Ms Sonia Magaharan:

Good afternoon Chairperson and members of the committee. I thank the committee for the invitation to attend this meeting. I work as a clinical nurse specialist in the north Cork child and adolescent mental health services, CAMHS, area. For anyone who does not know that catchment area, it includes from Charleville at the border with Limerick to Mitchelstown at the border with Tipperary to Millstreet at the border with Kerry to our border with Waterford.I have been working in the field of child and adolescent mental health for the past 34 years. During that time I have worked 18 years in the United Kingdom, two years in Australia and the past 14 years in Ireland. During that time I worked within three inpatient adolescent units and in five CAMHS teams in Ireland, England and Australia. I have been working for the past four years in the north Cork CAMHS area, which has a population of 94,000. I am the chairperson for the Forum in Ireland for Nurses in Child and Adolescent Mental Health, FINCAMH. We are a group of specialist nurses who meet a number of times a year to discuss issues of practice, education and development in child and adolescent mental health. Our mission statement is to promote the knowledge and interests of nurses in child and adolescent mental health services and to increase their profile and self-awareness for the benefit of the nurses and the service users. As a clinical nurse specialist in CAMHS, I work directly with children, young people and their families. I am responsible for managing a caseload. I carry out assessments, provide evidenced-based therapeutic interventions and work as part of a multidisciplinary team.

I came today to talk about the strengths of the team and the gaps that I see in the services. Those are the issues I would like to cover. Regarding the strengths of the CAMHS team in which I work, we work as a multidisciplinary team, which, for anybody who does not know that term, means we have a range of disciplines available to work with our clients. We carry out joint assessments. We provide a range of individual interventions and also group activities such as behavioural management parenting groups, dialectical behaviour therapy, emotional regulation groups, mind and mood groups and adolescent parenting groups. These groups all run on a regular basis throughout the year. As part of our work, we liaise and network with other agencies such as the autistic spectrum disorder, ASD, team; the adult mental health service; Tusla, which is our child protection service; national and secondary schools within and outside the region; educational welfare officers; the National Educational Psychological Service; special educational needs co-ordinators; and the regional and national hospitals.

I will outline some of the challenges we currently face in the CAMHS team in which I work. As I explained, there is the vastness of the geographical area we cover, given the population size. A Vision for Change recommends there should be two CAHMS teams to a population of 100,000. At present we have one incomplete team for a population of 94,000. Children who present with a possible attention deficit hyperactivity disorder, ADHD, are most likely placed on a routine waiting list as older adolescents are often presenting as emergencies with deliberate self-harm, eating disorders and psychosis. As a result of this, children sit on a waiting list which risks their difficulties becoming more entrenched and, therefore, they are not reaching their social, emotional and academic potential. Medical paediatric consultations are frequently required to clarify the physical health status of some children with mental health disorders. Lack of resources and waiting lists in those services have a knock-on effect on our diagnosis, intervention and can also impede discharge. Currently, children who have ADHD and are on medication are unable to be discharged due to a lack of a care pathway that meets their needs appropriately.

We have an absence of a hospital-based liaison team. During the 14.5 years I have been in posts in this area, there has been no liaison team. A Vision for Change recommends one team per catchment area of 300,000. A liaison team would provide cover to paediatric, general and maternity hospitals. National recruitment is unhelpful due to a lack of communication between the local level need and the national level recruitment drive. There is a time lag due to the processing of candidates and a mismatch between candidate's skill and the needs of the team. There is a lack of transparency for candidates about which team they will be placed in. Currently, the recruitment process gives neither the team nor the candidate an opportunity to prior information or knowledge. Currently in the CAMHS team in which I work, we have insufficient physical space for clinical intervention, waiting areas and staff offices. We have four clinical rooms available to a staff team of 10.5 clinicians. Rooms have to be booked or we are unable to see the clients. All staff should have appropriate experience, apart from college placements, prior to commencing in CAMHS, or if staff come in as a basic grade, they need to be under the direction of a senior clinician of their discipline that is based on-site.

Opportunities for training and continuous professional development are inequitable between disciplines placed on teams. Again, these do not always take into account the skills needs of the wider team. Children with both an ADHD and ASD query tend to sit on both a local CAMHS and an ASD team waiting list, despite both conditions being neurodevelopmental conditions. There is a high comorbidity between these conditions. We have no computerised system for collecting data, which prevents us from planning effectively for our client groups. We have insufficient administration support. This leads to clinicians using valuable clinical time to perform administrative duties such as sending out letters, reports and appointments. For the past four years in the north Cork CAMHS area we have had one full-time administrative officer. We were recently granted another administrative officer in November but on a temporary basis.

In terms of possible solutions, there is a need for two complete CAMHS teams to cover the catchment area that could be geographically located to best meet the needs of the client group and make more efficient use of clinician time. Currently, we are travelling across the region to provide satellite clinics. Access to the service by children with ADHD needs to maximised through the provision of a specialist neurodevelopmental team, which could consist of a paediatrician, CAMHS and ASD clinicians, as is the case and is working successfully in the UK. This could incorporate a nurse-led service with an advanced nurse practitioner, which would allow for children with ADHD on medication who have completed all other CAMHS intervention to be discharged to this nurse-led team. Discharging children is important for both the psychological well-being of both the child and his or her family. This also improves capacity for intake, improves staff morale and job satisfaction. In the UK, teams have a primary mental health worker, or workers, who is not discipline-specific, but is a senior clinician. Their role is to offer consultation to general practitioners, schools, on adult mental health, and to Tusla, our child protection service.

They also take on the role of interfacing with all of the agencies that refer to CAMHS to ensure referrals are appropriate and engage in preventive work and consultations with referring agencies. These clinicians do not carry a caseload. Preventive and early intervention work is essential to build resilience in young people and parents. It needs to be done at community level in order that referrals to CAMHS will be reduced in the long term. This can be addressed by supporting community teams, recognising the importance of infant mental health and psycho-educational groups for the parents of children who have commenced school. The service we offer should aim to improve the child's or young person's life chances by reducing and preventing comorbid acute mental health problems such as anxiety, depression and self-harm, thereby reducing the risk of family, social and educational breakdown and allowing a child to reach his or her full potential.

There is no national strategic plan for CAMHS. We need a five to ten year vision for the service. We also need to use technology in assisting with the diagnosis of attention deficit hyperactivity disorder, ADHD. The computer based QbTest is used successfully in the United Kingdom and within other CAMHS teams in Ireland and has improved the efficiency of the services. We do not have access to it within the Cork CAMHS team.