Dr. Maeve Doyle:

I am very grateful for the opportunity to appear before the Seanad Public Consultation Committee. I am here assisting Dr. John Hillery, president of the College of Psychiatry of Ireland, in my role as an executive member of the child and adolescent faculty of the college. As Dr. Hillery stated, I am a former chair of the child and adolescent faculty. I also served on the Mental Health Commission for a five-year period finishing in spring of 2017. I am currently the secretary of the board of the European Society of Child and Adolescent Psychiatry and, perhaps more important, I have been a practising child psychiatrist for the past 17 years in a rural catchment area.

Child psychiatry is a very young speciality in this country, with the first child psychiatry service established in 1963. I echo the concerns already outlined regarding the percentage of the health budget designated for mental health.

A 6% spend on mental health as a proportion of the total health budget is scandalously low compared with other countries. For example, in the UK 12% of the budget is allocated to mental health services. In addition, A Vision for Change, the blueprint document published in 2006 in regard to the provision and development of all mental health services, advocated that 25% of the mental health budget should be designated to CAMHS. As stated earlier, 25% of the population are under the age of 18. The chronic underfunding and under-recognition of the importance of development of CAMHS is critical.

The most recent census of the Irish population indicated that there are 4.7 million people in this country, one quarter of whom are under the age of 18. It should be borne in mind that the recommendation of A Vision for Change, which is more than ten years old, was based on a population of 3.6 million. Briefly, what was advocated in A Vision for Change was that there would be 99 multidisciplinary CAMHS teams, headed by a consultant child and adolescent psychiatrist. Each team would be allocated 11 clinical whole-time equivalents for a population of 50,000. Currently, there are only 64 multidisciplinary teams for CAMHS throughout Ireland and, on average, only 50% of the multidisciplinary staff are in place.

In regard to the provision of appropriate child and adolescent inpatient psychiatric beds, the working groups emanating from A Vision for Change advocated between 106 and 116 beds for the population of 3.6 million. Although there has been progress in this area, it is insufficient. Currently, there is designation of 76 beds nationally but as of today only 48 of these are operational. The public inpatient beds are located in Cork, which can currently only operate 12 beds; Merlin Park in Galway, which can only operate 20 beds and in Linn Dara, Cherry Orchard, which has two units of 11 beds each, one of which, unfortunately, from 1 June had to be closed due to lack of staffing, meaning its capacity is reduced to 11 beds. There is another adolescent unit, St. Joseph’s Fairview, which is currently operating at a capacity of six beds rather than 12 due to a consultant departing and another consultant job-sharing. I refer to both St. Joseph's Fairview and Linn Dara and therefore, my ability to secure a bed for a person over or under 16 years of age has reduced considerably in the last couple of months.

It is obvious that the capacity of the system to provide assessment, diagnosis and treatment and to manage the risk of severely ill, mentally unwell young people is not adequate. It appears as though many people are not aware that mental health problems can and do present in our population of children and adolescents aged under 18. The types of problems seen by the child and adolescent mental health service, CAMHS, include attention deficit hyperactivity disorder, ADHD, anxiety disorders such as obsessive compulsive disorder, school refusal, generalised anxiety disorder, mood disorders such as depression, anxiety, bipolar disorders, psychotic disorders such as schizophrenia, and eating disorders. The consultant child and adolescent psychiatrist is a professional who has completed medical training and has gone on to specialise in psychiatry and further sub-specialise in child psychiatry. He or she has the knowledge and expertise by virtue of their knowledge of physical conditions in childhood, developmental issues in children, psychiatric disorders in children and adolescents and psycho-pharmacology, as well as the clinical risk assessment, to be the clinical heads and leads of multidisciplinary teams. The complexity of the nature of some of the presentations to CAMHS, together with the risk inherent with many of these conditions, warrants leadership by a consultant child and adolescent psychiatrist.

The college is aware that there should not be a reliance on the admission of children to adult psychiatric units. A number of points need to made in this regard. As outlined by many speakers, there is an inadequate number of child and adolescent beds for the population in need of them. This means that in some cases a child or adolescent will have to be admitted to an adult unit because of the severity of his or her mental condition and the risk he or she poses. In general, these admissions are for short periods, with the aim of transferring to an appropriate adolescent unit. In some cases, capacity will delay this transfer. In other cases, particularly in the case of older adolescents, parents will want them treated in their geographical locality. I do not believe that people appreciate that often children and adolescents have to travel, on average, 100 miles to Dublin and back, to receive inpatient treatment whereas adults have a service in their local areas. In some cases, for example, a 17.5 year old with acute paranoid schizophrenia and co-morbid substance abuse who believes all of the staff on a unit are trying to kill him or her, the staff of an acute adult unit may be far more appropriately trained to manage this young man or woman's complex needs and the risk that he or she poses to himself or herself and others. In addition, he or she is likely to transition to adult services because of the nature of his or her psychopathology.

In regard to the issue of waiting lists for CAMHS, it would appear that the development of a single track of referrals needs to be dealt with as a matter of urgency. Many children and adolescents are placed on waiting lists for CAMHS inappropriately due to the lack of development of primary care services and disability services. For example, in my own area the number of primary care psychologists has declined from four when I started up my practice 17 years ago to only one. Although it is outlined in their brief that they can deal with children with mild anxiety by providing a brief number of sessions, by virtue of the fact that the waiting list to see a primary care psychology is 18 months, the problems of these children and adolescents will have escalated to the extent that they then present with severe anxiety problems that need to be addressed by CAMHS. A similar situation pertains in many areas around the county with regard to services for autism and autistic spectrum disorder. In some cases, including in my area, there are waiting lists of up to four years for this population. Many of these children are complex and will also have co-morbid psychiatric conditions and so they will be referred to CAMHS while their underlying condition, the autism, or ASD, will not be assessed or addressed.

A Vision for Change outlined a tiered approach to the complex needs of children, with primary care practitioners, such as GPs and public health nurses being the first port of call for identifying psychological difficulties in children. Referral should then be to well-resourced primary care psychology services, which unfortunately have been seriously under-resourced. If intervention occurred at this juncture, some patients would be referred on to the more specialist tertiary services of CAMHS but others would remain in primary care. Another major deficit in service provision is for those children who present with emotional and behavioural difficulties due to learning problems. The roll-out of the National Educational Psychological Service, NEPS, has been disappointing in terms of people being inappropriately referred to CAMHS.

I cannot emphasise enough the issue of recruitment and retention in CAMHS that already has been addressed. A number of factors contribute to the ongoing crisis in this area, salaries being one, but as part of their contract, consultant psychiatrists are meant to assist with the development and progression of their services.

In many areas governance structures do not permit the voice of child psychiatry to be heard. There is a lack of understanding of the clinical expertise, professionalism and training necessary to be a child psychiatrist, as well as a belief others can hold the risk and have this expertise. The lack of respect for the professionalism and expertise of child psychiatrists has led to a decrease in interest in this career. The lack of visibility of child and adolescent psychiatrists is clearly demonstrated in the disappointing fact that none was present on the expert group in the review of the Mental Health Act, despite many representations being made by the College of Psychiatrists. The college has advocated for distinct and separate mental health legislation for children, compliant with the UN Convention on the Rights of Persons with Disabilities, the Assisted Decision-Making (Capacity) Act 2015, the Mental Health Act 2001 and the Child Care Acts.

It is also disappointing that the new Mental Health Commission has no member from the profession of child psychiatry. Given that children and adolescents constitute almost one quarter of the population, one wonders if it is reflective of a lack of concern for young people. Once again, nominations from the College of Psychiatrists were sought and the president of the college wrote expressing concern that no child psychiatrist was a member of the Mental Health Commission. The body is charged with inspecting, visiting and addressing quality issues in approved mental health centres and community services.

I thank the representatives of the Seanad Public Consultation Committee for providing the College of Psychiatry with the opportunity to address members on the current state of child and adolescent psychiatry services.