Monday 27 May 2019

The threads that show we are building to a crisis

Four-year-olds are self-harming, doctors are quitting, Tusla is a disaster area, but here's one modest suggestion to break the cycle, says Brendan O'Connor

'Schoolchildren as young as four are apparently exhibiting signs of anxiety and self-harm and even suicidal ideation.'
'Schoolchildren as young as four are apparently exhibiting signs of anxiety and self-harm and even suicidal ideation.'
Brendan O'Connor

Brendan O'Connor

It's a sunny day and I don't want to depress you. But I want to draw your attention to some strands of a quiet crisis, some niggling things that keep popping up in various forms that point to an alarming picture. These are things indeed that suggest we should be the last people to be feeling judgmental about Donald Trump's treatment of migrant children, or indeed about our own dark chapters in the past.

Last week saw alarming headline results from a survey of school principals funded by St Patrick's Mental Health Services. Schoolchildren as young as four are apparently exhibiting signs of anxiety and self-harm and even suicidal ideation.

What was arguably more interesting were the reasons for this. According to one report, "The vast majority of principals reported problems among schoolchildren relating to 'general family issues' (86pc), separation or marital breakdown and anxiety (both 79pc). Bullying (54pc), cyberbullying (37pc), self-harm, depression (both 28pc), suicidal ideation (23pc), eating disorders (15pc) and sexual identity issues (9pc) were also cited as significant issues".

So there are often circumstantial reasons for what we would call mental health issues. Many of these kids were not in fact mentally ill but were suffering what might be very rational reactions to life stresses. And clearly family matters put hot topics like cyberbullying in the ha'penny place as causes of emotional difficulties among children. All of this backs up author Johann Hari's notion that mental health difficulties like depression are often ''the smoke and not the fire''. Depression and the like are often just a symptom of an external problem. They are what we traditionally called ''reactive''.

Okay. Take another thread. Last year, Dr John Hillery, consultant psychiatrist and president of the College of Psychiatrists in Ireland, said that many of those on the waiting list of Child and Adolescent Mental Health Services (CAMHS) do not need to be assessed by a psychiatrist, and that other interventions at primary-care level would be more appropriate.

Another thread. Children's Ombudsman Niall Muldoon reported last week that children and adolescents are often waiting several days to see a CAMHS consultant after presenting as suicidal. "We have been encouraging children out of the darkness and into the light and then left them exposed", is how he puts the general lack of response available to kids who do look for help.

So we have a situation where acute cases are experiencing a huge delay in getting attention they urgently need, while the waiting lists are clogged up with children who shouldn't be in the CAMHS system at all, children who are overwhelmingly suffering as a result of family issues. But then again, we also learnt last week that Tusla, which should be intervening earlier in these kinds of matters, is not fit for purpose.

Another thread. Former IMO president Dr Asam Ishtiaq said last week that the increasingly dysfunctional nature of public health services is driving consultants into the private sector. Doctors want to do what they are trained to do, he says, and they are increasingly unable to do that in the public sector.

We know already that they have difficulty recruiting consultants to CAMHS and we know of course that three consultant psychiatrists resigned in despair recently in Waterford.

Another thread. John Hillery himself resigned from the HSE in February. Last week he said he left because he spent too much time writing memos and making phone calls advocating for respite care and other supports for individuals and carers that should be taken for granted.

Again, Hillery was tired of not being able to provide the kind of early intervention that might keep kids, and indeed the adults who care for them, out of acute psychiatric services. For example, Hillery, who works a lot with people with autism, said that young people with autism, because they were not getting the supports they required, were being drugged up instead, purely to keep their lives manageable.

These are enough pieces of the jigsaw for us to see a picture of an impending meltdown. We pay loads of lip service to young people and their mental health in this country. But when these same young people are having difficulty, we have very little in place to help them. Specifically we have no effective early intervention system. The teachers who responded to that shocking survey feel ill-equipped to deal with the problems kids are coming to school with.

Tusla is a self-confessed disaster which has many fine policies and strategies but which do not translate into reality. Young people with disabilities don't get any help to keep their lives ticking along as well as they can either.

So all these problems, that could be manageable with some form of early intervention, become acute problems, and they are funnelled into a mental health system that is not only ill-equipped to deal with them, but which doesn't have the resources or the staff to deal with them anyway. This in turn means that kids with really serious mental health problems, who are possibly thinking of killing themselves, are sent home for their parents to try and watch and wait and worry with them for days on end.

And the failure and the choking of the mental health services means in turn that doctors are left feeling ethically compromised about medicalising problems that are not medical, about medicating children who should not really be medicated, and about being too busy to treat in a timely fashion the ones who really need their help. So increasingly they are leaving, they cannot be replaced, and it makes the system even worse.

Obviously we can't just fix everything overnight - but if you ask anyone involved they will tell you that one simple way of trying to stop this awful cycle would be to try and stem the tide before it becomes a flood.

In the medium term, early intervention will cost less in resources and less in human misery. The very simple and obvious suggestion arising from that St Patrick's survey of teachers is that we should urgently set up an early-intervention counselling service for young people, easily and quickly accessed locally. Maybe take something like the Jigsaw service and expand it.

Many kids will only need minimal intervention of a few sessions to nip things in the bud, and others can be referred on to suitable services.

There are no simple answers to these complex problems, but if we wait for more inquiries and reports and the kind of "bureaucracy gone mad", as he called it, that caused John Hillery to quit the HSE, we'll never get anywhere. And all these little threads that keep popping up suggest we are heading to a full-blown breakdown in the system.

Traditionally in this country we seem to prefer to deal with things only when they become a full-blown catastrophe. But perhaps this is the time to go against our usual instincts and invest more in some early intervention.

We're all about prudence these days, and the rainy day, and this would certainly be one way of not storing up huge problems.

Sunday Independent

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