Indigenous adolescent mental health: what is the role of primary health care?
Issue 24, June 2012
Indigeneity and mental health
An Indigenous Australian is "…a person of Aboriginal or Torres Strait Islander descent, who identifies as being of Aboriginal or Torres Strait Islander origin, and who is accepted as such by the community with which the person associates".1 Indigenous and non-Indigenous concepts of health and life are markedly different. For Indigenous Australians, mental health is a part of the broad concept of social and emotional wellbeing (SEW) which highlights the importance of an individual’s connection to land, culture, spirituality, ancestry, family and community.2,3
Collectively, Indigenous Australians are confronted by much higher levels of health risks and challenges, including mental health, than those encountered by the general Australian population.4 Mental disorders comprise 15.5% of the total disease burden for Indigenous Australians, who are more than twice as likely to be hospitalised for mental health disorders as other Australians.5 The problem is particularly dire in Indigenous youth, in whom it is estimated that up to 40% of those aged 13–17 will experience some form of mental illness.6 Indigenous youth face particular stressors including experiences of discrimination, loss of language, social dislocation and isolation, and the historical and contemporary effects of colonisation.5 The forced removal of children from families impacted on spiritual and cultural identity and continues to affect subsequent generations.4,5 Regrettably, grief and loss are enduring experiences within Indigenous communities due to the high death rates amongst adults and suicides amongst young people.4
To date, there has been little research conducted on the mental health of Indigenous youth, and existing research is limited by the lack of validated psychological assessment tools. This is currently being addressed through a national initiative to develop and test tools for measuring SEW amongst Indigenous Australians2 and the dissemination of recent validation studies on tools used to measure Indigenous mental health.7
What is the extent of the problem?
The most comprehensive data set currently available is the Western Australian Aboriginal Child Health Survey (WAACHS). This survey reported that 24% of West Australian Indigenous children aged 4–17 years showed signs of serious emotional or behavioural difficulties, compared with 15% of non-Indigenous children.8 These rates were even higher in children aged 4–11 years (26% for Indigenous children and 17% for non-Indigenous children).8 Additionally, in approximately one third of surveyed children, the carer or carer's parent had been forcibly removed from their family; and these children were twice as likely to be at high risk of clinically significant emotional or behavioural difficulties.4 Alarmingly, these figures may be underestimations due to cultural differences between the ways that mental health problems are understood, experienced and reported by Indigenous people.4
The yawning gap between Indigenous and non-Indigenous mental health status has been recognised in the Australian Government National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003-2013, which identified Indigenous SEW, including substance use and mental health, as a priority attention area.9
Indigenous use of PMHC services
Indigenous Australians can access primary health care through mainstream services such as general practitioners and through Indigenous-specific, culturally-appropriate services such as the Aboriginal Community Controlled Health Services network.4 However, Indigenous Australians are less likely than non-Indigenous Australians to access primary mental health care.5 The WAACHS found that only a small proportion of at-risk youth had contact with mental health services- 3.8% of children aged 4-11 years and 11.0% of children aged 12-17 years.8 This reluctance or inability may be due to many factors including remoteness, language barriers, affordability and cultural sensitivity issues. The enduring effects of forced separation may also play a role, with families avoiding accessing mental health services for fear of government involvement and possible removal of children.3
Several ongoing national PMHC initiatives are aimed at children and adolescents, including headspace and Kids Helpline. Although these initiatives were not specifically developed for Indigenous youth, it is likely that they are used by this population.
Similarly, several initiatives relating to Indigenous Australians are not specifically aimed at, but may encompass, Indigenous youth. The Australian Government has committed to increasing the number of training positions through the Improving the capacity of workers in Indigenous communities initiative, which funds additional national mental health worker positions. Additional resources have been allocated to the Access to Allied Psychological Services (ATAPS) scheme to increase the availability of psychological services for difficult-to-reach populations, including Indigenous people.10 The Australian Mental Health First Aid (MHFA) training was developed to teach people how to provide initial help to someone developing a mental health problem or in a mental health crisis situation. In 2007 this was further developed into a Mental Health First Aid for Aboriginal and Torres Strait Islander Program, which was recently evaluated as being culturally appropriate and acceptable to Indigenous people.11 Additionally, the Australian General Practice Network is developing a National Indigenous Resource Kit for general practice networks.12
Of the limited number of programs targeted specifically to Indigenous youth, even fewer have been evaluated, possibly due to funding constraints or the paucity of validated tools for measuring SEW in these populations.
The Aboriginal youth mental health partnership aimed to provide accessible and culturally appropriate mental health services (via a dedicated project worker) for Indigenous youth involved in, or at risk of involvement in, the juvenile justice system. During the three-year project duration, the number of Indigenous youth and their families receiving a service from the metropolitan Child and Adolescent Mental Health Services (CAMHS) increased by 44.6%, and there was a 117% increase in the number of Indigenous youth who received a service from the Country Services CAMHS.13 Overall, there was a 2.4% increase in the number of unique Indigenous clients receiving a service from CAMHS metropolitan and country services during the project period.13 The project's success was increased by "…building trust through networking, being responsive and flexible and becoming known and visible within the Aboriginal community".13
As part of the broader Building bridges: learning from the experts project, Indigenous youth and prisoners were provided with access to interactive kiosks that included a suicide prevention module Buluru Yealamucka - Healing Spirit. The kiosks were seen as a dynamic and sustainable tool for educating Indigenous people about suicide prevention and other important health issues. Overall, the Building bridges project resulted in community changes that enhanced resilience to, and reduced the risk of, self-harm and suicidal behaviours occurring in the community.14
MindMatters is a non-Indigenous-specific school-based mental health promotion program. This was implemented as a pilot project at an Indigenous school in Queensland, and evaluators considered it a success in terms of the school-related outcomes (professional development; curriculum development).15 However, it was unclear whether any mental health outcomes were measured or reported in the participants.
The evaluated Indigenous youth PMHC programs commonly noted that resources developed or contributed to by Indigenous people were well-accepted and relatable. Generally, evaluators noted that networks and relationships took time to develop, and that effectiveness outcomes were subsequently delayed. Culturally-sensitive delivery and location of services (ie. not adjacent to a child welfare office) were identified as important factors. Additionally, it was thought that the involvement of Indigenous workers across all sectors of PMHC programs was likely to increase client engagement and promote the cultural sensitivity of the provided services. As SEW issues experienced by Indigenous youth may be to be influenced by many factors (including housing, employment and health), effective collaboration across these sectors may improve the success of PMHC initiatives.3
To be culturally appropriate, any approach to Indigenous mental health should be cognisant of the broader concept of SEW and mindful of the factors that currently limit uptake of primary health care. As it is likely that these initiatives will take time to produce outcomes, long‑term commitment from their funders, research partners and community members is necessary.
- Australian Bureau of Statistics. (2010). Indigenous statistics for schools. Canberra: Australian Government.
- Australian Institute of Health and Welfare. (2009). Measuring the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples. Canberra: AIHW. [PDF:384Kb]
- Williamson AB, Raphael B, Redman S, Daniels J, Eades SJ, Mayers N. (2010). Emerging themes in Aboriginal child and adolescent mental health: findings from a qualitative study in Sydney, New South Wales. MJA 192(10), 603-5.
- Dobia B, O’Rourke VG. (2011). Promoting the mental health and wellbeing of Indigenous children in Australian primary schools. Canberra: Commonwealth of Australia. [PDF:1.0Mb]
- SA Health. (2010). Aboriginal health care plan 2010–2016. Adelaide: SA Dept of Health.
- Westerman T. (2010). Engaging Australian Aboriginal youth in mental health services. Australian Psychologist, 45(3), 212-22.
- Thomas A, Cairney S, Gunthorpe W, Paradies Y, Sayers S. (2010). Strong Souls: development and validation of a culturally appropriate tool for assessment of social and emotional well-being in Indigenous youth. ANZJP, 44, 40–8.
- Zubrick SR, Silburn SR, Lawrence DM, Mitrou FG, Dalby RB, Blair EM, Griffin J, Milroy H, De Maio JA, Cox A, Li J. (2005). The Western Australian Aboriginal Child Health Survey: the social and emotional wellbeing of Aboriginal children and young people. Perth: Curtin University of Technology and Telethon Institute for Child Health Research.
- Dept of Health and Ageing. (2007). National Strategic Framework for Aboriginal and Torres Strait Islander Health 2007–2013. Australian Government Implementation Plan 2007–2013. Canberra: Australian Government.
- Dept of Health and Ageing. (2011). National Mental Health Reform 2011-12. Canberra: Australian Government
- Kanowski LG, Jorm AF, Hart LM. (2009). A mental health first aid training program for Australian Aboriginal and Torres Strait Islander peoples: description and initial evaluation. International Journal of Mental Health Systems, 3, 10.
- Australian GP Network. (2010). Indigenous health and the Australian General Practice Network. Canberra: Australian GP Network.
- Dobson I, Darling K. (2003). Aboriginal Youth Mental Health Partnership Project: evaluation report. Adelaide: CAMHS Western Region. [PDF:181Kb]
- McKay et al. (n.d.). Building bridges: learning from the experts. Building bridges to implement successful life promotion and suicide prevention expertise across Aboriginal communities. Evaluation report. Manunda, QLD: Centre for Rural and Remote Mental Health. [PDF:997Kb]
- Sheehan M, Ridge D, Marshall B. (2002). This was a great project!: reflections on a 'successful' mental health promotion project in a remote Indigenous school. Health Promotion Journal of Australia, 13(3), 201–4.
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