The number of teenagers attending the emergency department (ED) of Children’s University Hospital, Temple Street, because they have self-harmed or threatened to self-harm has increased exponentially, according to Dr Brian Houlihan, consultant child and adolescent psychiatrist.
Dr Houlihan, who is also clinical director of the St Frances clinic at Temple Street, says that in 2014 they had more than “300 presentations for emotional concern” in the department, which is “the largest number to date”.
The numbers have increased each year for the past five years and Houlihan says when they arrive in the ED the children have already self-harmed, usually by cutting or overdosing. Or else they have threatened to self-harm.
“Our statistics here in Temple Street demonstrate to us that we have an exponential increase in children attending casualty having self-harmed or threatened to self-harm,” he says.
The psychiatric team know adolescence is a time of huge transition and, for some vulnerable adolescents, it can also be additionally risky, and then alcohol and drugs can be involved.
“We are especially aware of the risks associated with the increased complexity of social demand, peer and academic expectation, physiological and hormonal change and, in some vulnerable adolescents, the disinhibition of alcohol and drugs; these are often a lethal trap.”
Perfect storm Some would call it a perfect storm of risk factors and some of
those who do end up in the ED can find themselves among children who have fallen off trampolines or broken legs.
There is always a psychiatric team on call and a teenager who has overdosed or self-harmed, or is at risk of doing so, will be assessed by the team.
Some will need to be admitted either purely for psychiatric reasons “or undertaken jointly with paediatricians and is based on each person’s emotional and medical needs”.
The lack of beds in psychiatric hospitals is another reason contributing to the numbers attending an acute hospital such as Temple Street.
Indeed, it can happen that a teenager who is admitted can find themselves sharing a ward with children needing surgical or other medical treatment.
Of paramount concern is the safety of the child. Houlihan says: “The concern that psychiatrists have every time they meet an individual who self-harms or threatens to self-harm is: could it lead to a tragic outcome?
“It seems only logical that if you have more adolescents self-harming, particularly those with mental illness and those who do so repeatedly, that there will be more tragic outcomes.”
The ED is seeing more children with eating disorders and Houlihan says there is “a small but significant percentage” of adolescents with depression, anxiety disorders, obsessive-compulsive disorders, all of which are primary psychiatric disorders.
“These primary psychiatric disorders are of concern. Fortunately they are treatable when the correct team of professionals becomes involved at as early a point as possible.”
Although suicide is uncommon in school age children, Houlihan says: “The common denominator appears to be mental illness/psychiatric disorder. So psychiatric illness in adolescents touches more than families, hospitals, etc.
“It is a concern for society and deserves assessment in a timely manner by well-placed and properly trained professionals.”
For the children who are not in need of an acute paediatric hospital “we continue to struggle to locate community mental health beds”, he says.
Impact of technology The impact of technology on society generally, and children in particular, has not gone unnoticed by him or his colleagues who work with adolescents in need of support from the mental health services.
“We see children attached to mobile phones and iPods. Frequently when adolescents are admitted to an acute paediatric hospital [such as Temple Street], we find they cannot exist without their mobile being immediately available.
“We have to ban these devices from the ward in certain situations, often resulting as if a limb was being removed.”
In addition to the internet making everything instantly available online to children, he says, it makes global society “small and immediate, yet less intimate”.
It also bypasses time zones. “The seduction of celebrity fosters unreasonable expectation, and disappointment is not always easily reconciled. With heightened anxiety and expectation comes heightened risk,” says Houlihan.
“We know of material on the web that has little to offer constructively to anybody, let alone minors. We know of many cases where children have come unstuck because of bullying on the web, with very nasty outcomes.”
The possible impact on children of using their favourite devices to connect with the world is uncharted water.
“We really do not fully know what will unfold as children, who elected to interact primarily through technology, are later expected to engage with others as they negotiate their journey through adolescence and into adult life,” says Houlihan.
Real life contact brings with it things that cannot be picked up on a screen, such as “nuances, body gestures, the unspoken . . . Skype will get you only so far,” he says.
The two “fundamental needs” of all children, he says, are security and protection.
“It is only with those in place that nurturing can take place and the child can then grow in all other areas such as emotionally, socially and academically.”
The importance of meeting those two fundamentals needs become clear when he describes a child as being at the centre of a solar system and rotating around it, and exerting influence, are planets that represent the family and society.
“In emotional development, however, the child finds themself greatly shaped by the familial and societal pull and push. Influences that we, as adults, elect as important.”
All of this takes places in the context of our rapidly changing society.
Houlihan says that part of the role of a parent/guardian is to do what the title says and they should not be afraid to say “No” or to put down boundaries for the children in their care.
“We have a very confused understanding in certain quarters where parents befriend rather than parent their children,” he says. “Reasonable structure and reasonable boundaries are essential components of the security we mentioned earlier.”
Primary schools in the main succeed because they have boundaries, rules and expectations, he says, adding: “By removing these or other reference points from a child’s life [and/or] supplementing these practices with befriending, are we really moving closer to preparing the child to negotiate the demands and expectations of society?”
Psychiatric support Some of our adolescents are more vulnerable than others, whether that is due to a genetic disposition or related to their environment, or both, and they are in need of immediate psychiatric support.
“We have a disproportionate number” of children who have come from situations of “family breakdown, children’s homes or attending foster care”, says Houlihan.
Some of the children are ending up in the ED because some of the primary-care services are not available as needed because of the numbers involved.
Some of the children are there because they need to be admitted “and the presentation to an acute paediatric hospital happens because there are frequently no psychiatric beds available elsewhere”.
He says the number of beds available for adolescents in the Dublin region is not keeping up with the demand and this is despite “a modest increase” in the number of beds.
The impact of the new consultants’ contract is also a factor in the failure to attract consultants to fill vacant permanent posts.
“Senior medics have left this country and many junior [doctors] are making immediate plans . . . filling posts will remain a real issue for some years to come; and all the while the demand grows.”
It is not all bad news for our adolescents, because “most do well”, says Houlihan. The ones who do well and make the transition from childhood to adulthood “tend to do so helped by well-grounded and available parents and enjoy the additional support of schools and community”.