The message that “it’s okay not to feel okay” is getting through to children and young people. Most know it is no longer taboo to raise your hand and say, “I’ve a problem – I need help”.
But then what?
For those really struggling, who are referred to the HSE's Child and Adolescent Mental Health Services (CAMHS), it's likely to be a long wait.
Up to 18 months in some parts of the country.
"We have encouraged children out of the darkness into the sunshine and then left them exposed," says the Ombudsman for Children Dr Niall Muldoon, sitting in the designated "Cosy Corner" meeting room at his light-filled offices on Great Strand Street, off Dublin's north quays. "We're not delivering on the promises we've given them."
Concern about the availability of accessible and timely mental-health services around the country, particularly for children and young people who are seeking urgent support or may be suicidal, will be highlighted in the Ombudsman for Children’'s Office (OCO) annual report for 2017, to be launched tomorrow, June 13th.
Muldoon and his team have been hearing first-hand from teenagers about the difficulties of being on a waiting list while in the midst of a mental-health crisis. Later this summer, the OCO will publish the results of what it describes as “rare” direct consultation with young people receiving inpatient care for their mental health.
The six mental-health units around the country that provide inpatient care to under 18s were invited to facilitate the consultation and five of them agreed. Muldoon decided to approach them after seeing how the direct voice of children and young people was the one element missing in the Seanad Public Consultation Committee hearings on Children's Mental Health Services last summer, for which Senator Joan Freeman, founder of Pieta House, was rapporteur.
While the committee heard from a wide cross-section of professionals and also from parents, who told some “phenomenal” stories, he says, “they just couldn’t get the young people to come in”. They had contact with a few, but they weren’t comfortable with going public in that forum.
The Oireachtas Committee on the Future of Mental Healthcare, chaired by Freeman, faced a similar problem. Muldoon saw the opportunity for the OCO to step in and help bring children’s voices to the vital process of advising Government on policy.
“The main thing was to get very clear open consent from the children, young people and their parents,” he says. The five units – in Dublin, Cork and Galway – have 66 beds between them and a total of 25 patients aged 14 to 17 took part in the consultation, which was completed last December.
The young people, who each chose a pseudonym, were offered different ways to give their views – through drawing, painting, photography, poetry or semi-structured interviews.
“The bulk of them went with semi-structured one-to-one or group interviews. A good number would have added art – there were some fabulous pieces of art in which they expressed themselves.”
But they were also asked to write what the art meant to them “so it wasn’t my interpretation. We wanted the voice to be authentic,” Muldoon says.
They were all asked three very simple questions:
– What has been helpful?
– What has been challenging?
– What changes would you like to see made to mental-health services for young people?
It was never intended that the discussion would be restricted to the young people’s experiences in the unit to which they had been admitted.
“We wanted to talk about their journey, from the first time they looked for help with their mental health,” Muldoon explains. “They were the experts and we wanted to hear what they wanted to say.”
It will hardly come as a surprise that the young people would have much preferred the primary-care services to have helped them more. They recognised the need for early intervention and that the whole family needed to be supported if one member was struggling with mental-health issues.
The chronically under-staffed CAMHS is supposed to be the last line after the GP and then referral to a local psychologist or therapist. But every stage of the system is under-resourced. “You often find GPs are carrying children with a lot of pain and can’t get them in anywhere. The whole continuum is in trouble,” says Muldoon, a clinical psychologist by training.
While it might sound odd to ask if the young people seemed glad to be in the units, he replies “absolutely” – in that they recognised the value of the care they were receiving as inpatients. In fact, there was a high level of satisfaction whenever they were able to engage with services.
But perhaps it is a case of “what’s seldom is wonderful”, he suggests – that help is so hard to get that, once they are receiving it, they really appreciate it.
The OCO has been consistently asking the Government how much of the almost €1 billion spent on mental healthcare each year goes to services for the under 18s. But nobody seems to know. All we do know is that just 6 per cent of the overall health budget is allocated to mental healthcare – whereas in the UK it’s double that.
“They can say down to the last cent what is being spent on the new children’s hospital building but they can’t tell you how much is being spent on children in the health budget. I think that says a lot – we know what we’re spending on bricks and mortar but we don’t know what we’re spending on our actual children in the system,” Muldoon says.
For two-thirds of adults with mental-health issues, the problems began in adolescence. If a lot more is being spent on treating adults rather than young people, is that the right split?
Early intervention is a much-vaunted aspiration, with strong economic arguments for taking money from further along the line and investing it at an earlier stage. Policy makers talk about evidence-based research and evidence-based practice “but they are not gathering the evidence of what they are spending the money on”, he points out.
Muldoon, a native of Co Donegal and father of two teenagers, is only the State's second Ombudsman for Children. A former director of investigations at the OCO, he was appointed in February 2015 to take over from Emily Logan. He seems a bit surprised when reminded that he is now more than halfway through his first six-year term.
“The time has gone so very fast,” he muses, adding, “I think I have grown into it and enjoyed it.” But of course, there are frustrations. “This job is never going to be about cleaning things up and going home.”
He laments the slow progress in getting the Garda and Tusla to work side by side on child-protection issues. However, he acknowledges that Minister for Children, Katherine Zappone, has visited New York, Oxford and Belfast to see centres where police and social workers work in the same office and she is committed to finding a budget to enable it to happen here.
Those centres “were flabbergasted to think we hadn’t got that far”, Muldoon says. They were also incredulous that we don’t have 24/7 social-work cover.
“That is a ludicrous scenario at this stage. It seems to be we have done it this way for so long and we find it hard to change.”
While lack of resources is always the argument against introducing around-the-clock cover, “every other country is doing it and saying they can’t do without it. We seem to be resisting what everybody else is doing.”
He agrees with Geoffrey Shannon, the Special Rapporteur on Child Protection, that it would not be good enough, either, to have an out-of-hours service only in big, urban populations. "That's not fair. You might only need it twice in Donegal in a year, but those children deserve it as much as any child in Cork or Dublin or wherever. That's frustrating to think that we still have to argue for that."
Muldoon says he has put all thought about the possibility of a second, six-year term out of his head, in case it would slow down the momentum he has been intent on creating. His understanding is that “if everybody is happy I can go again but I don’t know who ‘everybody’ is,” he laughs.
The appointment is officially made by the President, as the Ombudsman needs to be independent of the Government it not only advises but criticises.
Having taken the job at a time when the OCO’s staff complement of 15 was temporarily down to eight, it’s “fantastic to have a few extra bodies in place”, Muldoon says. There’s now a staff of 21 and it is due to rise to 22 in August.
Among other it things, it has enabled increased awareness-raising of the office. Where awareness among children and parents is increased, “we are enhancing the opportunity for them to improve their lives as well”, says Muldoon, whose office can expect to handle more than 1,600 complaints a year.
Anybody who thinks a child has been treated unfairly by a public body or Government-funded organisation can get in touch. The majority of complaints come from parents, roughly 15 per cent from professionals and other people involved in children’s lives and just about 3 per cent from young people themselves.
The steady increase in contacts made with the office each year reflect not only the OCO’s higher profile but also, Muldoon believes, a new generation of parents who are more vocal and more aware of their rights. In turn, they are raising children who are more prepared to speak out.
“Children have a better emotional vocabulary – I am quite happy to say my generation was probably stunted, just not taught to say things on an emotional level,” he says. “We are much more open with children. That has got to be a good thing but the reverse of that is we have to support them.”
All the Ombudsman’s efforts to give children a voice are worthless if nobody responds to what they’re saying.
About 1,000 children using the three paediatric hospitals in Dublin have been asked for the first time to give their views on what it’s like to be a patient there.
“It is one of those things that seems so obvious now, it’s amazing it hasn’t been done before,” says Muldoon. “It’s like trying to get feedback on a restaurant and not asking the person who has had the food.”
“Joining the Dots: Connecting Voices for Child-Friendly Healthcare in Hospital” is a joint initiative between the Children’s Hospital Group Board, the Ombudsman for Children’s Office (OCO) and the three hospitals – Our Lady’s Children’s Hospital, Crumlin; Children’s University Hospital Temple Street and the National Children’s Hospital, Tallaght.
The intention is to create a new way of evaluating the hospitals’ work, which includes children and adult/child participation.
“That is a new departure for them – putting children’s rights into the centre of their work,” Muldoon says. They are keen to establish it now as part of the culture before the opening of the new children’s hospital on the site of St James’s Hospital in Dublin, due in 2022.
The OCO took an international questionnaire and adapted it to use here by working on it with one of its young people’s focus groups.
“Essentially the questions were: what do you like about the hospital, what do you not like, what changes would you make,” says Muldoon. Some 2,500 people were consulted altogether, including staff, managers and parents as well as children.
The issues on which participants were invited to express their views and ideas included: information and communications; opportunities for children and young people to express their views in relation to decisions affecting them; children and young people’s contact with parents/guardians during their time in hospital; privacy; rest and play/leisure; education and learning; the physical environment in hospital; child protection and pain management.
“It is really, really powerful and we are looking forward to publishing the findings on that” – later this month. Muldoon sees it as an exercise that should be carried out every two years from now on.
Both “Joining the Dots” and the OCO’s consultation with young inpatients in mental-healthcare units are examples of hearing the voice of the children in the public service in a way that hasn’t been done before, Muldoon adds. “Which in turn we hope will have ripple effects and change how people see children and how they engage with them in the future.”
Voice of the children by numbers
14 – years since State's first Ombudsman for Children, Emily Logan, was appointed.
58 – per cent of electorate voted in favour of inserting children's rights into the Constitution in 2012 referendum.
2015 – the year current Ombudsman Dr Niall Muldoon took up the role.
1,682 – complaints received each year (2016 annual report).
46 – per cent of complaints relate to education, the sector with the biggest share.
3 – per cent of complaints were made by children, while most come from parents.