Reaching the highest standard of health for adolescents

Speech given at the Australian Association for Adolescent Health 2017 Conference

Date: 10am - 11am, Thursday 6 July 2017

Introduction

Good morning. It’s a pleasure to be here to speak about the work I have done as Australia’s first National Children’s Commissioner.

Before I begin, I would like to acknowledge the Traditional Owners of the land we gather on today, and pay my respects to Elders past, present and future.

My job is to monitor and promote the rights of all children in Australia but I can and do pay particular attention to the needs of vulnerable children. In doing this, I report annually to the Federal Parliament about the human rights of children in Australia. To date, I have produced four reports and I am currently working on my fifth. Each report contains the findings of a major investigation.

Today, my presentation will address adolescent health from a child rights-based approach. In particular, I will focus on two areas of investigation: self-harm among children and young people, and the experiences of children and young people as parents.

Convention on the Rights of the Child

My work is grounded in the Convention on the Rights of the Child, and its four guiding principles of: non-discrimination, best interests, survival and development, and the right to be heard.

With respect to adolescent health, article 24 says that children have the right to enjoy the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. The UN Committee on the Rights of the Child has said that the notion of “the highest attainable standard of health” takes into account both the child’s biological, social, cultural and economic preconditions and the State’s available resources, supplemented by resources made available by other sources, including non-governmental organisations, the international community and the private sector. As a State Party to the Convention, Australia has committed to ensuring that no child is deprived of their right of access to health care services.

To fully realise the right to health for all children, the UN Committee on the Rights of the Child has emphasised that States Parties (Governments) have an obligation to ensure that children’s health is not undermined as a result of discrimination. A number of grounds on which discrimination is prohibited are outlined in article 2 of the Convention, including the child’s, parent’s or guardian’s race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, disability, or birth. Also included is sexual orientation, gender identity and health status, for example in relation to someone’s mental health.

Last year, the UN Committee on the Rights of the Child published some guidance on the implementation of the rights of the child during adolescence. A child is anyone under 18. The Committee emphasised “the importance of valuing adolescence and its associated characteristics as a positive developmental stage of childhood."

The Committee noted:

“The widespread negative characterisation of adolescence leading to narrow problem-focused interventions and services, rather than a commitment to building optimum environments to guarantee the rights of adolescents and support the development of their physical, psychological, spiritual, social, emotional, cognitive, cultural and economic capacities.”

Specifically regarding health, the Committee recognised that health services are rarely designed to accommodate the specific health needs of adolescents, a problem that is made worse by the lack of data and statistics broken down by age, sex and disability.

Further:

“When adolescents seek help, they often experience legal and financial barriers, discrimination, lack of confidentiality and respect, violence and abuse, stigma and judgmental attitudes from health-care personnel.”

These are common experiences that have been echoed by the children and young people who I have spoken to over the years, which I will share with you later in this presentation.

Children’s Rights Report 2014: Self-harm

In 2014 I looked at a big problem for young people: self-harm. 

Self-harm is a children’s rights issue. Article 19 of the Convention on the Rights of the Child says that States Parties (Governments) must protect children from all forms of physical or mental violence, injury or abuse. This includes harm that is self-inflicted.

I looked at:

• Self-harm data and trends for young people
• Barriers to children seeking help
• Why there is lower help seeking by the most distressed young people
• What protects kids and stops them from self-harming, and
• What we know about self-harm in vulnerable groups of children.

Tragically, the latest data shows that, in 2015, suicide was the leading cause of death of children between 5 and 17 years of age. Fifty to 60 children are admitted to hospital each week as a result of self-harming behaviours. This is likely to be the tip of the iceberg as most self-harm doesn’t result in a trip to hospital.

I also looked at data from the Kids Helpline, a national call centre for kids in distress. This revealed that around 40% of calls from children aged 5 to 17 years during 2012 and 2013 related to suicide or self-injury or self-harm.

I also sourced data from the ABS that showed that in the 2007-2012 period, there was a 657% increase in the number of deaths between the 12 to 13-year age range and the 14 to 15-year age range.

This tells me that intervention and prevention measures must be targeted at much earlier ages, which means working with children aged 12 and under - to build resilience, identify risk and protective factors and encourage help-seeking.

Overrepresentation of Aboriginal and Torres Strait Islander children

Using a rights-based lens shows the health inequity experienced by certain groups of children and young people who face discrimination, disadvantage and exclusion.

The UN Committee on the Rights of Child has recognised that:

“Mental health and psychosocial problems, such as suicide and self-harm, are primary causes of ill health, morbidity and mortality among adolescents, particularly among those in vulnerable groups.”

The Committee has expressed particular concern about the high rate of suicidal deaths among young people in Australia, particularly Aboriginal and Torres Strait Islander young people. 

Aboriginal and Torres Strait Islander children and young people comprise around 6% of Australia’s youth population, yet the data provided to me by the ABS shows they account for 28.1% of all recorded deaths in children under 18, and around 80% of deaths of children under 11.

In fact, Aboriginal and Torres Strait Islander children are more likely to be overrepresented in just about every measure of disadvantage. Aboriginal and Torres Strait Islander children: are more likely to be exposed to, or victims of, domestic violence; are overrepresented in out-of-home care; have higher levels of disability than non-Indigenous children; poorer health and educational outcomes, and much higher contact with justice systems. 

Vulnerability to self-harm is increased for children who are exposed to multiple risk factors and who experience a lack of key protective factors.

Risk factors

In the 2014 Report I discussed the factors that predispose a child or young person to the risk of self-harm. Examples include:

• mental health problems
• alcohol and drug abuse
• child abuse
• poverty, and
• exposure to domestic violence.

When mixed with other things such as a relationship breakdown, a death in the family or being expelled from school, the risk dramatically increases.

There are certain cultural and contextual issues that need to be understood in terms of Aboriginal children in particular.

Professor Pat Dugeon, a respected elder from WA, has summarised the inter-related contextual factors that contribute to the disproportionate rates of suicidal behaviour and self-harm among Indigenous children as:

“the brutal history of colonisation, the inter-generational trauma left by Stolen Generations policy, and ongoing racism, combined with the everyday realities in many Aboriginal communities, such as unemployment, poverty, overcrowding, social marginalisation, and higher access to alcohol and drugs.”

An important contextual risk factor which appears to differ for Aboriginal and Torres Strait Islander children and young people is in relation to contagion and clusters. Broadly speaking, we still know very little about these phenomena.

Just last week, an inquest commenced into a disturbing cluster of suicides by Aboriginal youths in the Kimberley region in Western Australia's far north. Of the 13 cases between November 2012 and March last year, five were children aged between 10 and 13, including two sisters. According to a report on the Kimberley published in the Medical Journal of Australia last week, suicide rates in the Kimberley are seven times the national average.

It is probable that these children and young people were exposed to multiple sources of risk, and that exposure to other suicides and self-harming in their communities contributes to and heightens this risk. It is also probable that these children had little outlet for their feelings, and very little, if any, access to the help they needed to get them through the difficult times in their young lives.

Self-harm and domestic violence

During the course of my investigation I was also consistently alerted to the relationship between domestic and family violence and self-harm. In particular, I heard about the disproportionate exposure to lateral violence which Aboriginal and Torres Strait Islander children experience and witness in community.

The NPY Lands Women's Council told me that data collected over the past three years in the NPY region of Central Australia showed that: ‘domestic and family violence is the most significant factor that is contributing to these incidents, along with prior exposure to suicide in close family members’.

This link was also present for non-Aboriginal kids.

In 2012 to 2013, Kids Helpline received 11,180 suicide and 18,737 self-harm contacts. Co-presenting concerns related to family relationships and conflict were 17.8% and 17.3% of contacts respectively.

Help seeking

Encouraging children and young people to seek help is particularly challenging, especially when they have a bad early experience or they feel that they will be judged.

Here is what a young person told me:

“I started very young. I started when I was 10 and it was a year-and-a-half or two years before somebody actually found out and I ended up telling the school counsellor and of course she told my parents. Neither of my parents knew what to do…and I didn’t know how to explain...it took a long time for me to get proper help, and I know that getting inadequate assistance when I was younger, it took longer for me to actually get the right help and for me to continue to seek out the right help.”

Many Aboriginal and Torres Strait Islander children and young people face specific communication barriers that prevent them from seeking help for self-harm. One of these barriers may be language. Although many Aboriginal children living in remote areas can speak two or three different Indigenous languages, they may find it difficult to communicate in English.  Explaining mental health concepts in English and not being able to speak in a familiar language can potentially be alienating and stressful and lead to misunderstandings, misidentification and wrong diagnosis of the symptoms, and impact negatively on the intervention that’s taken. 

Findings and recommendations

As a result of this work, I found that too much continues to be unknown about children and young people who self-harm, from prevalence to prevention.

To address this, I made a range of recommendations to lift the quality, consistency and breadth of data collection and research.

And while progress seems very slow, progress is happening.

For example, the Australian Government has:

• Commissioned a National Research Priorities and Implementation Framework for youth mental health research
• Sponsored the development of a National Minimum Data Set for suicide, and
• Added data tables to the published Australian Bureau of Statics’ data on causes of death,  for the first time including data on suicide deaths of children aged 5 to 17 years.   The ABS has promised to release regular data on hospitalisations for self harm.

Children’s Rights Report 2017: Young parents

This year I am focusing on the needs of young parents, a particularly vulnerable group of young people.

In 2015, births to mothers aged 19 years and under were 2.8% of all births, around 8,500 babies. 

However, research to date has reported that:

“Teenage motherhood is associated with significant health and social problems for the infant and the mother. Children born to teenage mothers are at greater risk of low birthweight and increased morbidity during their first year of life, tend to develop more behaviour problems than children of older mothers and are more likely to be born into, and continue to live in, social and economic disadvantage." (AIHW 2011)

Risks include a family history of teenage pregnancy, unstable housing arrangements, socioeconomic disadvantage, sexual abuse in childhood, and being Indigenous.

So while the numbers are small the risks are high.

Other groups that are more likely to become young parents include Aboriginal and Torres Strait Islander children and young people, children and young people in out-of-home care, those excluded from or not at school, and those not doing well at school.  

Vulnerable young people who become parents also risk removal of their children into the care and protection system.

I want to investigate the types of interventions likely to decrease the risk profile and trajectory of such young people, and improve their capacity for safe and effective parenting.

I have conducted roundtables with experts, including service providers, academics and researchers. I have also conducted a survey of young parents, and spoken to young parents about their experiences, challenges and aspirations.

Young parents: initial findings – stigma

Some of the initial findings in relation to young parents’ health are that there is ongoing stigma associated with young parenthood in society generally.

Here are some of the things that young mums have told me:

“It's a challenge and I do everything any other mum would do if they were older but I'm still judged even though they have no idea how far I've come.”

“Other than the crippling self doubt I experienced as a young mum, the judgement from other people including strangers was soul destroying. Stereotyping needs to stop, and we need to start celebrating young women who go on to be great parents, whether they finish a uni degree and buy a house, or have ten kids who they love and provide for with everything they have. Young women are strong and each one is capable. All it takes is a few people to believe in you.”

Young parents: initial findings – judgement from health services

Young parents told us that they also feel judged by health services and health professionals. Young mothers were often reluctant to seek support and engage with services due to fears that they would be treated poorly or that their child would be removed by child protection services.

One young woman who got pregnant at 17 told me that she felt judged and overwhelmed. She said that doctors “treated me like a 7-year-old”.

Another young mum told me that: “Workers need more compassion and actually want to help young people.”

Young parents: initial findings – health

Current health care policy and practice, which have narrowly focused on universal interventions to solve the “problem” of teenage pregnancy, need to shift to an approach that consults, considers and values young parents as the ‘experts’ of their own lives. Likewise, the training of health professionals needs to focus on developing skills in deep listening and fostering safe spaces for trusting, respectful and non-judgemental relationships to form. Such an approach is much more likely to foster a stronger sense of personal agency and resilience in young parents.

A joined up, cohesive approach to addressing the issue of young parents across the government departments at the state, territory and federal levels, as well as between government and non-government bodies, is desperately needed. There is a need for a holistic, coordinated approach between education, child protection, health, counselling and other services to ensure that young people do not disengage and can get the right help at the right time.

Services for young parents are often not culturally appropriate. Health providers need to ensure that support and interventions for young parents are culturally competent and effectively recognise, value and support culture, community and identity in raising healthy and happy children and young people.

Services for young parents are inadequate for those with mental health issues, such as depression and anxiety, which many of the young parents we have spoken to have said they are dealing with. Maternity and parental services should focus on ensuring the mental wellbeing of the parents and their babies.

There is a gap in health literacy in relation to sexual health, including non-oral contraceptive options and how to access contraception. Research suggests that young parents are more likely to have better health outcomes when there is informed choice of the most effective methods of contraception through improved access, awareness and education, and when additional support via Medicare is provided for the interventions shown to work, such as provision of long-acting reversible contraception. This is particularly important in preventing another birth soon after the first.

Young parents: initial findings – optimistic and genuine goals

Despite the challenges they face, overwhelmingly the young parents I have spoken to are optimistic about the future. They have genuine goals for themselves and their children. This is something we need to recognise and support.

A young mum who was 16 when she got pregnant told me that:

“Being a young mum has been one of the most rewarding experiences of my life. I have no doubt that I am a better person today with my daughter than I would have been without. She has given me the motivation to build a life good enough for her to thrive.”

One father, who was 18 when his partner fell pregnant, summed up his goals in just six words: “To be the best father possible.”

I hope that my work on young parents will help to shape policy, program development and investment in these areas by the Commonwealth, States and Territories and build an appreciation of the human rights obligations to these young parents and their children.

National initiatives

Having talked about two key areas where more can be done to improve young people’s access to the highest attainable standard of health, I want to end by highlighting some opportunities at the national level to achieve this.

Where we have seen some of the most potentially significant changes in recent times is under the auspices of the National Framework for Protecting Australia's Children.

The National Framework is the national policy initiative which has, since 2009, brought together the Commonwealth, state and territory governments and non-government organisations in a sustained commitment to improve the safety and wellbeing of Australian children. The key message of the National Framework is “protecting Australia’s children is everyone’s responsibility”. The National Framework is being implemented through a series of three-year action plans.

The Third Action Plan has a strong focus on prevention and early intervention, with a focus on the early years – particularly the first 1000 days for a child. There is also focus on ensuring that young people exiting care systems have the right support they need, as well as an emphasis on making everyone, including health professionals, aware of and responsive to the needs of vulnerable children and young people.

The National Strategic Framework for Child and Youth Health establishes a shared national vision of a future where all Australia’s children and young people are resilient, thriving and healthy. The Framework sets out the key strategic priorities for child and youth health in Australia for the next 10 years, focusing on outcomes for children and young people from preconception to 24 years of age.

The strategic priorities are to:

1. Equip children and young people with the foundations for a healthy life.
2. Support children and young people to become strong and resilient adults.
3. Support children and young people to live in healthy and safe homes, communities and environments.
4. Children and young people have equitable access to health care services and equitable health outcomes.
5. Improve systems to optimise the health outcomes of children and young people.

Government and non-government sectors can use this overarching framework to guide their work which will help to ensure that all Australian children are given the opportunity to be healthy, safe and thriving.

Important to health services, a Charter on the Rights of Children and Young People in Healthcare Services in Australia  was developed following extensive consultation by Children’s Hospitals Australasia (CHA) and Association for the Wellbeing of Children in Healthcare (AWCH). This Charter is a package of 11 rights, which are based on the Convention on the Rights of the Child. They include:

• The right to have the best interests of the child considered as a primary concern of all involved in their care;
• The right to express their views, and to be heard and taken seriously;
• The right to information in a form that is understandable to them; and
• The right to participate in decision-making and, as appropriate to their capabilities, to make decisions about their care.

Taken together, the rights in the Charter aim to ensure that children and young people receive healthcare that is both appropriate and acceptable to them and their families. The Charter applies to all children and young people in all healthcare services they access. It also applies to health promotion and health education activities aimed at children and young people.

Conclusion

One of the most significant common issues that has emerged across my projects is the lack of adequate data and focused research involving children and young people themselves. If we don’t measure these areas, or measure them well, we will never have the understanding we need to develop good policy responses.

Another common theme is the need for a holistic approach to addressing the needs of adolescents, which genuinely recognises their agency and voice. The UN Committee on the Rights of the Child has emphasised the need for an approach that “builds on strengths and recognises the contribution that adolescents can bring to their lives and those of others, while addressing the barriers that inhibit those opportunities.” It recommends that “States, together with non-State actors, through dialogue and engagement with adolescents themselves, should promote environments that acknowledge the intrinsic value of adolescence and introduce measures to help them to thrive, explore their emerging identities, beliefs, sexualities and opportunities, balance risk and safety, build capacity for making free, informed and positive decisions and life choices, and successfully navigate the transition into adulthood.”

The Committee identified several factors known to promote the resilience and healthy development of adolescents. These include a suitable standard of living, access to quality secondary education and freedom from violence and discrimination. They also include what the Committee calls “social assets”, such as strong relationships with and support from the key adults in their lives, opportunities for participation and decision-making, problem-solving and coping skills, and respect for individuality. The Committee emphasised that opportunities for adolescents to build and benefit from such social assets will enhance their capacities to contribute to the realisation of their rights, including by maintaining good physical and mental health, avoiding risky behaviour, and recovering from adversity.

I believe that all sectors of society – including health professionals and health service providers – play a role in promoting and supporting these social assets, which are essential for the physical and emotional wellbeing of children and young people.

Effective monitoring of what is happening to children and young people is critical to the full realisation of their rights. It becomes a mouthpiece for them and their experiences, one of the many ways to tell their stories and to honour their right to be heard, visible, valued and respected.

Article 12 of the Convention on the Rights of the Child says that children have the right to express their opinions freely and to have those opinions taken into account in matters that affect them. Essentially it is about ensuring that children and young people have the opportunity to participate and be heard, something which young people have consistently raised with me over the years. Article 12, having a voice and a say, is the gateway to achieving all other human rights.

I hope that this conference will provide all of you with an opportunity to listen to and engage with young people, and to adopt a positive and holistic approach to addressing their needs.