Mr. Gareth Noble:

I thank Senator Freeman for the invitation to address the committee as part of this ground-breaking initiative in identifying the challenges children and young people confront in accessing appropriate mental health services.

This day and period ahead is long overdue for families throughout our great Republic who have been affected by the challenges arising from a mental health crisis within their homes and communities. It has been too late for some but is an opportunity to assist so many others.

I address the committee as a solicitor who acts for children and young people and their families in a range of welfare cases. Through my work over ten years, I have witnessed at first hand the challenges families face in accessing mental health services at times of trauma and crisis. I have spoken to and advocated for many children directly who struggle with their mental health and well-being. I have collaborated closely with front-line staff employed by the HSE, Tusla and other public bodies which recognise and share many of the frustrations families and young people experience. Those committed people working within depleted services and dwindling budgets are in many individual cases heroic in their endeavours but they are also burnt out and the recruitment and retention of such talented committed and caring people is now also at crisis point. There has developed a culture within many parts of our mental health services of fire-fighting, but the fire has started by the time most children are seen and its often beyond the point of recovery by the time the problem has been identified and addressed.

The seminal document in reforming Ireland's mental health strategy published in 2006, the year I qualified as a solicitor, was entitled A Vision for Change. The strategy aimed to modernise our system and ensure better co-ordination and improved practices. As I reported to the Oireachtas Joint Committee on Children and Youth Affairs last week, I regret to say that this vision has not progressed at a rate that meets the demands and challenges placed upon services. The recent suspension of 11 beds from Linn Dara in west Dublin for inpatient care for children was accompanied almost with a resigned and collective shrug of the shoulder rather than with the urgent intervention at the highest levels that was required.

The Ireland of 2017 is one where 2,419 children and their families are currently awaiting a CAMHS appointment. Some 218 of these are waiting more than a year and 762 more than six months. This is a country where 15 of our counties remain without an out-of-hours and a weekend crisis service. Those of us who do provide a 24 hour service know only too well that most incidents occur after 5 p.m. and during weekend periods.

This is a modern progressive western democracy and yet 67 children were admitted to inappropriate adult wards in 2016. I strongly welcome and support the publication of a Bill by Senator Freeman in December 2016 to provide that no child under the age of 18 years is placed in an adult psychiatric unit. As far back as November 2006, the Mental Health Commission issued a code of practice relating to such admissions. This code was intended as a transitionary model of care pending the ending of such a practice by 2011. The year 2011 came and went, as did the following years and now we are in 2017. It is my view that such a continuing practice is a potential breach of many legal rights instruments, including Article 24 of the UN Convention on the Rights of the Child, and indeed our own Constitution, in respect personal rights guaranteed by Article 40.3. Article 43 and most recently by Article 42A. At an European level, the practice of detaining children in certain adult wards could well constitute a breach of Article 3 of the European Convention of Human Rights, whichinter aliaprohibits degrading treatment. Article 8 of the same convention promotes and provides a right to respect of one's private and family life. There are serious legal issues which arise out of this continuing practice. Our nearest neighbour in the United Kingdom has moved beyond us in providing a legislative basis for discontinuing such a model in line with best practice.

Adult psychiatric facilities are challenging and difficult environments, populated by very vulnerable individuals who often present with a range of mental health concerns. Some exhibit huge levels of distress and on occasion can be physically threatening. Such situations are difficult to manage and deal with for all concerned. Yet we are demanding that dozens of our most vulnerable teenagers each year cope with these placements and recover in them. I have seen many examples of young people returning home, having been exposed to such environments and being lost for ever. Effective recovery can only happen within the confines of a dedicated, safe and appropriate facility. The refrain from some who should and do know better is this: some bed is better than no bed. Are we so lacking in ambition, resolve and a rights-based approach that this is the best we can do?

I have spoken to many families and young people who talk about the sense of loneliness, rejection, fear and isolation in adult psychiatric facilities, often far from home. In contrast I visited adolescent facilities, including the service provided by Mr. Gilligan. In those contexts and in those care situations I have seen at first hand how young people supporting one another do so within a context where their care is managed by appropriate specialists in adolescent care, and where that sense of fear and isolation can be massively mitigated. We have a moral, political and legal duty to these children and this Bill is a crucial first step in achieving outcomes for children in situations of crisis.

This Bill may ultimately involve some timetabling and a need for staggered commencement orders to ensure staffing levels, protocols and facilities are available. Those timeframes need to be identified and they need to be short. They need to be driven by the same thirst for delivery as is present on the ground and in what this Bill sets out to achieve. Let the passage of the Bill proceed on those child-centred values, rather than on the pre-manufactured and restrictive concepts of ifs, buts, savers, exceptions, derogations etc.

Aside from the scandalously long waiting times for appointments for CAMHS there is also the lack of further CAMHS operating reports since 2014. This is a cause of massive concern and is despite the fact that annual reports were envisaged by A Vision for Change. Many CAMHS teams are excluding many young people from their services because they do not fit within the increasingly strict confines of their criteria and we find an increasing lack of flexibility in relation to same. Children with a dual diagnosis who experience mental health concerns but are also on the autism spectrum, for example, are not being provided for in a manner that has due regard to their needs. This non-inclusive approach to children with autism who experience mental health difficulties is something to which meaningful recognition must be given in any proposed national autism strategy.

Children between the ages of 16 and 18 years are often referred to as being in the Cinderella age in accessing mental health services, too old to avail of adolescent care and too young many other services. While children at the age of 16 years can often provide consent for general health services and procedures, it remains a grey area in respect of psychiatric care and interventions. Paediatric emergency departments are often accessible to children under 16 years, therefore the emergency presentation of children between 16 and 18 years occurs at adult hospitals, most if not all of which have woefully inadequate child psychiatry cover. Officially CAMHS refers to services being provided for young people until they reach adulthood. On the ground, however, referrals being accepted for children beyond their 16th birthday are virtually non-existent. Given that in 2010, 16 and 17 year olds constituted 68% of inpatient hospital admissions, the provision of care for this age group remains woefully inadequate. A full review of CAMHS services and priorities for this particularly vulnerable age group is required as a matter of priority.

The Government must lead in clearly identifying the terms of reference and areas of responsibility for each part of our mental health service, resource it and demand reporting mechanisms and protocols for accountable delivery. It can no longer be left to the HSE to dictate the rules of engagement. Such an approach since 2006 has demonstrably failed our children in crisis. Notwithstanding these many great instances of hardship, doors being closed, never-ending battles and burgeoning waiting lists, I have great hope and reason to be optimistic that the tide is turning in our endeavours to deliver for children. I am genuinely excited by the efforts by so many that are ongoing and are leading to real change. In 2012 I was asked by a small group of parents from across Ireland who had come together through the medium of Facebook to provide legal advice, advocacy and support. The DCA Warriors group was created as an online forum to lobby for change on behalf of parents and families who had children with additional needs, a disability or a specific life challenge. When I was approached by that group in March 2012, they numbered just over 200. As of yesterday evening, the number has grown to 14,152 and they are growing. Many of their stories relay shocking instances of State neglect in assisting parents as carers. I am seeing increasing numbers of cases where the mental health needs of children are deteriorating sharply and a rapid response to those presentations from State supports are simply not there. Those brave warriors are not going anywhere. Their bravery, resilience and fortitude should inspire us all. I could spend the rest of today highlighting examples of their successes in reversing adverse decisions made in respect of their children.

I met a grandmother from the south of the country recently. She took her hands in mine and she very quietly told me that the greatest challenge her family faces is ensuring that their very vulnerable teenage family member makes it through each day alive. When we as a country strive to assist those who get up early in the morning, let us also strive to ensure this approach includes those who do not get to bed at all at times of crisis. I refer to those who seek to secure the life and welfare of their children without appropriate support, respite or service provision, those families who remain on high alert and maintain a vigil, sometimes on shifts with other family members, sometimes carrying that burden alone to carry on fighting for their loved one, caring for them and willing they survive, never mind thrive. It is an intolerable position for so many. It is so far removed from child-centred approaches to policy making and policy delivery that it beggars belief.

This committee has demonstrated in its support for the public consultation process a proactive approach to leading a conversation on the specific requirements of a modern mental health service from the perspective of a child. Statutory obligations regarding children refer to the rights and needs of the child being of paramount consideration. Using this as our guiding principle, we need to develop policies and services that truly do put children first.

The Mental Health (Amendment) Bill 2016 is a vital first step in progressing the rights of children. It requires cross-party, cross-departmental collaboration in ensuring its safe passage and subsequent implementation into law. Families and children across Ireland will look back on this period with great regard and great pride if we all work together to prioritise children's mental health and if we walk that walk together.