Dr. Shari McDaid:

I thank the committee for inviting Mental Health Reform to appear here this afternoon. I particularly thank Senator Joan Freeman, rapporteur of the committee, for shining a spotlight on this significant matter and facilitating this space for child and youth mental health to be discussed within the Seanad. I also thank our colleague organisations who have appeared before the committee, and to reflect on the consistency that is being provided. Many of the organisations here are members of Mental Health Reform and members of the Children's Mental Health Coalition, which we have provided the secretariat for a number of years. There is a lesson in the consistency of what is being said about what could help. It is not a matter of figuring out what we need to do. It is much more a matter of implementing what we know needs to be done.

Mental Health Reform is the national coalition of mental health in Ireland, promoting improvement to health services and implementation of our national mental health policy, A Vision for Change. We have 59 member organisations, many of which operate in the area of child and adolescent mental health, including Jigsaw, Spun Out, ISPCC, the Children's Rights Alliance, the Irish Association of Infant Mental Health and the Union of Students of Ireland. We have shared and provided the secretariat of the Children's Mental Health Coalition. The primary object of that coalition has been to advocate for improvements in child and adolescent mental health services. This has been underpinned by evidence-based research and guidance produced by the coalition, including its most recent report on meeting the mental health support needs of children and young people in Ireland. We would be happy to provide copies of same to the members of the committee.

We welcome the opportunity to discuss the experiences of children and young people and their families in accessing mental health services in this country. We understand that this consultation is taking place during a period when the Mental Health (Amendment) Bill 2016 is moving through the legislative process. This legislation is designed to end the practice of admitting children to adult psychiatric units except for in exceptional circumstances. We recognise the positive intention of the Bill. Mental Health Reform and the Children's Mental Health Coalition have long called for an end to inappropriate admissions of children to adult wards, in keeping with the UN Convention on the Rights of the Child. Admission of a child to an adult ward can make the in-patient experience much more distressing for the child, as we in Mental Health Reform have heard when young people speak to us about that experience. It does not always provide a safe environment and it does not provide a place that supports the child's recovery. We see ending inappropriate admissions of children to adult wards as an urgent priority and an urgent policy objective. Fundamentally, what is required in order to make that right realised is the immediate implementation of the resources necessary to provide the community-based and age-appropriate acute care that would reduce child and adolescent admissions to acute adult wards. We have consistently called on the Government to develop early intervention and community-based mental health services and supports for children and young people, and I will address what a community based mental health service would look like.

We have heard about the need for early intervention. In the area of perinatal and infant mental health there is widespread consensus that the perinatal and early years period provides a unique opportunity for the prevention of mental health difficulties, in addition to the fact that early intervention for mental health challenges can happen with mothers and infants at that time. However, perinatal mental health supports remain significantly underdeveloped, and early years infant mental health has received little recognition and little priority in the Irish context. Early intervention needs to include a response which places the emotional health and well-being of mothers, infants and families on a par with that of their physical health. The absence of specific policy and supporting service provision to address such needs is a gap of huge significance that must be addressed as a matter of priority. I would agree with the previous speaker that all the evidence is that when those kind of supports are provided in infancy, huge value of money is achieved, as well as much better outcomes over the lifetime of the child.

In terms of mental health in primary care, Mental Health Reform has recently welcomed the sanctioning of the recruitment of 114 assistant psychologist for primary care teams across Ireland. We hope that those assistant psychologists will be recruited as a matter of urgency. The addition of these posts is a positive step towards providing earlier access to mental health support for children and adolescents. However, they will not be sufficient on their own, and it is imperative that such efforts by Government continue to increase capacity in mental health in primary care. Mental Health Reform and the Children's Mental Health Coalition have consistently advocated for enhanced capacity within the primary care sector to provide comprehensive mental health services. To date there have been significant shortfalls in this area. We specifically advocate for increasing the availability of mental health expertise through dedicated mental health workers across all primary care teams, who would enable early intervention, and significantly, we believe, reduce the number of referrals required to child and adolescent mental health services.

We would like to highlight the need for access to specialist mental health services, and our colleagues in Inclusion Ireland have identified one group of young people and children who need specialist mental health services. It is ironic that the services for the children who are most vulnerable because of having dual or co-occurring conditions, such as mental health and intellectual disability, children and young people with dual diagnosis of mental health and addiction or children with other disabilities, for example, from the deaf communities, have received the least development since publication of A Vision for Change. There are ongoing difficulties in accessing child and adolescent mental health services for these children despite a decrease in the CAMHS waiting list. We heard earlier today that, as of December 2016, approximately 2,419 children and adolescents were waiting to be seen by CAMHS, of whom almost half were waiting more than three months for a first appointment and almost 10% of whom were waiting more than 12 months. Between the end of 2015 and 2016, the number of children waiting more than a year had increased by almost 20%.

The difficulties for children and their families in accessing appropriate mental health care - the lack of community-based mental services - is reflected in the high numbers of child admissions to adult inpatient units. As of December 2016, almost 20% of children were still being admitted to acute adult services and the Ombudsman for Children has reported that a number of complaints submitted to his office were about children, particularly children at risk of suicide or self-harm, being inappropriately placed in adult inpatient facilities and that these situations appear to be due to a lack of suitable emergency placements.

We have previously identified the lack of 24-7 crisis services for children and young people as being particularly problematic and this is reiterated by UNICEF's report card on child well-being, which shows that Ireland has the fourth highest teen suicide rate in the OECD region. In addition, as figures were highlighted earlier, the rates of self-harm show that such practices are highest among young women aged 15 to 19 and among young men aged 20 to 24. Some experts in the area of child and adolescent mental health have pointed out that it is at the very point at which children and adolescents are most at risk that the least amount of provision is available and it is ironic that the point at which we could have the most impact on young people's lives and have the best outcomes for the future is where the least provision is available. We believe that 24-7 crisis mental health services should be made available to children and young people in every community in Ireland as a matter of priority.

We have also identified the challenge of providing high-quality accessible mental health services as a result of the difficulties with inter-agency collaboration. The Children's Mental Health Coalition conducted a small survey of two areas in Ireland and found that a bewildering number of agencies were involved in supporting the mental health of children. Therefore, we advocate for a national level approach to inter-agency collaboration to ensure there is a smooth process through all the myriad of agencies for the child and the family to be able to get the services they need.

Other shortfalls we would like to highlight include the lack of a common assessment framework for children in the care and youth justice systems. Such a common assessment framework would ensure that the mental health needs of children in the care and youth justice system were considered holistically as part of the wider supports that are provided for them.

We would also reiterate here the need for an advocacy service for children and families who are engaged with mental health services or who are trying to get mental health services. In the absence of an advocacy service that is tailored to children who are using mental health services and their family members, there is growing concern that this group of children and young people are not being heard in terms of their experience of the services, their will and preferences with regard to how mental health services are provided.

We agree that the lack of staffing in CAMHS must be contributing to many of the shortfalls in service delivery. As of the end of December 2015, there was just 51.6% of the staffing level recommended in A Vision for Change across child and adolescent mental health services and despite concerted efforts by the HSE to improve staffing levels in CAMHS in the past couple of years, there has been very little increase in the staffing available. In essence, child and adolescent mental health services are in crisis across the country in terms of being able to get adequate skilled staff. For example, there is no consultant psychiatrist in post in Cork at present, which is putting extreme pressure on existing services, in particular, in providing crisis support into the emergency departments in Cork.

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. The increasing demand on an already overstretched child and adolescent mental health system undoubtedly will continue in the context of an increasing demand from children and their parents for better supports.

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

We are happy to answer questions.