Focus area 1: Family and Community

The family environment is the single most important influence on a child’s development, with family relationships and interactions critical to positive mental health and wellbeing. The first years of a child’s life provide a foundation for their future, with quality parenting, high levels of family functioning and access to social and family supports contributing strongly to optimal development.

The Strategy identifies the importance of empowering families to promote good mental health and wellbeing as part of routine parenting and actively collaborate with services when these are required. The Strategy is also sensitive to the cultural, geographic or experience-based communities (such as migrant or LGBQTI+) with which children and families identify, and recognises the impact that community membership can have on perceptions and experiences of mental health and wellbeing.

 

Objective 1.1 Supported families

Support for families starts with looking at risk factors and challenges in the perinatal period. While this Strategy predominantly focuses on birth onwards, there are important issues (such as foetal alcohol syndrome) that arise in childhood and have their origins in the antenatal period. For families, the perinatal period (conception to 12 months post birth) is also a high-risk time for depression and anxiety, impacting one in five mothers and one in ten fathers or partners. In addition to impacting on the family and child’s wellbeing, perinatal depression and anxiety poses a high economic cost of approximately $877 million in Australia in 2019. Identifying parents who are struggling (or likely to struggle) and connecting them with supports is an effective strategy in promoting the wellbeing of their child (action 1.1.a).

All parents and carers want the best for their children. But not all parents and carers know what they can do to help their children develop positive mental health nor what signs to look for when things might not be going well for their children. While there is a range of resources already available to provide guidance on what parents and carers can do, many families would not be aware of them (actions 1.1.b and 1.1.c). There can also be a number of structural barriers that prevent children and parents accessing care (see Box 2).

Caring for young children is challenging, but it is important that parents understand effective parenting strategies. All parents and carers, whether biological family or extended kin networks can often benefit from learning evidenced-based parenting tools and strategies. Parenting programs are one option to support parents in optimising their confidence and in building safe, secure and nurturing relationships with their children.

Parenting programs have been found to have positive outcomes for child mental health and wellbeing. They have also been proven to have good outcomes for families of children both with and without developmental difficulties, and when delivered face-to face, online, in groups, or as self-directed learning. They have also been successfully tested in rural and remote communities, with positive outcomes. For these reasons, parenting programs should be routinely offered at key transition points and developmental milestones in a child’s life (action 1.1.c). Parenting programs should also include optional modules targeted to specific parental concerns and scenarios. For example, supporting transgender, gender diverse and nonbinary children; parenting children with disability; parenting through challenging circumstances (such as multiple births or parental separation).

Fathers and male caregivers are under-represented in terms of participation in current parenting programs and may not be well included in existing early childhood services, for example, post-natal peer support or ‘mothers’ groups’. Therefore, targeted engagement and tailored programs may be required, acknowledging cultural differences in parenting roles. Inclusion of fathers is likely to be an important element of addressing family abuse, the use of physical discipline and child wellbeing. But regardless of the family circumstances, involving multiple caregivers in parenting programs helps build consistency in parenting practices.

It is also worth noting that grandparents play a significant role in caring for children. For example, in 2014, Australian grandparents provided childcare for almost one-third of working parents. Grandparents should be included as part of targeted strategies to increase mental health literacy and participation in parenting programs. Parenting programs should also be tailored for the different challenges that present within diverse family structures such as same sex parents, blended families, and large or extended family structures.

Despite evidence of positive outcomes from parenting programs, parents and carers can be reluctant to engage with them. There are strong perceptions that parenting is something that should be natural and instinctive. This means that parents and carers can feel like they are failing if parenting does not feel easy or natural for them. As a result, parents and carers may not want others to know that they are struggling and feel defensive about participating in parenting programs. There is also stigma due to the association of parenting programs with child welfare contexts, rather than those pitched as providing practical information on children’s development (action 1.1.d).

By promoting such programs to all parents, stigma of ‘bad parenting’ as a driver for program engagement is minimised. In addition, the way parenting programs are discussed by service providers is important – for example, framing parenting training around the notion of supporting child development results in better engagement than focusing on learning how to be more effective as a parent. Higher (or ideally universal) levels of participation in parenting programs would mean that those who require assistance would benefit, and those who were not struggling would be better equipped to prevent their own future struggles or support other parents who struggle (action 1.1.c, action 1.1.d). One tool to reduce stigma is to ensure that programs are the result of co-design between the community and the organisations delivering them. In addition, barriers to access such as cost, childcare, and sub-optimal times and locations should be considered as part of local implementation, with the mitigations (for example, free transport and childcare) communicated widely to all potential participants.

Community education is an important tool to reduce stigma associated with parenting programs, especially in light of the association with the child protection system. Sharing stories of a wide range of parents and caregivers who have been through and benefitted from programs is an effective means of addressing stigma, along with use of traditional and social media. Where mainstream parenting programs are not culturally safe nor easily accessible (for example, for Aboriginal and Torres Strait Islander families) consideration should also be given to establishing partnerships with ACCHOsk to co-create, promote and deliver relevant content (action 1.1.b). In particular, information sessions should be informal and promoted as yarning circles at a location that is culturally appropriate and provides a safe space for parents to feel comfortable to engage in the program.

Other universal supports include parent helplines, available nationally and across each state and territory (action 1.1.e). Many parents also enrol in antenatal courses associated with their midwife or obstetrics practice, usually held at the same location as the birth clinic. There may also be similar courses offered via community health centres (action 1.1.f). Ideally, antenatal classes would include work on partnering and early parenting, be provided free in less well-resourced areas, and in a range of languages. They would also be backed by resources and presentations, and available in multiple languages, including Auslan.

 

Box 2. Children and families that are ‘yet to be engaged’.

Just because a service system exists does not mean that all families will engage with it. Julian Hart published a seminal paper in 1971 titled ‘The Inverse Care Law’, which proposes that the availability of good medical care tends to vary inversely with the need for it in the population served. In other words, those children and families who would benefit the most from services are the least likely to utilise them.

There are a number of factors that may act as barriers to receiving timely and appropriate care. In addition to the issues regarding accessibility (see objective 2.3) and complexity (objective 2.4), there may be (1) structural barriers – families not aware that the service exists, the hours of opening may be inconvenient, out of pocket expenses may make the service unaffordable, long waiting lists, or lack of transport to get to the service; and/or (2) relationship or interpersonal barriers – cultural sensitivities, language barriers, professionals may be perceived as having lack of empathy or poor listening skills, or parents may not have trust or be afraid the child will be removed from the family.

To address these barriers and ensure that all children and families engage with the service system as required, there needs to be systematic and organised outreach to these vulnerable families, with particular effort placed on building relationships with parents. This outreach depends on context and may take different forms, and will always be challenging, time consuming and require specific additional resources for a community-based service system. Non-threatening and non-stigmatising existing universal programs, such as immunisations, may be a useful base from which to plan outreach programs. In some cases, children will have no contact with early childhood learning services, and their first experience of formal education will be at school. The ABS reports that around 17% of 4-year olds are not enrolled in a pre-school program. While removing barriers to early childhood education is important due to the social and economic benefits, alternative touchpoints exist for reaching children prior to school such as visits to a GP (objectives 2.3 and 2.4), and improving outreach to vulnerable families (objective 1.1).

Health and social services connected with adults (such as Centrelink) provide data linkage for child supplement or associated payments. These could enable the identification of children who are disengaged from formal supports and services including health and education. This responsibility belongs to all agencies, departments and services providers across local, state and national levels (action 1.1.g).

Where children are not attending an early childhood education service, it is critical to engage them via universal health care systems and social services. Options to achieve this include outreach and family support. Other more informal options include home-visiting, mobile pre-schools, or supported playgroups that are facilitated by trained early childhood professionals. Other options include partnering with community, faith and cultural leaders to provide expert knowledge, bridge trust and reach out to families least likely to engage, and that areas of contact for children and families who are struggling are expanded to: libraries, child and family centers, food banks, welfare providers, and cultural networks.

Once the initial connection is made, support for at-risk parents should include: education as a preventative tool, intervention i.e connection to mental health services and supports where they are struggling, and evidence-based parenting programs in group or individual settings.

 

Things we can build on

NSW Health developed the First 2000 Days Framework, documenting the importance of this period for a child’s physical, cognitive, social and emotional health, during their lifetime and for future generations. The Framework provides key actions across the NSW health system, and underpins local priority setting and planning. Models of care in this document could be utilised across other states and territories.

In Queensland, access to the evidence-based parenting program, Triple P, has been funded for all parents of children up to age 16. Parents and carers can access it on a voluntary basis at no cost, and uptake has increased for many vulnerable groups during the current pandemic. The program is based around the development of self-regulation, and is underpinned by five positive parenting principles; safe and engaging environment, positive learning environment, assertive discipline, realistic expectations, and parental self-care. The original trial of the online format found that it increased parental confidence in managing problem behaviours, lowered the use of ineffective discipline, and parent users reported less child conduct problems.

Foster parents and adopting parents undergo mandatory parenting skills training, and parenting support programs are provided by maternal and child health centres antenatally and postnatally. They are also available via early childhood learning services, schools in the public and private sector, and in child mental health services in some jurisdictions, such as NSW. Although the extent to which these programs incorporate content focused on child mental health is variable (action 1.1.f).

As noted in the Productivity Commission’s Final report, there are improved outcomes with the use of regional coordinators in adult clinical mental health services to facilitate family-inclusive practice. Victoria’s Families where a Parent has a Mental Illness (FaPMI) initiative introduced coordinators in each catchment area, as a way to build capacity of the local workforce to improve identification and support for parents and children. Results from a preliminary, targeted evaluation compared two mental health services (one rural, one urban) with and without a FaPMI coordinator. The evaluation found that adult mental health clinicians had greater knowledge and skills regarding the effects of parental mental illness on children and were more able to provide referrals to family support service after the FaPMI services were introduced.

Models of support for families who cannot access mainstream services should also be explored. Statewide Outreach Perinatal Mental Health Service (SWoPS) delivers telehealth psychiatry support to NSW Health staff who care for perinatal women in rural and remote NSW who have limited access to local Perinatal and Infant Mental Health (PIMH) services. A PIMH Service is also offered within women’s prisons (Justice Health and Forensic Mental Health) for perinatal women with complex mental health needs. The Commonwealth Department of Social Services funds early intervention and prevention services and resources focused on children aged 0-12 years with the aim of improving development and wellbeing and supporting parents and carers. The Intensive Family Support Services focuses on reducing child neglect and providing vulnerable families with practical parenting education and support for 12 months. Other programs including the Child and Parenting Support Service and the Home Interaction Program for Parents and Youngsters include services such as supported playgroups and school readiness programs to help parents develop their child’s pre-literacy and pre-numeracy skills.

Use of language and reframing of parenting messages can have an important role in successfully engaging with target audiences. Successful examples include the 'Raising Children Network’ which is a complete online resource backed by the Parenting Research Centre, and the courses run by Developing Minds with titles such as ‘support for children with big feelings’ (rather than ‘improve your parenting’).

Actions 1.1

a. Implement perinatal mental health screening for expectant parents in maternity services (public and private), monitoring and reporting on alignment with the National Perinatal Mental Health Guidelines (see action 4.1.a).

b. Ensure evidence-based resources that provide practical suggestions on how families can support children’s emotional wellbeing are made easily accessible and promoted widely. These must include specific resources for families where there are additional physical, neurodevelopmental or cultural needs, developed via genuine co-design.

c. Routinely offer evidence-based parenting programs to parents and carers at key developmental milestones for their child – for example, the perinatal period (from 6 weeks), at commencement of early childhood education (age 2-4); transition to primary school (age 4-6), when their child moves to the penultimate year of primary school (age 10-11); and at the commencement of high school (age 12+), with targeted engagement and tailored programs for fathers and male caregivers.

d. Implement a nation-wide campaign aimed at promoting the availability and value of parenting programs, with specific efforts to address stigmatising attitudes towards participation in such programs and to removing practical and financial barriers to participation, especially in refugee and migrant communities.

e. Promote parent helplines and hotlines (available in each state and territory) as the first ‘port of call’ for any parenting concerns, and enable helplines to take calls through the Translating Interpreting Service, to communicate with parents who do not have English as a first language.

f. Include emotional wellbeing modules and information about locally available supports in all antenatal and parenting training courses delivered to new parents.

g. Design systematic methods for identifying children who do not start primary school by the required age, with this prompting a compassionate outreach of support to engage the child and family.

Objective 1.2 Increased mental health literacy

Despite increased general awareness of the importance of mental health in Australia over the past decade, the majority of parents and carers in one study (65%) would still not be confident that they could recognise signs of poor mental health in their child. Parents and carers report that it is particularly challenging to identify when a child is struggling with their mental health when there are also a range of other situational factors impacting on the family. Difficulties identifying when children are struggling can delay access to interventions and support.

Signs that children are struggling can look quite different to adults or young people. These signs also change over time as children go through various developmental stages that affect language acquisition, impulse control and behavioural regulation, and the development of emotional intelligence. Consequently, children’s social and emotional needs and capabilities may vary greatly depending on their age. Where signs of not-coping (such as changes in behaviour) are missed, so too are opportunities for prevention and early intervention, and access to supports in a timely manner. Children also have less autonomy than young people or adults and are therefore dependant on the adults around them (parents, carers, educators, health professionals) to identify that help is needed and to facilitate access to it (action 1.2.a, 1.2.b). Some parents may identify that their child is struggling, but be uncertain about whether the issues are ‘severe enough’ to warrant additional intervention beyond the support the parent or carer can provide. A lack of clarity about when parents should seek professional support for their child only adds to the delay (action 1.2.a).

Further complicating these matters, different families and communities may describe a child’s mental health very differently. A family’s understanding and prioritisation of mental health can vary greatly due to various factors, such as cultural and language background. In some cultures, even conceptualising emotional or behavioural struggles under the umbrella of ‘health’ may be unfamiliar.

For others, the term ‘mental health’ may be associated only with very severe mental illness and not resonate with the struggles that they might observe in their child (action 1.2.b). Increasing mental health literacy and health system literacy should therefore be a priority among refugee background communities, including those seeking asylum, in conjunction with initiatives which address stigma and misinformation, which can be heavily present in these communities. It will also be important to test the concept of the wellbeing continuum and anchor points in different communities and different languages (action 1.2.c), with any amendments undertaken as a result of co-design.

Increasing mental health literacy and reducing stigma must be supported by the whole community. Children and families interact with many different services and organisations that can either reinforce misperceptions and stigma or help to create positive change. The service system (focus area 2) and education system (focus area 3) are discussed in detail in this Strategy, however children and families participate in many other areas of the community. This may include sporting clubs, after school programs, performing arts groups, faith-based groups and a range of other community groups. Many leaders working or volunteering in these areas of the community would see children who are struggling, but not always know what to do or how they can help. There is an opportunity through community organisations to create a positive culture in relation to mental health and ensure reliable and accurate information gets to families (action 1.2.d).

 

Box 3. Supporting children and parents during national disasters

The Commission has developed a National Disaster Mental Health Response Framework that emphasises the needs of children, young people and their families. In particular, parents and carers need advice and information on ways to meet their own emotional and mental health needs, ways to support their children, and ways to manage changed family dynamics in the context of natural disasters and other community crises.

The compounding impacts of the Black Summer fires followed by the pandemic, coming on top of other major disasters such as droughts and floods, has highlighted risks to children’s mental health and psychosocial wellbeing in Australia. Most studies show that because of children’s vulnerabilities and their stage of development, major disasters are likely to have a more detrimental effect on their mental health and wellbeing and overall development compared to adults. For example, during the initial phase of the COVID-19 pandemic, parents reported that the pandemic negatively affected the mental health of more than one in three children.

However, the majority of families (73%) also reported that it brought them closer together and increased their appreciation of what was important. Services like Lifeline and Headspace quickly adapted their service models and were heavily utilised via web chat, while clinicians provided digital consultations that helped overcome COVID restrictions and also ameliorated the workforce and service gaps often experienced by rural and remote Australians.

Another variable is the extent to which young people are included in decision-making. A sense of agency can itself be a protective factor – actively involving children in preparing for disasters and helping with the response and relief efforts, for example, may help. Given children often do not volunteer information about their feelings for fear of worrying their parents or not being believed, their wellbeing will largely depend on the wellbeing of their family or household.

 

Things we can build on

The Commonwealth’s Head to Health website contains information for adults on supporting children with their mental health and wellbeing, including links to additional resources and public forums. There is also work underway to design, develop and deliver regular child development and mental health literacy messaging to parents via a digital platform. The program will be delivered through the Raising Children’s Network in collaboration with the Murdoch Children’s Research Institute. Given that parents frequently search online or communicate with other parents via social media, this new online platform could provide an effective vehicle to reach parents who are worried about their child’s emotional or social development.

In Australia, there have been many positive examples of child-focused initiatives that have aided children and/or whole community recovery. These include:

• The development and creation of a Community Trauma Toolkit by ACATLGN and Emerging Minds, accompanied by an online clearinghouse. The toolkit provides evidence-based resources and training aimed at building capability for disaster risk reduction, response, and recovery in different workforces, communities, and families at each stage of a disaster event with a focus on supporting infants, children and parents/caregivers.
• Save the Children’s Journey of Hope online to children and in schools to support recovery from recent disasters such as bushfires, but also the compounding distress children have experienced due to COVID-19. The project also entails building child participation in disaster planning at the local level.
• Child-friendly spaces in evacuation and recovery centres to enable children and families to begin processing their experiences, supported by qualified and appropriately trained staff. ACT Bushfire Relief Centres during Black Summer offered child friendly activities, Children’s Therapeutic Play Kits (designed for children in emergency / temporary accommodation) and child focused staff in order to meet their immediate needs – which usually involved play.

Actions 1.2

a. Plan and implement a program of activities (such as campaigns) to increase parents’ and carers’ understanding of the signs that a child needs mental health support, including during and after national disasters. These activities should directly address any common myths or misconceptions about child mental health and wellbeing, and promote children’s participation in mental health discussions.

b. Ensure mental health literacy resources do not assume any background knowledge about mental health, use terminology and examples that have universal relevance wherever possible, and are translated into languages other English.

c. The concept of the wellbeing continuum and its associated anchor points should be tested to see if they have resonance for different communities, including assessing how well they translate into different languages and cultural norms.

d. Provide resources about mental health to those in community organisations working or volunteering with children, including information on how to listen to and advocate for the child’s perspective and where they can direct children and families if they need additional mental health and wellbeing support.

 

Objective 1.3 Community-driven approaches

Like adults, children are members of communities. As they grow, they will develop a sense of belonging with their family, their neighbourhood, their school, their sporting team, their church, and in other aspects of their lives. Communities may be based on culture, geography, or simply shared experiences such as schooling and sport. One of the central principles of this Strategy is to consider each child and the context in which they live. This means including their family and their various communities in our efforts to understand and address the child’s struggles. In some instances, it may be necessary to support the health of the child’s community in order to improve the child’s wellbeing (action 1.3.a and 1.3.b).

The impact of social and geographical environments on child mental health and wellbeing is well known. With evidence that children’s temperament develops over time in response to environmental factors, including neighbourhood disadvantage (marked by access to nature and public open space and inadequate infrastructure) which can diminish their experience of community. In contrast, while family finances and public services go a long way to shaping children’s development, strong and supportive relationships, both inside and outside the home can have a protective effect, especially for children of minorities and those of low socioeconomic status. While addressing all social determinants of child mental health and wellbeing is beyond the scope of this strategy, they should remain key considerations as part of community-driven approaches. In some communities, strengthening links to culture may be a key component of a place-based approach. This would be consistent with studies that show strong cultural links and practices improve outcomes for children and families. An example of this is the need to use social and emotional wellbeing concepts when implementing mental health supports in Aboriginal communities. Place-based approaches need to be the result of co-design within the community (Box 4), including the approach taken for evaluation and use of indicators that meaningfully represent change from the community’s perspective.

Community based programs have also been identified as delivering promising results for suicide prevention for indigenous children, such as Koori Kids in NSW and the Let’s Start Child Parent program in the NT. Research by the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Report Project confirms that common elements of success are programs that:

• invest in locally based upstream approaches that promote young people’s connectedness, sense of belonging, stability, hope and control over their life and future
• are activity based and foster connection to cultural practices and identity
• support young people to have a vision for their future
• have a focus on recovery and healing from stress and trauma
• utilise digital technology
• are peer led and utilise the role of youth workers and others in less formal relationships with young people
• enhance communication between family members and within communities
• are both clinical and culturally based and are provided 24 hours a day.

One example of a place-based approach might include ongoing funding for supported playgroups, with attention to local government areas with high populations of refugee background families and other vulnerable groups. These would be accessible, fun, unique and culturally appropriate, staffed by health and educational professionals designed to engage and support families, and act as a gateway to more comprehensive support and services if needed.

 

Box 4. Co-design

Co-design is a practice that involves bringing consumers, carers, families, and health workers together to design, evaluate and improve services. Co-design involves consumers and health workers identifying problems within services, and working collaboratively to find solutions. Co-design should involve people who will be impacted by the proposed service, either directly or indirectly. Co-design is guided by 5 principles: equal partnership, designing together, openness, respect and empathy.

Co-design can be highly beneficial for services and consumers. Co-design encourages consumer involvement from the beginning of program development, rather than seeking feedback after a program has been developed. This allows services to be developed with the knowledge that they have been designed to provide the best care to consumers. Co-design prevents health workers from making assumptions about the services that will benefit target groups. This allows health workers to feel confident that they are providing the best care, whilst adjusting their expectations about best practice care. Co-design allows consumer groups to ensure that services are respectful and relevant to their needs. This allows consumers to feel confident that they are accessing a service that will benefit them.

Things we can build on

Collective impact and place-based initiatives are increasingly being proposed to address complex social issues in a manner that is sensitive and adaptive to individual communities. The Communities that Care program is an example of an evidenced-based community-change process that involves the development of targeted frameworks to address issues facing children and young people tailored to local needs. Through the program, key stakeholders in the community are identified and recruited, and data is collected about young people in the community to assist with identifying areas for action. A unique plan that addresses the community’s needs is then developed, implemented and evaluated. A range of different programs may be included as part of each action plan, such as mental health first aid training, social marketing campaigns, and parenting and child wellbeing programs. This program has demonstrated success in supporting prevention and early intervention for health and social problems amongst children and young people in Australia and overseas.

Children’s Ground is an Aboriginal and Torres Strait Islander-led and designed place-based approach for working in Australia’s most disadvantaged communities. The first partnership established by Children’s Ground is with the Mirarr people in the Northern Territory, through their organisation the Gundjeihmi Aboriginal Corporation. The Children’s Ground approach involves working with families with children pre-birth through to 8 years old targeting the social and cultural determinants of education, health, and wellbeing. It addresses five platform areas, each of which intersects with wellbeing; learning, family health, economic development, community development and creative and cultural development.

Evaluation of Children’s Ground found that the approach increased children’s engagement in learning and levels of adult employment, as well as greater inclusion of the community in governance, design, delivery and evaluation of services.

Characteristics of a successful place-based approach include:

• Communities participate, lead and own the intervention
• There is investment in capacity building
• There is adequate time for transformation to occur
• There is adequate funding for pilots, demonstration projects and infrastructure, and to support initiatives and ideas that flow from the project
• Effective relationships between stakeholder groups
• There are processes to rigorously measure and evaluate outcomes
• There is a ‘good fit’ – i.e. the scale of the project is appropriate to the policy challenge.

 

Actions 1.3

a. Identify and invest in communities that could benefit most from community level support; for example, those with low school attainment, high unemployment, poor physical and mental health, high imprisonment rates, high incidence of child abuse or neglect, or any other factors that contribute to or maintain an environment of social and economic disadvantage.

b. Work with communities to develop and deliver tailored programs focused on improving child wellbeing and based on the key characteristics of successful place-based approaches. These may build upon existing social networks organically built through contact with maternal and child health, educational settings, sport and other community settings.

 

Focus Area 1: Families and Communities – indicators of change

1.1. Uptake of evidence-based mental health and wellbeing resources for families

1.2. Adoption of a wellbeing continuum approach

1.3. Targeted investment in communities’ mental health and wellbeing