Child & Adolescent Emergency Mental Health Crisis: A Neglected Cohort
School of Medicine and Medical Science, University College Dublin, Dublin 4
To highlight the ongoing concern regarding the mental health well-being of children and adolescents in Ireland and access to appropriate and timely MH services.
With reference to existing literature and policy planning documents, this paper presents an over view of child and adolescent MH services (CAMHS) and paediatric liaison psychiatry services (PLPs) along with their respective roles in the management of children presenting with acute MH crisis.
Despite longstanding and growing public and professional awareness of unequal and inadequate MH services for youth, progress has been slow. The long-standing lack of parity between mental and physical health remains, most prominent in the area of access to urgent MH assessment.
Urgent action is needed given ongoing concerns about the rising prevalence of MH distress and disorders in youth, and the lack of access to MH services in Ireland.
Child and Adolescent mental health services (CAMHS) are the designated service set up by the HSE for the provision of specialist MH services for youth up to age 18 years in Ireland. Located in the community and staffed by multidisciplinary teams (MDT), these services offer assessment and treatment to young people with, or suspected to have, severe and enduring mental health disorders. Operational hours are typically nine to five pm, with significant regional variation in provision of out of hours service. Should clinical need require more than outpatient management; referral may be made to in-patient CAMHS settings. Demand far exceeds availability and access to inpatient or outpatient care often unacceptably delayed. Between 2012 and 2017, there has been a 26% increase in referrals1. Once accepted into CAMHS many service users report high satisfaction levels2,3.
By contrast, paediatric liaison psychiatry staff (PLP) provide psychiatric assessment and treatment to children attending paediatric hospitals. These children vary in category, from medical or surgical in-patients, day cases or patients attending Emergency Departments (ED). Team composition and governance differ across the country, from HSE funded services (community CAMHS providing in-reach consultation) to dedicated hospital based and funded staff. Even across the city of Dublin, significant differences exist in the operating models of the 3 paediatric hospitals. Tallaght and Crumlin follow a medical model (teams staffed by doctors and nurses only), while Temple St. has a full MDT team, with nurses, doctors, social workers and psychologists dedicated to both MH ED and out-patient MH service provision. All typically provide same day ED MH Service.
PLPs are also well placed to play an active role in indirect clinical work, by proving consultation with paediatricians, providing staff support, offering formal and informal teaching, and engaging in research and audit. However, a recent audit of one of the Dublin PLP services highlighted the overwhelming preponderance of PLP time directed towards the assessment and management of children with psychiatry emergencies4. In a 6 month retrospective audit, of the108 cases seen during that period, 79% were acute psychiatric emergencies, the majority arriving to the ED, outside normal working hours, many previously known to CAMHS. A much smaller number of cases were new cases, referred by the paediatricians for the assessment of psychosomatic or medically unexplained issues (N=16) or the management of children with eating disorders (N=7). An examination of current clinical activity (Jan-June 2018) suggests this trend is continuing but with increased number of referrals (N=121 in 6 months). Similar proportion of PLP time spent on managing acute MH presentations is reported by liaison colleagues in the other Dublin paediatric hospitals.
Resourcing of MH services:
CAMHS are currently fragmented, over stretched, and under resourced with current staffing levels well below recommended levels5. At the time of writing, there are 2,700 children on a waiting list, with 14% of these waiting longer than 12 months7. CAMHS understaffing is not limited to funding issues, but linked to significant recruitment challenges in all professionals groups. There has been recognition of staff burn out, consultant resignations, and services being viewed as ‘untenable and unsafe’8. Clinicians have perceived themselves to be placed in ‘ethically compromising situations’ by virtue of inadequate resources8. This seems understandable given the reverse trend in overall budget funding for MH services, the budget having consistently decreased from 13% in 1984 to the current 6.1%.
A Joint Committee on the Future of Mental Health (MH) Care, established in 2017, took evidence from practitioners and families regarding the state of CAMHS9, 10. It produced a very concerning report detailing inadequacies in provision of care. The essence of this report was that children were being ‘abused’ through neglect in the provision of adequate MH services11. Timely access to both community out-patient and in-patient CAMHS were recognized as problematic. Even cases known to CAMHS, lack of out of hour’s services required many to attend Emergency Departments at times of crisis ‘because there was nowhere else to go’11. For some, crisis presentations resulted in inappropriate admissions to adult MH wards 12.
Emergency MH services & the paediatric hospital:
The absence of universal out-of-hours MH services means that for many the ED is the only place to go. However, not all child and family crises are the remit of CAMHS. Many crises may relate to parenting difficulties, transient emotional turmoil, or other psycho-social stressors. Lack of community primary care educational, psychology and social services are recognized to put greater pressure on CAMHS, where they have become a ‘catch all service’ 13.
This does not mean that the EDs are the ‘wrong’ place to go at a time of crisis. Notwithstanding the resource pressures, there seems to be an agreement as to the benefits of an ED response. A rapid MH assessment will allow onward referrals to the appropriate services and interventions, maximizing health gains and reducing the risk of deterioration while sitting on an inappropriate list. Assessments are often conducted on the same day, and if admission is required, it is brief. Transition plans are made and the majority safely discharged back to CAMHS4 . A service user survey, conducted by the PLP department in OLCHC, in 2017, identified that the majority of parents (N=19, 76%) viewed the service as ‘excellent’ or ‘very good’ overall, and most (N=19, 76%) would ‘recommend it to a friend’.
Given that hospitals with acute paediatric ED are accessible 24/7, staffed and secure, available to all children and families, this offers a useful service model whereby the same pathway for children with medical emergencies may apply to those with psychiatry emergencies. In fact recent UK policy documents advocate for having child MH services co-located with paediatric services, giving parity to mental and physical ill health. They argue the need for ring fenced funding coming from the acute services, to ensure it is not diverted to other community endeavors14. Such integration is now considered ‘ethical best practice’15.
However, as the hospital audits have shown, the increase in emergency MH crisis presentation to the ED is at the expense of PLP availability to both direct and indirect clinical roles expected of a PLP service4. Given the expectation of increased clinical complexity in the National paediatric Hospital (NPH), it is anticipated that there should be a parallel development of specialist liaison MH services, i.e. to children with neuro-psychiatric disorder, gender dysphoria, transplant services, rare genetic disorders with behavioral phenotypes etc. In the absence of significant additional and ‘ring fenced’ funding, it is impossible to see how these will develop. Furthermore, PLP’s role in training, supporting paediatric colleagues, and advocating for patients, is at risk of being subsumed by a growing but equally deserving cohort of children with acute MH problems.
Intentions to develop 13 paediatric liaison psychiatry teams as stated in AVFC seem not only sensible, but urgent5. Such informed development would allow a planned and standardized equitable response to children and families in crisis and needs immediate and detailed planning. Our UK Liaison psychiatry colleagues believe there ‘is no other resource that is as responsive and potentially capable as an NHS emergency department, nor will there ever be’14, 15. Our own paediatric model of care (MOC) document seems to agree, and places the PAEDIATRIC emergency department central to the pathway of care for acute MH crisis16.
The latest CAMHS SOP6 acknowledges country wide difficulties with accessing urgent MH assessment at times of emergencies. Recent government commitments of an additional €47 million to CAMHS over the next five years are welcome1, 12. Priorities identified include improving access to timely and age appropriate MH services, developing an out of hours service, and the creation of a new 20-bedded CAMHS inpatient unit at the National paediatric Hospital. However, concrete plans for the delivery and funding of emergency MH crisis are not suggested, nor is there any mention of the very difficult and idiosyncratic situation for 16-17 year olds presenting with acute mental illness and where access to child MH assessment and triage is unclear. Given the high and oftentimes unrecognized cost associated with management of this cohort17, it is somewhat surprising that neither the paediatric MOC nor the CAMHS SOPs have given much consideration to the planning and funding of this service. As the three hospital PLP services move towards the NPH, careful and detailed consideration needs to be given to this group of children.
Despite the public, professional and government awareness of unequal and in general inadequate MH service provision, the focus on the development of emergency child and adolescent MH services and the role of the paediatric liaison psychiatry team, have not received the attention they deserve in MH or paediatric policy planning. Urgent action is needed now in anticipation of the National paediatric Hospital and the ongoing concern about the prevalence of MH distress and disorder in children and adolescents in Ireland.
Vision for CAMHS:
1. All children and families should be able to access urgent MH assessment at a time of crisis that is provided in a safe suitable environment and delivered by trained supported staff.
2. Following urgent MH assessment, all children and families should have timely access to recommended treatment and/or discharge plans. This includes access to CAMHS in-patients beds as required.
3. All children and families should feel valued, welcome and treated with respect, and experience the assessment process as therapeutic.
4. Emergency CAMHS services need to be considered, resourced and evaluated, and include the experiences of the family.
5. Employers need to consider the MH needs of staff and provide the necessary resources to allow them expertly and expediently carry out their work.
Prof Fiona McNicholas,
School of Medicine and Medical Science,
University College Dublin,
Phone: +353 87 799 4800
Conflicts of Interest
The author declares no conflicts of interest.
1. https://www.hse.ie/eng/services/publications/serviceplans/national-service-plan-2018.pdf 2. Coyne I, Mcnamara N, Healy M, Gower C, Sarkar M, Mcnicholas F. Adolescents' And Parents' Views Of Child And Adolescent Mental Health Services (Camhs) In Ireland. Journal Of Psychiatric And Mental Health Nursing. 2015 Oct;22(8):561-9 3. McNicholas F, Reulbach U, Hanrahan SO, Sakar M. Are parents and children satisfied with CAMHS?. Irish Journal of Psychological Medicine. 2016 Sep;33(3):143-9. 4. Lynch, F., Kehoe, C., MacMahon, S., McCarra, E., McKenna, R., D'Alton, A., Barrett, E., Twohig, A. & McNicholas, F. Paediatric Consultation Liaison Psychiatry Services (PCLPS) -what are they actually doing? , Irish medical journal, vol. 110, no. 10, pp. 652. 2017 5. Department of Health. ‘A Vision for Change’ Report of the Expert Group on Mental Health Policy. Department of Health, Dublin 2006)( AVFC: https://www.hse.ie/eng/services/list/4/mental-health-services/visionforchange/ 6. Standard Operating procedures ( SOPs 2015) http://www.hse.ie/CAMHSsop 7. https://www.breakingnews.ie/ireland/2691-children-on-list-for-mental-health-appointment-386-waiting-over-12-months-842751.html 8. https://www.irishtimes.com/news/health/president-of-college-of-psychiatrists-resigns-in-protest-as-hse-consultant-1.3536074 9. https://www.oireachtas.ie/en/press-centre/news-and-features/20180426-committee-on-the-future-of-mental-healthcare-publishes-interim-report/ 10. https://www.oco.ie/library/take-my-hand-young-peoples-experiences-of-mental-health-services. Ombudsman for Children (2017) 11. https://www.irishexaminer.com/ireland/mental-health-failings-are-abuse-469971.html 12.https://data.oireachtas.ie/ie/oireachtas/committee/dail/32/seanad_public_consultation_committee/reports/2017/2017-10-18_report-on-children-s-mental-health-services_en.pdf 13.https://www.irishtimes.com/life-and-style/health-family/over-2-400-children-waiting-for-child-mental-health-services-1.3130980 14. Department for Health and Social Care "Government publishes NHS Mandate for 2018/2019", British Journal of Healthcare Assistants, vol. 12, no. 6, pp. 287-289 (2018) 15. Kraemer S. Arch Dis Child Epub ahead of print: doi:10.1136/ archdischild-2018-314742 16. https://www.hse.ie/eng/about/who/cspd/ncps/paediatrics-neonatology/moc/chapters/ 17. Kehoe, C. & McNicholas, F., Hidden costs in paediatric psychiatry consultation liaison services, Irish Medical Journal, vol. 111, no. 3, pp. 715.(2018)