Dublin: BREAKING the SILENCE:2: The Most Vulnerable Of Children Are Abandoned By The Irish State: ‘Half Full’ – ‘Half Empty’

6 Feb

Lost Children in the Wilderness ©

By J. P. Anderson (International registered copyright of the author 2006)

Half-full, Half-empty, Children in State Care

In February of 2002, it was revealed that ’disturbed children’ were being put-up in hotels because there were no secure places available for them. A Judge, Mr Justice Peter Kelly, said that, the state’s record of ’care for troubled children’ had “descended to new levels of farce”. In the months leading up to the case before the court, it had come to light that disturbed children had been held in mental hospitals, Garda stations, units for convicted young offenders and assessment centres for disturbed children, which are not meant to actually house troubled children. 

The case before the court again highlighted the fact that that residential care in Ireland was in serious crisis. Health Boards / HSE were recruiting staff with ’four Ds’ in heir leaving certificate, for children’s residential services, and they were taking on people who were good babysitters. …there needs to be a root and branch examination of children’s residential care in this country.When it opened in Lucan, County Dublin, in the autumn of 2000, Ballydowd was seen as a major step towards a solution for the care of children with serious behavioural problems, from the Dublin area that come before the courts. With numerous court cases highlighting the lack of adequate care places for troubled children, and the death of one of them, Kim O’Donovan, the opening of Ballydowd was seized upon by the government and health authorities as an indication of the progress they were making in a most difficult area; It was the first of it’s kind in Ireland. A purpose-built, secure residential home to cater for up to 24 young people with severe emotional and behavioural problems. Seventeen months on, however, and staff at Ballydowd claimed that the home was in a serious state of ’crisis’ which was putting the safety of both staff and children at risk. With other problems in residential centres, such as, The Department of Education-run, Finglas Children’s Centre, residential home, which also cares for young people with severe behavioural problems? The evidence suggest that the ’care’ of Ireland’s most troubled children remains in a state of ’crisis’, despite tens-of-millions of euro in investment, new legislation and other initiatives by government.

In the case of Ballydowd, there are three units, each with a capacity to care for eight children. However, despite recruitment drives abroad, there has only been a sufficient number of qualified staff recruited, to open one of the units. …Quoting the Health Board’s / HSE statement, the health board’s spokesman, acknowledged, there were some problems at Ballydowd and said that an independent review of the working of the unit was underway. “One of the biggest challenges for the board since Ballydowd opened was the recruitment and retention of staff for the centre, because of the special care and attention required by the young people, and the demand on the current resources available”.

According to Mr Owen Keenan, head of Barnardo’s children’s charity, the problems at Ballydowd and Finglas are caused by a greater failure in the childcare and social services system in Ireland. “The whole thing seems to be ‘crisis-driven’. It appears that we are in a situation where you have a series of crises that are being responded to, so part of the problem is that we’re fire-fighting all the time. We now have a situation that, at 4,200, we now have more children in care on a per-capita basis than in the United Kingdom. …Building high support units and centres which, while necessary, will not address the ‘fundamental problems’ of why so many children are developing such serious problems. …Earlier intervention and better help for families at risk are seen as the areas that need attention; We need to be a little more sophisticated in our response,…and take into account that a mix of provisions, tailored very-much to the individuals needs is required”.

Mr Paul Bell, a SIPTU (trade union) official in the Finglas Children’s Centre, said that there had been ongoing problems at Finglas for over two years. …”Finglas Children’s Centre, is in a serious state of ‘crisis’ because of two factors, the first is staff shortages, between 85 and 100 staff have left Finglas during the past two years. Secondly, the courts are referring children to Finglas who have serious behavioural difficulties that the centre was not designed to cope with”. According to Mr Bell, “staffs have been violently assaulted by some of the children and the Gardai (police) have been called to the centre on numerous occasions to quell violent outburst”.

Up to 4,000 children are in state care at any one time, as many as 3,600 of these are in ‘foster’ care. Children end up in foster care for a number of reasons, some have suffered abuse, more are there because of poor parenting, but most are in foster care because of neglect. Foster families are overloaded and the HSE (formerly health boards) are always seeking new foster-carers for the children.

The 2002, Annual Report from the Social Services Inspectorate (SSI) expressed “serious concerns about the young age of some children in institutional care and their lack of access to psychiatric services. There are 176 children’s residential care centres in the state, 102 of tem are managed by health boards / HSE.

The Chief Inspector at the SSI, Ms Michele Cleark, said “Her staff had inspected up to 69 centres in all, but agreed that the fact that 33 had never been inspected by them was not good enough. (Authors note: What of the remaining 74 centres, not run by health boards?). In the centres examined during 2002, the number of children living in them was between four and five. Inspectors were concerned to find that the proportion of children in care under the age of twelve had increased from 26% in 2001 to 42% in 2002. “Two of these children were less than five years of age”. Said the report. …

 ”There was little evidence of children and young people being assisted ‘directly’ by their carers in understanding why they were in care, and in dealing with their feelings”. There was particular concern about the impact of this ‘deficit’ in the two ‘special care units’, which detain children under ‘special care orders’ from the courts. While these units have difficulty accessing child and adolescent psychiatric services, there is a “crisis” in obtaining such help for 16 to 18 year olds

 * .”With this age group Inspectors have encountered some extremely vulnerable young people–for whom a delay in access to services has seriously aggravated their difficulties” there is currently (2003) 4,500 children in care, with 13% in residential-care-centres, representing some 530 children.

 (*Authors note: The fact has been established, services must be in existence before patients can be referred to them.)

 Adult Psychiatric Services:
Existing adult services are not resourced to deal with adolescents. They lack appropriate multidisciplinary input, which would centre on family, school and social interventions. Adult services have acute psychiatric units and psychiatric hospitals and admit adolescents to these in-patient facilities. These facilities are not considered appropriate for the admission of adolescents. Adult out-patient clinics, day-hospitals and mental health centres are generally not appropriate for adolescents, and there tends to be a high number of referrals who do not keep their clinic appointments.

 Estimated Needs:

According to the 1996 Census figures, there are 140,816 persons aged 16 and 17 in this country. International and Irish epidemiological studies indicate that psychological disturbances of varying intensity exist in up to 20% of adolescents. However, only 2% of the total adolescent population has moderate to severe disabling conditions such as major psychiatric disorders. This would equate to 2,815 persons in Ireland in this specific target group, (I, e; 16 – 18 year olds who require an adolescent psychiatric service. Milder psychological problems could be dealt with by a primary care type service, for example, a community care psychology service.The Sub-Group experienced great difficulty in establishing the number of 16 – 18 year olds currently attending the adult services. Figures are available on the number of admissions to adult in-patient facilities. There is however, a lack of information relating to the number of referrals and non-attendees to out-patient clinics.

This lack of information made it difficult for the Sub-Group to establish how many 16 – 18 year olds, within the estimated 2% severe mental illness category are currently in receipt of psychiatric service input.
 
Service Principles:All members of the Sub-Group were in agreement that the services for 16-18 year olds should be *equitable (* Authors note: – impartial), accessible, user-friendly and flexible, taking into consideration the development level of the person involved.
Psychiatric services for adolescents should include the following:
1. Multidisciplinary teams,
headed by a Consultant Child and Adolescent Psychiatrist with a special interest in the psychiatric disorders of later adolescence. These teams should ideally consist of a Consultant Psychiatrist. Senior Registrar. Registrar. Psychologist. Social Worker. Psychiatric Nurse. Occupational Therapist. Speech and Language Therapist and Child Care Worker. 

2. Day hospital services

 

to include a mix of occupational therapy, various treatment programmes, such as group therapy, social skills etc, and an educational focus. This day hospital service would cater those who require more in depth assessment and a more comprehensive treatment than can be offered in the general out-patient setting, but do not require in-patient treatment. They will also provide rehabilitation after hospital admission.

 

 

3. Assertive outreach

services to provide nursing and supportive services in the home, school etc.

 

 

 

 

4. In-patient services: acute same day in-patient admission should be available to adolescents with major psychiatric illnesses who require it.

 

It is acknowledged that the number of such admissions would be small. In this age group, it is preferred to keep numbers of admissions to a minimum. The in-patient team should also have access to nursing staff to provide an intensive care community based treatment service in order to minimise the needs for beds . There should be a flexible system when under-occupancy in the in-patient unit would allow the flexibility for the staff to work in intensive out-patient ‘community-care’ or the day hospital facility.

 

 

5. Liaison to General Hospitals.

 

Adolescents who overdose, attempt self harm or have acute psychiatric illness often present to general hospitals as their first point of contact. Hospitals likely to encounter adolescents in these circumstances should have access to liaison adolescent psychiatric services.6. Rehabilitation services. There should be a rehabilitative approach to the care of adolescents who present with major psychiatric disorders. In some cases it may be necessary to provide step-down services such as, community residences for the recovery and early rehabilitation phase of treatment. …

 

“There is no capacity in the Child & Adolescent Psychiatric Service at present to cater for the needs of 16 to 18 year olds. However, there would be willingness on the part of the Child and Adolescent Psychiatric Service to take on responsibility for this group of patients if adequate additional resources required could be made available over the next few years“. In general adult psychiatrist has no difficulty in treating persons aged 16 to 18 who are suffering from a major mental illness. The particular concerns of the adult service in relation to 16 to18 year-olds, relate to those young people who are deemed to be ‘ out of control’ and, typically, have a conduct -disorder as opposed to a mental illness. In this regard, capital investment of approximately €38.09m / (£30m) is being made available by the Government to put in place additional high-support and special-care places for this particular group of children who need intensive intervention. The number of high support and special care places available nationally has increased from 17 in 1996 to a current total of over 120. These include the 12 place Rath-na-nOg, High Support Unit in Castleblaney and the 24 place Crannog Nua, High Support Unit in Portrane, which are being opened on a phased basis. The increased availability of such places should eliminate the pressure on adult psychiatric units to accept troubled children who are not suffering from a mental illness. The role of psychiatry in the high support child-care setting is a consultative one. Psychiatrist does not provide in-patient treatment to patients in the high-support/special care units because such units are not appropriate therapeutic environments for in-patient care. Therefore, if a resident of a special care unit develops a severe mental illness, admission to an acute psychiatric unit may be required. …

 

 

Recommendations:

The current arrangements, whereby the adult services provide a service to their catchment area, including the 16 to 18 age cohort, should continue on an interim basis. …It is proposed that the recommendations of this report be reviewed after five years.

 

‘A Better Future Now’ Position statement on psychiatric services for children and adolescents in Ireland. Extracts from, the occasional paper OP60. August 2005. By courtesy of the, Irish College of Psychiatrists. Dublin.The Faculty of Child and Adolescent Psychiatry of the Irish College of Psychiatrists commissioned a sub-group under the chairmanship of Dr Brendan Dowdy to provide this report to the Faculty on the current state of child and adolescent psychiatric services, estimate the service need and plan for future service development. This position statement was approved by the Faculty and the Executive Committee of the Irish College of Psychiatrist.

Executive summary:
In this report the Faculty of Child and Adolescent Psychiatry of the Irish College of Psychiatrists sets out where the psychiatric services for children and adolescents are now, estimates the need for services, and presents a model for future services. An action plan for implementation is also proposed.
The funding of the mental health services in 2003 accounted for just 6.8% of the health budget, amounting to €622.8 million. Child and adolescent psychiatric services accounted for only 5-10% of spending on mental health services, while serving 22.68% of the population (around €53 per child under 16 years of age).

 

 

 

The Faculty has made an estimate of the additional service resources and funding needed for:
Specialist-

 

out-patient, adolescent, in-patient, day-patient, hospital liaison, intellectual disability, forensic, alcohol and substance misuse, suicide prevention and deliberate self-harm, and also services for children with attention-deficit hyperactivity/hyperkinetic disorder, conduct disorder, autism spectrum disorder or an eating disorder and services for looked-after children, service evaluation, academia and research. There are currently 55 whole-time equivalent (WTE) consultant child and adolescent psychiatry posts in the Republic of Ireland, a ratio of 1:16 150 of the population under 16 years of age. In Finland this ratio is 1:6000 (of the population aged 0-19 years).
 

 

There are currently 40 specialist out-patient multidisciplinary teams (the recommended number is 59) serving local communities, the majority of which are significantly below the recommended multidisciplinary staffing complement.

  

In-patient facilities for the assessment and treatment of children and adolescents under the age of 16 years are located in two centres which have a total of 20 beds (the recommended number is 156 beds).

 

The in-patient facilities for the 16- to 17- year old age group require an additional 80 beds.

Adolescent services are poorly developed. Sub-specialty services have been developed to a very limited degree.

A comprehensive service for young people up to the age of 18 years would require a total of 150 WTE consultant child and adolescent psychiatry posts.

The recommended service level up to the age of 18 years would require an extra annual expenditure of approximately €80.million and a capital investment of approximately €150.million.

The Faculty requests that the Ministry for Health and Children undertakes further analysis and reports back to the Minister of with advice on the workforce development, funding plans and time frames necessary to support full implementation of the recommendations set out in this policy statement…

‘This position statement translates the principles and recommendations set out by a variety of bodies into a programme for the development of child and adolescent psychiatric services in the Republic of Ireland. It formulates a strategic plan to bring the service into the future‘…

The National Task Force on Medical Staffing (Department of Health and Children, 2003) in its report ’recommended increasing’ the number of consultant child and adolescent psychiatrists, (previously recommended by the Working Group’s first report), by a factor of two. It will therefore be necessary to increase the number of specialist training places to meet this projected need. …

In recognition of the fact that children’s lives do not occur in a vacuum, both policy (as set out in the Health Strategy 2001, Department of Health and Children) and best practice require a holistic approach to be taken to the needs of children and adolescents with mental health problems. Mental health problems in children that are more severe than their parents can with, without professional help, are not solely the concern of mental health services. The development and overall functioning of children and adolescents are the concern of a wide range of services and agencies, such as, education, community-care and paediatric medicine. Mental health services cannot respond to mental health needs in isolation. Developmental psychiatry can be defined as the recognition, assessment, treatment and management of mental health states and behaviours across the lifespan. It is not merely the study of childhood years, but of the continuities and discontinuities across the life cycle.

Need for child and adolescent psychiatric services

Early years (0-5 years) – ‘Trust, autonomy and initiative’The importance of early experiences to mental health functioning in later life has been well documented, particularly in areas such as the attachment relationship with parents and carers. Interventions specifically targeting this age group can have preventive/protective value and have been shown to be successful (e, g; the Community Mothers Programme and programmes for –

the prevention of antisocial behaviour in childhood and adolescence). …Where concerns arise regarding a possible delay or disturbance in development, it is not unusual for a number of services and professionals to be involved, as the precise nature of the difficulty may not be immediately evident. In addition to mental health services, other professionals likely to be involved include; general practitioners, public health nurses, speech and language therapist, clinical psychologist, educational psychologist, occupational therapists, paediatricians, specialist pre-school staff and representatives from the Department of Education and Science.

Primary-school-age children (6 – 11 years) – ‘Industry’

The mental health needs of primary-school-age children must also be responded to in a manner that takes account of the key people in their lives. A model such as that outlined for the younger child is again recommended. In addition to the services identified above, the Community Care Social Work Service or the Family Support Worker Service may also be included.

Adolescents, and young people (12 – 15 and 16 – 17 years, respectively) – ‘Identity, intimacy’

The Adolescent Health Strategy (National Conjoint Child Health Committee, 2001), underlined the importance of developing adolescent-friendly services. A challenge is presented to mental health services to become more appealing to young people, through liaison with schools, youth clubs and so on. If mental health services are made available in such settings they will be more accessible to potential users; there will also be benefits in terms of de-stigmatising mental health issues and encouraging *help seeking ( * Authors note: by young people). A wide range of services is also required within the mental health services, such as, day programmes, in order to make the service as accessible as possible to adolescents.

Implications of a developmental perspective:

 

A holistic approach to the child, as outlined above, has considerable implications for service delivery, as a significant amount of time will be spent liaising with other agencies and professionals involved with the child. The complexity of the child and family presentations requires ongoing, intensive, multidisciplinary assessment. The increasing awareness of disorders such as ADHD and of the importance of the early years has had a directly observable effect on services, with increasing numbers of children referred.

 

 

  

 

 

 

Benefits of a developmental perspective

 

This holistic approach to the mental health problems of children has both short-term and long-term benefits. There is evidence that it offers the best outcomes for the child, which should be the top priority of services. – Because the family are involved in the assessment and intervention, both as a unit and as siblings and parents, there are beneficial effects for all the family and family functioning can improve. Children’ teachers will also be involved, and they will gain knowledge and experience that will help them deal with other children, creating a ’multiplier – effect’. The beneficial effects can also encompass more than direct improvements in mental health. For example, when the behaviour of children with ADHD can be improved such that they are able to remain in school, their prospects for a fuller and more productive life is greatly enhanced. Children, who leave school early, show lower levels of attainment in many areas of life. Further, a problem that is addressed in childhood will in many cases prevent a problem remaining into adulthood, when it may be more resistant to treatment. Thus, the long quality of life for the child is enhanced. An additional benefit is the likelihood of these children becoming better parents for their own children, therefore breaking the cycle of problems that often exists. In these ways, the child and adolescent psychiatric services can add immeasurable health and social gain to all those with whom they come in contact, ensuring ’a better future now’ for our children.

 

 

  

 

Prevention of child and adolescent psychiatric disorders:

 

The prevention of child and adolescent mental health disorders can be conceptualised as having three layers (Graham et al, 1999):

 

Primary prevention tries to stop a disorder occurring by removing he cause.

  

Secondary prevention tries to stop the disorder at its onset, and prevent its extension.

 

Tertiary prevention tries to limit disability from an established disorder.

In the realm of public health, nine areas have been identified which, if improved upon, should lead to increased mental well-being among children. These are:

Poverty alleviation, 2. Increasing neighbourhood unity, 3. Good housing, 4. Increasing employment, 5. Good child protection from abuse and neglect, 6. Accident prevention, 7. Education, 8. Services to reduce marital disharmony, 9. Reducing alcohol consumption.

Specific primary prevention measures by health and other professionals can be conceptualised in terms of life stages. These sub-divide into six intervention phases:

1. Preparation for parenthood, 2. Antenatal care, 3. Birth and postnatal period, 4. Pre-school period, 5. Middle childhood, 6. Adolescents.

The quality of services provided during each of these six life stages by health and other professionals will impinge on mental health.

Secondary prevention tries to identify the presence of a disorder at onset and, by providing an appropriate therapeutic intervention, prevent it getting more serious.

Tertiary intervention tries to limit the secondary disability that arises from the presence of an established disorder. At the levels of secondary and tertiary prevention, the provision of comprehensive, effective services working with families and other professionals who have contact with the child is all important.

Children at risk of psychiatric disorder:

 

Research has shown that there are increased rates of psychiatric disorder linked to the following factors.

 

Social factors:

 

Children in urban (city) areas usually have twice the rate of disorder of their ‘rular’ peers.

 

Children who live in environments characterised by unemployment, family discord, family violence, family break-up, social disadvantage (discrimination, isolation, homelessness, immigration) and traumatised circumstances have increased rates of disorder.

  

Children who come to the notice of community-care social services because of child care and protection concerns-and in particular because of confirmed physical, sexual or emotional abuse or neglect – have increased rates of disorder.

 

Children in care (I, e; being cared for by a relative, or in foster care, children’s homes or a secure-unit), have significantly increased rates of disorder.

Children of families who are experiencing discrimination, a result of their cultural or ethnic background are more vulnerable to mental health problems. In Ireland, this specifically includes the Travelling community and refugees.

Other conditions:

 

Children with language and communication problems have three times the general population prevalence of psychiatric disorder.

 

Children with specific developmental disorders (e, g; dyslexias and dyspraxias) have increased rates of disorder.

  

Children with intellectual disability (I, e; an IQ less than 70) have two to four times the general population prevalence, with an increased prevalence as the severity of the intellectual disability increases.

 

Stressors:

 

Children who have been physically or sexually abused, or both, have an increased prevalence of psychiatric disorder, with rates probably three times higher than in the general population. The precise rate is influenced by the severity of the abuse and the family supports available following abuse.

 

Children whose parents have a psychiatric illness, or an alcohol or drug misuse problem, show increased rates of disorder. This risk is related to the effects of the parent’s difficulties, and on their ability to provide a safe and appropriate caring environment for their child or children.

  

 

Physical illness and disability:

 

Children with a chronic illness have twice the general population prevalence of psychiatric disorder; while with both a chronic illness and a physical disability have prevalence three times that of the general population.

 

Children with brain disorders, especially epilepsy and head injury, have five times the general population prevalence of psychiatric disorder.

  

 

Prevalence of childhood psychiatric disorders:

 

It is often the case that the data required to assess the need for services are not readily available. We are fortunate; however, to have reliable information on the prevalence of psychiatric disorders in childhood and reliable information on vulnerability factors in the population, based on international and Irish research findings. The incidence and prevalence of mental and behavioural disorders in childhood increase with age. Overall, 20% of children have a disorder at any one time; 10% will have a mild disorder, 8% will have a moderate to severe disorder and 2% will have a disabling disorder. There is an equivalent of mental health disorder in the child as in the adult population. Among younger children, boys have more disorders than girls, but this evens-out by middle to late adolescence.

 

Child and adolescent psychiatric disorders encompass a broad range, from psychosis, depression and eating disorders, through anxiety and attachment disorders, to autism and *pervasive ( * Authors note; ‘universal’) developmental disorders. Diagnosis of a childhood psychiatric disorder requires detailed assessment and observation, which build up a picture of problems and symptoms and the impairments which result. A number of factors are considered in assessing the significance of a mental health problem or disorder: its severity, complexity and persistence; the risk of secondary handicap; the state of the child’s development; and the presence or absence of protective factors, risk factors and stressful social factors. …

  

 

Estimating need:

 

As child and adolescent psychiatric services are specialist services, it is the 8% of children with moderate / severe and the 2% of children with disabling disorders who should be referred to them. As many disorders are often undetected in the community, these numbers are not always evident at the level of specialist services.

 

Estimates of prevalence can be used to enable services to estimate the level of undetected disorder. For example, one would expect to see 1547 cases of ADHD / hyperkinetic disorder in an area with a population of 340,000. If the services in this area see 300 cases, there are approximately 1247 undetected cases in the community. While many of these may be milder than the referred cases, severe undetected disorder can have major consequences for the child, the family, the school and community. Measures to improve detection of these disorders in the community could include educational initiatives for community-based professionals (e, g; family doctors, teachers and social workers). This type of initiative may bring about an increase in the number of cases being referred to child and adolescent psychiatric services, which could in turn bring about even greater pressure on existing services, unless they are adequately resourced.

( Authors note: Quoted from; A better future now. By courtesy of the Irish College of Psychiatrists).

  

 

The Health Strategy,

 

(Quality and Fairness) of the Department of Health and Children (2001), sets the health agenda for organising the future health system around a ‘new vision’: The system will be equitable, people centred, accountable, and quality driven. Quality and Fairness states that gaps exist in the provision of mental health services for children and adolescents. The health Strategy outlines a number of initiatives to improve children’s health, including;

 

 

“Mental health services for children and adolescents will be expanded:

Implementation of the recommendations of the First Report of the Review Group on Child and Adolescent Psychiatry:

Development of mental health services to meet the needs of children between 16 and 18 years of age“.

 

 

 

 

The Health of Our Children:

The second annual report of the Chief Medical Officer (Department of Health and Children, 2001), states:

“Approaches to the promotion and development of sound mental health for children, and the identification and treatment of psychological and psychiatric disorders, have been patchy, uncoordinated and under-resourced.The absence of epidemiological information relating to children’s mental health on a national basis is a significant limitation in our current system. …A highly developed information system is required, in order to underpin approaches to quality assurance and evaluation of mental health prevention and treatment services, to monitor trends in incidence, and to identify risk factors and risk groups”. The Department of Health and Children (2000), in its National Children’s Strategy, states; that ‘Children will be supported to enjoy optimum physical mental and emotional well-being’.

 

 

 

 

 

 

 

 

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