Bríd Smith on over-medication of children in CAMS services

I am here replacing Gene O'Kenny who cannot be here because he lost his mother this week, so I am trying to catch up and familiarise myself with all the reports and stuff from this committee in the past, but the first thing I would just like to ask following on from NASA's questioning there, it seems to imply that the answers seem to imply that a team will function properly where there is a consultant and that over medication like what happened in Kerry would not happen. Could you comment on that implication? Do you think there are any cases where consultants are in a situation but the over medication of children is a regular occurrence? I am looking back at the notes here from reports of the Joint Committee on the Future of Mental Health in 2018 which stated that in 2011 a report from mental health reform showed that there were significant gaps in the provision of primary care, a dominance of primary care, a dominance of primary care, a dominance of medication as a treatment option, a lack of referral options for GPs for counselling for psychotherapy, a lack of family therapy or community health teams and continued use of emergency departments as access points for mental health services and so it seems to me that we probably are living in a system where consultants or whomever have little option but to medicate because other services are not available so I would like you to comment on that. My second question is in relation to parliamentary questions asked by Deputy Boyd Barrett. As far back as 2015 he has been asking the various ministers for health parliamentary questions about the kind of malpractice that we are now dealing with, the over-medication of children. Specifically last April he asked the Minister Stephen Donnelly to order a review of the use and overuse of psychiatric medication in children across all CAMS services, and in particular to review the way chronic understaffing of CAMS and a complete failure to resource primary care was leading to over-medication. He says the Minister passed this review off to the HSE who apparently brushed off the request for review. That is going back to April 2021. I want to ask you, did the Minister pass this request for review to the HSE management and what was your response to that? I might start and ask Dr Bert to come in on the medication of children. In terms of CAMS in general, mental health has been lucky, you might argue, in that we have had Vision for Change for many years now, which has set a blueprint in terms of the delivery of services, which is based on multidisciplinary team working. And particularly in CAMS, this growth, and we have to remember CAMS came from a certain place in terms of a child guidance model, etc. We have sought through the development funding in mental health to develop those multidisciplinary supports. So in terms of our OT, social workers, psychology, speech and language therapists, in some cases dieticians for eating disorders, etc. However, as I said earlier, we must remember that CAMS is a very specialist mental health service. And in reality, something that we have been prioritising and this came from work that was done by the Youth Mental Health Task Force a number of years ago. We have been prioritising the early intervention supports for children, because we know that actually early intervention is the most important things in terms of youth mental health. So actually having other organisations and working with our funded partners to provide supports to children earlier in their pathway of care, providing supports, for example, in primary care. So most children who present with a mental health difficulty attend their GP in the first instance. And the priority is for the GP to have somewhere to send that child for support that might not be a CAMS service. A very small percentage of children actually attend a CAMS service. Many more attend other supports that are at the lower level of the pyramid in terms of how we provide our services. So multidisciplinary care is essential. We have increased the number of teams, but equally we have increased the numbers of those different disciplines across the team. And actually we have sought to invest in all of those multidisciplinary supports since the development funding started back in 2011. And we have seen significant increases in those areas. And we will continue to do that. And certainly in line with the ongoing implementation of sharing the vision, we will continue to invest in multidisciplinary care. Consultants and doctors are a key part. And as Dr. Young said, they're critical in terms of diagnosis and agreeing the care plan and ultimately prescribing where it is relevant. But as Dr. Burke said earlier, many children who attend CAMS do not get medication prescribed. They receive other interventions. But I might just ask Dr. Burke to comment on the medicating of children. I think it's important to differentiate between the over-medication of children and medicating in the absence of psychological intervention. There are different things. So a psychiatrist when they were taking history from a young person will always view the case in terms of biological, which is the medication piece, but also in terms of the psychological and the social piece. And you would not prescribe for a child without the other parts. So they wouldn't be done in isolation. But we do sometimes have challenges with psychological intervention. But the vast majority of psychiatrists would also have pursued other studies in psychological interventions and would be therapy trained. So I don't want people to go away thinking that the only tool that psychiatrists have is medication. And we think long and hard before we put any child on medication. And individual teams would have checks and balances in there in terms of medicating. It's not just a part of a national audit. We audit ourselves, individual teams audit. Good practice would have multidisciplinary team meetings every week. And even though the consultant lead may not see every single person on the team, they would be part of the discussions. And as Dr. Young said, they would, you know, they would sign off on the care plan for that individual, for that individual person. So I would say that we never prescribe medication without looking at the other aspects for these young people. But we do have challenges in terms of psychological therapies. And we do have waiting lists, which we're trying to work on. But I'd also like to point out that, you know, as evidence-based for treatments builds in, you know, there's more and more specialist evidence-based and evidence-informed treatments. It is difficult to provide them everywhere. I mean, the evidence base for psychological therapies is for experienced practitioners who see people a lot with particular conditions and with fidelity to the model. And in every generic CAMHS team, you may not be able to see those number of people or have those experienced practitioners. And that's why as part of the quality improvement and service development, we've been looking at the clinical programs and developing the hope and spoke models. for these more specialised treatments, so that you can have fidelity to the model and that you can have specific clinical guidelines. Can I interrupt you there, please? Because I'm going to run out of time and neither of my questions have been addressed. My first question was, is it possible that even where a consultant is in a situation, that over-medication could be a problem within the CAMHS services? My second question was, was the HSE asked by the Minister to review what was happening with the over-use of psychiatric medication in children in April 2015? And what was their response? That's two questions have not been answered and have not been addressed. Could you please attempt in the small bit of time we have left to do that? Yes. So, Deputy, in reverse order, I'm not aware of that request. That doesn't mean it wasn't made, but I'd have to check that out. I don't have that information available to me here. So, I'm not aware of if that request was made or when it was made or what happened with it. So, we'll have to come back to that. But if it was, you would imagine that you would be aware if the Minister requested you to review the medication of children in the CAMHS service? I'm personally not aware, but I don't know of any of my colleagues there. It would be expected that you would be aware, though, wouldn't it? Maybe, not necessarily as Chief Operations Officer. I may or I may not, but Deputy, I'd have to check and see. That may have been dealt with somewhere within the organisation when it came in, but I'm personally not aware of that request. I can check that out, though, and come back and see if somebody within the team is. In terms of whether it is possible, yes, I'm sure it is possible for there to be issues with prescribing even where there is a consultant in place. However, I think it is probably quite unlikely and certainly we have to work on the basis that it would be quite unlikely. But again, Dr Burke, in terms of your view on that? Dr Burke, I suppose just in terms of the normal checks and balances, junior doctors would be supervised by senior doctors by consultants. They would have mandatory supervision weekly, not optional, but mandatory supervision. Consultants partake in continuing professional development. They have peer support groups. In my own area, we meet every month and we review challenging cases. We would have regular reviews of our clinical complaints. In my own area, we would do that fortnightly. We would look at our serious instances and that would be reviewed by a very high-level team. To see if there is any learning from that, that would go through clinical governance committees. There is a robust and tiered structure. Regrettably, this broke down in this particular instance, but in the vast majority of areas across. I want to reassure the people using our services because it is important that we do that. There is good practice and very good practice in CAMHS and a lot of satisfaction expressed by our service users in terms of the service that they got. But at the end of the day, you look specially guaranteed to the focus on.