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BACKGROUND A growing literature supports the use of internet-based interventions to improve mental health outcomes. However, most programs target specific symptoms or participant groups and are not tailored to facilitate improvements in mental health and well-being or do not allow for needs and preferences of individual participants. The Be Well Plan, a 5-week group-facilitated, internet-based mental health and well-being group intervention addresses these gaps, allowing participants to select a range of activities that they can tailor to their specific characteristics, needs, and preferences. OBJECTIVE This study aims to test whether the Be Well Plan program was effective in improving primary outcomes of mental well-being, resilience, anxiety, and depression compared to a waitlist control group during the COVID-19 pandemic; secondary outcomes included self-efficacy, a sense of control, and cognitive flexibility. The study further seeks to examine participants’ engagement and satisfaction with the program. METHODS A randomized controlled trial (RCT) was conducted with 2 parallel arms, an intervention and a waitlist control group. The intervention involved 5 weekly 2-hour sessions, which were facilitated in group format using Zoom videoconferencing software. University students were recruited via social media posts, lectures, emails, flyers, and posters. RESULTS Using an intentional randomization 2:1 allocation strategy, we recruited 215 participants to the trial (n=126, 58.6%, intervention group; n=89, 41.4%, waitlist control group). Of the 126 participants assigned to the intervention group, 75 (59.5%) commenced the program and were included in modified intention-to-treat (mITT) analyses. mITT intervention participants attended, on average, 3.41 sessions (SD 1.56, median 4); 55 (73.3%) attended at least 4 sessions, and 25 (33.3%) attended all 5 sessions. Of the 49 intervention group participants who completed the postintervention assessment, 47 (95.9%) were either very satisfied (n=31, 66%) or satisfied (n=16, 34%). The mITT analysis for well-being (F1,162=9.65, P=.002, Cohen d=0.48) and resilience (F1,162=7.85, P=.006, Cohen d=0.44) showed significant time × group interaction effects, suggesting that both groups improved over time, but the Be Well Plan (intervention) group showed significantly greater improvement compared to the waitlist control group. A similar pattern of results was observed for depression and anxiety (Cohen d=0.32 and 0.37, respectively), as well as the secondary outcomes (self-efficacy, Cohen d=0.50; sense of control, Cohen d=0.42; cognitive flexibility, Cohen d=0.65). Larger effect sizes were observed in the completer analyses. Reliable change analysis showed that the majority of mITT participants (58/75, 77.3%) demonstrated a significant reliable improvement in at least 1 of the primary outcomes. CONCLUSIONS The Be Well Plan program was effective in improving mental health and well-being, including mental well-being, resilience, depression, and anxiety. Participant satisfaction scores and attendance indicated a high degree of engagement and satisfaction with the program. CLINICALTRIAL Australian New Zealand Clinical Trial Registry ACTRN12621000180819; https://tinyurl.com/2p8da5sk

Approaches to improving people’s mental health fall across a spectrum from those targeting risk and protective factors in healthy individuals to those targeting individuals with mental illness. Common to all approaches is a focus on mental health literacy, improving people’s knowledge about mental health and how it is fostered. Communication designers are not typically involved early in the development of mental health literacy campaigns or products, reflecting a prioritization of the mental health content. This article reports on the benefits of an interdisciplinary collaboration between mental health clinicians, undergraduate communication design students and tertiary design educators, called Visualizing Mental Health, which takes a different approach. Mental health concepts are used to inspire designers to create unique prototypes including games, apps, toys, and books. The development of these prototypes emerges from design thinking and creative idea generation methods. A key to the development of these outcomes is a focus on deliberately open-ended briefing, through which the creative skills of participating communication designers are expressed prior to finalization of client parameters. This approach in a mental health intervention context over a six-year period has attracted attention from mental health sector funding and led to the development of pilotable interventions into mental health literacy. Refereed/Peer-reviewed

Objective: To provide outcome benchmarks for evaluating student psychologist‐led training clinics providing outpatient adult cognitive behaviour therapy (CBT) for high prevalence disorders, and illustrate their application to the evaluation of a South Australian community mental health‐based psychology training clinic: The Centre for Treatment of Anxiety and Depression (CTAD). Method: Study 1 derived aggregated uncontrolled effect sizes and clinically significant change rates for the CBT and control conditions of randomised controlled trials (RCTs), with critical values for demonstrating equivalence to RCTs and superiority to control conditions for anxiety disorders and depression. Study 2 provided benchmarks for demonstrating equivalence, and superiority to other student clinics. Study 3 calculated outcome effect sizes and clinically significant change rates of 342 consecutive CTAD clients allocated to student psychologists between 2009 and 2015, who provided at least two questionnaires, attended at least three sessions and were primarily seen by a student therapist. Aggregated point prevalence estimates of key demographic characteristics of studies contributing to benchmarks were provided. Results: RCT CBT produced higher effect sizes than student clinics, but similar rates of clinically significant change. The application of benchmarking to CTAD illustrated that evaluations of student psychologist effectiveness would differ depending on the benchmark used. Conclusion: We have provided best‐available benchmarks for evaluating student‐led adult outpatient CBT which we encourage other student clinics to adopt. The benchmarking approach provided a profile of CTAD's strengths and weaknesses. Examples of how benchmark comparisons could be used to inform service improvement were provided. Refereed/Peer-reviewed

BACKGROUND During COVID-19, the psychological distress and well-being of the general population has been precarious, increasing the need to determine the impact of complementary internet-based psychological interventions on both positive mental health as well as distress states. Psychological distress and mental well-being represent distinct dimensions of our mental health, and congruent changes in outcomes of distress and well-being do not necessarily co-occur within individuals. When testing intervention impact, it is therefore important to assess change in both outcomes at the individual level, rather than solely testing group differences in average scores at the group level. OBJECTIVE This study set out to investigate the differential impact of an internet-based group mental health intervention on outcomes of positive mental health (ie, well-being, life satisfaction, resilience) and indicators of psychological distress (ie, depression, anxiety, stress). METHODS A 5-week mental health intervention was delivered to 89 participants using the Zoom platform during 2020. Impact on outcomes of distress, well-being, and resilience was assessed at the start and end of the program with multiple analysis of variance (MANOVA) and reliable change indices (RCIs) being used to determine program impact at the group and individual levels, respectively. RESULTS The intervention significantly improved all mental health outcomes measured, (F6,83=5.60, P2=.29) showing small to moderate effect sizes on individual outcomes. The largest effect sizes were observed for life satisfaction and overall well-being (η2=.22 and η2=.2, respectively). Larger effect sizes were noted for those with problematic mental health scores at baseline. A total of 92% (82/89) of participants demonstrated reliable change in at least one mental health outcome. Differential response patterns using RCI revealed that more than one-half of the participants showed improvement in both mental well-being and psychological distress, over one-quarter in outcomes of well-being only, and almost one-fifth in distress only. CONCLUSIONS The results provide evidence for the significant impact of an internet-based mental health intervention during COVID-19 and indicate the importance of assessing dimensions of both well-being and distress when determining mental health intervention effectiveness.

A previous review on the prevalence of psychopathology in siblings of children with mental health problems (MHPs) suggested that these siblings are at increased risk of a broad range of psychopathologies. No disorder-specific risk could be identified. It may be that a different approach to understanding mental health is needed. The following paper aimed to explore if using a dimensional approach could provide greater clarity and insight into the mental health of these siblings by conducting a similar systematic review using dimensional data on the psychosocial functioning of siblings of children with MHPs. An electronic search of publications from 1990 to 2011 identified 29 articles. The findings show that while mean sibling scores on internalising problems, externalising problems, social problems were in the normal range compared to standardised norms, siblings of children with MHPs scored poorer than control children and a greater proportion of siblings scored in the borderline/clinical range compared to children in the general population. Particular areas of functional impairments identified were delinquent behaviour, somatic complaints, anxious/depressed behaviour, and social problems. Effect sizes were moderate to large. Findings on symptom scores with categorical underpinnings were inconsistent.Implications for the debate between dimensional and categorical approaches are discussed and guidelines for future research are outlined. Implications for clinical treatment for siblings are highlighted. Refereed/Peer-reviewed

Background During COVID-19, the psychological distress and well-being of the general population has been precarious, increasing the need to determine the impact of complementary internet-based psychological interventions on both positive mental health as well as distress states. Psychological distress and mental well-being represent distinct dimensions of our mental health, and congruent changes in outcomes of distress and well-being do not necessarily co-occur within individuals. When testing intervention impact, it is therefore important to assess change in both outcomes at the individual level, rather than solely testing group differences in average scores at the group level. Objective This study set out to investigate the differential impact of an internet-based group mental health intervention on outcomes of positive mental health (ie, well-being, life satisfaction, resilience) and indicators of psychological distress (ie, depression, anxiety, stress). Methods A 5-week mental health intervention was delivered to 89 participants using the Zoom platform during 2020. Impact on outcomes of distress, well-being, and resilience was assessed at the start and end of the program with multiple analysis of variance (MANOVA) and reliable change indices (RCIs) being used to determine program impact at the group and individual levels, respectively. Results The intervention significantly improved all mental health outcomes measured, (F6,83=5.60, P Conclusions The results provide evidence for the significant impact of an internet-based mental health intervention during COVID-19 and indicate the importance of assessing dimensions of both well-being and distress when determining mental health intervention effectiveness.

Objective: This study sought to understand the perspectives of young people (12-25 years) with experience of mental health services on what makes for youth-friendly mental health services.Method: A purposive strategy was used to recruit 32 young people aged 12-25 years with diverse backgrounds, through mental health and youth services. Six semi-structured group interviews were undertaken and one individual interview. We were especially interested in aspects that facilitated or obstructed young people from seeking help, and key experiences across their consumer journey. Transcripts were analysed thematically to identify shared experiences and perspectives across the interviews.Results: Five key themes emerged: the central role that teachers, school counsellors, parents, and friends play in help seeking and responding to crisis; the impact of fear, uncertainty, and stigma in decision-making and engaging with services; finding the right therapist and effective help; ways to improve flexibility and ease of access; the need for better quality consumer information for accessing a mental health service.Discussion: The results of the study have implications for the design of mental health services, providing important insights that can increase young people's engagement with services, and ultimately, improve the mental health and well-being of young people in Australia. Refereed/Peer-reviewed

Policy Points: The developmental origins understanding of mental illness suggests the possibility of prevention, through addressing childhood adversities. More than 43% of Indigenous Australian children aged 6 to 10 years have 6 or more risk factors for mental illness in adulthood, and 23% are experiencing current psychological distress. Substantial risk is already present in infancy (eg, 67% exposed to 3 or more stressful family life events, and 42.5% are not living with both birth parents). An integrated service system response that can both offer high-level therapeutic services and address associated multiple adversities, from conception to late adolescence, is urgently needed to address current psychological distress in Indigenous Australian children and to reduce the future burden of mental illness. Context Mental illness is a high source of disease burden across the globe. Mental illness is now understood as largely developmental, with its genesis at least in part in adverse childhood experiences. We sought to estimate the prevalence of childhood risks for poor mental health in Indigenous Australian children, noting that Indigenous Australians by virtue of their history of traumatic colonization and dispossession, child removal, and racism are potentially at greater risk. Methods We conducted a descriptive study of the modifiable risks and adversities associated with mental illness in Australian Indigenous children (infancy to 10 years), using data from the Longitudinal Study of Indigenous Children (LSIC), a cohort of 1,671 infants enrolled in 2008 and followed up annually. Risk factors of interest were identified from a comprehensive literature review of childhood determinants of adult mental illness by Fryers and Brugha (2013). The age-category prevalence of individual risks and a multiple-risk score were computed using data extracted from 6 waves of LSIC. Findings The analytic data comprised 8,378 person-observations from the first 6 waves. Children in LSIC experience high rates of adversities. In utero, nearly 50% were exposed to smoking and 22% to alcohol. As infants, 42.5% were not living with both birth parents. Over two-thirds of survey children were in households that had experienced, in the previous 12 months, 3 or more major life events; 22% to 26% lived in households with a drug or alcohol problem; and 18% were exposed to domestic violence (41% were ever-exposed to age 10). At school, nearly 40% of children were bullied. Over 45% of children aged 6 to 10 years were exposed to 6 or more risks for mental illness. Few children (< 2%) were exposed to low parental warmth and, despite the high exposure to adversities, less than 5% of children report low self-confidence. This suggests considerable resilience. More than 1 in 4 children had conduct problems in the clinical range and more than 1 in 5 were experiencing high psychological distress. Conclusions Indigenous children in Australia face extreme levels of multiple disadvantage, exposing many to current psychological distress and high risk of developing mental illness, despite considerable resilience. For policymakers, this is a call for preventive action targeting the multiple risk factors already present in childhood. An integrated service system offering culturally appropriate, high-quality early childhood education services, linked to infant, child, adolescent, and family mental health services, and intensive family support services will be crucial in addressing this public health crisis.

Objectives: The prevention of mental illness involves identifying and modifying those characteristics and exposures of an individual that threaten their mental health – commonly referred to as risk factors. Existing categorisations of risk factors for mental illness are either limited in their scope or oversimplified in their description. As part of a large mental health workforce and service planning project, we set out to develop a more detailed and comprehensive categorisation scheme to describe risk factors for mental illness. Methods: We conducted a rapid review of MEDLINE and Google Scholar for meta-analytic studies that examined the characteristics and exposures that typify the population with mental illness in order to identify and categorise potential risk factors. Results: The search uncovered 1628 relevant studies, from which 10 primary and 23 secondary categories of risk factors were identified, ranging from genetic and biomedical to psychological and sociocultural. The review revealed interesting distortions in the focus of the literature, with the majority of studies focused on a few disorders (schizophrenia, depression and neurodegenerative disorders) and genetic, psychological and physiological risks. In contrast, environmental (e.g. media exposure) and occupational (e.g. employee health) were under-represented. Conclusion: The categorisation scheme developed in this paper is a step towards a more detailed taxonomy of risk factors for mental illness; this will be most useful in guiding clinicians, researchers and policy-makers in driving the prevention agenda forward.

While it is well recognized that family relationships have a significant impact on child mental health and vice versa, little research has examined the impact of living with a child with mental health problems (MHPs) on family relationships for their siblings. This report aims to synthesize the existing literature and comment on the current state of evidence. An electronic search of publications from 1990 to 2011 was conducted and 22 studies were included. The findings show that families of children with MHPs have less positive (e.g. less supportive) and more negative (e.g. more conflictual, aggressive) sibling relationships and more negative parent-sibling relationships compared to control families. Exceptions were sibling relationships in families of children with conduct disorder (more positive) and anxiety disorders (not significantly different from controls). Limitations of the existing literature include the types of measures used and the use of single informants. Methodological guidelines for future studies are outlined. Refereed/Peer-reviewed

Summary Background High-quality mental health services for infants, children, adolescents, and their families can improve outcomes for children exposed to early trauma. We sought to estimate the workforce needed to deliver tertiary-level community mental health care to all infants, children, adolescents, and their families in need using a generalisable model, applied to South Australia (SA). Methods Workforce estimates were determined using a workforce planning model. Clinical need was established using data from the Longitudinal Study of Australian Children and the Young Minds Matter survey. Care requirements were derived by workshopping clinical pathways with multiprofessional panels, testing derived estimates through an online survey of clinicians. Findings Prevalence of tertiary-level need, defined by severity and exposure to childhood adversities, was estimated at 5–8% across infancy and childhood, and 16% in mid-adolescence. The derived care pathway entailed reception, triage, and follow-up (mean 3 h per patient), core clinical management (mean 27 h per patient per year), psychiatric oversight (mean 4 h per patient per year), specialised clinical role (mean 12 h per patient per year), and socioeconomic support (mean 12 h per patient per year). The modelled clinical full-time equivalent was 947 people and budget was AU$126 million, more than five times the current service level. Interpretation Our novel needs-based workforce model produced actionable estimates of the community workforce needed to address tertiary-level mental health needs in infants, children, adolescents, and their families in SA. A considerable expansion in the skilled workforce is needed to support young people facing current distress and associated family-based adversities. Because mental illness is implicated in so many burgeoning social ills, addressing this shortfall could have wide-ranging benefits. Funding National Health and Medical Research Council (Australia), Department of Health SA.

Objectives: The study aim was to estimate the current level of ambulatory mental health service delivery to young people aged 0–24 years in Australia and associated government expenditure. Recognising the importance of the early years for the development of mental illness and socioeconomic outcomes, we were particularly interested in service access by infants and young children. Methods: We extracted information from government administrative datasets on the number of people who received mental health services, number of services and expenditure through the health sector for 2014–2015. Results are primarily reported by age groups 0–4, 5–11, 12–17 and 18–24 years. Results: Less than 1% of 0- to 4-year-olds received a mental health service in any one service setting, whereas nearly 11% of 18- to 24-year-olds received a mental health service through the Medicare Benefits Schedule Better Access programme alone. Many more services were delivered to 12- to 24-year-olds (>4 million) than to 0- to 11-year-olds (552,000). Medicare Benefits Schedule Better Access delivers services to more children and youth than do state/territory community mental health services, although the latter provide more services per client. In 2013–2014, Australian Government expenditure on ambulatory mental health services for 0- to 24-year-olds was AUD428 million, similar to the AUD491 million spent by state/territory governments. Conclusion: The study provides a benchmark for data-driven service planning to ensure that the mental health needs of infants, children and young people are met. Our results indicate that the youngest age group are underserviced relative to need, even noting infants and children may receive services for behavioural/mental health issues from providers not captured in our study (such as paediatricians). The developmental origins of mental illness underlies the urgency of adequate provision by governments of perinatal, infant and child mental health services to avoid loss of life potential and reduce the pressures on the justice, child protection and welfare systems.

Background: Siblings of children with mental health problems (MHPs) have been found to have higher rates of psychopathology and impaired psychosocial functioning compared to control children. It is not yet known how these siblings are managed within the clinical service context (e.g. are they assessed for mental health problems? Do they receive appropriate psychological treatment?). Aims: The following brief report describes a pilot study which aimed to explore (a) the rate of caregiver-identified MHPs in siblings and (b) the proportion of siblings receiving psychiatric or psychosocial treatment or support (i.e. treatment utilisation). Methods: Eighty-five caregivers of children receiving treatment at CAMHS were interviewed about the mental health and treatment utilisation of their siblings. Results: The findings revealed a high rate of caregiver-identified MHPs in siblings (34.1%) and a high rate of treatment utilisation (85.7%). Conclusions: The findings suggest that, for the vast majority, when siblings of children with MHPs are identified by their caregivers as having MHPs, they are receiving some kind of support and treatment. Implications for mental health service costs are discussed and recommendations for future research are outlined. Refereed/Peer-reviewed

Qualitative metasynthesis is an interpretive integration of primary qualitative research. It is a relatively new research methodology with questions remaining about utility, validity, and qualitative philosophical integrity. The aim of this article is to present an example of qualitative metasynthesis and to explore the utility, interpretive value, and clinical applications of metasynthesis in advancing our knowledge of the wellbeing and needs of siblings of children with mental health problems. An electronic search of publications from 1990–2011 was conducted. Ten articles were included and analyzed using thematic synthesis and constant targeted comparison. Qualitative metasynthesis allowed novel interpretations beyond those found in primary research in terms of theoretical frameworks and clinical implications. In addition, qualitative metasynthesis produced findings greater in depth and consistency and with more direct clinical implications than primary research and quantitative reviews. Qualitative metasynthesis provides a pathway by which more conclusive, reliable, and generalizable findings are produced and interpretive power and clinical utility are increased. It represents a significant advancement in qualitative methodology with the potential to provide unique contributions to research, theory, and evidence-based practice. (PsycINFO Database Record (c) 2015 APA, all rights reserved) Refereed/Peer-reviewed

While the importance of looking at the entire family system in the context of child and adolescent mental health is well recognised, siblings of children with mental health problems (MHPs) are often overlooked. The existing literature on the mental health of these siblings needs to be reviewed. A systematic search located publications from 1990 to 2011 in four electronic databases. Thirty-nine relevant studies reported data on the prevalence of psychopathology in siblings of target children with MHPs. Siblings of target children had higher rates of at least one type of psychopathology than comparison children. Risk of psychopathology varied across the type of MHP in the target child. Other covariates included sibling age and gender and parental psychopathology. Significant variations and limitations in methodology were found in the existing literature. Methodological guidelines for future studies are outlined. Implications for clinicians, parents, and for future research are discussed. Refereed/Peer-reviewed

Purpose: Quality of life mapping methods such as "Transfer to Utility" can be used to translate scores on disease-specific measures to utility values, when traditional utility measurement methods (e.g. standard gamble, time trade-off, preference-based multi-attribute instruments) have not been used. The aim of this study was to generate preliminary ordinary least squares (OLS) regression-based algorithms to transform scores from the Strengths and Difficulties Questionnaires (SDQ), a widely used measure of mental health in children and adolescents, to utility values obtained using the preference-based Child Health Utility (CHU9D) instrument. Methods: Two hundred caregivers of children receiving community mental health services completed the SDQ and CHU9D during a telephone interview. Two OLS regressions were run with the CHU9D utility value as the dependent variable and SDQ subscales as predictors. Resulting algorithms were validated by comparing predicted and observed group mean utility values in randomly selected subsamples. Results: Preliminary validation was obtained for two algorithms, utilising five and three subscales of the SDQ, respectively. Root mean square error values (.124) for both models suggested poor fit at an individual level, but both algorithms performed well in predicting mean group observed utility values.Methods: Two hundred caregivers of children receiving community mental health services completed the SDQ and CHU9D during a telephone interview. Two OLS regressions were run with the CHU9D utility value as the dependent variable and SDQ subscales as predictors. Resulting algorithms were validated by comparing predicted and observed group mean utility values in randomly selected subsamples. Conclusion: This research generated algorithms for translating SDQ scores to utility values and providing researchers with an additional tool for conducting health economic evaluations with child and adolescent mental health data. Refereed/Peer-reviewed

Parallel Parent and Child Therapy (PPACT) is an attachment-based therapy for mother-child dyads in which there is significant relationship breakdown and histories of relational trauma. Research on PPACT has focused on its application with high risk mother-child dyads where the child presents with disturbed behaviors and where there are multiple risk factors for maltreatment, including unresolved parental history of childhood maltreatment and parental mental illness Chambers, H., Amos, J., Allison, S. and Roeger, L. 2006. Amos, Furber, & Segal, 2011 Amos, J., Furber, G. and Segal, L. 2011. Amos, J., Beal, S. and Furber, G. 2007.). This paper presents outcomes for six consecutive cases treated over a five-year period where multiple types of assessment, including standardized instruments and interviews, were employed. Four of the six cases showed lasting improvements for the child, the mother, or both, evidenced by remission of psychiatric symptoms and parental reports of improved social and family outcomes. This early evidence suggests the PPACT model has promise in the treatment of high risk mother-child dyads and that the processing of relational trauma may be central to its impact. Refereed/Peer-reviewed

Objective: Acne vulgaris is a dynamic, complex condition that is notoriously difficult to evaluate. The authors set out to critically evaluate currently available measures of acne severity, particularly in terms of suitability for use in clinical trials. Design: A systematic review was conducted to identify methods used to measure acne severity, using MEDLINE, CINAHL, Scopus, and Wiley Online. Each method was critically reviewed and given a score out of 13 based on eight quality criteria under two broad groupings of psychometric testing and suitability for research and evaluation. Results: Twenty-four methods for assessing acne severity were identified. Four scales received a quality score of zero, and 11 scored ≤3. The highest rated scales achieved a total score of 6. Six scales reported strong inter-rater reliability (ICC>0.75), and four reported strong intra-rater reliability (ICC>0.75). The poor overall performance of most scales, largely characterized by the absence of reliability testing or evidence for independent assessment and validation indicates that generally, their application in clinical trials is not supported. Conclusion: This review and appraisal of instruments for measuring acne severity supports previously identified concerns regarding the quality of published measures. It highlights the need for a valid and reliable acne severity scale, especially for use in research and evaluation. The ideal scale would demonstrate adequate validation and reliability and be easily implemented for third-party analysis. The development of such a scale is critical to interpreting results of trials and facilitating the pooling of results for systematic reviews and meta-analyses.

Objective: To estimate the prevalence of children in the Australian population with risk factors for adult mental illness. Method: Key risk factors and risk domains were identified from a 2013 review of longitudinal studies on child and adolescent determinants of adult mental illness. Data items were identified from the Longitudinal Study of Australian Children that map onto the risk domains and were used to estimate the prevalence of these key individual risk factors and the magnitude of multiple risk in children aged 3 months to 13 years. Results: Even by infancy, risk factors for adult mental illness are highly prevalent, with 51.7% of infants having multiple risks. In 10 infants, 1 was born to mothers who consumed daily alcohol and 1 in 8 to mothers who smoked cigarettes daily during pregnancy. Also, 10.5% of infants were in families where the parents had separated, which increased to 18% in 10–11 year-olds. Psychological problems in the clinical range (based on the Strengths and Difficulties Questionnaire total problems score) ranged from 7.8% to 9.7% across the 4–13 years age range. Risks from negative parenting behaviours were highly prevalent across age groups. Two-thirds of children aged 12–13 years had parents who displayed low warmth or exhibited high hostility/anger. Across childhood, one in seven children are in families exposed to 3+ major life stressors. By age 8–9 years, more than 18% of children are exposed to ⩾5 risk factors. Conclusions: We find that modifiable risk factors for adult mental illness occur at the earliest stage in the life course and at greater prevalence than is commonly recognised. Considerable capacity will be required in child and adolescent mental health services and complementary family support programmes if risk factors for adult mental illness that are already apparent in infancy and childhood are to be addressed.

Background: The paediatric bipolar disorder (PBD) hypothesis arose in the USA and proposes childhood onset and high rates of prevalence. Method: Child and adolescent psychiatrists in Australia and New Zealand were surveyed about the PBD hypothesis. Results: Sixty percent responded (N = 199) and most (53%) reported never having diagnosed pre-pubertal PBD and a further 29% estimated seeing '1 or 2' cases. Most (83%) rated pre-pubertal PBD as 'very rare', 'rare' or 'not diagnosable'. Opinion varied as to whether PBD was over-diagnosed (25%), appropriately diagnosed (42%), or under-diagnosed (28%) in Australia and New Zealand, 5% were unsure. In contrast there was a consensus of views that PBD was over-diagnosed in the USA (90%), whilst less felt it appropriately diagnosed (3%), or under-diagnosed (1%) and 6% were unsure. Conclusions: The majority view was consistent with classical descriptions of bipolar disorder.Key Practitioner Message:Paediatric bipolar disorder (PBD) as defined by USA researchers, applies to a range of child behavioural patterns that differ in varying degrees from traditional descriptions of bipolar disorderPBD has become a common diagnosis in the USAThere is some evidence to suggest that adoption of the PBD diagnosis in the UK and Europe has been limitedThis paper reports on a survey of Australian and New Zealand child and adolescent psychiatrists and finds a solid majority retain a traditional view of bipolar disorder and are sceptical of the new PBD phenotypesThe PBD phenotypes remain hypothetical and the alternative hypothesis is that responses to trauma and other more recognised emotional and behavioural disorders of childhood remain sufficient diagnostic explanations

This case study explores Parent and Child Therapy (PACT), an attachment-based intervention for mothers and children experiencing intractable relationship distress originally developed by Heather Chambers (a Child Psychotherapist and Family Therapist working in New Zealand). We describe the use of PACT with a mother-child dyad presenting a history of severe abuse and neglect. The child had been diagnosed with Conduct Disorder and co-morbid Attention Deficit Hyperactivity Disorder. We consider the themes arising in the therapy, the emotional process experienced by the mother and child, the initial outcome and 10-month follow up. The case study indicates that PACT can be learned and used by practitioners outside of the team that conceptualised and developed it. The case highlights the links between externalising difficulties and attachment disorganisation and points to PACT as a promising treatment for the chronic sequelae of early interpersonal childhood trauma. The need for research and possible directions of this research are discussed.

Background: Mental illness is prevalent across the globe and affects multiple aspects of life. Despite advances in treatment, there is little evidence that prevalence rates of mental illness are falling. While the prevention of cardiovascular disease and cancers are common in the policy dialogue and in service delivery, the prevention of mental illness remains a neglected area. There is accumulating evidence that mental illness is at least partially preventable, with increasing recognition that its antecedents are often found in infancy, childhood, adolescence and youth, creating multiple opportunities into young adulthood for prevention. Developing valid and reproducible methods for translating the evidence base in mental illness prevention into actionable policy recommendations is a crucial step in taking the prevention agenda forward. Method: Building on an aetiological model of adult mental illness that emphasizes the importance of intervening during infancy, childhood, adolescence and youth, we adapted a workforce and service planning framework,originally applied to diabetes care, to the analysis of the workforce and service structures required for best-practice prevention of mental illness. Results: The resulting framework consists of 6 steps that include identifying priority risk factors, profiling the population in terms of these risk factors to identify at-risk groups, matching these at-risk groups to best-practice interventions, translation of these interventions to competencies, translation of competencies to workforce and service estimates, and finally, exploring the policy implications of these workforce and services estimates. The framework outlines the specific tasks involved in translating the evidence-base in prevention, to clearly actionable workforce, service delivery and funding recommendations. Conclusions: The framework describes the means to deliver mental illness prevention that the literature indicates is achievable, and is the basis of an ongoing project to model the workforce and service structures required for mental illness prevention. Refereed/Peer-reviewed

KESSLER 10 FOR USE IN YOUTH MENTAL HEALTH OUTREACH SERVICES Gareth Furber, PhD, Ann E Crago, Tom D Sheppard, Clive Skene (Clinical Psychology) Health Economics and Social Policy Group, School of Population Health, South Australian Health and Medical Research Institute (SAHMRI), North Terrace, Adelaide, SA, 5000; Bachelor of Nursing Youthlink, Women’s and Children’s Health Network, SA Health, GP Plus Health Care Centre Marion, 10 Milham Street, Oaklands Park, Adelaide, SA, 5046; Registered Nurse (Mental Health) Youthlink, Women’s and Children’s Health Network, SA Health, GP Plus Health Care Centre Marion, 10 Milham Street, Oaklands Park, Adelaide, SA, 5046; Master of Psychology CAMHS Executive, Level 1, 55 King William Road, North Adelaide, SA, 5006 Corresponding Author: E gareth.furber@unisa.edu.au

A previous case-series evaluation of a six-session guided self-help (GSH) approach with 15 people with bulimia nervosa (BN) showed significant reductions across all measures, including binge eating, self-induced vomiting, weight concern, shape concern and dietary restraint. However, the reduction of binge eating and self-induced vomiting was inferior to that achieved in more behavioural approaches. A further 10 people with BN were treated with an eight-session cognitive GSH, where the two extra sessions had a more behavioural focus. Although both conditions significantly decreased levels of binge eating and self-induced vomiting at post-treatment evaluation (with large effect sizes), comparisons of these two GSH conditions showed that an addition of two sessions did not significantly improve outcome on either of the behaviours. Cognitive GSH seems to be a worthwhile candidate for a first-step treatment in BN, but further improvements in this approach can be considered.

Background Mobile phones play a central role in the lives of young people and are being increasingly recognized as valuable tools in health care. However, there is a paucity of studies exploring the use of mobile phones in youth outreach mental health services. Our outreach team's experience is that enabling youth to access their therapist directly through mobile phone improves engagement and retention, and short message service (SMS) in particular, is a useful tool for coordinating appointments. The purpose of this study was to audit the content of SMS exchanges between therapists and clients and to investigate the extent of inappropriate SMS use. Method An audit of SMS messages sent and received from an outreach youth mental health service was conducted over a 7-month period. Results The majority of SMS traffic sent to and received from clients was micro-coordinating face-to-face-meetings (76% and 61%, respectively), reflecting a practical real-time use of SMS. Only a small proportion of the client use of SMS was classified as inappropriate (2%). Conclusions The results demonstrate that mobile phones and SMS can be used as a safe, practical way of maintaining contact and coordinating meetings within a youth outreach service.

Introduction In Australia there is an overwhelming need to provide effective treatment to patients presenting to the Emergency Department (ED) in mental health crisis. We adapted Improving Access to Psychological Therapies service model (IAPT) from the National Health Service (NHS) method for the large scale delivery of psychological therapies throughout the United Kingdom to an Australian ED setting. This telephone-based low intensity therapy was provided to people presenting in crisis to the EDs with combinations of anxiety, depression, substance use, and suicidal thinking. Methods This uncontrolled study utilised session-by-session, before-and-after measures of anxiety and depression via Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder-7 (GAD-7). Results Of 347 eligible post-crisis ED referred patients, 291 (83.9%) engaged with the IAPT team. Most patients (65%) had attended the ED previously on an average of 3.9 (SD = 6.0) occasions. Two hundred and forty one patients received an average of 4.1 (SD = 2.3) contacts of low-intensity psychological therapies including 1.2 (SD = 1.7) community outreach visits between 20th Oct 2011 and 31st Dec 2012. Treated patients reported clinically significant improvements in anxiety, depression and suicidal ideation. Uncontrolled effect sizes were moderate for anxiety (0.6) and depression (0.6). Discussion The Australian ED IAPT program demonstrated that the UK IAPT program could be adapted for emergency mental health patients and be associated with similar clinical benefits as the original program. Funding The Flinders Medical Centre IAPT program received Emergency Department project funding from the Australian Commonwealth Government through the Council of Australian Governments (COAG) and the South Australian Government initiative, Every Patient Every Service (EPES).

Objective: To describe the implementation of an Improving Access to Psychological Therapies (IAPT) service at Flinders Medical Centre emergency department (IAPT@Flinders). IAPT, a population-based model of guided self-help for anxiety and depression delivered mainly by phone, was rolled-out nationally in the UK in 2010. There is a growing body of evidence demonstrating its clinical effectiveness and efficiency that can improve treatment adherence, reduce stigma, remove appointment attendance barriers and improve access for hard-to-reach populations. Conclusions: IAPT@Flinders was the test site for the first IAPT in Australia and also the first IAPT service that was integrated with an emergency department (ED). IAPT@Flinders offers rapid access, low-intensity cognitive behavioural therapy, social prescribing and signposting to clients with adjustment disorders, anxiety and/or depressive symptoms. Successful implementation within an Australian crisis setting has demonstrated that many IAPT structures and protocols are applicable to ED settings and the model can be implemented with fidelity. Adaption required consideration of positioning of the service within the Australian mental health framework; staff qualifications; the referral pathways; and exclusion criteria. It is recommended additional test sites and larger scale trials are conducted to provide further evidence of the applicability of large-scale adoption of the UK IAPT model into Australian ED settings.

Background: Few studies have tested whether individually tailored text messaging interventions have an effect on clinical outcomes when used to supplement traditional psychotherapy. This is despite the potential to improve outcomes through symptom monitoring, prompts for between-session activities, and psychoeducation. Objective: The intent of the study was to explore the use of individually tailored between-session text messaging, or short message service (SMS), as an adjunct to telephone-based psychotherapy for consumers who present to the Emergency Department (ED) in situational and/or emotional crises. Methods: Over a 4-month period, two therapists offered 68 prospective consumers of a telephone-based psychotherapy service individually tailored between-session text messaging alongside their telephone-based psychotherapy. Attendance and clinical outcomes (depression, anxiety, functional impairment) of those receiving messages were compared against a historical control group (n=157) who received telephone psychotherapy only. Results: A total of 66% (45/68) of the consumers offered SMS accepted the intervention. A total of 432 messages were sent over the course of the trial, the majority involving some kind of psychoeducation or reminders to engage in therapy goals. There were no significant differences in clinical outcomes between consumers who received the SMS and those in the control group. There was a trend for participants in the intervention group to attend fewer sessions than those in the control group (mean 3.7, SD 1.9 vs mean 4.4, SD 2.3). Conclusions: Both groups showed significant improvement over time. Individually tailored SMS were not found to improve clinical outcomes in consumers receiving telephone-based psychotherapy, but the study was underpowered, given the effect sizes noted and the significance level chosen. Given the ease of implementation and positive feedback from therapists and clients, individually tailored text messages should be explored further in future trials with a focus on enhancing the clinical impact of the tailored text messages, and utilizing designs with additional power to test for between-group effects. [J Med Internet Res 2014;16(10):e219]

Specialist child and adolescent mental health services (CAMHS) must make decisions about what treatments to provide to whom, when, where and how, within limited budgets. This raises questions about how services make such decisions, to best meet the mental health needs of their catchment. The methods and practices of Health Economics, a field with considerable expertise in measuring performance in health systems, can help CAMHS make better informed decisions regarding service provision. This paper identifies a process through a set of focused questions to help CAMHS examine and improve their performance. The aspects covered are service profile, costs, conceptualisation of outcomes and identification of value for money. The recommended approach should help CAMHS redirect resources to maximise benefits for their catchment population. Refereed/Peer-reviewed

Treatment options are limited for families in which the child has severe and intractable disturbances of emotion and behavior, in which there is suspected or confirmed maltreatment by the mother, and in which the mother has her own history of childhood neglect and abuse. This paper proposes a model for understanding maltreatment in mother-child dyads, drawing upon the developmental psychopathology, behavior, and trauma literatures. At the core of this model is the hypothesis that a mother's maltreating behavior arises from unconscious attempts to experientially avoid the reemergence of an attachment-related dissociative part of the personality that contains the distress arising from her own early experiences of attachment relationships. The implications of this model for therapy are considered. Refereed/Peer-reviewed

Objective: The purpose of this study was to benchmark the cost efficiency of community care across six child and adolescent mental health services (CAMHS) drawn from different Australian states. Method: Organizational, contact and outcome data from the National Mental Health Benchmarking Project (NMHBP) data-sets were used to calculate cost per “treatment hour” and cost per episode for the six participating organizations. We also explored the relationship between intake severity as measured by the Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA) and cost per episode. Results: The average cost per treatment hour was $223, with cost differences across the six services ranging from a mean of $156 to $273 per treatment hour. The average cost per episode was $3349 (median $1577) and there were significant differences in the CAMHS organizational medians ranging from $388 to $7076 per episode. HoNOSCA scores explained at best 6% of the cost variance per episode. Conclusions: These large cost differences indicate that community CAMHS have the potential to make substantial gains in cost efficiency through collaborative benchmarking. Benchmarking forums need considerable financial and business expertise for detailed comparison of business models for service provision.

Rural families can find it difficult to access mental health treatment for children’s conduct problems. The current program was designed to provide immediate assistance to families who faced extended waiting times in the south-eastern region of South Australia. In this collaborative project, a primary care professional delivered a telephone-guided version of a clinically based parent training program (Barkley’s Defiant Children) with program support from mental health services. The 12-week trial included 29 children aged 2–12 years who were referred for disruptive behaviour, attention-deficit hyperactivity and learning difficulties. Children were randomised to either a parent training group or a waiting list control group. Parents in the training program were generally satisfied (Therapy Attitude Inventory overall rating = 4.3 measured on a 5-point Likert scale). The main behavioural measure showed significantly better outcomes for the training program (Eyberg Child Behaviour Inventory (ECBI): Intensity scale (F1,27 = 11.39, P

Background: Few cost-utility studies of child and adolescent mental health services (CAMHS) use quality adjusted life years (a combination of utility weights and time in health state) as the outcome to enable comparison across disparate programs and modalities. Part of the solution to this problem involves embedding preference-based health-related quality of life (PBHRQOL) utility instruments, which generate utility weights, in clinical practice and research. The Child Health Utility (CHU9D) is a generic PBHRQOL instrument developed specifically for use in young people. The purpose of this study was to assess the suitability of the CHU9D as a routine outcome measure in CAMHS clinical practice. Methods: Two hundred caregivers of children receiving community mental health services completed the CHU9Dalongside a standardised child and adolescent mental health measure (the Strengths and Difficulties Questionnaire –SDQ) during a telephone interview. We investigated face validity, practicality, internal consistency, and convergent validity of the CHU9D. In addition, we compared the utility weights obtained in this group with utility weights fromother studies of child and adolescent mental health populations. Results: Participants found the CHU9D easy and quick to complete. It demonstrated acceptable internal consistency,and correlated moderately with the SDQ. It was able to discriminate between children in the abnormal range and those in the non-clinical/borderline range as measured by the SDQ. Three CHU9D items without corollaries in the SDQ (sleep, schoolwork, daily routine) were found to be significant predictors of the SDQ total score and may be useful clinical metrics. The mean utility weight of this sample was comparable with clinical sub samples from other CHU9D studies, but was significantly higher than mean utility weights noted in other child and adolescent mental health samples. Conclusions: Initial validation suggests further investigation of the CHU9D as a routine outcome measure in CAMHS is warranted. Further investigation should explore test-retest reliability, sensitivity to change, concordance between caregiver and child-completed forms, and the calibration of the utility weights. Differences between utility weights generated by the CHU9D and other utility instruments in this population should be further examined by administering a range of PBHRQOL instruments concurrently in a mental health group. Refereed/Peer-reviewed