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’:

The Irish Times - Tuesday - Health - - Front Page - Michelle McDon­agh

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.

10-year strat­egy

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.

Re­cruit­ment

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.

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

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