Dr. Niall Muldoon:

I thank the joint committee for the invitation to present to it on a report prepared by my office entitled, Take My Hand: Young People’s Experiences of Mental Health Services. As the committee will be aware, the Office of the Ombudsman for Children is an independent human rights institution which was established under the Ombudsman for Children Act 2002. My office has a unique combination of statutory functions. We examine and investigate complaints made by or on behalf of children about the administrative actions, or inactions, of public bodies and promote the rights and welfare of children up to the age of 18 years.

One of the priorities of our strategic plan for the period 2016 to 2018 is to influence positive change for children with mental health difficulties. In the light of this priority, we decided in 2017 to undertake a consultation process with young people under 18 years receiving inpatient care and treatment for their mental health difficulties. The aim of the consultation was to facilitate young people in reflecting and sharing their views on mental health services based on their experiences from primary care through to inpatient services. I thank the 25 young people, aged between 14 and 17 years, who took part in the consultation process. We engaged with all six adolescent inpatient units in the country. I thank the management and staff of the five units who facilitated our work with the young people involved, including Linn Dara CAMHS inpatient unit, Dublin; Willow Grove adolescent unit, Dublin; Ginesa suite, Saint John of God Hospital, Dublin; CAMHS inpatient unit, Merlin Park Hospital, Galway; and Éist Linn CAMHS inpatient unit, Cork. I also thank Ms Lorna Walsh, a member of my staff, for her involvement. The young people involved were asked to consider three broad questions about their experiences of mental health services, namely, what they found helpful; what they found challenging and what changes they would like to see made.

Different methods were used by the young people concerned to express their views, namely, semi-structured interviews, painting, photography, collage and mind maps. Some of the images created by them can be viewed in the full report. On what they found helpful, many of them were positive about the support they received from professionals, family members and other young people in receipt of mental health services. According to them, professionals who engage and build trusting relationships with them have an important role to play in shaping their experiences of mental health services. They highlighted that medical professionals who used empathetic approaches and could relate to and communicate well with them and their families contributed to their feeling heard and understood. The knowledge and experience of teachers and school counsellors, as well as the arrangements put in place by schools to help them to cope, were commended by many of them. They spoke positively about the efforts family members made to help them, including by travelling long distances to visit inpatient units. Within the inpatient units, having a support group of peers who had experience and an understanding of the challenges in living with a mental health illness was identified as a valuable source of support. The benefit of programmes and activities such as music appreciation art, physical activity and life skills groups, was also noted by the young people concerned.

Despite these positives, the young people concerned highlighted a range of challenges that they had experienced, both as mental health services users and more generally. Many questioned the interpersonal and communication skills of the medical professionals with whom they had engaged. For example, the use of clinical language caused confusion for some young people and left them feeling they were not believed or understood. Some professionals were seen to be lacking in empathy and sensitivity, particularly when they made suggestions to "keep trying" and "keep working on it", even when the young people indicated that they felt "it wasn’t working."The lack of opportunities to be heard was also raised as a significant challenge, both within the inpatient units and in wider services. It was noted that professionals often communicated directly with the parent or parents as opposed to the young people.

Several of the young people concerned spoke about and questioned what they regarded as a rush to medicate, with the use of medication being suggested very early on in their treatment. A small number said they had sometimes been physically restrained. They found this challenging and frustrating and felt it should not be done. They also commented on the restrictions placed on them within inpatient units owing to low staffing levels and feeling institutionalised, with the main problem being a the lack of things to do.

Separation from family was a particularly significant challenge frequently mentioned by the young people concerned. Many spoke about the burden their mental health care had placed on their family and mentioned that it weighed heavily on them and was challenging in coming to terms with it.

With regard to school, some of the young people concerned felt their teachers and school counsellors lacked specialist knowledge of mental health and explained that their expectations of the supports available had not been met. They had also missed school owing to their mental health illness. As a result, their relationships with their friends had also been affected.

Many of the young people concerned spoke about the length of time it took to access CAMHS and the stark differences in the availability and consistency of the service throughout the country. They described these delays and inconsistencies as being very difficult. They also referenced the distance between the inpatient units and their homes, with one young person living an estimated six and a half hour drive from the unit. Another young person spoke about how the lack of adolescent inpatient places had previously resulted in him being placed in an adult psychiatric ward, an experience he described as traumatic.

The young people who took part in the consultation process recommended changes which they felt would improve mental health services and supports for young people in general. These recommendations can be found in section 2.3 of the report and include the following: increased supports and awareness raising initiatives in schools, including the availability of additional therapists or guidance counsellors; increased staffing levels in services, including community CAMHS services; the establishment of a youth advisory panel in each inpatient unit to ensure young people would be heard and have their views considered; greater autonomy being afforded to young people in inpatient units to self-regulate and manage their behaviour; and the availability of additional programmes and a less restrictive environment within inpatient units.

Following the consultation process and in the light of the complaints and investigations and policy work of my office, we have identified a number of key areas of concern and corresponding priorities for action. These are dealt with in detail in the report and include effective co-ordination and communication between those working in the area of children's mental health, as well as on a cross-sectoral basis, are central to delivering mental health services and supports that work for children. I welcome the recognition in the report of the national youth mental health task forcethat deficiencies in this area need to be addressed. The delay in making the youth mental health pathfinder project operational is unacceptable, given the commitment of the Government to it. The project will provide the vital structure to achieve greater co-ordination in the provision of mental health services for children and young people. It needs to be put in place urgently. Also, an independent mental health advocacy and information service specifically for children should be established without delay, as recommended by the UN Committee on the Rights of the Child and the national youth mental health task force.

I have serious concerns about the legislative framework for children’s mental health services and the slow pace of reform in this area. I welcome the passage of the Mental Health (Amendment) Bill 2017 and its focus on inserting rights-based, guiding principles for children into the Mental Health Act 2001. While these legislative proposals are an important step forward, the Government’s commitment to comprehensively revise the 2001 Act as a whole must be progressed without further delay. To address deficits in policy implementation and provide a single point of focus for everyone who has a role to play in advancing provision for children’s mental health, I am calling for the development of a dedicated A Vision for Change for children to provide a dedicated, cross-sectoral national policy framework for children’s mental health services. The framework should set out what clearly the actions that will be taken and by whom, timelines for delivery and associated costs.

On financial and human resources, once allocated, resources should be ring-fenced. The lack of clear and accessible information on the amount of money being spent on mental health services for children also needs to be addressed. On human resources, consideration should be given to the appointment of experienced professionals, other than consultant psychiatrists, to roles such as clinical leads, with a view to ensuring children and young people will not be left waiting for the support they need owing to unfilled posts. I call for all primary and post-primary schools to have access to an independent therapist-counsellor to ensure early intervention will be available to all children when they need it.

I again thank the committee for giving me the opportunity to present my report which I hope will assist it in its work. I will be happy to answer questions members may have. The views and experiences of the young people expressed in the report must be brought centre stage and considered meaningfully by all State and non-State actors with responsibilities to develop and implement proposals for reform in this area.