Ms Kate Mitchell:

I thank the joint committee for inviting representatives of the Children’s Mental Health Coalition to appear before it. We circulated copies of our report, Meeting the Mental Health Support Needs of Children and Adolescents: A Children’s Mental Health Coalition View, to members in advance. I am co-ordinator of the coalition and policy and research officer at Mental Health Reform which provides the secretariat for the coalition. I am accompanied by Ms Lara Kelly, our communications and campaigns officer. The coalition consists of more than 50 member organisations and concerned individuals from a range of backgrounds and sectors, including children’s rights, human rights, education and mental health services. Its key objective is to advocate for improvements in child and adolescent mental health services and supports.

The coalition acknowledges that there have been positive developments in child and adolescent mental health services and supports in recent years. Such developments include the expansion of Jigsaw direct access supports; an increase of 153 clinical staff in child and adolescent mental health services, CAMHS, between 2008 and 2015, from 352 to 505; and a decrease in the number on waiting lists from 3,117 in 2008 to 2,240 in August 2015, despite increases in the level of service demand. The number of children and adolescents waiting more than 12 months to be seen by CAMHS has also decreased, from 897 in 2008 to 241 in August 2015.

Additional developments include the publication of the standard operating procedures, both inpatient and community, for CAMHS, the roll-out of the yourmentalhealth.ie campaign, publication of the national guidelines on mental health promotion and well-being for both primary and post-primary schools and the establishment of the ACT service in Oberstown national children’s detention facility.

Despite recent Government efforts, the reality is that significant challenges continue to exist for a wide range of families and children who require mental health supports across the country. These challenges concern prevention, access to supports, effective co-ordination between agencies and ensuring the voice of the child is heard. In terms of early intervention, it is now widely accepted that the foundation for healthy, psychological, social and emotional health across the life span is developed in infancy and early childhood. Gaps that exist in the area of infant mental health include the absence of clinical psychology and-or parent-child psychotherapists in maternity hospitals, a lack of training on infant mental health among staff working in maternity hospitals and the absence of child specific public health nursing posts. These gaps in services should be addressed through allocated funding. Furthermore, while the publication of the national guidelines on mental health promotion and well-being is positive, there is a need for a clear implementation plan and effective resourcing to ensure the guidelines translate into action. Training and support for schools is needed in order to implement a whole-school approach.

Access to mental health services and supports is often difficult for children and families. The coalition attributes such difficulties to a number of factors, including inadequate capacity in primary care, restrictive referral criteria for access to community-based CAMHS, a lack of specialist services, the low number of child and adolescent inpatient beds, lengthy waiting periods, a lack of information about what to do during the waiting period as well as difficulties in navigating the child and adolescent mental health system. The HSE has reported that between January and August 2015, 29% of all child and adolescent admissions to acute units were to adult inpatients wards. This is only a marginal decrease, approximately 5%, on the proportion of child admissions to adult inpatient units when A Vision for Change was first published in 2006. It is well evidenced that adult inpatient units are not appropriate, safe environments for children and adolescents and that care in such settings may be ineffective.

The Ombudsman for Children recently reported that a number of complaints submitted to his office were about children being inappropriately placed in adult inpatient facilities, in particular children at risk of suicide or self-harm, and that these situations appeared to be due to a lack of suitable emergency placements. The Children’s Mental Health Coalition has also identified that a key challenge to providing high quality, accessible mental health services and supports is inadequate inter-agency communication and collaboration. A small survey conducted by the coalition in two areas identified 24 different agencies involved in supporting the mental health of children. Co-ordination is a challenge between CAMHS and adult mental health services, mental health and primary care services, mental health services and Tusla, and between schools and mental health services.

Particular groups of children, such as children in the care of the State, children with a co-morbid diagnosis of mental health and intellectual disability, homeless children and children and adolescents with a dual diagnosis of mental health difficulties and substance misuse have seen little development of services to meet their needs. The gaps in child and adolescent mental health services and supports extend further, including a lack of capacity at primary care level to appropriately detect, refer and care for children with mental health difficulties and the absence of a national counselling service for children.

The Children’s Mental Health Coalition believes that measures can be taken to improve mental health supports for children and adolescents. The coalition is of the view that in order to improve access to child and adolescent mental health services a national-level approach to inter-agency collaboration is required between Government Departments and agencies. This is particularly relevant for CAMHS and Tusla, as reflected in the report of the task force on the Child and Family Support Agency.

Better systems of co-ordination are also needed between schools and primary care and specialist mental health services. The coalition has consistently heard of difficulties that teachers face when they are concerned about the mental health of one of their students in terms of getting advice from CAMHS, referral into services and follow-up after the student has received mental health services. Specialist services for at-risk groups of children and adolescents, including those groups just mentioned, must be developed as a matter of priority. Given that figures for suicide in Ireland among young males aged 15 to 19 years are particularly high by international comparisons and that rates of self-harm in Ireland are highest among the younger population, it is imperative that appropriate crisis services are made available throughout the country for children and adolescents. The coalition has previously called on the HSE to ensure that all community child and adolescent mental health services provide a specialist out of hours and crisis service that is well publicised, fully staffed and resourced to provide a rapid response.

A Vision for Change recommends that children and their families are provided with appropriate opportunities to give feedback on their experiences and to influence developments within the mental health services. At present, guidance for CAMHS on enabling children to participate in decisions regarding their mental health has been included in the recently published standard operating procedures. In keeping with A Vision for Change and with the UN Convention on the Rights of the Child, such guidance must be implemented as a matter of priority across all services

The absence of a national advocacy service for children and adolescents accessing mental health services is also of fundamental concern. Advocacy supports must be made available to all such children as a matter of priority to ensure that some of our most vulnerable children can have their voice heard. There is no doubt that the lack of staffing in CAMHS has contributed to many of the shortfalls in service provision. Information provided by the HSE to the Children’s Mental Health Coalition last week confirms that the number of clinical staff in post in community child and adolescent mental health services is 505. This represents only 50% of the staffing level recommended in A Vision for Change. It also represents a decrease of 16 clinical staff in community CAMHS since December 2014.

In May 2015, the CAMHS in Waterford stopped taking referrals and appointments due to the absence of a consultant psychiatrist and difficulties in recruiting a consultant to the vacant post. Despite efforts by the HSE to recruit staff to CAMHS, this is proving largely unsuccessful to date. Additional measures must be put in place as a matter of urgency to ensure that child and adolescent mental health services are adequately staffed and to look at creative ways of using existing staff to enable prompt access to CAMHS.

Despite positive developments, there are still huge challenges to bringing about the type of mental health care for children and adolescents that fulfils national policy and international human rights obligations. These challenges reflect the continued vulnerability of child and adolescent mental health services across the country and the need to have sustained political will in order to improve the mental health outcomes of Ireland’s children and young people.