Child mental health crisis
‘If we focused more on wellness and inclusion, particularly for children with autism, I believe we would have far fewer people presenting with mental health problems’:
Many of the 2,400-plus children on the Child and Adolescent Mental Health Services (CAMHS) waiting list should not be on the list at all, however it has become “a catch-all service” in the absence of any other services, say leading mental health professionals.
Anne O’Connor, national director mental health, HSE, points out that CAMHS was never designed to be a catch-all service, but to cater for children and adolescents with severe and enduring mental illnesses.
“The problem is that CAMHS takes everybody because there is nothing else there,” says O’Connor. “In an ideal world, the first step for a young person who presents with a mental health problem is to get help in school, to go to their GP and get access to a primary care-based psychology or family counselling service. Our mission is actually to keep people out of CAMHS.”
The HSE is investing ¤5 million this year recruiting psychologists for primary care, but there is a very long way to go before a public psychology service at primary care level is in place across the State.
O’Connor says the HSE is trying to develop alternative pathways to treatment for the large number of children with diagnoses such as autism and ADHD on the CAMHS waiting list.
On May 30th this year, the Oireachtas Committee on the Future of Healthcare published Sláintecare, its proposal for a 10-year strategy to “radically transform” healthcare in Ireland. It recommends that ¤47 million be invested in the CAMHS teams by year five of the plan, and the resourcing of a universal child health and wellness service at a further cost of ¤41 million over the first five years.
There are currently 2,419 children and young people with mental health disorders on the waiting list for the Child and Adolescent Mental Health Service (CAMHS), 218 of whom have been waiting for more than a year. And over 80 posts across the CAMHS teams nationwide remain unfilled – these include consultant psychiatrist, psychologist and clinical nurses specialist posts.
Spending on the delivery of mental health supports in the context of national concerns about this issue remains “scandalously low” at 6 per cent compared to other countries such as the UK (12 per cent) and Canada and New Zealand (11 per cent), according to the College of Psychiatrists of Ireland (CPI).
Dr John Hillery, consultant psychiatrist and president of the CPI, says that many of those on the CAMHS waiting list do not need to be assessed by a psychiatrist, and that other interventions at primary care level would be more appropriate for children and adolescents with less severe mental health problems – however, the services are simply not there at the moment.
He points out that the issue of recruitment currently facing the CAMHS and general psychiatry services is an international one. The terms and conditions of working for the HSE are a major issue, according to Dr Hillery, and even getting paid can be difficult.
He says: “I recently discovered that my registrar had not been paid for two months, so I had to write letters and send emails to try to get him paid. This is a regular occurrence that does not encourage people to come into the Irish health service and it would not be tolerable in the private sector. It’s embarrassing when you are looking at these highly trained young people, often with mortgages and young families, not getting any money into their pockets but still coming in to work.”
To attract people back from abroad where they enjoy better pay, have more predictable hours and a better quality of life than they would in Ireland, Dr Hillary says the key issues to be addressed are pay, quality of life, proper training pathways and support for lifelong learning.
O’Connor acknowledges the impact that key medical and nursing vacancies are having on the delivery of CAMHS services, particularly in the Dublin area.
“Medical vacancies are a big issue for us, and a challenge we have been battling for a number of years. In CAMHS at any one time, there is upwards of 20 per cent of vacant consultant posts, and consultant pay has been reduced since the Financial Emergency Measures in the Public Interest (FEMPI) Act 2015 came in. This is an international challenge, we are not alone. Australia and Canada have equal or worse problems than us.”
O’Connor points out that through significant investment in CAMHS, they have been able to develop and fund 69 new posts in psychiatry, but 39 of these remain unfilled.
“You could argue that the pay rate and scale is not high enough, and we are not offering enough to attract people home from overseas. We have been in discussions with the Department of Health and the Department of Public Expenditure and Reform as we have to get their approval if we want to go above the current pay scale.”
Jane Johnstone, an Irish Autism Action advocate based in the south-east of the country, is a mother of three children, two of whom have autism.
While none of her children require the services of CAMHS, she meets lots of families who are struggling to keep their children with autism in school and to keep them safe.
She remarks: “The general pattern I see is that a lot of teenagers and young people with high functioning autism or Asperger’s develop mental health problems when they get into their teens and start secondary schools. When the Government cut the SNAs (special needs assistants) and resource teachers in 2011, we warned this would cause problems down the line and we are seeing the impact of these cuts now.
“The whole neurological make-up of a child with autism or Asperger’s is completely different to the typical teenager. If you do not give these children the supports they need in primary school to develop the social skills they need to make friends and become an active part of their school and community, not all, but a proportion can experience problems in the early years of secondary school.”
Johnstone explains that some of these children, many of whom are extremely bright, are targeted by bullies, causing them to withdraw from school and become
I recently discovered that my registrar had not been paid for two months, so I had to write letters and send emails to try to get him paid – Dr John Hillery
very isolated. They develop depression, anxiety and panic attacks and suicidal ideation is quite common.
The impact of this stress can often lead to depression and anxiety in the parents she meets.
Cause of problems
As a psychotherapist herself, Johnstone says that rather than focusing on what’s wrong with the services, we should be asking what’s causing the mental health distress in these children and young people and is there a way we can stop it.
“If we focused more on wellness and inclusion, particularly for children with autism, I believe we would have far fewer people presenting with mental health problems and if the counselling services were put in place on onset of depression, anxiety, etc many crisis situations could be avoided.
If people had access to counselling at GP level as envisaged in Vision for Change, they wouldn’t be ending up in A&E in a crisis, and being sent home in an even more vulnerable position,” she says.
Johnstone points out that there is no holistic relationship between the HSE’s disability and mental health services and she believes there should be a separate specialised service for young people with disabilities and mental health issues.
You could argue that the pay rate and scale is not high enough, and we are not offering enough to attract people home from overseas– – Anne O’Connor, National Director Mental Health
Anne O’Connor, national director of Mental Health, HSE; Dr John Hillery, consultant psychiatrist and president of the College of Psychiatrists of Ireland: both acknowledges the impact that key medical and nursing vacancies are having on the delivery of CAMHS services, particularly in the Dublin area