I am making this submission as a concerned citizen, the parent of two boys, Oisín and Darragh, and a practising clinical psychologist, with over 20 years’ experience in health care. I see and understand the negative impact of the lack of services and vision for children and adults with mental health difficulties, autism and disabilities, as well as their families and communities. Mental health services are now where cardiac and cancer services were in the 1970s, namely, neglected, underfunded and tokenistic. As the cancer services launch their third national cancer strategy, we are waiting for a first national strategy focusing specifically on children’s mental health.
Having recently experienced the youth mental health task force, although well meaning, it was essentially tinkering at the edges of a broken system, akin to putting an engine on a paddle boat when what was needed was an aeroplane. It underwhelmed, as well as lacking measurement, accountability, resources and, most of all, a vision.
Children’s mental health needs to be seen beyond health care, a task that involves all of us. It is a societal issue covering the areas of justice, health and education. Gardaí, dedicated teachers, youth services, statutory, voluntary and charity partners all play vital roles. It is an equality issue, with vulnerable children at the brunt of social, educational and health inequalities and, particularly, the two great inequality challenges of 21st century society - health and housing. It is about more than the absence of mental illness. It is about services which offer positive well-being through vision, passion and authenticity to advocate for rapid access, quality-driven, compassionate and evidenced-based therapies which promote hope, optimism, mental fitness and resilience. Effectively, services must be needs-led for children and their families.
I propose a vision which centres on three pillars, namely, children’s centres of excellence with a one-stop shop and single point of entry; a needs-led step-care model and getting real about youth suicide prevention. The current system is broken. The dual track of CAMHS secondary care. on the one hand, and primary care, on the other, does not work. Children, families and carers are overwhelmed in having to navigate fragmented health care systems and bounced around local services, creating delays and causing further distress. Many times they fall through the cracks in service provision. CAMHS is a secondary service. It is the absence of appropriate primary care services, as well as school and community-based services, which exacerbates needs in CAMHS. GPs are totally frustrated by the system of referrals for children and refer simultaneously to important, underfunded and understaffed CAMHS secondary care services and primary care psychologists, where they exist. There are only 110 primary care psychologists. Medical classification models which use the diagnostic and statistical manual, DSM-5, or the international classification of diseases, ICD-10, as the sole criteria for acceptance into CAMHS are too narrow. They are not child or family-friendly or needs focused.
Children continually fall between the cracks. Recently, Mary, a 15 year old child with depression and self-harming whose name I have changed, was deemed not unwell enough for a CAMHS service. John, whose name I have changed also, who is on the spectrum with ASD and anxiety based issues, was not accepted in CAMHS and referred to a non-existing disability services where parents are overwhelmed and clamouring already in disability services for scarce resources and over the absence of intervention services. I see this on a daily basis. This is replicated right throughout the system. The system is broken.
A radical rethink on how services are provided is needed for children and families. We need to focus. It is better to light a candle than shout at the darkness.
We need one stop, single point of entry children's centres of excellence with appropriate staff governed through a broader psycho-social model - not a medical model - to deliver child and family centred care services. It would include psychologists, family support workers, child care workers, youth workers, play therapists, psycho-therapists, social care workers, medical staff such as GP, child psychiatrists, paediatricians and AMOs, audiologists, physiotherapists, occupational therapists, social workers, speech and language therapists. If we want to build a secondary school in the morning, we have a model and we can go out and build it and deliver that within a year to 18 months. We can deliver these appropriate centres if we have vision. All the care needs - the physical, sensory, emotional, disabilities and mental health - need to be seen from these sites. Significant strategic investment needs to ensure that these centres have family spaces, crèches, playgrounds, etc.
We need a single, open point of referral. Currently, there is no seamless single open point. If one asks any GP in the country, he or she is totally frustrated with the existing system. GPs cannot get children into the non-existing primary care services or CAMHS services. The CAMHS have raised the entry requirement so high, it is very difficult to get them in. I note my GP colleagues nodding here. They know it. They are at the front line. They see it every day. We see it every day and we see families in distress every day.
If we are serious about children's mental health, we need to be serious about funding and resources. Functioning and staffed children's centres of excellence need funding and resources. Currently 6% of health funding goes to overall mental health. The corresponding figure is almost 13% in advanced economies. This is why I am saying mental health is neglected, underfunded and tokenistic.
The next thing we need is a needs-led stepped care model. That is what people are talking about. A needs-led model would start by being population based. Then it would be school based, with school guidance services. If one can imagine it like a pyramid, the top of the pyramid is the inpatient unit or day hospital, the next layer under that would be a CAMHS service but we need to look at making it broader. We need to look at the school based services, youth services, GP services and then primary care centres of excellence that encapsulate all of this.
With that stepped care model, one has a graded level of intervention appropriate to the needs of the child so that it is developmentally appropriate. It delivers rapid access initial assessments to prevent the escalation of presenting difficulties and the subsequent requirement for specialist health care services. We need to ensure that there is effective gate-keeping for specialist health care services and that way we will increase their capacity to see the most ill children. It would improve continuity of care for service users via co-ordinating shared care activities with specialist services. It would provide early intervention focusing on at-risk groups. My presentation includes some other bits in that regard but I want to talk about getting real about youth suicide.
Rapid access to primary care services serves an important suicide prevention function. For example, evidence indicates that many of those who complete suicide have prior contact with primary care staff. It is critical that those individuals in distress can rapidly access primary care mental staff who can reliably evaluate risk and organise care to meet their needs.
We need increased access to psychological therapies. Families are increasingly requesting more evidence-based talk therapies. We need to promote recovery-focused partnerships. A recovery focus for children needs to be adopted across children's mental health services, as in adult services where we ensure we are getting recovery focus.
It is important that we provide care in appropriate settings and provide emotional and mental health care outside of physical care environments, such as accident and emergency, on a 24-7 365 days-a-year basis once the person has been medically assessed. We need to increase access. People typically engage, and by increasing next-day access, we will achieve greater traction and a faster turnaround for individuals. Important quick actions would include the need for a focus on well-being, early intervention and prevention, enhanced well-being and mental health. We need to progress with passing the Public Health (Alcohol) Bill 2015 because alcohol and gambling impact significantly on Irish society.
We need to address the issue of children and families who are in direct provision, which is Ireland's new industrial schools outrage. We need to support families by prioritising affordable and quality child care services. We need to get a helicopter view on this and to get away from the issue of beds. We need to look at how we are delivering mental health care and wellness and well-being for our children.
We need to prioritise disability, autism and emotional support. There is nothing new there. There are children waiting two years or four years haphazardly around the country. It is important that children with disabilities get supported. Otherwise, they or their families are impacted with significant mental health needs. In education, we need a full restoration of guidance counsellors and to deploy more counsellors to secondary schools, and provide life skills for primary and secondary school teachers.
Finally, there is the issue of legacy. I encourage the committee to think strategically and highlight the need for new thinking for 21st century services for children and families. The 1916 Proclamation refers to cherishing all the children of the nation equally but a line often forgotten is that the Republic declares its resolve to pursue the happiness of all its citizens. Let us have children's centres of excellences based in communities, appropriately funded and staffed, with partnerships with parents and children so that our children get the best physical, sensory, emotional, mental and psychological care where and when they need it. That is the measure of a society and the legacy I want for my children and all children in society.