or not –for –profit organizations who receive money targeted to benefit children and their families is sufficient to successfully implement the policy requirements and has transparent accountability mechanisms to demonstrate the effectiveness of the outcomes of these monies.

Communication

 Peak bodies concerned with children develop a working relationship with the Office of the Premier and Cabinet, the Department of Community Development, the Department of Health, and the Department of Education and Training.

 In the absence of one organisation of affiliates, major stakeholders and peak organisations concerned with children, instigate quarterly formal briefing sessions with the Social Policy Unit in the Office of Premier and Cabinet and with the Director-Generals whose departments impact on children’s well-being.

69

 Enable the achievement of the ability for self regulation and decision making in adulthood by providing children with the opportunity to participate in decision making processes especially in relation to themselves as much as is practicable.

 All agencies Government, non-Government and not-for-profit agencies that impact on children’s lives actively include children through:

• consultative processes
• listening to children
• enabling them to participate in decision-making
• finding out about children’s aspirations, hopes and fears
• acknowledging the role played by children within the decision-making process
• demonstrating how they included children  All agencies working with a child and his/her family will ensure that they inform the parents/guardians of their intention to work with other agencies to maximize the benefits for the child.

 Develop a website to share resources with government agencies, local authorities and community organizations on the benefits and issues of children’s participation in decision making, including a database of relevant contacts in organisations

 Promote a wider understanding of the Rights of the Child through a public education campaign

STRATEGIES FOR GOVERNMENT

Structures and Systems

 That Government make it mandatory for Department’s whose work impacts on children to show in their Annual Reports that their policies and services are based on current research knowledge and give evidence of their effectiveness

 Government Departments whose policies impact on children include in their Annual Report the outcomes of their efforts to maximise the opportunities for rural and remote children to access services, knowledge and skills that are more readily available to metropolitan children.

 Strengthen existing efforts by Government to eliminate child poverty by having a robust research base for future policy development that: -analyses the effectiveness of various policies to alleviate and prevent child poverty -identifies the ages at which children are most affected by low family incomes -investigates the effects of family income assistance in reducing negative outcomes for children -improves measures for monitoring poverty levels for children

 Consolidate the structure of government agencies to more effectively improve the well-being of children and their families

 Support all agencies with robust policy and funding to prevent the continuation of neglected and/or emotionally, physically, and sexually abused children and their families.

 Review the treatment of children subject to non-penetrative social acts of abuse to ensure they have access to medical, therapeutic and protective action.

70

 Strengthen existing efforts by Government to eliminate neglectful or abusive situations for children by drawing on existing research and promoting further research to analyse the most effective ways of preventing its continuation.

 That each Government Department establish a mixed –aged reference group of children to inform the Department on the likely impacts to children in any new proposals and to give feedback on the proposed and implemented Departmental policies.

 Include a requirement within policy development for an input from children

Resource Management

 Commission Treasury to evaluate the effectiveness (value for money) of the present Government investment in early years provision in WA.

 Commission Treasury to do a cost-benefit analysis that factors in the research findings of the savings that can be made from investing in the early years.

 Give consideration to placing a cent tax on confectionary to be used toward funding high quality co-ordinated multidisciplinary early childhood education centres for children from birth to school entry age and their families.

Collaboration and Inclusion

 That Government and Private Enterprise collaborate to fund “ A Book for You,” scheme whereby all rural and remote children and children living in poverty in urban areas are sent a picture reading book to celebrate their birth and subsequent birthdays for the next 4 years.

 That the Department of Aboriginal Affairs monitor Government Departments and report to Parliament on the effectiveness of Government policies to improve the health, social and educational outcomes and general well-being of Aboriginal children and their families.

 That the Equal Opportunities Commission give higher priority to discrimination against children and especially children from ethnic minorities

 Establish networks of related agencies to improve the integration of policy work and delivery of services across the state sector

 Strengthen the education, health and community development system’s capability to work collaboratively and coherently with all agencies that work for children and their family’s well-being

 Increase the ability of families with young children to access affordable, responsive high quality early years services regardless of their location or the child’s individual requirements

Quality Assurance

 That Government establish a review committee to examine and report to Government on the supply and quality of early childhood care and education services for children and their families from birth to school entry age.

 Establish an Office for Children and appoint a Commissioner for Children who is an advocate for children and who advises, monitors and reports independently to Parliament on the impact of Government policies on children.

71

 Provide an infrastructure that enables the collation of coherent research information on the state of Western Australia’s children with the view to developing a State of Western Australian Children’s Report. This would provide benchmarks from which improvements or deterioration could be measured

 Fulfill children’s “provision,” “protection,” and “participation,” rights as set out in the United Nations Convention on the Rights of the Child (UNCRC.)

 Require all Government Departments to provide evidence of high quality accountability processes in policies for children’s well being and report on the outcomes of these accountability requirements.

 Review all present legislation that applies to children and evaluate its fairness, human rights implications and compliance with the UNCRC and the United Nations Declaration on Human Rights.

 Ensure policies and services that assist children and their families who have been neglected or subject to sexual, physical or emotional abuse results in:

• the abuse ceasing
• further abuse being prevented
• accessible, immediate assistance being made available for medical, therapeutic, educational, legal and community support.

 Review the natural justice provisions in all education and care services regarding the practices of suspension and exclusion of children

 Evaluate across Government Departments the resources allocated to improving staff’s awareness of the impact on children of each Department’s policies and practices and require each Department to assess the impact on children of all new policy proposals.

Communication

 Promote a wider understanding of the UNCRC through a public education campaign and requiring Government Departments to reappraise their staff of their obligations under this convention.

If there is anything we wish to change in the child, we should first examine it and see if it is not something that could be changed in ourselves. Carl Gustov Jung

CONCLUSION

In 1989 the United Nations Convention on the Rights of the Child endorsed that as human beings, all children no matter where they lived, deserved to live in dignity and to be treated according to their best interests. The rights of the child specified within the convention document outlines the responsibilities of families, caregivers, and governments to uphold these rights. Only Somalia and the United States of America have not ratified the UNCRC.

Children’s inherent rights fall into 3 basic groups:  Provision: the right to an adequate standard of living, health care, education and services, and to play  Protection: the right to protection from abuse, neglect, exploitation, and discrimination.  Participation: the right to express their views about things that affect them and to participate in communities, programs, and services for children.

72

To learn more about the Convention, go to the United Nations Convention of the Rights of the Child at http://sen.parl.gc.ca/pearson/index-e.html

(Exchange Every Day. March 4 2003. Issue 587. http://www.childcareexchange.com)

APPENDIX 1: ROLES

Roles are the parts played in the human journey through life. Everyone has many roles over their lifetime. Some of the roles are strongly influenced by the family, institutions or a person’s cultural heritage. Some roles are determined by biology such as sexual orientation or the place a person holds in the family like mother, son, first child, uncle, and cousin. Adults have more ability to determine their own roles.

There is no doubt that the early years play an important role in maximisng or inhibiting children’s opportunities for healthy development. All citizens whether they are parents, family members, government employees, professionals, politicians or artisans all play a role in determining children’s

futures.  It does take a community to raise a child.  It takes a family to raise a unique child. In today’s

world it takes a planned educational process to raise an educated child. In modern societies it takes collaborating and co-operative agencies to work within a coherent and co-ordinated policy framework to have effective systems for the raising of healthy, well educated children. We are all inter dependent on each other.

This strategy supports what may seem to some as a new role for children. It advocates that society listens to children’s voices and that children be included in decisions that affect them. Participation in decisions that affect their lives recognizes children as thoughtful human beings and future citizens of our society. Becoming a decision-maker and problem-solver is an essential survival skill for everyone. It is a role practised in childhood and necessary in adulthood. [A teacher affects eternity; no-one can tell where his (her) influence stops- Henry Adams]

THE ROLE OF CHILDREN

 To be active participants in their own lives and those of their family and community.  To bring hope for the future by their presence  To live their lives to the best of their ability  To contribute to society through their opinions, activities and involvement.  To experience being parented, in adulthood to be able to parent, and then to grandparent.  To learn from their elders and pass that knowledge on to their children.

THE ROLE OF THE FAMILY

 To provide an environment of love, understanding and acceptance  To provide a nurturing environment that enables children to fulfill their inherent capacity to develop and learn.  To support children in the development of their ability to confidently participate empathetically in and contribute to society  To encourage children’s involvement in decisions that affect them  To pass on traditional cultural knowledge and the specific history of each family  To provide an ongoing support network to family members throughout their lives  To protect children from neglectful or abusive relationships and situations.

THE ROLE OF SOCIETY

 To protect children from all forms of violence, exploitation, neglect, cruel or inhumane treatment  To provide children with opportunities to play a positive part in community life and participate in active citizenship

73

 To provide a social context in which all people are valued, accepted and celebrated for their diversity, difference and cultural heritage  To promote the role children can play in decision-making both within the family and within the community  To respect children for their unique contribution to community life  To provide children with opportunities to develop their physical, emotional cultural, social, cognitive, spiritual and creative abilities  To support communities in providing healthy, safe, educational, cultural and social engagement for the well-being of children.  To support parents to understand the wide range of developmental patterns of individual children and their needs, abilities and talents.  To promote the value and beneficial life outcomes for children raised in loving, responsive, caring and affirming home environments  To acknowledge that families embarking on parenthood may require support. All organizations that inter-relate with families need to understand and respect both the adults potential for change, their present skills and knowledge and their vulnerability as new parents. [We leave traces of ourselves wherever we go, on whatever we touch. – Lewis Thomas]

THE ROLE OF GOVERNMENT

At all levels is:  to ensure policies that impact on children and families are given priority and are assessed for likely outcomes for children.  to facilitate collaborative and cohesive systems of cooperation among Government Departments, non-government agencies and not-for-profit institutions to best support children and their families  to promote policies and services that respect cultural diversity and support children’s place and potential within their own cultural context that is compliant with Australian law  To ensure that policies and services reflect current evidence of their effectiveness and appropriateness to local communities  To involve children in decision-making  To make a positive contribution to the quality of life of Western Australian children  To ensure that children have an appropriate share of the community resources that reflects and meets their needs and recognizes their vulnerabilities.  To adequately fund all essential universal services for young children and their families at a standard of quality that will achieve the known beneficial outcomes.

REFERENCES

Brownlow Publishing Company Dear Teacher.101 Words of

6309 Airport Freeway Encouragement.

Fort Worth Texas 76117

Exchange Every Day Date: March 4,2003-03-07

Issue: 587 http://www.childcareexchange.com

Department of Community Development Creating The Office for

Children and Young People’s

Policy. October 2002.

74

Hon. McCain M. N. and Mustard J.F. Reversing the Real Brain Drain

(Co-Chairs) Early Years Study. Final Report

April 1999. Publications Ontario

50 Grosvenor Street, Toronto ON

M7A IN8

Ministry of Social Development New Zealand’s Agenda for

Mahere rautaki ma te Hunga Tamariki Children: Making life better for

New Zealand Children. June 2002

Raynor Moira Discussion Paper: Children’s

Strategy Group, National

Investment for the Early Years

Shankoff J.P. and Phillips D. A. From Neurons to Neighbourhoods;

The Science of Early Childhood

Development.

National Academic Press

75