Understanding relapse prevention from the developmental viewpoint of children and adolescents is complex. Children and adolescents are usually at an earlier point in the developmental trajectory of mental illness, although the onset of mental health problems and mental illness appears to be occurring earlier in the lifespan. Nevertheless, for most children and adolescents mental health interventions are focussed on indicated prevention and early intervention (NSW Health 2001), rather than continuing care for recurrent or chronic mental illness. Consequently, relapse prevention must be considered within this developmental context.
The mental health system has developed with a focus primarily on adults, although international policy has recognised the importance on focusing initiatives on the infant, child, adolescent and family mental health sector and have acknowledged that this area needs dedicated planning and implementation to ensure that the needs of these population groups are not overshadowed by those of general adult mental health services (AICAFMHA 2003). A fundamental barrier to including these groups under the general umbrella of mental health is that the adult focus of the mental health sector is reflected in the language that is used to communicate within and about the system. Unfortunately, this paper is also bound by such language, as terms such as 'rehabilitation', 'recovery', 'consumer' and 'carer' derive from the adult-focus of mental health. This can lead to alienation of the child and adolescent mental health sector.
Despite differences in terminology, the elements of relapse prevention still apply for child and adolescent mental health although they are framed in different terms. It needs to be emphasised that childhood and adolescence are times when the opportunities for successful outcomes in terms of relapse prevention are maximised. Consequently, much of the focus of child and adolescent mental health services is on building resilience and enhancing wellbeing. Effective child and adolescent mental health services operate within a preventive and holistic framework; arguably more so than is current practice in many of their adult-focused counterparts.
- We work within a protective behaviours framework. We don't do 'rehabilitation' and we don't focus on illness. We concentrate on strengths and opportunities, particularly opportunities to remain in school and to stay connected to family and positive influences. —CAMHS clinician
While the health behaviours of children are often determined by their parents or guardians, the health behaviours of adolescents become increasingly under their own control. Encouraging positive health behaviours that promote mental health, and encouraging early help-seeking behaviour in particular, are issues of concern. Young people seek mental health help in different ways as they mature, and these changes need to be understood in order to provide services that they are prepared to use (Rickwood et al in press). The availability of mental health resources that are acceptable and accessible to young people is a priority. In this regard, the Headroom website (www.headroom.net.au) and resources developed by young people for young people are essential. A resource entitled 'Keeping yourself well after mental health problems' has been developed as part of the Headroom project specifically related to relapse prevention for young people. Youth-friendly services of all types are required to remove the stigma of seeking mental health help and encourage adolescents to access them, and there is currently a paucity of such services, especially outside large urban areas.
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Peer support is optimally important for adolescents and the development of effective peer-based programs needs prioritisation. However, it is important to caution about the nature of such programs, as the development of a 'deviant' peer group can encourage persistence of a mental health problem (National Crime Prevention 1999). Positive peer group interactions are essential for young people, and such an approach has been targeted specifically to young people who have experienced mental health problems through programs such as 'Amigos'. Innovative work is being undertaken by Adolescent Services - Enfield Campus (ASEC) in South Australia and the Early Psychosis Prevention and Intervention Centre in Victoria (EPPIC) around training peer consultants to provide mental health information, hope and role modelling for young people. Importantly, AICAFMHA has been successful in proposing the development of a youth participation strategy for mental health to the Federal government.
It is a special challenge to be the parent of a young person with a serious mental health problem. Increasing independence from parents is a developmentally appropriate goal of adolescence and this, along with occasional adolescent rebellion, makes the parent/carer role especially complex. While parents need to be involved in the continuing mental health care of their adolescent children, they need extra support to negotiate the issues that arise. For example, parental monitoring of symptoms may or may not be appropriate: for some families this will be a source of conflict. Increasing adolescent independence must be recognised and facilitated by all the parties involved in providing continuing care. This can be a particularly vexed issue in areas where, through lack of services, parents have to provide a lot of input into continuing care.
- If only we had a case manager. It is not appropriate for me to be acting like the case manager, but there is no-one else to do it. He gets angry that I interfere and tells me that it's none of my business and I should leave him alone. But if I don't get involved to find services and try to get help, then we end up in crisis, which can be very bad. I have to try to stop that happening. If I don't try, then it will happen and we all end up with the police and hospital. In the end he will end up in jail if I don't keep on it. I think he would accept it much better if someone else, who was not his mother, took this role. —Rural carer
Clearly, there is large variation across the developmental needs of children and adolescents. Furthermore, young people with mental health problems may be developmentally immature for their chronological age. Providing services based on inflexible age criteria is, therefore, not appropriate, and services need to be flexibly organised around the developmental needs of young people.
- There is huge variation in the developmental needs of children and young people. Some are still at home with their parents and go to school, some have left home and are no longer at school, some even have families of their own. Services that are provided solely on an age basis, whether it is up to 18 years, or even the 15-25 year approach, are not able to meet the needs of these hugely different levels of maturity. —CAMHS clinician
There are additional risk factors for young people with mental health problems (Resnick et al 1997). Risk-taking behaviour around alcohol and other drug use and sexuality are common, and support services need to deal with these issues. Illicit substance use is a major risk factor of special concern for young people, and strong partnerships between mental health and drug and alcohol services need to be routine. Appropriate accommodation for young people is also a challenge: it is especially inappropriate to house teenagers with mental health problems with older people who have more chronic mental illness or who have established drug and alcohol problems.
At maximal risk are young people who are involved with the justice system, particularly those who have been incarcerated. These young people often have social and emotional problems and other issues related to their incarceration that add substantially to their risk of future mental health problems.
Young people from Aboriginal and Torres Strait Islander backgrounds and from culturally and linguistically diverse backgrounds also have additional risk and protective factors related to culture, identity and belonging that need to be identified and considered.
The children of parents with mental illness are another group of young people who have unique risk factors: the COPMI project is a national initiative that is investigating the best ways to meet the needs of these young people, many of whom may have significant mental health problems themselves. A document has recently been published outlining the Principals and actions for services and people working with children of parents with mental illness (AICAFMHA 2004) along with development of a website of supporting documents (see the COPMI website (www.copmi.net.au)). These initiatives are not only important to these children, but are highly relevant to the ongoing wellbeing of their parents.
It is important for mental health service planners and policy makers to recognise that the types of services accessed by children and young people with ongoing mental health problems can be quite different to those for adults. For example, while primary care provides a first point of contact for most people seeking mental health help, for children and young people primary care "includes care from services such as general practitioners, school counsellors, paediatricians in some instances, community health centers, and other community-based health, maternal, child, family and youth health and welfare services" (Raphael 2000 p40). Furthermore, much of the demand for a mental health service response for children and adolescents is for community services (rather than hospital and emergency services), and waiting lists for community clinics and other community services are a barrier to implementing effective relapse prevention approaches.
Raphael (2000) argues that a comprehensive mix of clinical and support services is required to address children and young people's individual physical, emotional, social, cultural and educational needs and provide for all age groups spanning across childhood, adolescence and early adulthood. Children should receive services in the least restrictive, most normative and stable environment that is clinically appropriate—where possible, in their local community. Services should be integrated and coordinated, with partnerships and linkages with other agencies for children and specialist mental health services, to ensure continuity of care across the service system and through young people's developmental transitions. Mechanisms for joint planning, developing and coordinating services should be developed that include young people in ways that match their developing maturity.
Finally, it must be acknowledged that the transition to adult services can be traumatic for a young person who has been in the child and adolescent mental health system, and these transitions must be undertaken sensitively (Raphael 2000). In some instances, young people must move to the adult system as soon as they turn 18 years of age, and such transitions may not be appropriate to their developmental maturity and particular needs. The development of more flexible and individually-tailored interfaces between child and adolescent, youth, and adult-focused services, both clinical and non-clinical, needs urgent attention: a betterunder standing of developmental needs, and the planning of services accordingly, will benefit people at all ages across the lifespan.