Building the evidence for better responses to acute mental health distress among children and adolescents

All children and adolescents deserve access to timely and appropriate mental health support. Yet finding the right support quickly can be difficult, particularly during periods of acute distress. For many young people and their families, emergency departments and inpatient settings can appear to be the only pathway to support when they need it most. 

Demand for child and adolescent mental health services in NSW and across Australia has increased substantially over the past decade. More children and adolescents are seeking support for mental health concerns, and many have complex needs that require coordinated responses across service providers, settings and support systems. This growing demand has placed further pressure on emergency departments and the wider health system. 

The NSW Ministry of Health established the Safeguards Child and Adolescent Mental Health Response Teams (Safeguards) program to address these challenges. Safeguards aims to strengthen responses to children and adolescents experiencing acute mental health distress by improving access to rapid assessment and evidence-based brief interventions. The program helps families navigate care and strengthen links with ongoing community support. Through this support, Safeguards aims to help children, adolescents and their families feel more stable in times of crises and build skills and confidence to understand and manage their mental health. 

The NSW Ministry of Health engaged Nous to evaluate Safeguards’ implementation, outcomes and economic impact as the program rolled out across NSW. The evaluation needed to generate practical insights to guide ongoing implementation, support improvement across sites and help decision-makers understand how to maximise the program’s effectiveness, efficiency and sustainability.

This was a complex evaluation task. Safeguards operates across a large and devolved health system, where local contexts, referral pathways, workforce arrangements and service partnerships vary across sites. Given the program supports young people and families experiencing acute mental health distress, evaluation engagement also needed to be trauma-informed, culturally responsive, and ethically robust. At the same time, the evaluation needed to assess state-wide outcomes, including mental health and wellbeing, emergency department presentations and hospital admissions across the Safeguards cohort.

“It’s an exciting opportunity to evaluate a program during implementation,” says Nous Director Georgia Stern. “There was strong buy-in from the Ministry and NSW Health staff to understand what was working, where there were opportunities to strengthen the model, and to use those insights as the program evolved.” 

“That meant the evaluation wasn’t just about whether Safeguards was working, but understanding how and why it was working, and using that evidence to support continuous improvement.”

We worked with the Mental Health Branch to design an evaluation framework covering process, outcomes and economic components. We also refined the theory of change and program logic so the evaluation aligned with Safeguards’ objectives and could examine how program activities and outputs contributed to outcomes.

“A robust program logic with clear mechanisms of change gave us a strong foundation for the evaluation,” says Nous Manager Hannah Dews. “This allowed us to test not only whether Safeguards was achieving its intended outcomes for consumers, families, staff and the system, but how the different components of the Safeguards model of care were influencing experiences and outcomes.”

“Critically, we were able to explore where and how local adaptation was strengthening delivery and progressively identify learnings to support continuous improvement and ensure Safeguards was working as intended.”

Governance helped connect the evaluation with both the program’s delivery and the experiences of young people and families. We supported the establishment of an Aboriginal Reference Group and Evaluation Reference Group, and maintained engagement with the Safeguards Advisory Committee and Safeguards Implementation Committee. We also engaged with the NSW Health Mental Health Youth Advisory Group. This helped ensure the evaluation reflected lived experience and was technically sound, culturally informed and grounded in the realities of the mental health system.

Ethics and data governance were critical given the sensitivity of this work. Nous sought approvals from the Sydney Children’s Hospitals Network Human Research Ethics Committee, the NSW Population and Health Services Research Ethics Committee, the Centre for Health Record Linkage and the Aboriginal Health and Medical Research Council Ethics Committee. These approvals enabled linked data analysis, consultation with consumers and reporting of outcomes by Aboriginality in line with appropriate ethical and cultural standards.

The evaluation brought together three components:

• The process evaluation examined how Safeguards was implemented and identified common and site-specific barriers and enablers. 
• The outcomes evaluation assessed short- to medium-term impacts for young people and their families, including mental health and wellbeing, access to care and service experience across sites and consumer cohorts. 
• The economic evaluation assessed value for money by analysing cost-benefit ratios and avoided system costs, including reduced emergency department presentations and hospital admissions.

“What made this evaluation powerful was bringing together rigorous system-level evidence with a deep understanding of how the program was working on the ground,” says Stern. “The data could tell us what was changing, while the experiences of young people, families, staff and partners helped us understand why, and what that meant for strengthening the program.”

The evidence base included linked health data, program activity and funding data, surveys of consumers, carers, staff and referrers and partners, and visits to six sites across NSW. During those visits, the evaluation team consulted 42 consumers and carers, 65 referrers and partners, and 45 staff. These perspectives helped the evaluation examine how the program was experienced in different contexts. 

“Bringing together the perspectives of young people, families, staff and service partners gave us a much richer understanding of how Safeguards worked in practice,” says Dews. “Each group saw the service through a different lens, but their experiences consistently showed how a timely, positive first interaction can build trust, foster a sense of safety in times of need, create confidence in the care being offered and shape the experiences of young people and their families in the mental health system.”

The evaluation demonstrated that Safeguards is improving access to timely, evidence-based and trauma-informed mental health care for children and adolescents experiencing acute mental health distress. It also showed the program was contributing to improved mental health and wellbeing outcomes for young people and their families, while also reducing emergency department presentations and hospital admissions.

Linked health data allowed us to compare Safeguards consumers with a counterfactual cohort. This provided a basis for assessing the program’s cost-benefit and its effect on the broader health system, giving decision-makers stronger evidence about the value of the model.

The evaluation is now informing service delivery and investment decisions across NSW. It will also contribute to the evidence base for rapid, evidence-based, brief interventions and transitions to appropriate long-term support for children and adolescents experiencing acute mental health distress. For the NSW Ministry of Health, the evaluation provided a clearer view of how Safeguards was operating, what it was achieving and how it could continue to evolve. For families and young people, the ultimate value lies in a system better equipped to respond early, safely and effectively when mental health needs become urgent.

“The value of evaluations of a new program is the early indicators and evidence it gives decision-makers,” says Stern. “By understanding what works, how it works and where it can be strengthened, we can support the continued evolution of services that respond earlier and more effectively to young people and their families.”