A.Synopsis -Rules for the Medicare Better Access scheme should be changed to allow psychologists and other mental health professionals, when working with children under 12, to have the flexibility to use all 10 allowable rebateable Medicare sessions per calendar year to work with parents/caregivers without their (under 12 year old) children present, when required and agreed upon by their legal guardians, in order to provide parent-directed treatment for children’s mental health concerns. -This change will significantly increase the effectiveness and efficiency of therapy for children’s mental health, avoid the harms currently occurring because of children being exposed to potentially traumatic content discussed by their caregivers within Better Access sessions as they exist in the present and increase the longevity and sustainability of the child mental health workforce. -This change is supported by Australian parents/caregivers and has been recommended by several recent government national reviews and peak advisory bodies. -Economic analysis and clinical research suggest this change will be either cost neutral or result in cost savings for the Better Access scheme, firstly as it will not require additional annual session allowances for children and secondly given its likely result of an increase in effectiveness and efficiency of child mental health treatment. B.Background Medicare's Better Access scheme provides Australian children with mental health concerns 10 rebateable psychology sessions per calendar year when referred by their GP. At the introduction of this scheme, rules required the individual named on the referral - ie for our purposes, a child with mental health concerns – to be present in the room and be directly receiving the psychological service themselves for all these 10 sessions. In March 2023, changes were made to the Better Access scheme to allow parents/caregivers of the child to be the recipient of services for up to two of the child’s 10 annual allocated sessions (“Family and Carer participation sessions – FACS”), without the child being present in the room. This was done to recognise the importance of family and carer involvement in a person (child or adults) mental health treatment (Department of Health and Aged Care, MBS Online, 2023). However, for the remaining 8 sessions, for children referred with mental health concerns, the child is still required to be present and receive the service directly themselves. The resulting problematic implications and missed opportunities for the Australian community of this system are outlined below. C. Problematic implications of rules preventing parent directed treatment for children with mental health challenges under Better Access Problem 1: Mental health professionals working with children under Better Access, are unable to provide the first line, evidence based, universally recommended treatment approach (specifically parent directed treatment - sometimes referred to as ‘parent management training’ or ‘parent focussed treatment’)- for children with disruptive behaviour disorders and Attention Deficit and Hyperactivity Disorder. Attention Deficit and Hyperactivity Disorder (ADHD) is the most common diagnosed mental health disorder for children in Australia today (AIHW, 2022). Disruptive behaviour disorders (DBDs - eg Oppositional Defiant Disorder and Conduct Disorder) or symptoms of these disorders are the most common reason for presentations at paediatric mental health clinics (Loeber, Burke, Lahey, Winters & Zera 2000). Although ADHD and DBDs are different in many respects, they share significant comorbidity (Gnanavel et al, 2019) and furthermore when not treated effectively, both conditions lead to children experiencing higher risk of engaging in criminal behaviour, and substance abuse, experiencing unemployment in adulthood, poorer academic outcomes, increased reliance on social welfare systems, being involved in disrupted classroom environments and school bullying (Sawyer et al., 2018, Fergusson et al 2005, Fredriksen et al 2014). The economic burden associated with untreated Conduct Disorders in particular, considering increased costs in healthcare, education, justice system involvement, and lost productivity, has been estimated to be exceptionally high (Goulter, 2024, Rivenbark et al., 2018). Fortunately, several decades of extensive and high-quality research has found that both disruptive behaviour disorders and ADHD in young children (ie those aged 12 and under) are able to be effectively treated by evidence-based psycho-social treatments often referred to as ‘parent management training’ interventions or ‘parent focussed treatments’ (see Helander, Maria et al, 2024 for review). These treatments consist of 10 to 24 sessions of parents/caregiver directed interventions whereby parents/caregivers work themselves with mental health practitioners and are provided with strategies to coach, support and treat their child to reduce symptoms of disruptive behaviours and/or to manage problematic ADHD symptoms. As a result of this effectiveness research, these parent directed treatments have been universally recommended by numerous high-quality reviews and peak organisations. For example, the Australian Government’s NHMRC treatment guidelines for ADHD (October 2022), the NICE (2017) guidelines for the treatment of disruptive behaviour disorders and the Australian Psychological Society recommendations for evidence-based treatment of Conduct Disorder in childhood (2018) all strongly recommend parent directed interventions as first line, gold standard treatment. However, due to the Medicare rules which permit only 2 of the 10 sessions allowed per year, Australian child mental health professionals are unable to provide this this recommended treatment to Australian parents/caregivers. These professionals therefore usually implement a different, less effective approach – a child directed (usually CBT based) approach. While this is valuable for some children (especially those from mid childhood onwards), using this child directed treatment for all children (especially younger children) as a first option directly contravenes the numerous reviews and treatment guidelines recommendations outlined above. In fact, a recent expansive review of the evidence for children with disruptive behaviour disorders has directly examined the question of using child versus parent directed interventions and concludes that parent interventions are more effective than child interventions for treating disruptive behaviour and conduct disorders in early and middle childhood (Gatti, 2018). This research finding echoes the “common sense” understanding that Australian parents and their mental health professionals have always had –young children do not always have the motivation to fully engage in therapy nor the understanding or skills to be consistently able to take strategies learned in therapy and apply them to novel situations. It is not surprising therefore that it is an open secret among mental health practitioners working with children under Better Access that a large proportion of young children with problematic ADHD symptoms and DBDs – will not and do not improve after therapy– simply because mental health professionals are not able to provide these children with what is well known as the best and most effective treatment, despite the fact this treatment is unlikely to result in additional costs to the Better Access scheme (see Section 4). It is therefore also predictable that the associated short- and long-term societal burdens of child disruptive behaviour concerns continue to be a source of media attention in Australia (eg see ABC News. (2024, September 25). As bullying and violence surge in schools, these parents feel the system is failing them. ABC News. and Goss, P. (2023, September 25). Australian classrooms are among the least favourable for discipline in the OECD: Here's how to improve student behaviour. The Conversation). Real (de-identified) Example: Sam, 6 years old and in Year 1 at school, is a child with high levels of disruptive and inattentive/hyperactive behaviours. Sam has been diagnosed with ADHD and Oppositional Defiant Disorder (ODD) by his paediatrician. He has daily meltdowns during which he frequently hits, kicks, screams and hits his two younger siblings and other children at school, is unable to follow instructions at home and school and frequently runs away from home. His siblings have been the subject of child protection concerns given Sam’s frequent aggressive behaviours towards them. His school have recently informed his parents that he may only attend school two mornings a week given the safety risk he poses towards other children (and their inability to adequately supervise him outside these times). Sam’s paediatrician provided Sam with a Mental Health Treatment Plan to see a psychologist who works with children. After assessment of his symptoms, Sam’s psychologist, who has been working with children for 20 years, knows the most effective treatment for Sam would be to use a parent directed treatment approach – to work directly with Sam’s mother and father to provide them with strategies to reduce Sam’s challenging behaviours. She knows from the literature that this would likely significantly reduce Sam’s aggressive behaviours and improve his relationships with his peers, family members, improve his self-concept and increase his academic functioning. However, Sam’s psychologist is also aware that they are unable to provide this parent directed treatment using Medicare funding. Due to these constraints, she begins an alternative child directed CBT approach whereby she works directly with 6-year-old Sam himself. This requires much time to be spent in each session trying to engage the very young Sam using play and game like activities, before trying to motivate him to use strategies to manage his emotions. As predicted by the research, due to Sam’s limited capacity to engage in therapy - this turns out to be a much slower and less effective method for Sam and he continues to experience high level symptoms. His parents and paediatrician (who is also providing medication to Sam) monitor Sam’s ongoing challenges over 3 years and given the ongoing difficulties, continue to refer/bring Sam to therapy for over 30 Medicare funded Better Access sessions. At the end of this time, when Sam is 9, while all parties believe he has learnt some strategies, Sam is still experiencing significant behavioural challenges, does not attend school full time and now has significant educational delays his siblings have been temporarily removed from his house due to child protection concerns and his relationships with family members and peers are strained. His parents are also experiencing high levels of distress, and his Mum has resigned from her job to manage her own distress and Sam’s schooling. This situation is in stark contrast to the significant progress research suggests would have been possible for Sam if Medicare rules allowed his psychologist to instead use the 10 rebateable sessions with his parents, instead of working directly with him. Problem 2. Child mental health professionals working under Medicare are unable to use evidence-based therapy for the treatment of low-motivated, low-capacity children with anxiety disorders and OCD. Anxiety disorders and Obsessive Compulsive Disorder (OCD) are also highly prevalent mental health problems in childhood, affecting 6.5% of children (Polanczyk et al., 2015). Ineffectively treated anxiety disorders/OCD in children, like disruptive behaviour disorders, also lead to significant societal burden, with research finding associations between anxiety problems and worse physical health, behaviour, self‐harm, eating, relationship, educational, health care, employment, and financial outcomes (Pollard et al, 2023). Fortunately, once again – there are evidence based psycho-social treatments for childhood anxiety/OCD. Cognitive Behavioural Therapy which includes a focus on ‘exposure’ (gradually facing fears with support) - is the first line treatment for anxiety disorders as recommended by the most comprehensive reviews of the literature (eg James et al (2020)) as well as by Australian, UK and US based National guidelines (eg Evidence-based Clinical Practice Guideline for Anxiety in Children and Young People, Melbourne Children’s; 2024, APS Evidence based guidelines (2018), National Institute for Health and Care Excellence. (2013). Unfortunately, 40-50% of young children with anxiety/OCD who complete an individual CBT program either still meet criteria for or have significant symptoms of their anxiety disorder or obsessive-compulsive disorder following treatment (Barrett, 2008, Kyu, et al 2016). Part of the reason for non-response in the specific case of children under 12 is that many young children have lower levels of cognitive capacity which can make it difficult for them to fully engage in this type of psychological treatment – for instance young children who don’t understand the problems and long term costs of their current avoidance/anxious behaviours, nor understand the benefits of practice and commitment to at home tasks. Furthermore, children with more severe anxiety and OCD symptoms are more likely to be resistant to this CBT treatment. With growing recognition of this difficulty engaging in treatment for some children, there have been a number of recent studies outlining the development of an alternative parent directed treatment approach in the treatment of children with anxiety disorders and OCD. This parent directed treatment consists of parents/caregivers attending therapy sessions instead of their children whereby they are coached by mental health professionals, over the course of 10 to 12 sessions, to use a step-by-step approach (including changing key parent behaviours) to respond to and gradually reducing the child’s problematic avoidance and other anxious behaviours. Several randomised controlled trials (RCTs) and meta-analyses examining these individual trials have concluded that parent-only directed treatment are highly effective treatments for child anxiety disorders (Jewell et al., 2022, Yin et al., 2021). Arguably these treatments are likely to be particularly effective with younger children who experience more difficulty to engage fully in treatment themselves – or with older children who have characteristics or are in situations which mean they find it difficult to engage in treatment themselves. However, again under current Medicare guidelines, evidence-based parent directed treatment for childhood anxiety disorders is not able to be used under Medicare funding, despite the fact these interventions could be included at no additional costs (see Section E) leading to ongoing undertreatment of childhood anxiety disorders. This also continues to also be a source of media concern in Australia (Baker (2023). Gen stress: Prescriptions surge for children’s anxiety medicines. The Sydney Morning Herald.) Real (de-identified) example: Tali is an 8-year-old girl with severe anxiety about cooking smells and vomiting, and who is resistant to leaving her home due to these fears. Tali’s GP has referred her to a psychologist under the Better Access scheme. Her psychologist explains to Tali and her Dad Simon at their first session that a CBT/exposure-based approach for Tali will likely to be effective for her and reduce her anxiety and avoidance. However, on hearing the psychologist describe the treatment approach (whereby Tali will very gradually start to approach small aspects of the situations she avoids), Tali leaves the room and tells her Dad that she is unwilling to come to further sessions. Later at home, when Simon tries to talk with Tali about this, she lies down on the ground and screams – and he is unable to get her to attend any further sessions. In a phone call with Simon, Tali’s psychologist talks with Simon to tell him that if he is willing to attend sessions himself and undertake an evidence-based parent directed treatment he will be likely be able to assist Simon to know how to treat Tali himself. He explains this alternative approach has been found in the research to be just as effective (and possibly produce quicker results) than Tali coming to sessions. Simon is keen to do this however when he is told that there are no Medicare rebates for this approach, he tells the psychologist cannot afford to pay privately. Instead, Tali and Simon go back to their GP and are referred to a psychiatrist to see whether medication might be helpful. Unfortunately, this process takes 12 months, and medication ultimately had several side effects for Tali such that they end up discontinuing it. Two years later, Simon calls the psychologist again to update him on the fact Tali still does not attend school, rarely leaves the house and is being seen by her GP for a cascading number of other health problems likely related to her avoidance of food and lack of exercise. Simon is experiencing a high level of distress about Tali’s situation and has now engaged his own psychologist to manage his own mental health. Again, this situation is in stark contrast to what could have occurred if the Psychologist was able to work directly with Simon to help him successfully treat his daughter’s anxiety condition and assist her to return to school and other life activities. Problem 3. Inability to flexibly offer parent only rebated Medicare sessions means that children in mental health treatment sessions are frequently witness to parents/caregiver’s dialogue and discussion of psychologically damaging and potentially traumatic, emotionally abusive material. Parents/caregivers of children with mental health concerns usually accompany young children to sessions (to clarify in the case of any confusion – although Better Access rules prevent parent directed treatment and (more than 2) parent only sessions, parents are allowed to be (and often are) present while the psychologists provides child directed treatment sessions). While in these sessions with their children, many parents/caregivers will disclose and discuss information which is psychologically damaging and distressing to the listening child. This material may include instances of family violence (“she’s been upset this week, you should know her Dad hit me this week while he was there, he has been hitting me when he is drunk for this kids’ whole life”), child abuse (“I’m pretty sure the reason he can’t learn at school is because when he was a baby, his Mum used to shake him all the time, he didn’t know that but I think you should know”) and very harsh child criticism (“you have to do something about this (expletive) kid, I’m at the end of my tether, I don’t think I can have him in the house anymore”). Unsurprisingly, research suggests that children being exposed to this type of emotionally abusive and traumatic material, even briefly, is potentially highly emotionally damaging and should be avoided at all costs (eg see Swenson (2016), Afifi et al (2009). It should be noted that child mental health practitioners cannot prevent or predict this information from being provided by parents/caregivers in front of the child. Some of this information (for instance, the example of information about family violence) must be allowed to be heard (at least briefly) in order to assess the safety and health of the child and cannot be “scheduled” in the two parent/caregiver annual parent sessions as it is prompted by unexpected and frequent events and where safety concerns are identified, needs to be responded to urgently (either in the form of advice about ways to protect children or via a Child Abuse report). Some of this information (for instance, parents’ harsh criticism and emotionally abusive statements about their children) occurs spontaneously and rapidly in session without an opportunity to prevent the child from being exposed to it. (Real - Deidentified - example): 8-year-old Jack is working with a psychologist using Better Access funding to manage trauma symptoms prompted by exposure to previous family violence when he was younger. Jacks’ Mum, Susan, brings Jack to sessions and has already used her two FACS sessions to provide history and background to help Jack’s psychologist start working with him. However, today she calls the clinic’s receptionist before Jack’s scheduled session and asks to come into session herself without Jack because she needs to discuss something important about his mental health and doesn’t wish to have him present. The receptionist explains Better Access rules about the child needing to be present for sessions and invites her to use private funding instead if she needs a further parent only session or to briefly email the psychologist. Susan says she is unable to afford a private session and says she needs to discuss the issue in person and so brings Jack to her session. When she sits down in the room with Jack next to her on the couch, she tells the psychologist: “My new partner has been violent to me this week. He also hates Jack, and I’m scared he is going to hurt him. He says we would get along better if Jack wasn’t here anymore. I know he is doing the wrong thing, but I think that the best thing is for Jack to be taken into care somewhere, as he just has too many problems for me to manage anyway”. The psychologist looks at Jack after Susan finishes speaking and sees he has buried his head in his hands – she immediately asks Mum to provide any further relevant information about safety via email or after the session - but Mum continues to insist that she needs to discuss it with the psychologist now. Jack’s psychologist is also aware that she now needs to ask at least some questions about Susan’s comments to ascertain Jack’s immediate safety at home. While she starts to carefully formulate her phrasing, she notes that Jack has slumped to the ground and has started banging his head against the floor. It is important to understand that these parent/caregiver disclosures are not rare occurrences for mental health professionals working with children and the issue of how to manage them safely is a frequent question in training and supervision for this group of professionals. Problem 4. Being forced to work in ineffective (and sometimes distressing) ways with children reduces the already scarce child mental health workforce. It has been widely recognised that in Australia there is a scarcity of child mental health professionals able to provide mental health services to children/young people (eg see National Children’s Mental Health and Wellbeing Strategy, Mental Health Commission, 2024) with this problem being the subject of media attention over the last few years (eg see Bourke (2022). Children missing out on mental health treatment due to Psychologist shortage, particularly in regional areas). The scarcity of the Australian children’s mental health workforce is in part perpetuated by this group of professional’s inability to provide evidence based and the most effective treatment to children and the consequent witnessing of lack of improvement in many young children. This is a predictable outcome - mental health professionals continue to work in this sometimes very emotionally taxing field only when they feel they are providing helpful, effective, non-harmful and meaningful work. When Medicare rules prevent this from being able to occur, it is foreseeable they will experience burnout and choose to leave the field. This is especially likely when they have options to switch to an alternate field of mental health work such as working with adults where they can more readily apply evidence-based treatment under Better Access. Furthermore, when we force mental health professionals to be in sessions where are witness to (and have to manage) children being exposed to damaging adult content and conversation – this is the final ‘straw that breaks the camel’s back’ and leads to depletion of this workforce. Deidentified (real) Example: Jane is one of only two students in her graduating cohort of 10 provisional Psychologists attending her state’s largest university who wish to work with children. During her Master of Clinical Psychology degree, she learnt about gold standard parent directed treatments and looks forward to implementing these with children and families. Once she graduated and was working in a private clinic, she realised that at least half of the children she sees have mental health conditions where they should, according to national recommendations and clinical research, be receiving an evidence based parent directed treatment. However given that 90% of families she worked with each day were funded under Better Access, she quickly realises she is unable to provide effective treatment to many families she sees each day. In addition, during at least one session per day she navigates the potential harm caused by a parent/caregiver raising psychologically damaging content in front of a young child. Jane becomes increasingly troubled by the lack of improvement she sees with children, troubled by the damage they experience in sessions in front of her - and demoralised that she can’t do the work she knows would result in improvement. Exhausted, at the end of one particularly difficult day, she talks with the others in her recently graduated psychology cohort who went on to work with adults instead of children. She hears about the evidence based and effective work they are doing with adults. As a result of this conversation, she ultimately decides to leave her position working with children and work at a clinic with adults instead. This means that after 2 years, only one of that graduating class of psychologists have stayed working in the child psychology field. D. Perspectives of families and advisory bodies Parents/caregivers express distress and incredulity that they have almost no opportunities to privately tell psychologists about their child's mental health concerns, family violence and other sensitive material about their child without their child being present under Better Access funded psychology sessions. When they are told that there is an evidence based intervention for their children which requires their involvement, they are keen to use it and distressed that Medicare will not fund it. In the evaluation of the Better Access scheme (Pirkus et al, 2010) there was overwhelming consensus from participants suggesting there should be better processes for family/caregiver support and involvement in the child’s mental health treatment. In addition, numerous Australian reviews and organisational position statements have recommended parent directed treatments for child mental health concerns be more accessible to Australian, for example: -The Mental Health Commission’s (2024) National Children’s Mental Health and Wellbeing Strategy report stated that the Better Access system “creates barriers to parents accessing information from services that would in turn support their child” and recommended “Enabling providers to claim for consultations with parents and carers (without the child present) as part of the child’s care (action 2.2.c)”. It should be noted the limit of only 2 FACS/parent/caregiver sessions of the 10 sessions was not recommended by the Commission - and as outlined above, this limit prevents any form of evidence-based parent directed treatment (which usually involves a minimum of 10 to 12 sessions) to be provided. -The Productivity Commission report (2020) recommended the introduction of parent/caregiver sessions. “The Australian Government should amend the Medicare Benefits Schedule so that family interventions provided by psychologists and other allied mental health professionals are rebated.” -The MBS Review Mental Health Reference Group (2018) stated that sessions for carers were a fundamental element of evidence-based best practice and that they would enhance collaboration and recognition of carers. -The Australian Psychological Society’s White Paper (APS 2019) on the future of psychology in Australia recommended parent directed treatment and the introduction of a specific Medicare item enabling Psychologists to provide parent directed treatment to parents/caregivers of children with mental health concerns. -Finally, it should be noted that other nations have recognised the importance of subsidized parent directed treatment of child mental health concerns. For example, the CYP-IAPT program in the UK which is designed to provide accessible child mental health interventions to children has no such restrictions on children having to be present for all sessions (Young Minds, 2020). E. Budgetary Concerns There are three reasons to believe that the introduction of sessions for parents/caregivers under their child's Mental Health Treatment Plan would not result in significant additional costs to the Better Access scheme and may even result in cost savings. First, this proposed change only suggests the ability to have parent only sessions instead of direct child sessions, thereby not increasing the total number of allowable sessions per calendar year. Second, as per the research outlined above, it is likely that the provision of parent directed treatment will result in larger and faster treatment benefits than what is currently occurring while children are receiving treatment. For instance, instead of a five-year-old child receiving 30 sessions over 3 years, it is likely that parent/caregivers who attend 10 sessions would receive the same benefit. This therefore results in cost savings compared to the current treatment approach. In fact, there has been some UK based economic analysis directly addressing this question. A recent study , found there was a 96% probability that a parent directed CBT therapy (without the child present) was more cost effective than a therapy program which included the child (and parent together) (Creswell et al., 2017). Third, also as outlined above, even if parent directed treatment did result in a small number of additional sessions than what would have been otherwise accessed (for example, a family using a total of 10 sessions per year rather than them using 2 sessions and dropping out when the child does not engage) – arguably this increased engagement and effectiveness of the therapy will result in overall health, education and other government savings in the long run. This is especially likely given the significant societal costs in education, welfare, justice, health costs of unresolved child mental health difficulties, as well as the costs associated with lost productivity and increased mental health supports required for parents who have children with high levels of mental health challenges. F. Summary -A change in rules for the Medicare Better Access to allow families and mental health professionals the flexibility, when working with young children with mental health conditions, to choose between child directed and parent directed treatment - would be a cost neutral or cost saving measure which would likely significantly and substantially improve Australian children’s mental health within the first weeks and months of implementation, and result in cost savings for Australian health, education and welfare sectors. -This change would not require the creation of brand-new rules, regulation and item numbers, but instead just the extension of the existing allowance of the use of two sessions – to the full ten sessions with parents/caregivers for children. -Australian parents/caregivers would welcome and approve of this change. -It would likely support and extend the working life of the scarce child mental health workforce. References: Afifi, T. D., Schrodt, P., & McManus, T. (2009). The divorce disclosure model (DDM): Why parents disclose negative information about the divorce to their children and its effects. In T. D. Afifi & W. A. Afifi (Eds.), Uncertainty, information management, and disclosure decisions: Theories and applications (pp. 403–425). Routledge/Taylor & Francis Group. https://doi.org/10.4324/9780203933046 Australian Psychological Society. (2018). Evidence-based psychological interventions in the treatment of mental disorders: A literature review (4th ed.). Retrieved January 24, 2025, from https://psychology.org.au/getmedia/23c6a11b-2600-4e19-9a1d-6ff9c2f26fae/evidence-based-psych-interventions.pdf Baker, N. (2023, April 3). Gen stress: Prescriptions surge for children’s anxiety medicines. The Sydney Morning Herald. https://www.smh.com.au/national/nsw/gen-stress-prescriptions-surge-for-children-s-anxiety-medicines-20230403-p5cxop.html Barrett, P. M., Farrell, L., Pina, A. A., Peris, T. S., & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive–compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 37(1), 131–155. https://doi.org/10.1080/15374410701817956 Bourke, E. (2022, February 23). Children missing out on mental health treatment due to psychologist shortage, particularly in regional areas. ABC News. https://www.abc.net.au/news/2022-02-23/children-mental-health-treatment-psychologist-shortage-regions/100854252 Creswell, C., Violato, M., Fairbanks, H., White, E., Parkinson, M., Abitabile, G., Leidi, A., & Cooper, P. J. (2017). Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: A randomised controlled trial. Lancet Psychiatry, 4(7), 529–539. https://doi.org/10.1016/S2215-0366(17)30149-9 Fergusson, D. M., Horwood, L. J., & Ridder, E. M. (2005). Show me the child at seven: The consequences of conduct problems in childhood for psychosocial functioning in adulthood. Journal of Child Psychology and Psychiatry, 46(8), 837–849. https://doi.org/10.1111/j.1469-7610.2004.00387.x Fredriksen, M., Dahl, A. A., Martinsen, E. W., Klungsoyr, O., Faraone, S. V., & Peleikis, D. E. (2014). Childhood and persistent ADHD symptoms associated with educational failure and long-term occupational disability in adult ADHD. Attention Deficit Hyperactivity Disorders, 6(2), 87–99. https://doi.org/10.1007/s12402-014-0126-1 Gnanavel, S., Sharma, P., Kaushal, P., & Hussain, S. (2019). Attention deficit hyperactivity disorder and comorbidity: A review of literature. World Journal of Clinical Cases, 7(17), 2420–2426. https://doi.org/10.12998/wjcc.v7.i17.2420 Goulter, N., Hur, Y. S., Jones, D. E., Godwin, J., McMahon, R. J., Dodge, K. A., Lansford, J. E., Lochman, J. E., Bates, J. E., Pettit, G. S., & Crowley, D. M. (2024). Kindergarten conduct problems are associated with monetized outcomes in adolescence and adulthood. Journal of Child Psychology and Psychiatry, 65, 328–339. https://doi.org/10.1111/jcpp.13837 Jewell, C., Wittkowski, A., & Pratt, D. (2022). The impact of parent-only interventions on child anxiety: A systematic review and meta-analysis. Journal of Affective Disorders, 309, 324–349. https://doi.org/10.1016/j.jad.2022.04.082 Rivenbark, J. G., Odgers, C. L., Caspi, A., Harrington, H., Hogan, S., Houts, R. M., Poulton, R., & Moffitt, T. E. (2018). The high societal costs of childhood conduct problems: Evidence from administrative records up to age 38 in a longitudinal birth cohort. Journal of Child Psychology and Psychiatry, 59(6), 703–710. https://doi.org/10.1111/jcpp.12850 National Institute for Health and Care Excellence (NICE). (2013). Antisocial behaviour and conduct disorders in children and young people: Recognition and management. Retrieved January 24, 2025, from https://www.nice.org.uk/guidance/cg158/chapter/recommendations Pirkis, J., Ftanou, M., Williamson, M., Machlin, A., Warr, D., Christo, J., Spittal, M., Bassilios, B., & Harris, M. (2010). Evaluation of the Better Access to Psychiatrists, Psychologists and GPs through the Medicare Benefits Schedule Initiative: Component A: A study of consumers and their outcomes: Final report. University of Melbourne. Pollard, J., Reardon, T., Williams, C., Creswell, C., Ford, T., Gray, A., Roberts, N., Stallard, P., Ukoumunne, O. C., & Violato, M. (2023). The multifaceted consequences and economic costs of child anxiety problems: A systematic review and meta-analysis. JCPP Advances, 3(3), e12149. https://doi.org/10.1002/jcv2.12149 YoungMinds. (2020). Parent and carer participation: A toolkit for mental health services. YoungMinds. https://www.youngminds.org.uk/media/h4uexcw1/ym-parent-carer-toolkit-2020.pdf