In their own words: Young people's mental health in ...

Aust. J. Rural Health (2011) 19, 244–248

Original Article In their own words: Young people’s mental health in drought-affected rural and remote NSW ajr_1224

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Tracey-Lee Carnie,1 Helen Louise Berry,1,2 Susan Audrey Blinkhorn1 and Craig Richard Hart1 1

Centre for Rural and Remote Mental Health, School of Medicine and Public Health, The University of Newcastle, Newscastle, New South Wales, and 2Centre for Research and Action in Public Health, The University of Canberra, Canberra, Australian Capital Territory, Australia

Abstract Objective: To record the drought-related experiences of young people and to contrast these with their teachers’ and other adults’ observations. Design: Content analysis of issues and priorities raised in semistructured school-based forums. Setting: Rural schools in NSW centres. Participants: Young people, their teachers and service providers. Intervention: Six youth and community forums organised under the Rural Adversity Mental Health Program. Results: Participants welcomed increased community connectedness in response to prolonged drought but reported that drought’s mental health impact was mainly negative. Adults observed children’s distress, wondering if anyone else noticed it. They witnessed young people worrying about their families, increasingly isolated, at risk of harm, unable to obtain help and facing educational and employment limitations. Young people disclosed many mental health and relationship difficulties at school and at home. They worried about their families, communities and futures and about money and being isolated. Conclusion: Adults and young people reported similar effects of prolonged drought on young people’s mental health. But, while adults were more concerned with risks to young people (of harm, abuse, homelessness, problems with the law and constrained opportunities), young people were simply overwhelmed, wanting help for their immediate worries. They sought coordinated support within schools, schools working together, more information about mental health and where to seek help for them and their friends, and support people who understood Correspondence: Helen Louise Berry, Centre for Research and Action in Public Health, The University of Canberra, University Drive, Bruce ACT 2617, Australia. Email: helen.berry@ canberra.edu.au Accepted for publication 8 June 2011.

drought and rural circumstances and on whose discretion they could rely. Mental health programs that are developed in and for metropolitan contexts need to be adapted before being deployed in rural settings. KEY WORDS: adolescent, children, climate change, psychiatric, rural adversity.

Introduction Over the decade to 2010, New South Wales (NSW) experienced its worst drought in a century.1 A national inquiry into the effects of this drought on rural Australians found wide-ranging adverse impacts on individuals, families and communities, including on their mental health.2 With climate change driving underlying warming and drying in Australia,3,4 more frequent and severe droughts might be expected with consequent adverse impacts on health, including mental health.5,6 These impacts are likely to be most severe for people who are already vulnerable, disadvantaged, living in rural and remote locations and for children.7 A NSW study of the impacts of prolonged drought on children has revealed that, while initially able to cope with the pressures it creates, with long-term exposure, children experience increased hopelessness, distress and behavioural problems.8,9 Rural Australians, including children,8,9 do not generally have worse mental health than their urban peers;10 indeed, among adults, the opposite appears to be the case.11 But they experience greater poverty and less access to infrastructure and services.12,13 Like their parents, rural young people encounter multiple barriers to accessing mental health services.14 Against a background of climate change and rural adversity, the impacts of drought on young people have implications for future provision of child and adolescent mental health services. Although services do exist, they are often inadequate, or poorly coordinated (see Box 1

© 2011 The Authors Australian Journal of Rural Health © National Rural Health Alliance Inc.

doi: 10.1111/j.1440-1584.2011.01224.x

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What is already known on this subject: • Young people are resilient to drought for a time but, with prolonged exposure, start to exhibit increased distress, hopelessness and behavioural problems. • More frequent, prolonged and intense weather-related disasters, including drought, are expected as a result of continuing adverse climate change. Because this will be harmful to mental health, particularly for young people and other vulnerable groups, strategies to support these groups need to be developed urgently.

for a recent exemplar case). In addition, service design and development is typically undertaken by health professionals and policy-makers in metropolitan settings, with little input from those most closely involved in children’s welfare (such as parents and teachers) and little or no input from young people themselves (e.g. School-Link,15 MindMatters16). In response, the Rural Adversity Mental Health Program (RAMHP)17 has been adapted for children to offer a range of mental health interventions in school settings in rural and remote NSW. The aims of this paper are to describe the adaption of RAMHP to school settings and to record the drought and adversity-related mental health needs of young people in rural and remote NSW.

Method RAMHP has been adapted for young people in multiple ways.18 For example, collaborative partnerships have been formed with non-metropolitan Area Health Services, SchoolLink Coordinators, the NSW Department of Education and Training and principals from the private and boarding school sector to offer Mental Health First Aid training for teachers19 and boarding school staff. Support for these activities was provided by the Black Dog Institute20 and beyondblue.21 In addition, consultative forums were held to: (i) better understand children’s and young people’s needs (including children’s own views) about how drought had affected them; (ii) to learn what could be done to better support children; and (iii) to identify possible service delivery partners. Government and nongovernment organisations and community stakeholders were invited to forums by letter, with telephone follow up. The first, a statewide forum held in Orange in June 2008, attracted 45 participants and was followed by a similar forum in each of the rural health service regions

What this study adds: • Adults and young people share many perceptions about how drought affects young people’s mental health. Young people also have unique perspectives. They feel overwhelmed and worry extensively about families, communities, friends, money and their futures. • School-based mental health programs can be effective but most are developed in metropolitan settings. They must be adapted for deployment in rural schools, as demonstrated in the Rural Adversity Mental Health Program. • Young people seek coordinated, school-based help from trustworthy adults who understand drought.

BOX 1: Exemplar case study: barriers to accessing effective child and adolescent mental health services in rural and remote NSW Sam* is a 10-year-old boy with a history of abuse and neglect within his family of origin. He lived with a foster carer to whom he was very attached, an older woman in her sixties, who struggled at times to meet the complex needs of a psychologically disturbed and hyperactive child. Sam and his carer lived some distance from a remote town in rural New South Wales. During a crisis in the child’s life related to memories of abuse, he became increasingly distressed and behaviourally disturbed, including making an attempt to hang himself. The only child mental health worker position in the town was vacant. Specialist child mental health services were located 350 km distant from the town and inpatient assessment (which was considered necessary) was over 500 km distant. Over two days, the child was transported (with support, but without his carer) to the paediatric ward of a Base Hospital. Over several more days, the child’s mental state was assessed and his psychiatric history retrieved. Child protection services, the Family Court and the foster carer were linked (by telephone and videoconference) to share relevant information and develop a plan for ongoing management. While videoconference technology was helpful in resolving the crisis for the child, nonetheless, a young child travelled over 500 km without his carer in order to have the problems resolved. *Name changed to protect identity.


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(in Casino, Albury, Dubbo and Tamworth). At each forum, participants broke into small groups and noted their responses to the question: ‘In the context of drought and other rural crises, what mental healthrelated problems do young people face?’ Participants shared their responses in plenary, grouped like issues and prioritised these issues by voting. Forum feedback indicated that boarders from rural schools experienced unique pressures. To explore this issue, a further forum targeting years 9–11 students from drought-affected boarding schools was held in Orange in April 2009. The Black Dog Institute and headspace Bathurst partnered with RAMHP to deliver The Black Dog Institute INSIGHT program to these students. The RAMHP consultant child and adolescent psychiatrist also presented information on depression and anxiety in young people. Forty-five students (and six teachers) from six rural boarding schools responded to questions about the impact of drought on the young people, their families and their communities. As before, responses were shared in plenary and like issues were grouped and prioritised by voting. With the boarders’ approval, this information was distributed to schools and government and nongovernment agencies to help promote and inform localised strategy development for young people.

Results The issues prioritised at the forums from adults’ and young people’s perspectives are summarised separately below. Some adults mentioned the benefits of increased connectedness that emerged from the drought, for example, through the church, ‘farm family gatherings’ and sports and community activities. Overwhelmingly, however, participants spoke of negative impacts. On the farm, succession plans were no longer attractive or possible, while pessimistic attitudes towards change or adopting new technology and fearing being ‘left behind’ made it difficult to adapt. The situation in which farmers received drought-related financial support while other community members did not polarised some communities and, with prolonged drought, communities and individuals ran out of energy to cope. This was made worse by feelings of being out of control in the face of government policies. Children were affected by these factors, by the stress of financial pressures at home and by being unable to afford necessities, such as fuel and food. They reported feeling shame, embarrassment and anger at their situations. Impacts on young people as identified by adults: 1. Worrying about family. Adults felt that young people were affected by their parents arguing or separating and divorcing, more single parent families, poorer child care and more strain for everyone, including extended families (with grandparents

taking on more caregiving). Some children were taking on adult roles, such as providing emotional support for families and others (referred to as a ‘stolen childhood’). 2. Social isolation. Young people lost friends and support people (partly because many were experiencing the same issues), had to undertake homeschooling and had reduced participation in community activities. Declining populations in home communities also provoked a sense of increasing isolation. Some young women were moving away to study, leaving the young men behind alone. 3. At risk of harm or abuse. Some children were exposed to increased domestic violence, parents’ excessive alcohol consumption at home and parents’ reluctance to seek help. Children faced increased risk of injury when they had to leave school to work on the farm. 4. Unrecognised distress. Adults were concerned that children were experiencing distress that was not being recognised and treated. Children withdrawing and worrying were seen as examples of this, as were children misusing drugs and alcohol, experiencing sexual health problems, homelessness, teenage pregnancy and problems with the law and physical safety. Distress was also thought to arise because children did not fully understand what was going on or what was happening to them. There were fewer happy, positive role models and mentors for young people. 5. Barriers to accessing services. Remote location, not knowing service providers and lack of health services, partly due to the difficulty of attracting professionals to the area, were examples of barriers to accessing services. Many young people were unwilling to seek help, fearing compromising their privacy. 6. Employment and education problems. Young people had few employment opportunities and difficulty accessing youth allowance for tertiary study. Some had been withdrawn from school due to financial problems and had to undertake farm work, with consequent loss of future opportunities, friends and social position. Issues identified by young people themselves: 1. Harm to health and well-being. Young people spoke extensively of wide-ranging mental health problems and relationship difficulties at school and in their families. They had trouble accessing services. 2. Worrying about family. Young people worried about their parents’ mental health, family relationships and not being home to help. Boarders’ distance from their families increased their stress.


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3. Worrying about money. Young people worried about whether the farm would survive, whether it would get government financial support and whether they could stay on at school. Boarders felt deprived relative to other students with more money. 4. Worrying about their communities. Young people said that businesses and services had closed due to families leaving the area. They worried that their towns might die and felt that the drought’s pernicious effects were widespread and inescapable. 5. Worrying about their future. Young people worried about what might happen when the drought broke and expressed uncertainty about whether they would take over the family property. One student said: ‘I have taken all agriculture subjects and I don’t know if I can continue . . . if we have no farm’. They noticed that worry had already affected their school performance and were torn between wanting to stay in school and feeling obligated to return home to help. 6. Isolation. Young people felt the loss of friends and of opportunities to participate in community activities: feeling obligated (and being required) to work on the farm, many had no time for recreation or socialising. Boarders had less contact with families.

Suggestions Young people reported that they would benefit from: (i) more information about mental illness, where to get help and how to help others; (ii) better coping skills and a choice of counsellors who understand drought; (iii) support groups within and between schools; and (iv) for boarders, improved telephone and email contact with family.

Discussion There was overlap between adults’ and young people’s views about how the drought had affected young people in rural and remote NSW. Both agreed: consistent with other research,9 young people’s mental health has been harmed by prolonged drought; it was difficult for them to access services and, as previously reported,14 young people sought confidentiality; they worried about their families; and they were increasingly socially isolated. Adults also saw in young people multiple signs of unrecognised and untreated distress, were concerned about increasing risk of harm or abuse and believed that their educational and employment opportunities had diminished. Economic crises in farming communities can make rural adolescents uncertain about their future:22 young people in the present study reported feeling anxious and overwhelmed by the drought. They worried

about their families, their own long-term future, whether the farm would survive financially and the implications for their future employment if it did not. They also worried about whether their communities, to which they have a strong and protective sense of belonging,8 could survive the drought. In speaking about what would help them cope with the mental health impacts of drought, young people emphasised the need for integrated appropriate help: adults who understood drought; information about what help was available and where to get it; and better in-school support and between-school cooperation. This is consistent with findings that students prefer confidential, competent and caring in-school support for mental health, especially for emerging problems, and feel that schools could do much more to provide it.14 Yet, while parents frequently consult teachers about their children’s mental health,23 teachers have only moderate confidence in dealing with these issues.24 The substantial uptake of teachers’ Mental Health First Aid courses offered through RAMHP suggests teachers’ interest in learning more about children’s mental health. Our small and non-random sample of young people and their teachers and other service providers limits the generalisability of conclusions that can be drawn from this study. However, our findings are consistent with the few other studies that have been published in this area and our study is the first to contrast adults’ and young people’s views. There is an acute and growing need for mental health services for young people affected by drought and recovery from drought. New policies for school students need to be adapted before being transferred from metropolitan to rural schools and need to take account of young people’s own views. RAMHP is a rural program which has been adapted successfully to school settings in a child-inclusive manner; it could be extended to other rural or remote educational settings, such as for children attending School of the Air.

Acknowledgements In addition to our gratitude for general support for RAMHP (see Hart et al., this issue17), we thank all the schools, the Black Dog Institute, beyondblue and headspace for their generous assistance with this project.

References 1 Bureau of Meteorology. Annual Australian Climate Statement 2008. Issued 5th January 2009. Canberra: Commonwealth of Australia, 2009. 2 Drought Policy Review Expert Social Panel. It’s about People: Changing Perspectives on Dryness – a Report to Government by an Expert Social Panel on Dryness. Canberra: Commonwealth of Australia, 2008.


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