Seven years as a clinician working with children and young people in the Child & Adolescent Mental Health Services (CAMHS) in Castlebar, Co Mayo, taught Dr Sharyn Byrne something fundamental - of those attending the service, almost one in two had a parent with a known mental health difficulty.
Dr Byrne, who co-founded the WITH (Well-being In The Home) project, says: "This is consistent with international figures, which indicate that the figure is one in three, 49pc. Of that, 64pc have a mother with mental health difficulties, and for just over 20pc, it's a father. Around 15pc of our children and young people attending CAMHS have both parents who experience distress due to their mental health."
There is, she says, "lots of evidence of young people taking on carer roles for younger siblings when their parents are compromised to the extent that they can't manage. In the absence of information, in the absence of an understanding of what's happening, and the language to describe it, there can be emotional, social, behavioural, psychological and mental health consequences.
"And right now, although there is a recognition of the need to move towards a more family-focussed intervention - like Denmark, for example, where, if you arrive in an adult mental health service and you are a parent, the family automatically get the intervention - that doesn't happen yet. At the moment, in this country, you deal with the person in front of you with the mental health issue, rather than wrapping around the family".
The result, she says, are "forgotten children", who are not sufficiently supported and cared for. "These are the children who don't come on the radar. They sit quietly at the back of the class, worried - 'was dad able to manage his suspicion?' 'did mum get out of bed?'. Their heads are somewhere else. The child might be very dysregulated with the classroom, be given a diagnosis of ADHD, but might just be trying to manage what's happening within the family."
She explains: "[Children] are naturally egocentric. It's part of their development that they would perceive what happens in the world relative to themselves. They take ownership of what's happening and of the energy that surrounds them. For instance, young children take on roles and responsibility above their developmental capacity, but also, they internalise.
"Say that morning, mum has got annoyed because toys are all over the floor, and goes to bed for two or three days - and this can happen; these are examples drawn from experience - the child may take that and create an association in their head, that they caused mum to go to bed because they weren't tidy enough.
"Or, an eight-year-old whose father is experiencing a psychosis, involving paranoia and delusions, and the child witnesses overly-elaborate safety precautions every night - an eight-year old needs to feel safe in the world and looks to their parents to provide that safety.
"But if the parent is anxious and carrying that frightened energy, well then, the child cannot perceive the world as a safe place, and that is detrimental."
In response to this, the WITH project aims to provide clear, appropriate information and support.
"A big part of this is naming the massive elephant in the home," says Dr Byrne. "Helping the young person to understand what's happening, to name it and have a language for it. The WITH Project emerged from a series of focus groups we had with parents who attended mental-health services. One of the themes that emerged from that was that it can be very difficult for parents to dialogue with their children about their own mental health. They were very conscious of frightening their children, and very conscious of the impact of their mental health on their children.
"They were also very aware of the lack of resources and support, even within services around helping them to dialogue with their children around this issue in a way that wasn't frightening. They were aware of their children's fears around 'catching' it - 'if you have it, will I have it?'."
"After a considerable amount of research around what was available in Ireland, I found there are small pieces of written information available to children and young people, but there is no dedicated resource that actually tackles this issue and brings their attention and understanding to what their parents might be going through. WITH is the first ever online resource for children and young people, created with Mindspace Mayo and focus groups with young people who represented CAMHS, Comhairle na nÓg and the Mindspace Youth Panel."
WITH is a series of informational videos, developed for children from the age of eight up to young adults, performed by young people and available on YouTube. The idea is that they will assist children and young people to understand what mental health is and how to mind themselves.
"We go through various mental health difficulties like anxiety, depression, alcohol and substance abuse, with three more videos to come on psychosis, personality disorder and bi-polar disorder," Dr Byrne explains. "These would be the primary mental health presentations that their parents may present with. The videos explain what these difficulties are, what they might look like, feel like. They reiterate all the way through to the young people that they are not responsible for causing the mental health issues and not responsible for making it better.
"They also point them towards services they might need if they get overwhelmed, and talk them through minding their own mental health."
This 'self-care' video "points them in the direction of what they need to do to keep their resilience so they can manage. For example: social engagement, engagement in activities, all the things that would be resilience-building for any of us. We talk about a trusted adult, because it may be that they can't dialogue with their parent directly about this issue, but there may be an aunt, a teacher, a cousin, a friend, who they can talk to".
And, she points out, the evidence is absolutely that this works. "All the research in this area suggests that even small pieces of information can be extremely protective for young people in this situation. It prevents them from internalising the distress, they are more able to see the situation for what it is, and then it doesn't affect their developing self-confidence to the same extent. The evidence is that this reduces their vulnerability to developing their own mental health distress. Looking at some of my clients, I can't not wonder - if they had this earlier in their lives, would they have internalised the amount of distress they have?
"And therefore, my hope would be that I can infiltrate schools and make guidance counsellors across the country familiar with this as part of their list of resources for children and young people."
WITH project co-founder Peadár Gardiner played football for Crossmolina Deel Rovers and Mayo, including in the 2006 All-Ireland Final, until he retired in 2012. His background is teaching and he did a post-graduate in mental health promotion in NUIG and is now project manager of Mindspace Mayo.
"I have a big interest in youth mental health," he says. "I always have had, from my involvement with Mayo, and I was a rep with the GPA - Gaelic Players Association. We would have worked with mental health and young people. That was always a passion of mine.
"Mindspace is a service for 15 to 25-year-olds to support young people with mild and emerging mental health illnesses," he explains. "All the common stuff young people go through - school, relationships, bereavement, bullying, drugs, alcohol. Through that, we identified that a large number of those who came to us, their parents or a family member had a mental health issue. We started to see a common thread coming up there."
Young people were involved with developing the WITH Project at every stage, he emphasises. "This is CAMHS, Mindspace, and young people themselves. It was very organic; we listened to young people who came to use our service and parental mental health came up again and again. We wanted to support these people at an earlier stage. We see them from 15 to 25, but we wanted to get in there earlier - the 10 and 11-year-olds - and give them the tools to support themselves; upskill them in relation to what's happening with mam or dad.
"If you're an eight-year-old or a 10-year-old, you don't know what's going on. I know mental health is out there in the media much more, but if they have an eating disorder, addiction issues, a psychosis - a child doesn't have the language to understand that, so we try to make the language simple. Accessible services for young people are the key. Somewhere they can open the door, walk in and get the support they need. And that's what we're trying to change in this country."
As for what he hopes for the WITH Project: "I'd like to see young people being supported. That they would find out they are not alone, there is support there, to let them know there are appropriate services out there. Everyone needs to share their problems. It's so difficult being a young person now; much harder than when I was young. To be a sportsperson now - the pressure on the top-level sportspeople now, there's so much more attention on social media, they cannot get away from it.
"There's a lot of expectation within their own communities, in any sport. The pressure to perform - whether it comes from yourself, your family, your community - is huge. Then there is the fact that there are no summer jobs out there now for young people. They have no money, they might be going back to college, the cost of accommodation is rising, there are issues with drugs, alcohol, and social media is a pressure. We all need support."