Perspective on child development services in Western Australia | External submission

Select Committee into Child Development Services

Submission on the Inquiry into Child Development Services

Dr Elizabeth Green

MBBS (Hons) FRACP

Consultant Paediatrician

Childhood Advocate

Author of Parenting is Forever @parentingisforever.com.au

INTRODUCTION

RECOMMENDATIONS

CONCLUSIONS

INTRODUCTION

A perspective on child development services in Western Australia is provided as an independent advocate of children. From a background of clinical experience as a doctor and paediatrician, working with babies, children, young people and their families in metropolitan and regional centres. And for twenty-four years, until 2022, drawing from a clinical caseload of around forty thousand children as a sole private paediatrician in Perth. Caring for children, many with complex neurodevelopmental conditions – autism, attention deficit hyperactivity disorder, learning problems, anxiety and depression.

My passion for the health and wellbeing of children was ignited when I was a flying doctor in the Royal Flying Doctor Service, based in Kalgoorlie, in the eighties. Visiting remote communities in the Central Desert and the Trans Line, on the Nullarbor. And, as a senior paediatric registrar, working in Port Hedland and Karratha.

My exposure to metropolitan and tertiary paediatrics was during the nineties and the two thousands. I looked after newborn babies at King Edward Memorial Hospital, and completed my training to be a paediatrician at Princess Margaret Hospital for Children, now the Perth Children’s Hospital, as the Chief Registrar. The pivotal role of early brain growth and childhood development on long-term mental health was taught to me by Dr Trevor Parry AM, a respected WA career developmental paediatrician.

For more than thirty years I have been immersed in the healthcare system, working with vulnerable children as their world was overwhelmed by change – social, climactic, political and most recently by COVID. On my watch, with other carers and protectors of children, we were overwhelmed and missed the nuance of what was happening to them. Investment in our kids and our future faltered and created a deficit in workforce resources – doctors, nurses, early educators and carers and allied healthcare workers.

Over the past twelve to twenty years we didn’t fight hard enough to create new green spaces for children, or plan and build places where parents could seek help when they struggled to raise their children safely. When patents had to give up work and being financially viable because they could not afford childcare support. When the buildings parents took their children to see child health nurses, doctors, clinical psychologists and speech therapists were run down and unfriendly. And the trust of families in children’s hospitals and doctors became broken.

It is not too late to shift the social climate for our kids and families. I hope an inquiry into Western Australia’s child development services can do that, and not just translate into white noise.

My reflections are my own, well intentioned and passionate. They shout out for the children who don’t have a voice, and are not constrained by a government body. A good and helpful thing, I think.

RECOMMENDATIONS

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

The definition of ‘child development services’ demands a formal and flexible definition to incorporate established, affiliated and potential adjunctive health care providers and spaces with the capacity to share and build on current and future resources.

Historically, WA public child and adolescent health services have had rigid referral criteria to manage the numbers of children on waitlists or standby – because of ‘workforce’ issues. In 2022 there are newborn babies on standby lists, unable to be seen, as relayed to me by reliable child health nurse sources.

A child with a learning disorder and anxiety may be excluded from a government developmental assessment service if they also have a history of alleged sexual assault. Or, a child with autism or attention deficit hyperactivity disorder, referred with depression struggles to get an appointment within the mental health sector because of their complex neurodevelopmental diagnoses. And specialised tertiary services for ADHD, only funded for acute assessments, can’t provide ongoing management, despite their expertise.

To address limited people resources, government education departments will need to partner health and mental health portfolios as a ‘power body’ for ongoing child development services – a logical transition. Schools have excellent facilities and a capable and competent workforce to address some of the neurodevelopmental problems waiting months to be seen by paediatricians – reading and writing, attention, concentration and coordination problems and social and behavioural difficulties. For schools to cope with this added responsibility they will require a serious investment in people, tech, time, infrastructure and educational resources.

Funding two teachers for each primary school classroom and speech pathologists and occupational therapists within the school, in my opinion, would be doable, appropriate and, long term, financially sound. Planning classrooms as a sensory space – noise limited, structured and visually calm would assist all children, and especially those with autism and anxiety.

Child development services require a multi-disciplinary approach to assist families to parent better, with community outreach options from the time a parent prepares to give birth to their first child. Midwives, lactation specialists, child health nurses and school nurses are often the point of first contact for families. As are educators in formal daycare centres, structured playgroups, kindergartens, early childhood classrooms and after school care facilities.

Tertiary child and family focussed centres, such as the Child Development Service exist in West Perth and outlying areas. They would benefit from upgrades – physical improvements to their buildings, green spaces and carparks, improved tech and better

funding for staff. Current hearing and vision screening services for newborns, toddlers and pre-school age children require more funding.

Every child and family in Western Australia has the right to be valued. To have access to early childhood services that provide safe, timely and high standard care across all areas of child development. Globally these domains are recognised as – speech, language and communication, physical fitness, fine and gross motor coordination, cognitive growth and social competency. A child has to meet these milestones within a reasonable timeframe to learn, socialise and gain emotional resilience and robust mental health as a young person. They have to cope with childhood before they can survive the pace and pressures of a changing adult world.

Dr Trevor Parry AM, during his life as a paediatrician, was a reliable and compassionate voice for children in Western Australia. Responsible for the establishment of the State Child Development Centre in the mid-seventies – now the Child Development Service in West Perth. This has remained a clinical hub of excellence for paediatricians in training and consultant paediatricians, working alongside a team of dedicated allied health workers. He taught about the importance of the first five years of childhood on the neurological secure attachment between a child and their caregiver and their future developmental outcome. And, that the role of child health nurses was not to screen babies, but to use their clinical skills to asses a child’s development.

Dr Parry was also a Founder of the WA branch of the National Investment for the Early Years (NIFTeY), introducing WA paediatricians to the early childhood studies done by Dr James Fraser Mustard. This Canadian doctor’s research showed that brain growth in the first few years of a child’s life influenced their language and literacy development and had a significant impact on their verbal skills by age three. Poor verbal skills at three then persisted into the school years and the gap remained at age nine.

No-one can dispute the importance of early child development, nor excuse the detrimental impact the failure to act and intervene early for all children causes. Especially in those who are vulnerable because of social circumstance or childhood trauma due to emotional, physical or sexual abuse. Dr Mustard’s case studies from Romanian children in orphanages, adopted into Canadian middles class families, showed a correlation between time spent in the orphanages before adoption. His findings were consistent with the observation that intellectual ability as measured by IQ, is influenced by the quality of a child’s early development – the first five years of life.

We should be proud that in WA there are dedicated researchers invested in The Origins Project, following 10,000 children, prior to delivery and for their first ten years, adding to the knowledge base of how a child’s early environment, even before they are born can influence physical and emotional health. We now know, for example, that toxins such as alcohol affect the brain of the unborn child in the weeks and months before birth, as seen in Foetal Alcohol Spectrum Disorders, FASD.

In November 2006 and March 2007, Dr Mustard was the Adelaide Thinker in Residence and provided to the South Australian government a report, Early Childhood Development: The best start for all South Australians that gave five key

recommendations pertaining to the issue of early child development. I will acknowledge some of these as I further address the terms of reference provided for the Select Committee ‘s inquiry into child development services.

How child development services are delivered in both metropolitan and

regional Western Australia

Early childhood services across diverse regions of WA are restricted because of critical workforce issues, amplified by COVID. Staff shortages continue to grow because of attrition, resignations, disrespectful salaries, unreasonable working conditions, burnout and failure to recruit and support dedicated people to work with children. Facilities for children are not always family friendly, being aged, cold, clinical and scary. Referral systems are complicated, requiring online access and IT competence or lengthy and time consuming referral forms. These have to be completed by a doctor, clinical psychologist, educator, parent or carer or allied health professional such as a speech pathologist, occupational therapist or physiotherapist.

While workforce issues remain, metropolitan child development services will be prioritised. They remain more affordable and reliable than remote centres which are more vulnerable to staff and patient relocations. People in country areas come second.

With increasing social and technological change, the shift in how we treat and care for each other widens. Disrespect, tolerated in our homes and schools becomes engrained and problematic. In 2022 this threatens the engagement of potential teachers, nurses and doctors. If schools, medical centres, nursing posts and hospitals can’t provide their employees with a safe environment, they can’t recruit, retain and grow their workforce. This people deficit is already being reported in the media – teachers afraid of their students and nurses fleeing from remote and rural postings as they feel unsafe.

During my time as a flying doctor there were nurses in isolated nursing posts who had to leave when they were physically assaulted or allegedly raped. There were allegations of child sexual abuse and teenage pregnancies that were not questioned. These are sensitive but real issues that continue to impact on the way medical and child development services are delivered without sufficient back up supports.

Visiting services to rural centres will become possible now that intrastate and interstate COVID lockdowns have ceased, dependent on staff recruitment. Rural areas currently rely on locum paediatricians from Perth or Sydney, but as there is a critical shortage of developmental paediatricians in Perth, increasingly locum doctors will be sourced from interstate. Families already travel to Adelaide, Brisbane, Melbourne and Sydney for their children’s medical treatments when they can’t source them in WA – psychiatrists, paediatricians, psychologists and gastroenterologists. The State needs to consider reimbursing travel and accommodation costs for those desperate families.

More school based therapies, contracted to government and private services will be required to help children with hearing and language delay, autism, attention and behavioural problems and movement disorders. This is relevant in rural towns where there is limited or no access to speech pathologists, audiologists, occupational therapists

and physiotherapists. There may be a place for some adjunctive telehealth sessions, although in children, especially with autism, face-to-face is preferred.

Dr Fraser Mustard’s recommendation two in his Early Childhood Development paper was to ‘provide universal education and training in Early Childhood Development to cultivate community understanding of the importance of the early years.’ Recommendation five was ‘to facilitate community participation in the development, implementation and running of Children’s Centres.’

To ensure children have access to universal childcare and early education, an initiative embraced in Victoria, more funding has to be committed for training positions for childcare workers and early childhood teachers. Childcare and early classroom facilities should be COIVD compliant with child friendly spaces to encourage play and learning. Parental support with paid leave allowances and options such as tax deductions for approved childcare options, including, where applicable, private child care workers or carers within the home. An option for very young children with brittle medical conditions – immune deficiency, severe anaphylaxis, asthma or epilepsy. Or those with parents who work antisocial hours.

Communities are the best places to ensure tolerance and cultural inclusion – it starts with saying hello to a neighbour. With one child reaching out to another to play. To be human is to seek a social connection – doable in metropolitan and rural regions.

To improve child development services across the State, given a paucity of available services, requires first determining the areas of greatest or unmet need. Many of these will be rural, but some will be in established suburbia. Demographics don’t protect children from developmental trauma that is covert, such as emotional abuse and overt – physical and sexual assaults.

The role of specialist medical colleges, universities and other training bodies in establishing sufficient workforce pathways

There is a critical shortage of country general practitioners, already an ageing cohort. A climbing number, from peer feedback, plan to retire or change their vocation within the next three years because of the burden of increased accreditation requirements to remain registered as a doctor and due to the added work pressures associated with COVID. As the State’s and Australia’s doctor shortage is dire, there is no longer an option to upskill enough GP’s to cover or share the work of developmental paediatricians. GP’s, especially outside the metropolitan area do not have the time or resources to see more complex children. Their work load is already excessive and underpaid.

Financial incentives will not entice enough registered doctors away from the city areas. Locum salaries in the country are lucrative, but the work is daunting for many doctors. Many don’t have the necessary clinical skills or training to cope with medical and surgical emergencies in isolated practice. The medico-legal risks are higher, and the disruption to families too great, particularly during the high school years, when education and extracurricular options may be limited.

To increase workforce numbers, we need to first prioritise childhood. To educate young people at school, university and colleges about the importance and privilege of working with children and helping them have a more positive future. And respect their work by adequate remuneration, the provision of excellent training positions that are well funded and supported with adequate mentorship. Incentives like tax breaks for working in rural and remote areas, concessions for HECS fees and accommodation costs while studying and job permanency will encourage more people into jobs to care for children.

Universities and colleges can only provide more training positions for doctors, speech pathologists, social workers, clinical psychologists, nurses and other allied health professionals if they are allocated government funding. A discussion between State and federal governments needs to determine who funds what and how much.

Medical colleges can encourage doctors to pursue a specialty in developmental paediatrics or child and adolescent psychiatry, but they can’t force them into this pathway. To do this, by introducing quotas, would not attract suitable candidates. Children deserve better – doctors who are passionate and invested in childhood. Until developmental paediatrics is a financially viable choice, few will pursue it. Paediatricians are one of the lowest paid specialties, especially within the private sector, as are GP’s. Yet, these two specialties are expected to step up and carry the bulk of the emotional vicarious load carried by our young people – anxiety, depression, self-harm, suicide and eating disorders.

A private paediatric practice has parallels with running a small business – high outgoings, medical insurance, college fees, salaries and rent or mortgage payments for consulting rooms. Appointments are time intensive with new and follow up appointments twenty to ninety minutes. There are bad debts, no shows and disrespectful patients and clients. Medicare refunds for families have barely changed in twenty years, necessitating private fee gaps to keep practices afloat. Private paediatric practice is a dying business model. Government will need to consider other options to provide paediatric care for children. This could involve funded sessions for private paediatricians in the hospital system and tertiary child development services.

If society invests more in their children and respects them, caring for kids will be seen as a more prestigious and worthy profession to pursue.

Dr Fraser Mustard also recommended improving the profile of early childhood and the importance of early child development by increasing community awareness, and providing sufficient and sustainable funding for Children’s Centres. He advised ‘an independent South Australian Early Child Development Council, led by an Ombudsman for children and families to advocate for healthy Early Childhood Development.’ And to ‘provide education and training for the upskilling of existing health care professionals and early childhood educators in the area of neuroscience and early child development.’

I support those initiatives, and make the comment that in WA we have a Commissioner for Children and Young People and a number of passionate childhood ambassadors. WA also has the ‘Thrive By Five’ initiative, endorsed by the Minderoo Foundation – advocating for effective policy and investment in early childhood. Their support

highlights the growing awareness of society to commit to early childhood and change the social trajectory that is one of escalating mental ill health and falling literacy and math levels compared with other countries.

How to increase engagement with, and collaboration between, government and non-government child development services including Aboriginal

Community Controlled Organisations

While private paediatricians have wait lists of around twelve months or they are no longer accepting referrals to see children with complex and challenging emotional, behavioural and neurological conditions, there is limited opportunity for them to liaise with government services.

What could work, is the setting up of some hybrid private and public developmental clinics attached to tertiary children’s hospital or developmental centres where private paediatricians could see patients privately for a small administration fee, and in return they could mentor and supervise paediatric training in developmental paediatrics.

Private paediatricians, speech pathologists, occupational therapists and clinical psychologists could be contracted by the education department to provide assessments and where appropriate, therapy and the provision of expert opinions in developmental areas that impact on school learning – autism, ADHD, specific learning problems and anxiety.

Dr Mustard in his considerations, recommended: ‘provide incentives and opportunities for people from diverse backgrounds (culturally and socially) and/or people who are bilingual (or interested in learning a second language) to train in Early Childhood

Development.’

Understanding communities and their cultural sensitivities, keeping them engage to learn with incentives that may be monetary, or extracurricular pursuits like sport, music or drama will encourage young people to train in health care and education, and to consider returning to their community to be role models to others from within their community.

How child development service models and programs outside of Western Australia could be applied in Western Australia.

WA is a large, sparsely populated State with a unique demographic. Early childhood programs set up for other States may not be the best fit. However, the needs of children are the same, irrespective of where they live and the language they speak. Children respond to kind, calm and consistent instruction. They love to learn. To play, read, be read to and have opportunities to explore their environment, feeling, tasting, listening and watching.

Victoria is investing in a universal early childhood programme for three and four year olds, increasing the number of funded houses for children in pre-kindy and early childhood programmes in those age groups. It makes sense for WA to do the same.

In 2006 and 2007, Dr Mustard advised the South Australian government to ‘provide universal education and training in Early Childhood Development to cultivate community understanding of the importance of the early years.’ This advice was based on the knowledge that early brain development effects the physical and mental health, learning and behaviour of a child throughout life.

That is a worthwhile investment. Why wouldn’t we wean to invest in our children. Their future is also ours.

CONCLUSION

As I reflect on the emotional, social and physical health of our children today I sense the frustration of those that work with children – nothing has changed.

Dr Trevor Parry in the seventies, eighties, nineties and the two thousands was fighting for our kids. In 2006 and 2007, his colleague, Dr Fraser Mustard was campaigning the rights of early childhood to our governments.

For more than twelve years I have been shouting out for our kids. Stating to politicians that paediatricians are an endangered species. Warning about the enormity of social shift, of a digital divide, rising anxiety, declining literacy and too few doctors, paediatricians, child health nurses, clinical psychologists and speech pathologists.

WA has people who care and I hope that this year’s spirit of Telethon will inspire. But, it will take more than the seventy-one million dollars gifted for kids in telethon 2022. Hard yakka, passion, sweat, resolve and intent is required by every person invested in childhood, to change the way we raise, teach and nurture our children. To fight for real change. To address the elephant in the room – the disintegration of family structure, of failing to be kind, calm and consistent in the way we speak to children. To allow anxiety to drown our kids while we watch and fail to invest the time in playing, talking, reading, walking, listening and teaching them.

We know how important the role of early child development is on the ability of children to socialise, to self-regulate, to learn, to communicate and survive and thrive as young adults. We don’t need an inquiry to tell us that. We have people who care about our kids and the money and resources to invest in early childhood. What is holding us back? We already know what to do.

It starts with us – parents, teachers, doctors, psychologists, allied health workers and politicians. It ends with us too – our watch, our responsibility.