Youth Mental Health: Discussion (Resumed)

I welcome Members and viewers, who may be watching proceedings on Oireachtas TV, to the public session. The purpose of today's meeting is to meet representatives of the HSE's National Office for Suicide Prevention, the Irish Society for the Prevention of Cruelty to Children, ISPCC, Mental Health Reform, Empowering People in Care, EPIC, the National Youth Council of Ireland, and SpunOut to continue our consideration of the topic of youth mental health. This meeting is timely given that this is mental health awareness week.

On behalf of the joint committee, I welcome from the National Office for Suicide Prevention Mr. John Meehan, head, who is accompanied by Professor Philip Dodd; from the ISPCC, Mr. John Church, chief executive officer, and Ms Caroline O'Sullivan, director of services; from Mental Health Reform Ms Kate Mitchell; from EPIC Mr. Terry Dignan, chief executive officer, and Ms Karla Charles, policy manager; from the National Youth Council of Ireland Ms Rachael Treanor; and from SpunOut Mr. Ian Power, chief executive officer, and Ms Kiki Martire, head of training and quality.

Before we commence, in accordance with procedure I am required to draw the attention of our guests to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. They are directed that only evidence connected to the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I remind Members and witnesses to turn off their mobile phones or switch them to flight mode as they can interfere with the sound system and make it difficult for parliamentary reporters to report the meeting. Mobile phones also adversely affect television coverage and web streaming.

I advise witnesses that any submission or opening statement they have made to the joint committee will be published on the committee's website after the meeting. Following our guests' presentations there will be an exchange and Members will pose questions. Given the number of representatives attending today, opening statements will be limited to five minutes each. I will indicate when the time has expired. Co-operation in this regard would be very much appreciated.

I call Mr. John Meehan to make his opening statement.

Mr. John Meehan

I am an assistant national director in the HSE and I am responsible for mental health strategy and planning. I am also the head of the HSE's National Office for Suicide Prevention. I am joined by Professor Philip Dodd, consultant psychiatrist, clinical professor and clinical adviser to the National Office for Suicide Prevention.

On behalf of Professor Dodd and myself, I thank the committee for the invitation to speak about the topic of youth mental health and suicide. We have submitted a briefing paper in advance of the meeting that gives greater detail on my remarks in my opening statement.

I will outline the strategic context for suicide prevention.

Connecting for Life, Ireland's national strategy to reduce suicide was launched in 2015 to run until 2020. The strategy was developed in line with the best national and international evidence available for effective suicide and self-harm prevention strategies. The strategy contains seven overarching goals and 69 targeted actions, each of which has a specific lead responsibility assigned to it. Along with the HSE, 22 Government Departments or agencies have made commitments to deliver on actions assigned to them under the strategy and over 28 charities or NGOs are receiving funding to deliver on work that supports these actions. While the NOSP carries lead responsibility for 16 of the 69 Connecting for Life actions, the role of the office also extends to driving the strategy, defining its milestones, monitoring its implementation and reporting progress across the multiple sectors and stakeholders.

The implementation of any strategy is a complex process. As such, one of the roles of the NOSP is to provide real-time visibility of how lead agencies are advancing their work and initiatives, across all Connecting for Life actions. In 2017, we developed a new monitoring system to track the implementation of Connecting for Life. The system was informed by the best implementation literature available. Monitoring dashboards are provided every quarter to the cross-sectoral steering group chaired by the Department of Health and are publically available online at www.connectingforlifeireland.ie. We also initiated in 2017 an independent interim strategy review in respect of Connecting for Life. The review was published this year and has provided a rigorous top-down assessment of progress across each Connecting for Life goal. The review has also made clear recommendations for the remainder of 2019, 2020, and beyond. The interim strategy review is also available at www.connectingforlifeireland.ieConnecting for Life, Ireland's national strategy to reduce suicide, was launched in 2015 to run until 2020. The strategy was developed in line with the best national and international evidence available for effective suicide and self-harm prevention strategies. The strategy contains seven overarching goals and 69 targeted actions, each of which has a specific lead responsibility assigned to it. Along with the HSE, 22 Departments or agencies have made commitments to deliver on actions assigned to them under the strategy, and more than 28 charities or NGOs are receiving funding to deliver on work that supports these actions. While the National Office for Suicide Prevention, NOSP, carries lead responsibility for 16 of the 69 Connecting for Life actions, the role of the office extends also to driving the strategy, defining its milestones, monitoring its implementation, and reporting progress across the multiple sectors and stakeholders.

The implementation of any strategy is a complex process. As such, one of the roles of the NOSP is to provide real-time visibility of how lead agencies are advancing their work and initiatives across all Connecting for Life actions. In 2017, we developed a new monitoring system to track the implementation of Connecting for Life. The system was informed by the best implementation literature available. Monitoring dashboards are provided every quarter to the cross-sectoral steering group chaired by the Department of Health and are publicly available online at www.connectingforlifeireland.ie.

We also initiated in 2017 an independent interim strategy review in respect of Connecting for Life. The review was published this year and has provided a rigorous top-down assessment of progress across each Connecting for Life goal. The review has also made clear recommendations for the remainder of 2019, 2020, and beyond. The interim strategy review is also available at www.connectingforlifeireland.ie.

Apart from the national strategy, 17 localised versions of Connecting for Life have been established nationally through the work of the NOSP team in collaboration with our operational colleagues in the HSE, the community healthcare organisation, CHO, chief officers and their teams, and the wider stakeholder group. Oversight is provided by local implementation teams working to national frameworks supported by the national office of NOSP. While each local version was developed over a different time period from 2015 to 2018, all are now in full implementation mode.

I turn to young people. While Connecting for Life adopted a whole-population approach, special consideration was given to priority groups at the development stage. These are groups that always require specialised or targeted initiatives because they are known to be particularly vulnerable to suicide or where evidence shows a potential greater risk of suicide. The priority groups identified in our strategy include stated demographic cohorts such as young people. In the context of today's meeting, I draw attention in particular to strategic goal 3 of Connecting for Life and the related objectives and actions under that goal. The overarching aim here is to target approaches to reduce suicidal behaviour and improve mental health among priority groups, including young people. The highlights of the initiatives related to young people and Connecting for Life actions are outlined in our submission document from page 8.

It is important to speak to our understanding of suicide and self-harm statistics among young people in Ireland as there are often mixed messages on this issue. Suicide data in Ireland are provided by the Central Statistics Office, CSO, and it is important to note that the only official decision as to whether someone has died by suicide is a legal decision made by a coroner, not a medical decision made by doctors or the HSE. There are many caveats attached to the information provided by the CSO and a significant time delay in receiving information on, for example, late registered deaths. Currently, we have full sets of data, which include late registered deaths, only up to 2014. Nevertheless, looking at provisional data for the most recent year available, which is 2018, we know that the highest rate of suicide in Ireland per 100,000 of population was among 45 to 64 year olds. Among males, the highest rate was among 55 to 64 year olds. Among females, the highest rate tends to be within younger groups, currently among 15 to 24 year olds.

Given that our European counterparts use varying systems to collect and report suicide data, it is not always advisable to compare countries on a like-for-like basis. That said, our best understanding of how we compare with other countries comes from EUROSTAT. The most recent comparisons from EUROSTAT show that in 2016, Ireland had the 11th lowest rate of suicide across 34 European countries among all age cohorts. In 2015, Ireland had the ninth highest rate of suicide across 33 European countries for young people age 15 to 19. This ranking has fluctuated widely in preceding years, from 12th lowest in 2014 to second highest in 2011.

Members can read further details of these statistics on page 14 of our submission but I would like to add that regardless of what the figures seem to indicate, we continue to be of the firm belief that co-ordinated, concerted, multi-sectoral approaches to suicide prevention must be in place across all sectors of society if a difference is to be made.

Data on self-harm presentations to emergency departments in Ireland is provided separately by the National Self-Harm Registry and the full data are in that. My office provides funding to the NSRF.

It is important to note that recent studies show similar increases in England. This coincided with the release of season two of the Netflix series "13 Reasons Why" and the high profile death of a DJ. They all had implications. We respond to self-harm through our emergency departments and we have clinical programmes related to young people which are set out on page 8 of our submission.

In regard to investment in suicide prevention, there also remains noticeable financial-----

I have to ask you to conclude. Do you want to go to the concluding part? It is all here for us to read anyway.

Mr. John Meehan

There is a lot in that, Acting Chairman. I tried to get it all in within five minutes. My apologies.

No worries. Thank you very much, Mr. Meehan. I ask Mr. Church of the ISPCC to make his opening statement.

Mr. John Church

I thank the members of the committee for having us here today. The ISPCC is delighted to be in a position to present to the committee on the topic of youth mental health. As the national child protection charity, I would like to present the ISPCC’s insight which arises from listening to, and working directly with, children and young people. The ISPCC’s Childline service operates 24 hours a day and answers more than 1,000 contacts every day from children and young people up to the age of 18. A high proportion of these engagements come at night, often when other services are unavailable. In 2019 to date, 19% of Childline engagements with girls have focused on mental health and anxiety compared to 10% of engagements with boys. Children and young people who contact Childline discuss issues, including depression and sadness, self-harm, suicidal thoughts and bullying. Our childhood support services have received 341 new referrals to date in 2019. Of these referrals, 42% have related to children experiencing mental health difficulties. Typically, these young people present with anxiety, difficulty coping, school refusal, being socially isolated and having very low self-esteem.

The ISPCC’s childhood support service received a referral for a young boy who was experiencing anxiety and was at the point where he felt he could not leave the house, even to go to school. The boy and his family had refused previous supports. The ISPCC support worker worked with the boy and his family, giving them the chance to talk about their concerns as well as what steps they could take. The family appreciated that they could complete sessions in their own house as they had felt overwhelmed at the thought of meeting professionals at their offices. Over the course of the ISPCC’s engagement with the family, they agreed to work with CAMHS also. The boy is now making positive progress in that he will leave the house for short periods of time and is talking to his parents about his worries and feelings of anxiety.

Of the families who have completed work with the ISPCC childhood support service this year to date, 96% have reported improved knowledge and understanding of the issue and 77% have reported a change in behaviour. The ISPCC is aware from evaluating these service outcomes that community-based, strengths-focused therapeutic work can have lasting positive impacts on young people.

Through our work with children and young people, we know mental health is a key concern for that cohort. Children and young people have been hugely impacted by delays in access and lack of resources in mental health services in Ireland, at a time when waiting lists for mental health services in this country are at an all-time high. Families are left with very few service options available to them. In the first quarter of this year, 365 young people were waiting for more than 12 months for their first appointment with CAMHS. As my colleague mentioned, the suicide rate among young people aged 15 to 19 in Ireland is the seventh highest among 33 European countries.

Ireland has a population of 4.75 million people, of which over a quarter is aged under 18 years. Despite this, the voice of the child is often forgotten in the process of developing and evaluating services.

While the implementation of the Pathfinder project ought to help ensure children’s voices are heard, progress has been slow in this regard.

There is an acute need for 24-7 child and adolescent mental health services across Ireland. In its absence, children often feel they have nowhere to turn. In serious cases involving attempted suicide or self-harm, parents are forced to bring children to accident and emergency departments, which is a wholly inappropriate setting for any child in distress. It is essential that no child is admitted to an adult unit in future, even in the short term. Timely and appropriate early intervention support should be available to all children and young people, regardless of where they live in the country, when mental health issues arise. They should not have to wait to experience a crisis before they can access support. It is imperative that waiting lists are reduced and recommended resources and staffing for CAMHS are ensured.

I now invite Ms Kate Mitchell to make her opening statement.

Ms Kate Mitchell

I thank the committee for inviting Mental Health Reform to appear before it today to discuss youth mental health. Mental Health Reform is Ireland’s leading national coalition on mental health. With over 75 member organisations, we work together to drive progressive reform of mental health services and supports in Ireland. In partnership with our membership, many of which work in the area of child and youth mental health, including Jigsaw, SpunOut, the ISPCC, the Children’s Rights Alliance, and Barnardos, we have consistently advocated for improvements in mental health services and supports for children and young people living in Ireland.

In recent years, Mental Health Reform sat on the national task force on youth mental health, developed evidence-based research and guidance on meeting the mental health support needs of children and young people in Ireland, actively campaigned on the need for investment in child and youth mental health services and supports, including with regard to budget 2020, and has delivered a dedicated campaign on the need for out-of-hours crisis services for children and young people in all communities across Ireland.

From the outset, it is important to acknowledge the progress that has been made in the provision of child and youth mental health services and supports. This includes the expansion of Jigsaw youth mental health sites; the publication of CAMHS standard operating procedures, including a revised version; the development of digital technology mental health supports for children and young people; and the establishment of a mental health crisis text line.

Despite recent Government efforts, the reality is that significant challenges continue to exist for numerous families, children and young people who require mental health services and supports. To start, there is no doubt that Ireland's child and adolescent mental health services are at breaking point. Just over half of the required CAMHS staff are in post, which ultimately has a significant impact on access to and quality of services. As of June 2019, there were almost 2,500 children on the waiting list for CAMHS, of which 10% were waiting more than a year to be seen. There are ongoing practices of admitting children to acute adult services, with a total of 20% of all child admissions to adult inpatient units in 2018. There continues to be a lack of out-of-hours crisis mental health services for children and young people, with many being unable to avail of such supports in their communities. There are ongoing difficulties with the implementation of the CAMHS standard operating procedures, which seek to promote consistency and standardisation in services across the country, difficulties with transitions from child to adult mental health services, and continued gaps in mental health legislation, which fails to protect adequately the rights of children and young people when they go into hospital for mental health care and treatment.

This is further compounded by the continued absence of a national advocacy service for children and families engaged in mental health services, who may require support in having their voices heard. Unmet mental health need is also evident in the lack of specialist mental health services to meet the needs of particular groups of individuals. These include children with a mental health and intellectual disability, children with autism, children and young people from the deaf community, children with a dual diagnosis of addiction and a mental health difficulty, and children and young people in the care system.

There are significant shortfalls in supports outside of the specialist mental health services, including in primary care. For example, there are more than 8,500 people on the waiting list for primary care psychology nationally, of which almost 25% are waiting more than a year to be seen. It is important to recognise that the majority of individuals on this waiting list are under the age of 18 years. In addition, there has been a lack of investment in enhancing the capacity and resources afforded to other primary care professionals to meet the mental health needs of children and young people adequately.

No doubt, there are myriad additional gaps in mental health service provision, including in perinatal and early years mental health supports, a lack of investment in community and voluntary organisations that provide essential mental health services to children and young people in communities throughout the country, a lack of focus in investment in prevention and early intervention, and of particular note, inadequate inter-agency collaboration.

Overall, there remain significant challenges to bring about the type of mental health supports for children and young people that fulfil national policy and international human rights obligations. There are various measures that must be taken. These include, to name a few, increased investment in child and youth mental health services; a national roll out of crisis out-of-hours services for children and young people; investment in primary care psychology; the implementation of the CAMHS standard operating procedures; the reform of Ireland’s Mental Health Act 2001 to promote compliance with international human rights treaties, including the UN Convention on the Rights of the Child; the establishment of a national independent advocacy service for children, young people and families engaged in mental health services; the implementation of a nationwide schools programme on mental health promotion and well-being; the establishment of a universal approach to responding to perinatal and infant mental health needs; and a greater focus and investment on the prevention of mental health difficulties.

The prevalence of mental health difficulties among children and young people in Ireland is significant. Almost 20% of young people aged 19 to 24 years of age and 15% of children aged 11 to 13 years have had a mental health disorder. In July 2019, a report published by Eurofound showed that young Irish women are suffering the highest levels of moderate to severe symptoms of depression among their EU counterparts. Demand for services is increasing substantially with a 40% increase in referrals to CAMHS from 2011 to 2019. The cost of mental health difficulties is enormous. The figures suggest that this may amount to as much as 4% or more of GDP in some countries equating to approximately €12.4 billion each year based on Irish figures.

To enhance mental health services and supports for children and young people effectively, a cross-departmental agency approach is essential. This must be complemented by the required investment and resourcing from prevention and early intervention to specialist mental health services. This includes the full implementation of Better Outcomes, Brighter Futures, including its recommendations pertaining to child and youth mental health. Mental Health Reform's specific appeal to the committee today is that it takes on the fundamental need to improve the mental health outcomes of children and young people living in Ireland as an immediate priority in terms of parliamentary oversight.

I invite Ms Karla Charles to make her opening statement.

Ms Karla Charles

I thank the committee for the opportunity to address it today and to be involved in what we hope will be the start of a fruitful dialogue where the voices of children in care will become a more prominent part of the ongoing discussion on youth mental health. I am the policy manager in Empowering People in Care, EPIC. I am accompanied by my colleague, Terry Dignan, CEO of EPIC. We are delighted to see colleagues from across the sector here and would like to place on record our support for their work in this area. For members who may not be familiar with our work, EPIC is the only independent voluntary organisation in Ireland that advocates with and on behalf of children and young people who are or have been in care.

EPIC acknowledges the progress that has been made since A Vision for Change, the recommendations of the national youth mental health task force report of 2017, and the excellent report entitled Someone to Care; the mental health needs of children and young people with experience of the care and youth justice systems. It is widely accepted that significant challenges still exist in youth mental health, and one of the key priorities for mental health generally is the provision of additional appropriate supports for children and young people. EPIC requests that recognition be given to children in care, and those with care experience, as a particularly vulnerable group in the sphere of youth mental health and that specific recommendations and a strategy be developed for children and young people in care and aftercare and with care experience within the youth mental health sector.

While there is a general absence of statistics on mental health outcomes for children in care and young people with care experience in Ireland, numerous studies carried out in the UK show that the outcomes for children in care, compared with their non-care counterparts, are stark. Currently, half of all children in care in the UK meet the criteria for a possible mental health disorder compared with one in ten children in the general population. The net result is as devastating as it is unsurprising. Children in care, or who have been in care, are four times more likely to have a mental disorder than children in the general population.

An Irish study entitled Looked after children in Dublin and their mental health needs found that despite a higher prevalence of mental health difficulties among children in care, under 30% were attending CAMHS. The low attendance rate at mental health services has been attributed to narrow CAMHS referral criteria; poor recognition by social workers; reluctance to pathologise children’s behaviour, mobility and engagement difficulties; and general pessimism among social workers in accessing mental health services.

This is less surprising when we consider that children and young people who enter care do so because they have generally experienced trauma, often severe trauma, through neglect or abuse. Being taken away from their family, regardless of the reasons for this, compounds this trauma for most children and, quite understandably, places them at greater risk of behaviour and mental health challenges and difficulties from early in their lives. It must be acknowledged that there is an urgent need for every child entering the care system to have a mental health assessment and to be able to avail of support and intervention as and when they need it throughout their time in care and aftercare.

It is perhaps illustrative of why the mental health of children in care has been referred to as the silent crisis when we consider that children in care do not appear in the national youth mental health task force report of 2017. We, therefore, call for a specific mental health strategy for children in care.

It is acknowledged by EPIC that over the past number of years, Tusla has made, and is continuing to make, improvements in the collation of data on children in care in Ireland. However, we lag far behind the UK and other jurisdictions in this regard. Ten years after the Ryan report recommended that a longitudinal study should be undertaken to follow young people who leave care and map their transition into adulthood, this work has still not been started.

Without such a study, benchmarked against the general population, we will continue to fall short in our understanding and, through this understanding, developing ways to optimise outcomes for children in care.

EPIC welcomes the committee's focus on youth mental health and would like to emphasise how often we see, through our work, the devastating social exclusion, discrimination, with both short and long-term consequences that the failure to address childhood mental illness brings. The longer term economic and social costs of not addressing mental health issues among our children and young people, and particularly in our care population and care experienced young people, is a considerable drain on our system and our social capital. This cannot be allowed to happen. Vulnerable children and young people must be protected and given every opportunity to reach their full potential.

We have a number of recommendations to make to the committee. More research is needed to collate data and on outcomes for children and young people in the care system generally, and mental health has to be a key focus within this. Data on waiting times for children in care to first avail of mental health services, the regularity and variety of supports received and the overdue longitudinal study on children in care and leaving care must be collected.

Ms Charles will have to shorten her recommendations.

Ms Karla Charles

I will shorten them.

I feel for her, but I am being strict. I will give her a little extra time, as I did everyone else.

Ms Karla Charles

I appreciate that.

It is unrealistic that we will get through this number of recommendations.

Ms Karla Charles

We would like to draw the committee's attention to the long waiting lists that currently exist and the need for children and young people to receive creative therapeutic intervention at the earliest appropriate opportunity. More services need to be developed. We need to take an holistic and multidisciplinary approach. We must look at trauma support earlier, as soon as children are able to involve themselves in this.

The provision of both universal and targeted measures to promote positive mental health among children and young people in the care system must take place.

Children in care should receive a level of priority for child and adolescent mental health services, CAMHS, and adolescent community treatment schemes, ACTS. There should be an opportunity for all children in care to have a dedicated service such as the Tusla national psychology service in special care, which should be open to all children in care.

We need more focus on behavioural issues because CAMHS will only work with a child if there is a diagnosed mental health issue. We need to look at transfers from CAMHS to adult services, as has been mentioned.

We need to focus on advanced trauma informed training. We wish to point out that no child in care should have to be placed out of state.

Schools must be used more as a gateway to accessing and supporting children in care. We also stress the need for an independent advocacy that currently exists for adults admitted under the Mental Health Act. The same provision should exist for children accessing mental health services.

Positive mental health is the cornerstone to positive lived experiences for children and youth. Early intervention and prevention must be a priority in attaining this goal. A root-and-branch review of CAMHS is now a priority. Children in the care of the State are a particularly vulnerable group who need much more attention.

If time permits, I would like to read a quote from a young person in care who had direct experience of mental health services. I acknowledge and thank the young person in question for sharing her experience with us. She said:

I did not have a good experience of CAMHS and anyone I talked to who had gone to CAMHS felt the same. They just don’t understand and the tactics they use just don’t work. They need to change how they work with children and young people, especially as it is the first interaction you have with therapeutic services, it would turn you off counselling in the future. It is not child friendly - writing in their notebooks, all very daunting.

The only way to get seen by the CAMHS service is to be a danger to yourself and even at that you have to wait three weeks before you get an appointment. You have to be literally in intensive care to get an appointment with CAMHS.

In relation to CAMHS and the care system, I felt they had no understanding of the care system, the terms, how the system works. No understanding that a huge amount of young people in care experience attachment issues, they don’t understand this and just see you as acting out and work on trying to fix you.

The effect being in care has on children needs to be explained to children at a young age as they don’t understand what they are going through and they compare themselves to their friends who have come from a stable home. They need to be helped to understand at a young age why they are feeling the way they are feeling. It is not a mental health illness, they just can’t regulate their emotions because of attachment issues.

I thank the committee very much.

Ms Charles took three minutes more than the time allowed. If the notes of our guests look as if they will take longer than five minutes to read, I ask that they please try and rein them in a little. We did ask in advance for statements to be limited to five minutes.

I call Ms Rachael Treanor of the NYCI to make her opening statement.

Ms Rachael Treanor

I thank the Chairman, Deputies and Senators on behalf of the NYCI and the national youth health programme for the invitation to speak about youth mental health.

The council is the representative body for 51 national voluntary youth work organisations working with young people in every community in the country. We represent and support the interests of our member organisations and use our collective experience to act on issues that impact on young people.

The national youth health programme is a partnership between the council, the HSE and the Department of Children and Youth Affairs with a vision for Ireland to be a country where all young people can experience positive health and well-being.

As outlined in our submission, youth mental health is a specialist area of work for the health programme, working in partnership with the HSE, the youth sector, education and training boards, ETB, youth officers and numerous children and young people’s services committees, CYPSC, co-ordinators to facilitate training and aid in meeting the identified needs of young people.

The training programmes rolled out by national youth health programme include applied suicide intervention skills training, ASIST, MindOut 2.0, and the implementation of the health quality mark, HQM.

I do not want to quote pages of statistics because, in our submission, we have outlined many of them. However, I want to highlight some that illustrate what is affecting young people’s mental health. In 2015, the health programme conducted a rapid mental health needs assessment among youth work organisations to investigate the mental health needs of young people. The main issues identified were anxiety, stress and body image.

We have continued to work with the youth work sector to collect information on the mental health needs of young people. It is evident that many of the issues identified in 2015 are still relevant. However, additional issues and themes are emerging, which include the influence of social media; the influence and misuse of alcohol and drugs; societal expectations and pressures, including peer pressure; bullying; lack of skills, to include communication, resilience and self-awareness; and isolation and lack of support.

Young people are responding to these issues in a variety of ways. One coping mechanism is self-harm. Self-harming is becoming an increasingly prevalent issue among young people, especially young girls. Statistics are illustrating the increasing rates with one in every 132 young women aged 15 to 19 years presenting in hospitals with self-harming injuries. Youth workers working with these young people who are self-harming are also working, or have worked, with those who are attempting, have contemplated, or have died by suicide.

There is also evidence to suggest that media and entertainment industries are having an impact on young people in respect of self-harm. Recently, numerous studies have been published examining the impact and trends of the Netflix series, "13 Reasons Why", on the incidence of self-harm. These studies have found a correlation between an increase in the number of Google searches around suicide and also a 13% increase in suicides among 10 to 19 year olds. This has helped influence the World Health Organization, WHO, in updating its media guidelines on suicide in 2017.

Youth workers have stated that young people are presenting in youth organisations with extremely challenging behaviours. They indicated that some young people, and some young men in particular, find it difficult to express their emotions. The resulting frustration experienced by these young people can sometimes be expressed as anger and sometimes results in violent behaviour. In some instances, workers believed that this anger is connected to drug use.

Within the youth work sector, the needs and issues which have been identified above are addressed through the delivery and implementation of the programmes that the health programme currently delivers. Within our submission, we have outlined the different programmes that we run and they are all aligned to national policy and strategies. However, continuous awareness and support are needed.

The youth council has a number of recommendations, which I will set out. We recommend an increase in funding and resources for the youth work sector. The 2016 census indicates that the number of young people aged between ten to 24 will have increased by 13.2% between 2015 and 2025 to just over 1 million. This will make Ireland the only European country with a growing population. With our growing youth population, investment in universal youth services is more important than ever. However, this has not been recognised by the Government, with current investment still at 17% below the level of investment in 2008. While overall Government expenditure has increased by 12% since 2011, youth work services funding has only increased by 0.3%.

The council recommends more accessible, youth friendly counselling services. Youth workers have highlighted the challenges for young people trying to access services, including long waiting lists, lack of public transport and the appropriateness of the service for that young person, if that young person is even deemed suitable for a successful referral. These issues are hugely challenging for young people, especially for those in crisis. Some youth services have accessed funding to provide youth friendly counselling. This funding should be increased to enable more youth services to provide counselling and therapy and to expand current service provision.

The council recommends support for young people to build their skill sets and confidence to cope, not only with their own mental health concerns, but also to support their peers, where appropriate. For example, while ASIST training is available to youth workers and others working with young people and provides a framework to support someone with suicidal ideation, there is a gap in supporting the young person in building their own capacity to support their peers. This support system could be developed either an online tool, or as a training programme, which could be accessed directly by them.

It is important also to investigate initiatives in other countries such as those New Zealand and Australia have in place. One example is #ChatSafe, which is a young person's guide for communicating safely online about suicide. This initiative would complement SpunOut.ie's crisis line and texting services. The initiative has been developed in partnership with young people to provide support for those who might be responding to suicide-related content posted by others or for those who require support in respect of their own experiences about suicidal thoughts, feeling or behaviours. More training and information is needed to support those working with young people especially in dealing with challenging behaviours, self-harm, trauma informed practice and adverse childhood experiences.

I will conclude by reading a quote from a youth worker that illustrates the importance to young people of youth work, youth workers and the relationships involved:

Youth Workers are often the first port of call when a young person is in crises, especially because of the relationship they have with the worker. Youth Workers should not have to wing it when they find themselves in this situation. Mental wellbeing with young people can be complex, but clear training as to how to respond, whether the issue is mild, moderate or very serious. This will support the young person.

I thank the committee.

Mr. Ian Power

On behalf of SpunOut.ie, I thank the committee for the invitation to address members. As Ireland's youth information digital platform, run by young people for young people, SpunOut.ie meets the information needs of more than 150,000 young people each month. SpunOut.ie is run by Community Creations CLG, which also operates the new Crisis Text Line digital active listening service. Crisis Text Line is Ireland's first free 24-7 text service for anyone in crisis at any time. It is a place to go if one is struggling to cope and in need of immediate help. The Crisis Text Line platform connects texters with a volunteer who is most likely at home and who has been trained to listen, reassure and guide people from a hot moment to a cool calm. Both services receive the majority of their funding from the HSE on an annual basis.

It is welcome that the committee has chosen to hold meetings on the important issue of youth mental health. I hope our contribution can support this committee in its endeavours. Given that time is limited and a number of colleagues from different organisations are present, I will focus on two of the 13 areas highlighted in our submission to the committee. The first is Pathfinder, the youth mental health project, which is an initiative of the Civil Service management board. Pathfinder aims to enhance the cross-departmental collaboration between the Departments of Health, Education and Skills, and Children and Youth Affairs in the co-ordination of youth mental health policy, funding and accountability. The Pathfinder report was finalised two years ago and approved by the Secretaries General of all three Departments for implementation. The report recommends a number of transformative actions for youth mental health in Ireland, including the establishment of a team of dedicated officials from the three Departments on a time limited basis.

The creation of the Pathfinder team and the implementation of the report's recommendations was viewed by the members of the national task force on youth mental health as potentially transformative in addressing the crisis in youth mental health in Ireland. The Ombudsman for Children is also enthusiastically supportive of the proposal.

While the Pathfinder proposal has the support of all three sponsoring Departments, it has yet to receive sanction from the Department of Public Expenditure and Reform and the Attorney General to proceed almost two years after it was first proposed. Every day the Pathfinder report gathers dust, we delay the opportunity to radically reform how we approach youth mental health in Ireland. Pathfinder has the potential to demonstrate an effective model for cross-departmental co-operation and working, which could be replicated in other policy areas. The Department of Public Expenditure and Reform should resolve promptly the administrative issues holding the sponsoring Departments back from establishing the Pathfinder team. This must happen without delay and, as lead Department for the project, the Department of Health must continue to drive this initiative forward with urgency.

The second issue we wish to highlight is primary care. Prevention and early intervention should be at the heart of everything the State does when it comes to mental health care. Almost three quarters of all serious mental health difficulties first emerge between the ages of 15 and 25. It is, therefore, vital that properly-funded mental health interventions are available to young people in this age range to prevent problems from becoming acute, sometimes irreversibly so, and to promote recovery and long-term mental wellness. There is significant demand for accessible early intervention services for young people that charities, NGOs and acute services simply cannot satisfy on current levels of investment. We need to build a consensus on funding services that work and make the early, effective interventions that can have significant positive impacts on individuals and communities. There is a wide acceptance, informed by the work of the WHO and others, that the overwhelming majority of mental health interventions should take place in primary care settings. Any plan to improve mental health services must, therefore, have quicker, easier access to psychology in primary care at its core. While the decision last year to appoint more than 100 new assistant psychologists posts is a welcome start, we encourage the Department and the HSE to engage with the Psychological Society of Ireland, PSI, to establish an evidence-based training programme for those recruited to ensure they make the contribution we want and need to primary care.

The apparent global shortage of mental health clinicians makes it more challenging than ever to attract the skilled professionals we need, especially for services in rural areas. I point to our submission and the need to continue to expand the number of places in psychiatry, mental health nursing, clinical, counselling and education psychology to begin to address the skills shortage. In addition, we encourage the committee to examine the need for mental health teams to regain autonomy over whom they hire into their teams. While headcount can be managed or controlled centrally by the relevant business unit corporately in the HSE, HSE mental health services at local level must have a say in who joins their teams for a proper people strategy to take effect and to build effective teams.

I emphasise the excellent on-the-ground work carried out by the 13 current Jigsaw services, soon to be 15 with the expansion to Wicklow and Tipperary. Extending the reach of Jigsaw to more parts of the country would be an extremely positive step for the future of Ireland's mental health. The service meets an essential need for brief interventions and has a notable 98% satisfaction rating among those who have been able to access its services. As the committee continues its work, I hope the need for more of these services is front and centre, especially given Jigsaw's unstated role in supporting the case management of young people with mental health difficulties in many areas of the country. This role is pivotal to ensure there is a joined-up, responsive national service. In fact, a no-wrong door approach is exactly what is needed to ensure young people get access to the help they need early, instead of having to undergo what can often be a very frustrating search for the right help at the right time.

As a former member of the task force on youth mental health, I encourage the full and speedy implementation of the Pathfinder report's recommendations, including an independent advocacy service for children and young people, legislative change to allow 16 and 17 year olds to consent to their own mental health treatment, and a ring-fenced fund with the HEA to provide resources to higher education institutions to help satisfy the ever-growing need for counselling support services in third level education. Each of these recommendations, if fully implemented, would remove barriers to proper treatment and strongly enhance youth mental health provision in key areas. I thank the Chair and committee and welcome questions from members.

We have been given a great deal of information, but I will try to be brief. I can read through the submissions in my own time. My first question is for the National Office for Suicide Prevention. I read in the office's 2018 report, which was provided to the committee three or four weeks ago, the suicide statistics from 2008 to 2018. The highest figure was 579 in 2011 whereas the figure for 2018 was 352. I am looking for information to educate myself. Are there any studies showing why the number has reduced? I spoke to the HSE last week and was told there are myriad reasons affecting suicide rates.

I was asked to direct my questions to the National Office for Suicide Prevention, NOSP, as it is more expert in the area. I would welcome some background information on where that is, why it fluctuates, what kind of data exist, what kind of research is there and what kind of intelligence is around that.

When I spoke to the HSE two weeks ago, I also spoke about my experience of shadowing the bridge patrol in Limerick, operated by the Limerick Suicide Watch, which was a learning experience for me. Is there any co-ordinated communication between the office and the groups on the ground? There was one intervention during the four hours I was there. A couple of people the group spoke to were also feeling quite low within that period. My intention is not to sensationalise that, it is just to say how it was on that evening. There are evenings where there will be no interventions and then there may be a peak in activity. Is there a formal communication process between the office and such groups to get feedback and to provide data? I refer to what they are finding on the ground, what may help and any other parameters that might be included that would be helpful.

Reference was made to SpunOut.ie and the Pathfinder project. That is something I am working on myself behind the scenes. The last update I got is that there was a meeting on 19 July. I think I sent the information to the NOSP. I was advised that what has been suggested has never been done before. We are trying to push it. I want to see it done and I will seek an update.

I am not sure which of the witnesses to direct my next question to. Where are we at in terms of stigma? There was no mention of it in the contributions today. That is no disrespect to the contributions: I am aware that the witnesses have only five minutes to get their points across. I do not intend any disrespect to anyone, but it is incumbent on us to ensure that stigma does not go off the radar. We should not stop talking about stigma. What are the initiatives in that regard?

Ms Treanor spoke about the increase in self-harm among 15 to 19 year olds. Is there research to indicate what is the major factor behind that increase in recent years? Is it being driven solely by social media or is it a more complex issue?

Mr. John Meehan

Deputy Neville directed two questions to the NOSP. I will ask my colleague, Professor Dodd, to take the first one on statistics and I will follow up on the Limerick issue.

Dr. Philip Dodd

Deputy Neville inquired about the high level of suicide in the 2011 period. That is very much reflective of international trends in suicide rates, which are directly related to periods of recession. A direct impact is seen on restrictions in public services and personal income that significantly impacts on people's ability to maintain positive well-being. That is very much reflective of research across the world. In the UK, for example, suicide rates have just been published for 2018, which shows a small increase. Many commentators, both within the research and clinical setting, feel they are directly related to fears around the impact of Brexit on the economy in the UK.

There was also a point about elevated levels of self-harm among young people between the ages of 15 to 19 years. The NOSP funds the national suicide research foundation that is based in Cork. We are lucky in Ireland to have a very important data source, which is the national self-harm register. It is the only national register monitoring self-harm in the world. In fact, its annual report is about to be published tomorrow. It shows a 6% rise in self-harm rates in 2018. There is a rise in self-harm rates across all of the age groups, but repeatedly in recent years there are elevated rates of self-harm in young people. I think that possibly reflects the fact that we are seeing a rise in self-harm rates across many western European countries. We are not necessarily different in Ireland to other countries.

We are probably seeing a change in prevalence rates of mental illness across western European countries. A recent European survey comparing various European countries in rates of depressive illness showed that Ireland, unfortunately, was presenting with a particularly high level of depressive symptoms. The reason is multifactorial; there are lots of different reasons. When one looks at the detail of the self-harm rates, unfortunately, the involvement of street drugs in the 2018 rates is showing a significant increase, including cannabis and cocaine among young men. They are taking overdoses of those street drugs that seem to be associated with a rise in self-harm in recent years. Any discussion associated with the liberalisation of cannabis needs to take into account that in other countries where that has happened, there has been a significant impact on increasing the levels of self-harm rates. In recent years in Ireland we are seeing an increased rate of self-harm associated with cannabis and cocaine use.

I asked a question about suicide watch groups that patrol bridges. The one I know is in Limerick, but there are other groups throughout the country. Is there any co-ordinated communication process between the NOSP and those groups?

Mr. John Meehan

Deputy Neville raised the issue some weeks ago with my colleagues, Mr. Jim Ryan and Dr. Brendan Doody. There are two riverside patrols in Limerick. There is the Limerick Suicide Watch group and the Limerick Treaty Suicide Prevention group. In our supporting documents I see we have 22 resource officers for suicide prevention. Although we do not provide funding specifically to either of the groups in Limerick, there is a standing agreement that the voluntary patrols in Limerick city and county have reserved spaces for training on the applied suicide intervention skills training, ASIST, and safeTALK programmes. We support them in training and also in identifying with them local contact numbers in the event of needing assistance. Deputy Neville provided an example. There was a reaction to that and there was a follow-up, which we support.

We have 17 local actions plans for our resource officers around the country. The HSE has always been accused of having national strategies and launching and leaving them. Connecting for Life is the only strategy in Europe that has an action plan and local area plans. The demographics and needs in Limerick are a bit different from my own county in Donegal and different again to those in Dublin. The groups link in locally. We do not provide direct funding. However, we provide training and support to the volunteers. A third community crisis response team is based in west Limerick and it has plans to go national as well.

I welcome that. My question is whether there is a two-way feedback on what the groups see and the data they collect. I do not mean to be so black and white about it because behind every statistic is a person. Are the data the groups collect fed back to the NOSP? Is there any formal communication process between the NOSP and the groups nationally in terms of the intelligence they are gathering on the ground every night?

Mr. John Meehan

We work through the local resource officers. The local resource officers in Limerick liaise with the groups and data and feedback is provided to us. There is a local area implementation group as part of the Connecting for Life strategy. The resource officers provide information to us. If services or supports are required, that can be done at a local level. It is very important to have the feedback and it does happen.

Mr. Ian Power

I thank Deputy Neville for his support on the Pathfinder project. We understand that it is potentially the first time it is going to happen and that it is difficult to get it to work. I am concerned that officials in the three Departments are losing confidence that it is going to happen. It has been remarked that the idea is dead. I hope we can avoid-----

Who made that remark? What Department was it?

Mr. Ian Power

A couple of Departments feel that is the nature of the proposal at this time. We hope that we can perhaps send some signals out from the Department of Public Expenditure and Reform or elsewhere to the people who are expecting this proposal to happen in order to give them confidence that it will happen. That is what I would like from the Department of Public Expenditure and Reform.

With regard to stigma, there are two issues. First, we have definitely seen an improvement in stigma reduction over the past five or six years thanks to all of the different campaigns that have happened. In regard to young people in particular, we see a kind of confusion in terms of mental health literacy, for example, the difference between being anxious and suffering from anxiety and the ease with which people use those different terms. Campaigns to improve mental health literacy would be hugely welcome to reduce stigma generally. There is also the question of listening. One of the other things many organisations have done to great effect is educate people on how to actually listen to others in an effective way. We are a great country for asking "How are you?" but not necessarily always wanting to hear the answer. Understanding how to listen effectively to friends and understanding that it is not necessary to fix a friend's problem if they open up with an issue is another aspect.

The first meeting took place last week of the group in the HSE to create a mental health promotion plan, which is a very welcome step. It is the first time the health and well-being division on that side of the house, as distinct from any of the mental health divisions, is taking the lead on a mental health promotion plan specifically for the area of mental health, which I hope will also work to reduce stigma.

To clarify, the reply I received to my parliamentary question of 5 July, which was answered on 19 July, was as follows: "The proposal to establish a cross-governmental youth mental health Pathfinder team with participation from the Department of Health, the Department of Education & Skills and the Department of Children & Youth Affairs has Civil Service Management Board and Ministerial approval." That is there in writing and is nailed down. I do not want any misinformation, although I am not saying anyone else is saying that. It is just to have clarity for people who are looking in here.

That is very recent factual information ,which is on the record.

The reply states: "They are very supportive of the proposal, subject to resolving the outstanding matters." I agree we need to get to the bottom of these outstanding matters and to push that on.

Ms Kate Mitchell

To add to Mr. Power's comments on the issues of stigma, I want to acknowledge the work of SeeChange, which runs our national stigma reduction campaign and has done significant and valuable work in terms of opening up the conversation about mental health and promoting public attitudes to mental health. SeeChange would acknowledge that while we have seen progress in terms of public attitudes, the attitudes towards more severe and less common mental health difficulties, such as schizophrenia, psychosis and bipolar are still very much lagging behind. We can see also from the National Disability Authority research on public attitudes to people with mental health difficulties that people are least comfortable working with someone with a mental health difficulty, living beside somebody with a mental health difficulty or sending their children to school with other children with mental health difficulties in comparison to any other disability group. It is very important that we keep the spotlight on stigma reduction and ensuring we are adequately investing in that issue and not just talking about more common mental health difficulties.

What are Ms Mitchell's thoughts in regard to self-stigma among people who may have had a mental health challenge? They will talk about mental health with other people and will work with other people but will find a stigma within themselves in speaking about their own experience.

Ms Kate Mitchell

It is still an issue. In that context, it is very important that people are supported through that process in employment, and that people with mental health difficulties are supported in acknowledging the experience they bring and their own experience brings, and supported in terms of issues around disclosure with their employers and colleagues. Those supports need to be put in place for individuals, not just in the area of employment but in terms of housing and engaging with local authorities, schools and a whole range of sectors.

Until those supports are adequately in place, we will continue to have those issues.

Ms Karla Charles

To add to the discussion on stigma, children in care face multiple stigma levels and they are often unwilling to share in schools or even with their friends that they are in care. This has come to the fore in many cases where advocates have worked with young people. It obviously impacts on their mental health to reveal this fact they are trying to hold something that has such a significant impact on their lives and is close to themselves. This plays out in their behaviour, in particular given the fact that half of all children in care in the UK meet the criteria for possible mental health disorders. That shows the significance of where we are coming from with regard to this issue.

One of the things we and many people acknowledge is that the schools are a great gateway to reduce stigma. There is a wide, captive audience, including those suffering from mental health issues, either themselves personally or within their families, and, therefore, we can really work through the school systems in supporting children and accessing those who may themselves be suffering from mental health difficulties or know somebody in their family who is.

It is a very important discussion, which is why I am letting it go on a little bit longer.

Mr. John Meehan

I concur with my colleagues. The Green Ribbon campaign, which is funded by the HSE, is being reviewed. I would also like to mention to Deputy Neville the Little Things campaign, which has been on national and local print media and national television. We are now reviewing that because it has been going on for several years and we are looking to provide a more updated approach.

Stigma is such an important nut to crack in all of this and the fact we are discussing it here is important. It is about working with organisations, working with the workforce and working with trauma-informed workforces to break down that stigma. It is important to note the work of the Green Ribbon campaign but it needs to be reviewed in the context of identifying its positive outcomes and looking at other ways of dealing with these issues, in particular for those with long-term and enduring mental health problems.

There was a question on those aged 15 to 19. If the witnesses want to submit the answer to me afterwards, that is fine.

There is time for a quick response.

Ms Rachael Treanor

For 15 to 19 year olds, their whole life is online and we cannot deny that everything they do is on social media. Therefore, it is having an impact on them but they have no capacity and they have not developed those core competencies to have the resilience to make good decisions because everything is online. The National Office for Suicide Prevention spoke about the death of the high profile DJ and the "13 Reasons Why" series. This has an impact on young people because that is what they are living through. If it is reported through the media with a sensational headline but without the facts underneath, that plays a role in influencing young people. It is brilliant that the World Health Organization, WHO, has developed guidelines in and around suicide, the media and development programmes but there is still a case to be made around media reporting.

This is like history repeating itself. In 1994, when Kurt Cobain took his life, it was exactly the same. It was a different media format but I see the same traits. I thank Ms Treanor for sharing that with us.

Dr. Philip Dodd

I want to support my colleagues' comments. The WHO guidelines on the portrayal of suicide and self-harm in the media is being launched tomorrow in Cork to coincide with the annual report of the national suicide research foundation. I would encourage all to be aware of the content of those guidelines.

I thank all the witnesses for coming in and for their work. I apologise for the length of the intervention.

It is an area of huge interest for the Deputy so that is no problem.

I thank everyone for accommodating our request for five minutes. I know it is a difficult request but it is a discussion we had last week. We thought there was a benefit in having as many voices at the table as possible and I hope the conversation will be able to flex out. I thank the witnesses for the work they do in supporting our young people. I must apologise because I will have to leave the meeting early.

A number of witnesses referred to the reform of the Mental Health Act, which has been promised for a long time by the Government in order to realise the A Vision for Change document.

I worked with my colleague, Senator Devine, on the Mental Health (Capacity to Consent to Treatment) Bill 2018. Mr. Power mentioned the age of consent for mental health treatment. Would any of the delegates not support the Bill's enactment as soon as possible or the proposals it contains?

Deputy Alan Farrell took the Chair.

Ms Kate Mitchell

I thank the Senator for raising this issue. He may be aware that Mental Health Reform has advocated consistently for approximately two years for full reform of the Mental Health Act. We had positive news in July when the Department of Health sent draft legislation in that regard to the Mental Health Commission. The hope is the commission will review it by Christmas and that it can then proceed. The issue raised by the Senator is among those that will be addressed in full reform of the legislation. We 100% support the need to reform it to ensure 16 and 17 year olds are presumed to have the capacity to consent and refuse admission and treatment in mental health inpatient units. An array of other issues pertaining to young people attending hospital need to be addressed also. Full reform of the legislation is an immediate priority if we are to ensure the rights of people, including the young, are adequately protected.

I appreciate Mental Health Reform's work in that regard and the update on the Government's legislation. Yesterday Mental Health Reform and other groups sought clarification on budget allocations, for example, whether the €25 million not spent last year formed part of this year's €35 million allocation. Has anyone received an update? I spent most of yesterday reading between the lines of the Fine Gael announcements.

Ms Kate Mitchell

We expect it to be new money and that any commitment on development funding to be in addition to what was committed to in 2019.

Ms Kate Mitchell

The Department of Health will hold its press conference at 2 p.m. We will be waiting eagerly for clarification on the details in that regard.

I sit on the new Joint Committee on Key Issues affecting the Traveller Community. Recently, we heard about mental health issues affecting that community, with suicide rates six times higher than in wider society. One of the delegates invited the committee to ask a meeting of Travellers anywhere in Ireland whether they had been affected by suicide. He said nearly every Traveller would raise a hand. Where there is an added layer of marginalisation, how best can the State support such a group and the most vulnerable?

Mr. Ian Power

I will make a brief point. The social determinants of health are important when discussing young people in the Traveller community. The young people to whom we speak refer to the ability to live in stable accommodation that is serviced properly. The No. 1 recommendation we would make - it is called for by young people in the Traveller community - is for local authorities to spend the budget available to them for Traveller accommodation. There is little point in trying to address psychological issues with young people if the basic needs they require to live happy lives are not being met.

The new Crisis Text Line will be funded by the HSE. We are working with Pavee Point as one of our first partner organisations. We are piloting the service with young people from the Traveller community. An important element was developing a training module for the people working in the service that showed them how to engage with young people from the Traveller community on their terms and in the ways in which they wanted to be engaged.

That has taken a significant amount of time, but it is important. State and voluntary services should be trying to engage and understand how to provide services for young people, no matter from what priority group they come, and to design them in such a way as to make them engaging and welcoming for them.

Ms Karla Charles

It is in speaking to the vulnerable, marginalised groups directly that one will hear how they want to be best served and supported in dealing with the difficulties they face. Many years ago I worked for the National Consultative Committee on Racism and Interculturalism and was involved a great deal with Travellers. Many points similar to those that arose in dealing with a marginalised population like the Traveller community are appearing in my long-standing work with children in care. It is when we hear directly from children in care that we learn how best to support them, how best they want to be supported and, therefore, how they will engage with services and supports appropriately.

Mr. John Meehan

We have been invited to attend a separate committee meeting next week on the issue of Traveller health, including mental health. Travellers are seen as a priority group, just like young people. It reflects international statistics which show high rates of suicide within that community. It is also important to note that we fund Traveller movements within the country. However, I will reflect what my colleague stated, that it is an amalgamation of housing and health.

Having members of the Traveller community training themselves is also a target. International research from Australia, Canada and the USA has shown that training indigenous peoples to provide assistance in cases of self-harm within their own communities has better outcomes than training provided by statutory organisations. We hope to have a full report. I will be able to provide the committee with the details after next week's committee meeting.

Ms Karla Charles

Recently, there was a call for a national action plan against racism. Obviously, it would involve working directly with the Traveller community. Such a plan is long overdue.

Dr. Philip Dodd

I will make a couple of comments, the first of which is on official suicide statistics. The Cental Statistics Office does not gather specific data for any particular group, including the Traveller community, including levels of suicide. On the other hand, we know through our network of HSE research officers in suicide prevention that if there is a cluster of suspected suicides in the Traveller community, for example, the local resource officer for suicide prevention, ROSP, will be in a position to link with local Traveller organisations and statutory agencies to ensure postvention services are put in place as soon as possible, including by fast-tracking affected individuals to mental health services. This is taking place across the country in discreet but important, ways. In addition, the ROSP is cautious in monitoring any local media exposure of suspected clusters of suicide. We know of the concerns associated with inappropriate and sometimes inaccurate reporting of clusters. Unfortunately, it can impact on vulnerable persons and lead to an increased rate of self-harm and suicide.

Mr. John Church

Without repeating points, I will try to add to what has been said. It is important that we intervene with the most appropriate service. In the ISPCC we work with individuals and their families. It is important to reach out to the extended family. In many instances, we have a child and family support service in the home. Since it is daunting for children to go to some of our locations throughout the country, we travel to their homes instead. Immediately, they are in their own environment and feel supported and a little more confident. Be it for good or, in some cases, bad, they have their family with them.

It will not just look at the provision of the most appropriate service because where it is delivered is also important.

The point about racism is one we all need to acknowledge and take ownership of. We also need to acknowledge that there might be an unconscious bias. It was embarrassing to sit at a meeting of the Joint Committee on Key Issues affecting the Traveller Community with no Traveller voice on our side of the room. There is a job for all political parties to do in that regard. Seeing oneself in public office and as a role model is important. The racism we saw so publicly during the presidential election is felt every day by the Traveller community. We need to acknowledge that there is outright racism.

Will the delegates expand briefly on the National Youth Council of Ireland's project and recommendations on chatsafe which is a guide for young people on communicating safely online about suicide?

Ms Rachael Treanor

Chatsafe is an app that is available in New Zealand and Australia and which was developed by young people and universities. It is an online tool for those who believe they need support because of suicidal ideation. The National Youth Council of Ireland made a recommendation that something similar be developed for young people in Ireland to complement the text line. The ISPCC phone service is great, but, as I said, young people are all online. If there was an app on which they could receive credible and informed evidence-based information in order that it would not just come from a Google search, it would close a gap.

Ms Kate Mitchell

I want to come back to a previous point about Traveller specific issues. There is a fundamental need to develop and implement culturally sensitive mental health services. It is the area that has received the least amount of attention in mental health service development and implementation, particularly in implementation of A Vision for Change. Mental Health Reform, in collaboration with the Mental Health Commission, has produced guidelines on delivering culturally competent and aware mental health services. They look at issues such as identifying communication and language needs, cultural bias and the needs of ethnic minority groups, including the Traveller community, in terms of family involvement and advocacy. I urge committee members to look at the guidelines. There is a fundamental need to implement them, as well as to invest in and resource them.

The Traveller community is one priority group, but there are a number of other particular groups of individuals, including children with autism, people with a dual diagnosis of addiction and mental health difficulties and children in the care system, who have received very little attention in mental health service development. They require significant attention. We will shortly see the publication of the revised mental health policy, in which I hope there will be a greater focus on particular groups of individuals.

Mr. John Church

A point of information is that since last November Childline has been operating an online chat system which children access every day. We have approximately 100 chats a day on Childline online. We also operate Childline text. Traditionally, ours has been known as a telephone listening service. We still listen to 1,000 children every day, but in recognition of the fact that children now operate online, we are also up and running online. It is not a 24/7 service, but we hope to get there within the next 12 months.

Mr. John Meehan

Recently, we introduced co-ordinators with a specific remit that covered Traveller health, including mental health, in the nine CHO areas. I agree that we must be culturally sensitive and bring it into mainstream mental health services in order that it is not a parallel process. The HSE has invested in nine posts to look at the issue of co-ordination. The process is multifaceted and must be culturally sensitive and understand the needs of priority groups. There is training associated with this and we hope to develop it further based on needs in local areas.

I apologise because I have to leave. I thank all of the delegates for the work they do in supporting young people.

I have a number of questions and wish to make some points. I am not sure what experience the delegates have of CAMHS, but I have experience of filling in a referral form and it was like doing a thesis in college. I am torn when it comes to discussions about CAMHS because we need far more resources and bodies on the ground, but there is also a need for complete reform of how CAMHS deals with people. Generally, it is the parent who fills in the form. This means that we do not get the child's opinion in the first instance but the parent's opinion of him or her. The vast majority of parents want the very best for their children, but they do not know their opinions. The thing about mental health is we do not know what another person is going through. It is extremely daunting. For many, it is even difficult to consider in the first instance t hat their child may be struggling or having difficulty and then they are faced with a huge number of forms. After filling them in, they might be invited to a drop-in clinic, which is totally unsuitable.

Perhaps it is different in various parts of the country, but this is not the right way to go about it. People need to be able to speak to a human being to explain what they believe their children are going through. Depending on the age of the child and whether there are additional needs, the children could speak. I understand people will not enter a service immediately, but at least they should receive assistance in trying to access it. I believe it was Ms Charles who made the point about having to have a diagnosis on paper before someone was seen in the first instance. People do not ring CAMHS for information for the good of their health but because it is an important service at that time in their lives, but the way it has been designed is not user friendly. My cynical view is that it was designed in order that people would give up. It puts far more pressure on voluntary systems. In Kilkenny, when people ask us for advice or recommendations, we tend to look towards the voluntary organisations in the area because we know that they will listen, that they are available and that people will not have to ring a number for the following two weeks wondering whether anyone will get back to them. I would like to hear the opinions of the delegates on CAMHS. When we speak about it, we generally talk about waiting lists and needing more resources, which are important. I would like to hear the opinions of the delegates on reforming CAMHS, how their organisations are structured and run and how people access them in the first place.

My next question is about prevention. We could do far more at a school-----

I apologise for interrupting the Deputy, but would she like answers to her first group of questions now?

We have plenty of time.

Dr. Philip Dodd

I thank Deputy Funchion for asking her questions and highlighting an area on which the HSE is focused in trying to improve the service. She touched on a number of pressure points in CAMHS. It is important to contextualise with CAMHS with reference to the entire mental health service offering that should be available to young people. As I said, the level of mental health difficulties among young people is rising. Therefore, the numbers of referrals to our services at primary care and specialist levels have increased significantly. If we review any of the statistics that capture our waiting lists, we will see that the numbers of referrals have shot up throughout the primary care and specialist areas. As a result, young people are not accessing in a timely way the services available at primary care level.

CAMHS is designed based on the provision of the multidisciplinary team and the types of specialties available. It is more appropriate for people presenting with more severe mental health problems. The Deputy is correct that a significant amount of information is sought on the referral form and it can prove to be very daunting to fill it out, which is usually done with the GP. That is because given the number of referrals being made, the triage process with every one of the 70 teams in the country is important, where they try to work out, based on the information provided, whether it is an urgent and emerging issue or a less urgent issue. In some way, therefore, they are able to manage the referrals despite the daunting number of referrals.

The second version of the CAMHS standard operating procedure seeks to streamline the referral process and the referral form will be redesigned based on the new guidance document. Until we deal with the myriad problems in CAMHS, however, including the adequate provision of services at primary care level, and until we confront the recruitment challenges in CAMHS throughout the country, there will, unfortunately, continue to be frustrations, difficulties and poor outcomes for children and young people throughout the country. It will not happen until we try as a nation to challenge the problems.

Is there an alternative to form filling? The Deputy made a fair point about it. Dr. Dodd mentioned streamlining the process, but forms nonetheless have to be filled out and copious information provided.

Dr. Philip Dodd

In many parts of the country, waiting list initiatives take place in a reactive way. The waiting lists are actively managed and I am familiar with a number of initiatives in various parts of the country whereby when waiting lists get significantly long, members of the CAMHS team will enhance the triage role and contact the GP or the family who filled out the form to get more information and determine whether the individual still presents in the way described. Nothing in the system precludes CAMHS teams from contacting the referrer or the family to seek additional information, as takes place throughout the country, specifically in the context of waiting list initiatives.

There needs to be far more consistency in that regard. As Dr. Dodd must be aware, the south east has severe difficulty with CAMHS and staff resigning due to not being able to cope with being unable to help the people waiting, and I would be shocked if what Dr. Dodd outlined happens there. Even getting on the waiting list can be very difficult and a cohort of people will slip through the cracks. If someone has a mental health difficulty, he or she may need someone else as a voice to get onto the waiting list. It is not a matter of filling in all the forms and providing all the information. It is more likely that a person in such a position would decide to leave it, not to bother doing it, and wonder whether anyone will even remember that he or she sought a referral. In any event, often the reply will indicate that the person is considered more suited to psychological therapy, which is fine, but the service offered is a drop-in clinic. While that differs throughout the country, a drop-in clinic, especially a group one, will not be suitable. It relates to why people are struggling in the first instance. It is rare that someone enters a drop-in clinic and starts talking about his or her difficulties. Such a person is more likely to say, "I knew it. No one is there to help me."

Dr. Philip Dodd

In 2017 and 2018, the HSE engaged with a service improvement process called the choice and partnership approach, CAPA, which is largely what the Deputy described. CAPA has been used in many CAMHS services in the UK. It sets at its centre the booking visit, which uses a much less detailed referral form and to which there is rapid access.

The issues that are significant for the young person are discussed quickly and a waiting list to access various types of therapy from the team may well develop. We are trying to establish three demonstration sites for the process in various parts of the country in order that we can demonstrate the effectiveness of the model within an Irish setting. Unfortunately, for the demonstration sites that were selected in 2018, there were recruitment difficulties with backfilling staff to take on the work. Nevertheless, we remain committed to improving the whole experience of the referral and the CAMHS intake.

Ms Karla Charles

I mentioned considering an holistic and multidisciplinary approach and the fact we need to put the child at the centre. The Deputy spoke about the adult filling in the form, but where possible, it is better to speak to the young person and hear directly from him or her. In the meantime, while we wait for an assessment and referral to take place, other interventions could be considered. We could examine providing creative therapies that may even just help to bridge the time gap that exists. I acknowledge there is a shortage of staff across the board and the issue is with trying to secure more funding and bodies in posts. We need to consider the matter creatively and always bear in mind we need to keep the young person at the centre.

I have some observations on prevention. People have a range of difficulties, some which are severe. So much could be done in respect of prevention, not least at school level. A major issue I always raise is that the school system is far too academic and pressurised. When kids join junior and senior infants, they tend to love school, but by the time they have finished, they cannot wait to leave. While the work becomes more difficult, there is less and less free time. Perhaps there could be a greater focus on mindfulness, meditation and the listening skills that were mentioned.

Fifteen years ago, I did voluntary work with the Samaritans, which provided an excellent course in listening. It was the first training that volunteers had to do and it took approximately four weeks. It is beneficial to one's entire life. We were taught to listen without judging, which was difficult because one's first instinct is to say the problem can be solved. Learning to sit and listen without judgment was invaluable. I do not suggest that that level of training should be provided to children. It would have to be age appropriate but we could do far more at primary level from the moment the child enters the school system. It is not all about academics. Being kind and being a good listener are important skills, but it is as though they do not matter because pupils have to get As or be top of the sports team.

I even have a difficulty with the idea of awarding a student of the week, although I understand why schools do it. While schools will argue it means every child will get a chance, the child who is awarded it every May or June, for example, will realise he or she is awarded it every May or June, not September or October. It bothers me. We cannot get away from it because it is so widely discussed. We are all guilty as parents of being proud of our kids, but it is expressed in so many ways, whether through the student of the week award, junior certificate results or parent-teacher meetings. Years ago, people did not really talk about such matters and one would not have known the details, whereas now it is everywhere, including online, and one can access everything. We are all aware of the pressure it puts on kids, and our guests are the experts and deal with it every day, but far more could be done in school in respect of prevention and early intervention. We say all the time it is okay not to be okay, but do we mean that? If a young person is struggling in school, it is not okay. There needs to be a greater emphasis on the matter.

I do not know whether our guests have much interaction with the school completion programme and I accept that its activity throughout the country is hit and miss. In my experience, it is fantastic. Schools that are in the programme in my region have access to play therapy and counselling, and there is no waiting list. It is based entirely on the needs of the child rather than requiring the parents to take a means test. The parents' means are irrelevant. It is about what the child needs at the time. A number of other services are also provided. If there was more play therapy and counselling, depending on what is age appropriate at primary and second level, there would be a far better outcome for many of the less complex difficulties, such as those relating to anxiety, coping mechanisms and building resistance.

The schools that participate in the school completion programme tend to have that early intervention, which stops it from becoming a major issue or at least gives children an idea of how to cope going forward. A lot of it is about coping mechanisms and building resilience.

Mr. Ian Power

We were involved recently in the launch of the ESRI evaluation of the Youthreach programme. One of the interesting things to emerge from it was that young people involved in Youthreach ended up leaving school early because of difficulty with mental health issues and also difficulties with the curriculum and it not suiting their learning style. It is a two-track thing. The Deputy describes it really well. The reforms to the junior cycle curriculum and those planned for the leaving certificate curriculum are really welcome in respect of trying to approach people's different learning styles in different ways. However, as we have also seen in the youth justice system in particular, students leave school early because of the lack of vocational learning opportunities in our second level system. They have to leave school and become an apprentice to access those types of opportunities. Having those earlier and in the formal school setting would be really appropriate.

In addition to the new well-being curriculum, which is very exciting and a great opportunity to increase the type of learning the Deputy is talking about and introduce it earlier, we would endorse the recommendation of the Irish Association for Counselling and Psychotherapy, IACP, for a pilot for a schools-based counselling programme. One of the things young people tell us is that if they really needed help, they would seek it, which suggests that they are waiting until they get to a crisis before looking for support. Having lower level brief interventions or basic psychology type services within school settings could help us to prevent young people from ever needing to access services such as primary care psychology or at the more acute end in terms of CAMHS. We firmly believe we need to look at the education system. I welcome the committee's examination of this topic because it is multifactorial. As we heard when we discussed the issue of suicide, it is complex and it needs multiple initiatives to be able to address it.

We ran a campaign a couple of years ago called Listening is Helping. It was based on the active listening tips of the Samaritans and aimed to educate children and young people on how to listen to others without trying to fix their problems. Some of the resources we provided in schools were videos of pairs of friends, one of whom was the listener, showing how the listener demonstrated good listening skills. It is about trying to educate our young people to be there for each other. Peer support is a massive help where it is appropriate.

Ms Kate Mitchell

I thank the Deputy for her question. I wholeheartedly agree with her that there is a requirement for a greater focus on prevention and early intervention. That needs to happen at the earliest stages possible, including at the perinatal stage. The HSE has developed a model of care on perinatal mental health service provision. It is important that we see that progress. It should be a holistic approach so that we see things like public health nurses being trained to identify where there is a mental health need and able to refer appropriately. Maternity staff should also be trained and able to refer into more specialist services where required. Primary care psychology should be built up for families and young children.

On our early years programme, the Department of Children and Youth Affairs over the years has invested in area based childhood, ABC, programmes which support families, parents and young children. Some of those programmes are highly effective in addressing mental health but the approach is ad hoc. In some communities there is no focus on mental health or it is a small part of the programme. We need to see a national focus on mental health in these programmes and appropriate investment and resourcing.

On education, I would echo Mr. Power's comments. We welcome the reforms to the curriculum and the introduction of components on well-being. It is important that we ensure a strong focus on mental health within that. It is necessary not just at post-primary level but also within primary schools. We must ensure that we are not just presenting schools with guidelines or introducing a framework but that we are supporting our schools, teachers and administrative staff to be able to support children and young people.

There are initiatives in other jurisdictions. For example, in London mental health advisers who are specifically dedicated to mental health are appointed through local authorities. Their sole job is to support schools in identifying where the mental health needs lie and how to address them, and to frequently review them and respond to those needs. They are the types of initiatives that we need to look at.

Mr. John Meehan

I concur with the Deputy. Prevention and early intervention have been mentioned so many times. As my son tells me, "Dad, you need to take things upstream." I welcome the statement of the Minister for Education and Skills that well-being will be part of the curriculum, just like history. Under Connecting for Life, the Department of Health with the Department of Education and Skills has focused on implementing the well-being policy which aims to foster and promote well-being of children and younger people in all schools. There is also the National Office for Suicide Prevention. The HSE is supporting the ongoing implementation of the national anti-bullying action plan, which is so important if we look at an upstream level. The junior cycle well-being programme has been implemented for three years of junior cycle as of 2019. SafeTALK suicide prevention training has been rolled out in education centres as part of a pilot project providing SafeTALK to teachers. Teachers tell us that sometimes they do not feel equipped with the knowledge and skills to provide that. My colleagues in the HSE health and well-being section continue to train teachers in health promotion programmes such as Zippy's Friends and MindOut. It is very important to bring that upstream and, as a parent and former psychiatric nurse working in CAMHS, I would welcome well-being as part of the curriculum. I also highlight a need for a global well-being to take in both physical and mental health, social aspects, gender - all of those together. We look forward to that.

Ms Karla Charles

I support what everybody else has said. As we are talking about early intervention, which is a must, we want to look at a requirement to focus on training. I refer to training across the board, particularly in respect of children in care. We are looking at supporting foster carers who do tremendous work but might be going through a difficult time and need extra support. Social workers should have adequate training in terms of giving mental health support. I would add to that the difficulty we currently have of a decreasing number of social workers. The young people do not even have that key consistent figure in their lives to whom they can turn in difficult times. As mentioned by others, there should be key designated people within schools who are trained and informed and to whom young people can go. They should not be guidance counsellors and should not stand out as somebody the students are going to because they have a problem with their mental health. We need to look at transition periods. For children in care, they include leaving care and going into after-care, and becoming a parent. Statistics show that the number of care leavers who become parents early in life is significant and this often creates trauma for them. The death of a parent is another transition period. All these factors contribute. Significant resourcing and training are needed, as is investment in data and research, which needs to be encouraged. We need to look creatively at big sister and big brother type programmes within the mental health context, for example, reaching out to people who have suffered from mental health problems in the past and may now be able to support a younger person. We should look creatively at doing this within communities. We would say the same for children in care. We should try to get people who have been in care to speak to them, encourage them and act as role models. As the Senator said, we need role models to speak out throughout society.

Mr. John Church

I wholly support the Deputy's comments. From the perspective of the ISPCC, I do not think anybody would disagree that education is very important. Recently the Minister for Education and Skills, Deputy McHugh, spoke of having well-being as part of the junior cycle.

All these buzzwords like "well-being" and "resilience" are becoming part of our language. In our experience, it is best to intervene or to tick the prevention box and get in early in primary school. We run a small number of group resilience training activities. We do not have enough funding to do more. I was at one in Cork recently. It was fantastic to see young children talking about these issues in a group situation. It is vital to reach eight to 12 year olds. I am unsure how many members of the committee remember the old health promotion videos in schools but they stopped me taking up smoking. They ran back in 1975 and 1976. When I saw those videos, I did not want to smoke. We need to get into schools and start doing the equivalent with resilience. That is what we are all about with Childline. We listen to children but we do not direct them. We help them to build resources around themselves. Children nowadays are not as resilient as many were years ago. We need to intervene early and help to teach them.

Ms Rachael Treanor

I want to speak about the MindOut programme. There is a MindOut programme in schools and another MindOut programme for outside schools. The programme is about building the core competencies of young people so that when they transition from school into college or whatever field they follow, they have the skills that will support them. Everyone is talking about schools but the youth work sector is also a major area where young people are involved. The National Youth Council of Ireland has the remit of rolling out the MindOut programme in the youth sector. The programme is slightly different in the youth sector because it is very much tailored to each young person's specific needs. The young person will fill out a needs assessment and will be able to indicate what area needs work, whether it is behaviour that develops confidence or decision-making skills. The programme is tailored to support each young person. Youth work organisations are trained up on this. From November onwards, schools completion officers will also be trained up and each programme will be tailored to the young person.

Another programme, FRIENDS, was introduced by Carlow Regional Youth Services. It is the only programme that is cited by the World Health Organization as evidence-based for anxiety in children. It is effective at all levels. However, there is a capacity issue in rolling it out. The service simply does not have sufficient capacity to roll out the programme. Such programmes provide great support to young people from a young age. The well-being guidelines will be great. It is similar to the health quality mark whereas the school will have to take a holistic approach. Those involved will not only do work on mental health. They will look at the whole organisation to identify how they will create a more health-promoting environment. That is what the youth work sector does. Everything we do is about embedding health promotion. The Department of Children and Youth Affairs did a review of youth work funded projects to find out what was working and what was not working. One finding of that process was that there are seven potent mechanisms. The title may have changed since the review was done. If a programme is seen to be developing a young person's communications skills, relationship skills or decision-making skills, it is considered to be highly effective. That is what is needed in prevention. If a young person can develop these core competencies, he or she will be quicker to deal with whatever comes his or her way. There are programmes which address that but there are funding and capacity issues.

It is hard to come up with something fresh after two hours of discussion, but I wholeheartedly agree with much of what Deputy Funchion said. I also concur with Mr. Church on primary schools. Do children start first year of secondary school at 11 or 12 years of age? In any event, by the time children reach the teenage years, many of their core skills are very much developed. Although they are still developing, the groundwork has been done. Prevention and early intervention work should be done at primary level.

I wish to make two specific points on social media abuse and negative or difficult material online. Have the organisations had interactions with social media firms? Are they doing enough to help, for want of a better word, contribute or provide funding in the area to support mental health? I have read several studies that came out in the UK. God knows, we all know that Twitter is a negative space. We question it to protect our own mental health sometimes in the positions we are in. This is something that was touched on by one of our guests. Does a teenager have the objectivity to recognise reality as it relates to Instagram? It may seem that the world is perfect but people filter things. It must be recognised that someone might have just had the biggest row in the world. Yet, he or she looks in his or her element and it appears that life is perfect. Teenagers do not have the objectivity or skills to know that the person may actually have had a bad day yesterday and will probably have a really crap day tomorrow. Life is not as perfect as these people's clothes look or as their smiles or filters makes them look. What can social media firms do? What can we do policy-wise to counter that? It is ever increasing. We have to accept that being online is life for many young people now. Do our guests have any thoughts in that regard which could be helpful for our report in terms of direction and policy?

Mr. Ian Power

It is a timely question in light of all that is happening for young people online. The interesting thing is that there is a limited evidence base. There is emerging evidence but every new study with a questionable sample size makes headlines. It is difficult to distil what is evidence and what is subjective commentary. What we know from the good solid evidence base that what is emerging is that it is not necessarily social media but how we interact with it that is making the issue greater for children and young people. There are two tracks to it. The first is the way a person is engaging with social media. If people are passively consuming content and not engaging with friends and individuals they know or having meaningful interactions, then it negatively impacts on their mental health. Screen time is not necessarily a major indicator of poor well-being. However, it is if a person is using a device from midnight to 3 a.m. and not getting a good night's sleep, which we know is crucial for mental health.

The emerging literature suggests that a certain young people are predisposed to being more vulnerable to things like, for example, being on certain platforms and lacking the perspective that not everyone's life is perfect. Those young people would be more vulnerable eating disorders and things of that nature. It is a question of understanding that as a factor for a certain cohort and trying to build the resilience for that cohort.

How do we do that in a practical sense? It feels so intangible.

Mr. Ian Power

It does. That is because it is like resilience. Resilience is such a global concept in itself and it is not something we can give to children. It is, rather, the result of multiple things, including interactions, programmes and interventions over the course of life. I agree fully with Senator Noone that we need to start at a far younger age to build resilience at the pre-teen stage so that when young people get to that stage they are able to cope with it more readily.

The Senator also asked about social media companies. Generally, there are numerous initiatives and we are partnered with them on a couple of them. We are a member of the global suicide and self-injury advisory committee for Facebook. It is quite difficult because on Instagram, for example, young people will post content relating to self-harm. We know that content could be triggering for others. It could prompt others to engage in that behaviour if they are vulnerable to it themselves. Where do we draw the line? Someone may post something but may be in recovery and may be proud of his or her recovery, while another person might be posting something that is encouraging or promoting the activity. It is quite difficult. The policy line is quite severe in that area. We are all grappling with it. However, to speak to the larger point we cannot get the digital safety commissioner soon enough. From our perspective these are policy decisions the platforms do not want to make. They want to be told what it is, because from their perspective that is far more efficient.

Some of the content that they are allowing fuels their industry.

Mr. Ian Power

That is for sure.

There is no major buy-in from them on that. It must be imposed on them.

Mr. Ian Power

I believe there is an appetite for that to take place. From our perspective, an emerging issue with children and young people that is severely impacting their mental health as well is the non-consensual sharing of intimate images. The definition of "harmful communications" must be expanded to include that, so the Garda is more readily equipped to respond in those circumstances. It is particularly affecting younger men. For whatever reason, images are being shared and then, essentially, they are being blackmailed. It is causing huge anxiety for them. We had two cases in the past week alone that we had to refer to the Garda National Protective Services Bureau.

In our opinion, the legislation is the silver bullet. It means having a body we could go to that can both co-ordinate the education campaigns and also enforce take-down, which is a big thing for children and young people as well.

It is interesting how we interact with the language Mr. Power uses. I would say we are all responsible for our behaviour and we develop culturally in ways whereby we act and interact with things differently. However, social media firms are responsible, in a way, for how we interact with them, if Mr. Power knows what I mean.

The Senator is right. I will intervene in the conversation at this point given that Mr. Power has raised this. The Irish Council for Civil Liberties yesterday called for amendments to the Non-Fatal Offences Against the Person Act 1997 specifically relating to what he mentioned, which is very timely this week. When Mr. Power referred to images being shared, it sparked the memory of Dara Quigley, a lady who sadly took her own life - I believe it was last year - after images of her got into the public domain. It highlights a very unfortunate inertia in the Department of Justice and Equality in such an important space. The Department is responsible for this and it is not as if it is a bolt from the blue. People have been talking about it for years and it has been debated in the Houses on several occasions, yet nothing is being done. I want to put that forward because it would be inappropriate not to mention it.

I did not ask questions earlier and I thought I would be more brief.

Please do so.

Senator Warfield failed to mention that Senator Mac Lochlainn is from a Traveller background. He has been a passionate advocate in the Seanad, and previously in the Dáil, and I do not understand why he would not be on the committee Senator Warfield mentioned.

This is totally out of left field, but I have a question for Professor Dodd on the legalisation of cannabis. There has been much talk about medical cannabis and there are many sane reasons-----

I cannot find the hook into mental health in that, but the Senator should ask her question.

Cannabis use was touched on earlier. I know a few psychiatrists and, anecdotally, much psychosis and difficulty in mental health has been brought on by cannabis. Where does Professor Dodd stand on that question?

Dr. Philip Dodd

I do not think it is anecdotal-----

It is anecdotal for me.

Dr. Philip Dodd

Yes. First, this is an important issue to raise in the context of a mental health discussion, be it in respect of young people, children, adults or the general population. The association of the use of cannabis with the subsequent development of mental health problems is well established. I will not go into the technical aspects of the literature but a recent comprehensive publication aligned the use of cannabis with the subsequent development of psychosis, depression, self-harm and suicide. That link is very strong so any discussion on the liberalisation of cannabis must be very much aware of the experience in other countries of the impact it has had on presentations. In Ireland, after psychoactive substances that were available in head shops were restricted, a number of Irish research studies, including research from our national self-harm database, showed that the level of psychiatric admissions reduced.

The prevalence of relevant associated self-harm also dropped. Society must always be aware of the unintended or intended consequences of the liberalisation of what are psychoactive substances. In the same way, we know alcohol is associated with up to one third of self-harm presentations across our emergency departments.

Even depression, not to mind self-harm.

Dr. Philip Dodd

Absolutely. We hope any evidence-informed legislative changes, such as through the Public Health (Alcohol) Act 2018, that could impact on the availability of psychoactive substances, including alcohol, will see a positive impact.

A psychiatrist I know, who is a colleague of Professor Dodd, said that he cannot quantify it exactly but that almost half of the admissions are related to cannabis.

Dr. Philip Dodd

Absolutely.

That is frightening. Professor Dodd has not said that he does not think it should be legalised, but I would be very reluctant to go down that road.

I call Deputy Eugene Murphy on behalf of Deputy Rabbitte.

There are hardly any questions left to ask at this stage. Many of the questions I had lined up have been asked. I will pose them in any event and our guests can shorten their replies or indicate that they have already answered. First, I acknowledge the presence of Ms Kate Mitchell. She was in Roscommon at a seminar I ran and she was excellent. She was extremely impressive and had a good grasp of the situation. Everybody who attended the seminar was highly impressed by her commitment and knowledge. It was great to have her with us and I thank her.

I will turn briefly to the issue of care. It is amazing that this country has very poor statistics in the context of young people who have been taken into care, which is very sad and traumatic. We all know people who have been taken into care. Statistics in England show that over 45%, perhaps up to 50%, of children taken into care go on to develop mental health issues. There are approximately 6,500 children in care in this country at present. There is one thing that greatly upsets me. Obviously, many children are taken into care for good reasons, such as their safety or welfare. It is not a criminality situation, yet young people who have been in care are over-represented in our criminal justice system. Does any witness wish to comment on that? I find it quite disturbing.

I do not doubt the goodwill of everybody in this room to make things better and to help people in extraordinary situations. It is good that we are all talking about this more. However, I often get the sense that we appear to always be lagging behind other countries. We have so many reports and so much conversation. I have been a Member of the House since 2016 and I have heard plenty of talk about mental health and what we can do but, with no disrespect to anybody here, there is a lack of real action. One thing that is emerging from this meeting is the need to get back into schools, particularly in the context of dealing with schoolchildren at primary level. We always say that we must move away from the past. We have quite a shameful history in caring for children, but in the past, and it was not today or yesterday that I was in primary school, there were always road safety programmes, civics programmes, etc. It is good for young people to discuss climate change - and we have to listen to what they are saying - but surely there should be a huge focus for young people on the damage caused by alcohol and drugs, which are in every corner of society. They are as prevalent in the rural areas of Roscommon as they are in any part of the cities of Dublin, Cork or Galway.

Why can we not move things on and make progress? It may be said back to me that I am a legislator now and that I need to do it but I need to put that question out there. We seem to be always talking about the issue, having reports prepared, and we are still very slow to move on.

I come from a county where on mental health, in three years, 2012, 2013 and 2014, €17.5 million was returned by the HSE, unused, where we had people in desperate situations. We have had situations where people have died in our hospitals because of incidents. This is a fact, yet this money was returned. Whose fault was that? Why did it happen? When one considers what families and communities have gone through in losing loved ones, whether they were young, parents or old, this does not matter. The family effect is the same. To think that the money was granted and not used. Why is that happening and why can things not be moved on?

I have a quotation from the Scottish First Minister, Nicola Sturgeon, who said recently on mental health and about those who left care homes: "We will make changes as we go along rather than simply wait until the review makes its recommendations." That is what we need to adopt in this country. Can I have a quick comment from the panel on this and I accept that some of this may have been answered before?

I thank Deputy Murphy and ask Ms Charles to speak first, please.

Ms Karla Charles

I thank Deputy Murphy and for mentioning also children in care which is the focus of EPIC's work. I do not know if the committee is aware but the Irish Penal Reform Trust completed a report on the correlations between care and justice. There are a number of findings and suggestions within that report which I draw the committee's attention to and which I highly recommend.

One of the things we have all mentioned here today are early interventions and supports. We need more data on children in care and have that longitudinal study done that has been long promised. We need to have a mental health strategy specifically for children in care as part of the bigger mental health strategy or specifically for children in care. We need training on mental health as regards children in care, including the trauma-informed training that many have mentioned.

Ms Nicola Sturgeon in Scotland, who was mentioned, is an impressive woman and speaks from the heart. The point about making changes as we go along is valid, as any change in little steps is better than none. While we are waiting for posts to be filled, strategies to be developed and Acts to be reformed, we should be taking those smaller steps and thinking creatively about how we can do that.

I thank Ms Charles and call Ms Mitchell.

Ms Kate Mitchell

I thank Deputy Murphy and thank him for his very kind comments. I am always very happy to take a visit to Roscommon.

On his first point on children in care, that is EPIC's expertise, and to draw attention more widely to the issue of mental health and the criminal justice system where we are seeing many people with mental health difficulties ending up in the criminal justice system, and more specifically in the prison system because they are not getting the appropriate mental health supports that they require. There is certainly a complete lack of resources in the prison system in providing a range of mental health services and supports and in particular psychological services and supports. One of our asks in our budget campaign for 2020 is that there would be adequate investment in mental health supports among the prison population and also towards developing our specialist forensic mental health services. There are plans to develop a new forensic service, which is due to open in Portrane next year. I draw the attention of the committee to the fact, however, that the European Committee on the Prevention of Torture has previously reported that even with that new facility, it will still not meet the demand. We need to continue to look at that issue.

I will also address the Deputy's point about lagging behind or not fulfilling our own national standards and international obligations.

There are a range of issues related to that as to a lack of implementation of policy. A prime example is our existing national mental health policy: A Vision for Change. There were a number of reasons for that. The group that was tasked with monitoring implementation was disbanded and there was not a costed implementation plan. Going forward, we need to do much better. With the revised policy, it is so important that we have an independent monitoring group, that the plan is costed, time-lined, and there is effective oversight of that.

Another issue is a lack of coherence between our policy and legislation. If one takes our current policy, which promotes the implementation of the recovery ethos in mental health services, on the other side, people do not even have a statutory right to a recovery plan in mental health legislation. That clearly shows that lack of coherence. If we are to be truly effective in improving our services and ensuring that we have a modern recovery-focused mental health system, that coherence must be there between policy and legislation. In that context I would raise the urgent need for reform of the legislation.

I thank Ms Mitchell.

Mr. Ian Power

I thank Deputy Murphy. In response to his frustration as to there being a lot of talk but where are we going, in our discussion today we should not lose focus on the root causes of mental health issues, especially in how they affect certain vulnerable communities. The core of it is that mental health is a social justice issue. The single most impactful factor in a person's holistic health is how much societal oppression and discrimination that person or group experiences. This might be as regards young people in care, as the Deputy has described, or people who are experiencing socio-economic discrimination, racism, as already discussed, people who are LGBTI+, gender-based discrimination, or emotional, sexual or physical violence and neglect. These are all social factors and root causes that we need to understand. These lead to the traumatic brain-body responses that can cause significant mental health difficulties. We should not forget about those root causes when we are talking about many of the symptoms and different issues we have discussed this morning.

As to the general point about action, I cannot overstress the point about the Pathfinder mental health initiative, for instance. As we have discussed and based on that point that I have just made, mental health is cross-cutting. It is not just the purview of the Department of Children and Youth Affairs, or the Department of Health, it has as much to do with housing as with health. We should establish this unit to be able to co-ordinate Government policy effectively across all Departments as suggested by the Pathfinder initiative and its proposed unit. It has the support all of the Secretaries General from each of those three main sponsor Departments and the Ministers have signed off on it. It is still, however, being looked into. We need the urgency to establish that type of model of policy-making to be able to drive some of the changes that the Deputy would like to see in the question that he asked.

I thank Mr. Power.

Mr. John Church

I thank the Deputy for his comments. There is nobody on the witnesses side of the table who would disagree with anything he has said. We all share frustration. We constantly ask questions of Deputies, Ministers and committees like this one. If they cannot answer the questions we are in real difficulty.

I am a year in this job now and one thing I am growing to learn - there is a Joint Committee on Justice and Equality next door talking about new legislation that is going through - is that as a country we are very slow to enact legislation that to the public's eye is absolutely obvious. For the ISPCC there is nothing more obvious than passing the legislation that is being debated next door. If we are looking for small things that can make a big difference, there does not appear to be any political wrangling around this. All the political parties, in my observation, seem to agree that it is a motherhood and apple pie situation going on here. The Digital Safety Commissioner, right now - probably within its own commission or within the Broadcasting Authority of Ireland and giving it real teeth - would make a significant difference.

There is legislation in place, which is well worded. Rather than engaging in too much wordsmithing, we should get the legislation through very quickly and get it out there. Online safety is the child protection issue of our day. The quicker we get this through, the better.

Given that this committee has repeatedly called for the establishment of a digital safety commissioner - such a request was included in our report - Mr. Church's comments are very much appreciated. As he has rightly pointed out, we are all in agreement. We just have to get it done.

Mr. John Meehan

If Deputy Eugene Murphy visits the Connecting for Life website, he will see a progress report on the actions involved in Connecting for Life. The fundamental lesson from Connecting for Life was that there was a need for a robust implementation plan and a governance structure. My office is responsible for driving it through. It is very difficult when we have to deal with other Departments that may not see this is a priority. The governance structure, through the cross-sectoral group chaired by the Department of Health, has informed decisions and enabled progress to be made with the implementation process. I would advocate for that.

I refer to social media, which was mentioned by Senator Noone, as an example of the other actions that have been taken. We have intervened with Facebook to ensure certain uploads are taken down, for example in the case of an individual who has posted his or her intention to make a suicide attempt. Facebook has been very forthcoming in such cases. Our information is that Facebook now has a mental health specialist with whom we can liaise directly. Our research shows that the contagion effect has a negative effect on vulnerable members of the community, particularly vulnerable younger people.

I draw the attention of the committee to our Mind Monsters initiative, which we launched in 2018. It was developed by experts and young people. Young people are a fundamental part of it. As part of the digital forum, we include little animated programmes about minding one's own mental health. We are getting in on the digital conversation in a positive and preventative way. We are engaged in a collective effort with our colleagues in ISPCC and SpunOut.ie.

I am not sure where the figure of €17 million came from. Is that just from County Roscommon? Deputy Murphy must remember that the county is part of CHO 2, which includes counties Galway and Mayo.

No, it was Roscommon only. I can give Mr. Meehan the material.

Mr. John Meehan

Okay.

It came at a time we had particularly bad issues with mental health in our county. It was disturbing. I am here to contribute in a positive way and I acknowledge that everybody is trying to improve things. It is such a critical area. We need to move as quickly as possible. A sum of €25 million might not now be expended on mental health. This should not be happening when we have such a crisis.

Mr. John Meehan

I cannot provide information about the €17 million at the moment. However, I will endeavour to provide it at a later stage. Perhaps we will communicate after the meeting.

We will communicate.

That is appreciated. I call Deputy Buckley.

I thank all the witnesses for their honesty, which is important. Being the final speaker has given me a great opportunity to listen. I want to pick up on a few points that kept coming up, before throwing a few other points into the conversation. I will try to be as fast as I can.

We have heard about coping skills, funding and joined-up thinking, the many programmes and the 47 reports that have been produced. I was lucky to be a member of the progressive Joint Committee on the Future of Mental Health Care, which was shut down. Consensus was agreed and signed off by all parties. There is agreement on the issues. It gets difficult when it comes to trying to get legislation passed.

The television programme, "13 Reasons Why", has been mentioned. When it was aired, people came to me because they were panicking. I advised them to see what it was about first. I listened to people afterwards.

We have to be more outspoken. Some people thought it was very offensive, but my view was that it was very educational. I have been saying this for years, since I first educated myself about these issues. I have been a mental health advocate for many years. We need to get this issue into primary schools. We need to get back to civics. I was told at a conference that this could not be done because talking about mental health and suicide would put thoughts into people's heads. I said in the politest way possible that this was like saying that giving someone €20 to put petrol or diesel into a car means that the person is going to crash the car.

We have to get out of the bubble we are in. We are dealing with very different people nowadays. It is very different and complex stuff. Every time a person anywhere in the world buys a cup, a pen or a set of headphones, it comes with a set of instructions and a warning on the packaging. The Internet does not come with instructions or a warning. The younger generation has advanced very quickly. Young people have moved on. The Internet has made them slightly detached from reality. This is where I go back to education again. We are not giving our children the skills and the ability to cope with life's pressures as they come along. It has to start at an early age.

We expect that our parents will die at some stage. We are not going to like it, but we expect it to happen. This means we need the skills to deal with it. In the same way, people need the skills to deal with their sexuality or whatever the issue is. People need the skills to deal with relationship challenges. It goes on and on. It is probable that the most recent one or two generations do not have those skills. They have been lost. We have to go back to the education system to restore them. We have to resource it fully. Education in the area of mental health is not being resourced. It is being pushed along. Pilot projects have been spoken about. It has been suggested that the Samaritans will take this over, but they are not capable of doing so.

I am trying to build a picture here. While everything is moving in the right direction, it is not joined up. My biggest fear is that it is going to get lost. If we are talking about looking at demographics, as Deputy Eugene Murphy suggested earlier, we will all have problems. I recall that 69 young people took their lives in my local area between 2000 and 2002. When I spoke about it, I was criticised on the basis that I was bringing the tone of the area down. I found that disgusting. It is a question of education. How do all of the families affected feel?

Everyone who has come to me in the past two years, young and old, has said that even though they were being told that services were available and hearing the messages about minding their mental health that were being broadcast on television, they could not access the services they need. A person who has a disability in addition to a mental health requirement certainly will not access any service in the country. I have spoken to the Minister of State, Deputy Daly, about this. We need to start picking demographic areas in the country or in the CHOs to be targeted with fully resourced pilot projects.

The most frustrating thing I hear within CAMHS is that there is a premier league of 74 teams. One cannot have a premier league with 13 people on one team, nine people on another team, five people on next team and 22 people on yet another team. It does not work. Something has to be done in this regard. If we do not get to the crux of this from the start, and if we cannot provide the best ingredients to make the proper cake, it will not work.

It is ironic that we are speaking about this issue the day before World Mental Health Day. I will finish by asking two questions. I thank the Chair for her patience. In the honest opinion of the witnesses, are things going forward? What is the one thing they would change today to get things done right? We have had issues here. The Assisted Decision-Making (Capacity) (Amendment) Bill 2019 has been sitting in the Chamber for almost three years. I am black and blue from trying to get it through the Chamber. I cannot do so.

Reference has been made to preventative measures. In July 2016, just after I was elected to this House, the first legislation I proposed was a simple Bill on the issue of suicide training and prevention. It provides that everyone who takes up a public sector job must do the SafeTALK programme. This would give people coping skills and spotting skills straight away. The political will does not exist to progress this legislation. These preventative measures are simple. I hope the witnesses understand where I am coming from when I talk about being bounced back into it. Are they happy with where we are now? If they could change something today, what would it be?

Ms Kate Mitchell

I thank the Deputy for his comments and questions. Things have changed in a number of respects. For example, there has been a substantial decrease in child admissions to adult units and investment in initiatives and services like Jigsaw, which provides valuable support to young people in the community. However, it seems that we take one step forward but two steps back and I shall give a good example. A national director for mental health was appointed and a national mental health division was established but the service was dissolved early last year and resulted in a gap in services. There is a requirement for a director who has distinct leadership and oversight when it comes to the national mental health budget, planning, reporting and implementation. The Mental Health Reform organisation has, since the dissolution of the office and post, consistently advocated for re-instatement.

I am sure that Members are well aware that there have been issues with releasing mental health development funding this year. The fund amounts to €55 million but only €30 million has been released to date and this is October. We need investment to sustain the existing levels of services. We also need investment in new mental health services to develop the sorely needed supports, not just in specialist mental health services but in primary care, community and voluntary supports. We also need a clear commitment. To echo the comments made by Mr. Power, it is not just the business of the Department of Health to address these issues. There needs to be a whole-of-government approach if we are to effectively improve the mental health outcomes of children and young people who live in Ireland.

Data and research are required. At present there is no national mental health information system. The child and adolescent mental health services, CAMHS, used to report and provide comprehensive details on who accessed its services and what happened in the services. Unfortunately, the data is no longer provided. If we are to effectively plan, deliver and implement services that meet the needs of children and young people then we need data and research.

Dr. Philip Dodd

I thank the Deputy for his raising these very important issues. I shall specifically answer the question on the broadcast of "13 Reasons Why" and the tension between the balance of freedom of expression and freedom of the press versus social responsibility. It can be very difficult for us to understand the impact a careless description of an episode of self-harm can have on vulnerable individuals in creating a triggering experience. The one benefit that we have in Ireland, and I have said three times so I have probably over-emphasised the fact, is that we do have good self-harm data. As one will see from that data that will be published tomorrow, in May 2018 there was a surge in self-harm presentations at emergency departments across the country that coincided with the broadcasting of the Netflix series called "13 Reasons Why".

I totally respect the data. I believe that where there is an action there is always an instant reaction and I do not want to specifically dwell on the series. Is it possible that children did not have the skills before watching the series to realise what was wrong with them but afterwards saw it as an outlet and an opportunity to cry for help? Does Dr. Dodd understand my point?

Dr. Philip Dodd

Yes.

Education is key. Everybody knows what to do if they break a leg.

When a person feels confused, his or her heart and mind are not in the right place. It takes a lot to hurt oneself. A person may think he or she is abnormal and wonder why he or she is doing it. Nobody else knows because he or she believes he or she is the only person in the world doing it. Thankfully, that attitude is changing. Yes, it is hard to strike a balance, but sometimes we must be brutally honest, which is why I have raised this matter. I can see the clinical side, but education is key. When Deputy Eugene Murphy and I were first elected, we were given a big box, as was the Chairman. I went through everything that was in it and read all of the instructions, but there was no mention of common sense. Therefore, we must strike a balance.

Dr. Philip Dodd

I agree with the Deputy that it is important to support any educational initiative that enables individuals to develop resilience, be they children, young people or adults, but that is the message. The counter argument to sensationalist or negative messages on suicide and self-harm is as follows. We know that positive stories in literature about recovery have an impact in reducing levels of self-harm. Therefore, it is not good to consider narrowly the prevalence of self-harm on a dashboard that indicates the impact of a message. There is the so-called Papageno effect, by which means a prominent message of recovery has a positive impact on levels of presentation at hospitals. One can argue that is a very blunt indicator. However, when one argues for public messages and education programmes, personally, I argue more for a positive message of recovery, rather than sensationalising and giving detailed accounts of episodes of self-harm. I get that there is tension between freedom of speech or freedom of the press and the importance of social responsibility.

We will agree or disagree.

Dr. Philip Dodd

I have talked enough. It is time for others to comment.

Mr. Terry Dignan

I will answer the questions posed by Deputy Buckley by referring to the issue raised by Deputy Eugene Murphy concerning children in care. I will restrict my answer to children in care.

Deputy Eugene Murphy asked whether we were happy where we were. From our perspective, as an organisation that works with children in care, we recognise that progress has been made, but the honest answer is "No". As long as children in care are over-represented in the criminal justice system and homelessness and addiction services and as long as children in care become parents and have children who end up in care, we cannot say we are where we want to be.

Reference was made to Nicola Sturgeon. She has ordered a review of the entire Scottish care system which we view as being further ahead than ours in terms of initiatives. Ms Sturgeon sees herself as the corporate Mammy. For children in care, all of whom do not have parents or a family to fall back on, we need a system that is child focused and centred. Under the current system, for children who leave care to receive support or an aftercare service, they have to engage in continuing training or education. Where children have had a fractured second level education, with multiple placements, it is very difficult for them to make a decision to move straight into third level education and training because there is no provision for them to take time out when they would be fully supported in considering what they want to do in their lives. They are forced to make quick decisions when often they do not have the information required to choose what it is they want to do. As long as these structures stay in place, we will end up continuing the cycle of having children in care being over-represented in all of the areas about which we have talked and they will potentially become the parents of children who will be placed in care because of their inability to look after them because of the ineffective support they will have received. We are making incremental improvements, but until we review the system and make it focus on the child, rather than the structure that suits the State more than the child in care, we will continually face these problems. If we could take the money that has been spent on inquiries into issues affecting children in care and put it into a review of the care system, it would be money very well spent.

Mr. John Meehan

I thank Deputy Buckley for his questions. Yesterday when I spoke to my colleague, Mr. Jim Ryan, he said he was preparing his responses to the questions about referrals, particularly in the courts.

I asked questions about a certain platform and appreciate what Mr. Meehan has said.

Mr. John Meehan

He will get back to the Deputy.

I appreciate that.

Mr. John Meehan

The Deputy asked whether things are going forward. Two weeks ago, we had an international congress on suicide prevention in Derry attended by 800 people from all over the world. I am happy going forward that we are the only country that has a strategy and an implementation plan, which we reviewed mid-term, warts and all, from the top down. We have to be honest about that and how we are progressing. The way forward is the cross-sectoral aspect. As I say at every public appearance I make, suicide prevention is not only a HSE responsibility. It is a responsibility for all of us and we must work collectively.

I was very happy with presentations made by colleagues in my office on evaluation and monitoring. We evaluate and monitor to see how we are getting on. We have an active as opposed to passive strategy and an implementation plan. Notwithstanding the negative view of the mental health services that is sometimes taken, the National Office of Suicide Prevention is viewed as an exemplar internationally. It is important to recognise that.

Mr. Meehan is spot on and I thank him for that. This crosses every sector, including banking, housing and the general health service no more than mental health services. It is difficult for us to cross all the sectors. Deputies encounter barriers too. When we raise an issue with a certain section, we may be told that responsibility lies with the Department of Justice and Equality and that Department, in turn, may tell us that responsibility lies with the Department of Children and Youth Affairs. In that sense, I can understand the frustration.

Mr. Meehan is correct that when things work, people should be praised and given credit for it. We are not generally a society which likes to knock things. Basically, it is about telling the truth. When things are going well we should put our hands up and say they are going well but when things are going badly, we should put our hands up and say they are going badly.

Mr. John Meehan

I always say that those working in housing in local government usually see people at their lowest ebb, mentally and physically. These staff need to be trained. Our resource officers provide ASSIST and safeTALK. We have now guaranteed by 2020 that every Garda recruit will be trained in ASSIST and safeTALK. This involves working collaboratively and it took a fair bit of-----

We need to get the Bill passed.

Mr. John Meehan

We are working collaboratively and it is part-funded by my office. Funding is a big issue, which was raised by a number of Deputies and Senators. Like Deputy Buckley, I look forward to this afternoon and hearing the Minister give his overall view, particularly on mental health services. The increase in the budget of the National Office of Suicide Prevention from €5 million in 2012 to €13 million in 2019 is positive for the future. It will be reflected in the outcomes as we move forward with the implementation plan. I must acknowledge the role of colleagues around this table and NGO partners, as well as public representatives because their voice reaches us.

Ms Caroline O'Sullivan

I wanted to speak at the end because the Deputy's questions hit home. As for whether we are on the right track, I think we are. Listening to everybody on this side of the table speak of the recommendations for the future and the cross-party recognition that this is an issue, I believe we have to be on the right track and we must learn from that.

On the "13 Reasons Why" television programme, I agree with the point that education is very important. Rather than educating children around reasons others may take this step, we need to educate children on how to cope, inform them of who to go to if they have a worry and point out to them who the one good adult in their life is. If they cannot go to their mum, dad or youth worker, who can they go to? It is a matter of showing children the way. We can do that in primary schools but the biggest educator of children are parents in the home.

The unconditional love that that child feels is one of the key components of having a resilient child. The second key area of being resilient is that the child knows that he or she can go to his or her parents or grandparents and talk to them if he or she has an issue. The final key area is the fact that children will learn that they can cope, deal with adversities and can come out the other side. That is where one has resilient children. The language has changed in this country. We are talking about coping capacity and about resilience. We are on the right path but we have such a crisis now and that can be clearly seen in terms of the CAMHS waiting lists. That has to change. We need a review of all the resources within CAMHS to see what disciplines are the worst hit so that we can get those children seen to.

Prevention is always better than cure. Listening to children is the very first step and that is why Childline is there 24 hours and the crisis text line is there 24 hours. We have to let our children know about these services and we will do our part to make sure children look at what support systems they have.

Thank you very much, Ms O'Sullivan.

Can I make on very brief comment on mental health? It is important to put it on the record.

In regard to mental health, there are some incredible people working in the HSE. Looking at it from our perspective, we are frustrated with waiting lists and waiting times. We have to represent our people. People very close to me had to use these services. The people they have dealt with have been outstanding - in fact, they have been their saviours. I wanted to put that on the record. However, we really need to sort out CAMHS.

This may elicit a response. It is not mandatory but if the witnesses would like to respond, they should feel free to jump in. There are a few things on my mind, having listened to the witnesses this morning. I am very conscious of the time. We started at 10.15 a.m. and it is now almost 1 p.m. but we will finish very promptly. Mr. Meehan mentioned the HSE is not solely responsible - of course, it is not. We are all responsible. In terms of promoting mental health awareness, there are so many things we have done and so many things we must do, including resilience and all the things that are patently obvious at this stage. There is no doubt in my mind that children with anxiety need all the supports available to them at a young age because it is critical to support young children in primary school who suffer from anxiety, and it is an ever-growing trend. I have read publications from most of the bodies represented today and it is a common theme throughout. I refer to the peer pressure and bullying young children in primary and secondary schools face and the role social media firms play in not just policing what is on social media or doing it properly, which they do not, or being given directions, which they are not.

I will give an example. I was not going to mention this, but I will do so. I was away last weekend and I made a comment on Twitter which I do a lot. Somebody inferred that I should be beheaded. It was not because I was in an Islamic state but I presume that is why the idea popped into their head. I very rarely do so, but I reported the tweet but it did not break the Twitter rules. I did not mention that to make a headline or whatever but show the sheer stupidity of that. The computer said "No". Some eejit somewhere in the world decided that it was not appropriate to take something like that down. It really got under my skin. I was so annoyed and I asked myself: what if I was a teenager and it was sent by the guy who lives down the street from me? Those pressures and that form of bullying are so prevalent in our society. Nameless, faceless people believe it is okay to do this, but it is not. That is why giving the Digital Safety Commissioner teeth and putting it into the BAI, or at least the code, would be an important step for us to take.

I am also aware of the work teachers, resource teachers and SNAs are doing in relation to young children.

I am also aware of the work that teachers, resource teachers, and SNAs are doing with regard to very young children. I am not sure if the public is aware of them but things likes Braincalm are being used. This is a very minor programme but it is really beneficial to children. It calms them and allows one to work with them to get to them to a point at which they can talk about things and understand the impacts of the world around them. When I took the Chair earlier, I heard Mr. Church says that 1,000 calls come into Childline every day. That is just one NGO, I am sure there are thousands more. In a country with a population of almost 5 million, it is very disturbing that 1,000 children are making such calls every day, and we only know about the ones who picked up the phone. What percentage of the children who need help feel strong enough to pick up the phone? Is it 5%, 10% or 50%? I do not know.

To tie back into what the witnesses have said in response to Deputy Buckley's very relevant question, are we in the right place? Are we going in the right direction? The witnesses are the experts. They are the people working in the field. If they say we are heading in the right direction, I accept that. I know there are problems. Representatives of the child and adolescent mental health services, CAMHS, were here at the end of September. Deputy Buckley and I were here for that meeting. I know how important what they do is, but I also fully understand the need for us to understand why there are gaps, where they are, and what we can do to fill them. The committee has three reports outstanding. We will probably be publishing them before the Christmas break. One of them is on the recruitment and retention of social workers and one will be on youth mental health. The common theme is that we cannot get people into the positions to deliver the service. The budget does not matter, as Deputy Catherine Murphy quite rightly pointed out. One cannot spend the money because one cannot get the people to deliver the service. Something has to give. We have to figure out what it is. We know what it is. The question is whether we can afford it.

We have been here for the guts of three hours. I thank the witnesses very much for their engagement with us on this subject. The meeting is adjourned until 15 October, when the committee will meet in private session to finalise the report on child homelessness.

The joint committee adjourned at 1.05 p.m. until 1.30 p.m. on Tuesday, 15 October 2019.