Go raibh maith agat, a LeasCheann Comhairle. Ba mhaith liom mo bhuíochas a ghabháil leis an Dr Mac Dónaill agus leis an Uasal Mac Meanman as deis a thabhairt dúinn an ganntanas i seirbhísí síciatracha d'ógánaigh a phlé.

Thóg Comhaltaí ceisteanna tábhachtacha faoi na seirbhísí seo le linn na díospóireachta agus ina gcuid oibre sa Tionól. Tá mé ar aon intinn leo faoin a lán dá n-ábhair bhuartha agus tá mé tiomanta do na seirbhísí d'ógánaigh ar a bhfuil fadhbanna meabhairshláinte a fheabhsú agus a mhéadú.

Tá meabhairshláinte páistí agus ógánach ina hábhar mór imní. Tá fadhbanna meabhairshláinte coitianta i measc páistí agus ógánach. Ar na neamhoird mheabhairshláinte a bhíonn ar ógánaigh tá neamhoird mhothúchánacha, neamhoird fhorásacha, neamhoird itheacháin, siondróim iarthráma agus neamhoird shíocóiseacha. Meastar go bhfualaingíonn idir 10 agus 20 faoin chéad de dhaoine óga galar acu seo ag am ar bith, agus tá seo ag dul chun leitheadúlachta. Tá níos mó aird á tarraingt ar thionchar gearrthréimhseach agus fadtréimhseach na bhfadhbanna seo ar chuid mhaith gnéithe de shaol páistí agus fosta ar an chontúirt go dtitfidh siad i ngalar meabhrach agus iad fásta. Táthar imníoch fosta faoin éileamh ard atá ag sárú soláthar reatha na seirbhísí meabhairshláinte.

Cúis bhuartha dúinn é gur tugadh isteach den chéad uair ar meán beagán faoi 130 duine óg idir 14 agus 17 in aghaidh na bliana chuig ospidéil mheabhairghalair sna blianta 1996 go 1999. Mar bharr ar an bhuaireamh, tugadh a mbunús isteach i mbardaí síciatracha aosacha. Le 12 mhí anuas tugadh 103 duine óg faoi bhun 17 isteach i mbardaí síciatracha aosacha.

Tá ag méadú ar an imní faoi sholáthar do othair chónaitheacha ógánta. Faoi láthair, níl ann ach aon saoráid sé leaba amháin i nGairdíní an Choláiste, Béal Feirste. Glacann na sé leaba seo daoine óga idir 14 agus 18: cheannaigh Bord an Oirthir cúig cinn agus cheannaigh Bord an Iarthair ceann amháin. Fágann an t-ardéileamh ar na leapacha seo gur minic nach dtig le hothair teacht a bheith acu orthu. Cé nach mbíonn seirbhísí cónaitheacha de dhíth ach ar bheagán othar, is cuid riachtanach iad mar sin féin den tsamhail ceithre shraith don mheabhairshláinte ógánach - samhail ar a bhfuil glacadh coitianta.

I thank Dr McDonnell and Mr McMenamin for giving us this opportunity to discuss concerns about the shortage of adolescent psychiatric services. Members have raised important issues about those services, both during the course of this debate and in their work in the Assembly. I share many of their concerns and am committed to improving and increasing services for adolescents with mental health problems.

Child and adolescent mental health is a major area of concern. Mental health problems are common in children and adolescents. I am clear on the range of mental health disorders faced by adolescents and the need for us to ensure that the services are in place to deal with them. They include emotional and development disorders, eating disorders, post-traumatic syndromes and psychotic disorders. It has been estimated that between 10% and 20% of young people are affected at any one time, and the prevalence rates are rising.

There is a growing awareness of the short- and long-term impact of those problems on many aspects of children's lives and on the risk of later adult mental illness. There is also concern about the high level of demand, which, as many Members have said, outstrips current mental health service provision. It is a disturbing statistic that in the years 1996-99 there has been an average of just under 130 first admissions of people aged 14 to 17 to mental illness hospitals per year. More worryingly - and Members also pointed this out - most of those young people have been admitted to adult psychiatric wards.

As I said in a recent written reply to Sue Ramsey, in the last 12 months 103 young people under 17 have been admitted to adult psychiatric wards. Concerns about adolescent inpatient provision have, understandably, been increasing. Currently, there is only one six-bed adolescent inpatient facility, situated in College Gardens in Belfast. These six beds admit young people between the ages of 14 and 18. Five of the beds were purchased by the Eastern Board and one was purchased by the Western Board. The high demand for these beds means that patients are regularly unable to gain access.

Turning to some of the specific points raised by Members, I recognise the many problems relating to suicide and parasuicide. It is necessary to invest across a range of mental health services in order to target those persons viewed as high risk and also the much larger number viewed as low risk. In this financial year I have invested an extra £2 million in community mental health services and inpatient services across the range. That will include services for adolescents.

At this stage it is not possible to assess accurately the success of those interventions, but I agree with Members that the range of factors that can influence suicide, such as unemployment and social deprivation, has to be tackled across society.

David Ford and Sue Ramsey raised the issue of the interface between mental health services for young people and specialist residential care provision. The issues relating to residential and community-based services for children with psychological and psychiatric needs will be taken forward through, among other things, the future work of the Children Matter task force.

The Department of Health, Social Services and Public Safety's policy on young people who are survivors of abuse in adult psychiatric wards is that adolescents should not be accommodated with adults. However, in some specific cases where that is unavoidable, steps should be taken to secure the young person's welfare and to protect him or her from any form of abuse.

Inclusion of a secure treatment capability within the additional beds announced in the Programme for Government should help to ensure that younger people will be admitted less often to adult wards. It is indeed, as Monica McWilliams pointed out, difficult for us that adolescents are currently admitted to adult wards. We do not want to see that. We are also faced with the difficulty, as are others throughout the service, of how to deal adequately with those adolescents in the absence of any other provision.

Areas of social deprivation, and possible preventative measures, were also mentioned. Research has shown clearly that socially disadvantaged children have a higher risk of mental health problems in childhood and later life. Members mentioned a range of stresses and their impact on the life of a child.

A variety of social interventions aimed at improving the health and social well-being of children in deprived areas have been well evaluated. In particular, high-quality school and nursery education has resulted in improvements in self-esteem and motivation, social behaviour and other educational and social benefits.

As part of the Programme for Government we are also committed to working with the Department of Education to improve, among other things, mental health education in schools. The Sure Start programme has been resourced to protect children from developing mental health problems by giving them a better start in life. As Members have said, it is up to us to ensure that a range of services is provided for children and adolescents as well as for adults.

Current service provision for educational and rehabilitation facilities for adolescents, particularly adolescent inpatients, has been criticised, but all future planning for services will include every agency involved in providing the appropriate rehabilitation and recreational facilities for that age group. The planned units will include dedicated education facilities.

Through Monica McWilliams's question I have been informed about the Chief Medical Officer's review group. Members of the group visited the young people's centre and interviewed Dr McEwan. The team also went to Edinburgh to learn from good practice elsewhere. I remind Members about the range of difficulties we are facing. That review was specifically concerned with inpatient services, but other measures have been also taken to look at other services.

Does the Minister agree that in the appendix to that report costings were based on the Edinburgh example rather than on information from the 10 years' experience of the young people's centre? If we are to plan a new unit, it might be more appropriate to base the costings on what that centre reckoned would work for Northern Ireland.

Obviously I do not dispute the points made by Ms McWilliams on the appendix to that report. However, I stress again that both centres were visited and that Dr McEwan was specifically interviewed at the time of the report.

Although these inpatient services are required by only a small number of patients, they are an essential part of the widely accepted four-tier model for adolescent mental health. The first tier will deal with relatively minor emotional and behavioural difficulties, and non-specialist practitioners within primary care will provide that treatment and care. The key action is to develop the adolescent mental health skills and knowledge of GPs, health visitors and social workers.

The second tier will deal with moderately severe problems that require attention from professionals who have been trained in child and adolescent mental health. The priority is to establish mental health practitioners who will work within the primary care setting.

The third tier will deal with severe and complex mental health problems that require a multi-disciplinary team approach from specialist child and adolescent mental health practitioners. The health and social services boards are addressing this.

The fourth tier will deal with the most severe, persistent and complex problems and will require highly specialised inpatient and/or outpatient services.

One of the effects of the lack of inpatient spaces is the necessity to admit adolescents to adult health facilities. No one wants adolescents to share psychiatric wards with adults. Apart from the obvious difficulties that are inherent in that practice, the patients do not receive treatment that is targeted at their specific needs. The areas of particular concern are a lack of group work with similarly aged patients, a lack of structured daily activity and access to education, and the additional stress, as Members have pointed out, caused by the presence of mentally ill adult patients.

The Department's policy statement on child and adolescent mental health, issued in January 1999, recommended that adult-based provision for adolescents should cease as soon as possible. My aim is to achieve that and I have outlined the steps that we are taking to bring that about. That statement also set health and social services boards two specific targets. Mr McMenamin talked about the need for a long-term view, and others spoke about the need for an overview.

The two targets set in 1999 were the review of the existing provision and the identification of needs that had not been met, and a commissioning strategy for delivering services based on identified needs and meaningful and measurable objectives. The first task has been carried out and everyone expressed concern at the lack of specialist inpatient facilities for adolescents. Mental health professionals, users and carers also expressed similar concerns.

The Chief Medical Officer, working with the directors of public health from all four health and social services boards, commissioned a review of inpatient facilities for children and adolescents. The report 'Commissioning Inpatient Psychiatric Services for Children and Young People in Northern Ireland', which Ms McWilliams mentioned, was completed in October 2000. It recommends that there should be 25 inpatient beds for adolescents and that those should be split into two inpatient units. There are six beds currently available.

The report also recommends that the inpatient places should be supported by an appropriate level of community- based services. I am sure that some young people who have been admitted as inpatients could have been better treated in the community, if the appropriate services had been available. The Programme for Government set a target of securing 10 additional beds by December 2001, which would leave a shortfall of nine. I will be bidding for additional resources to secure those additional beds.

The December 2001 target is very challenging, as are all of the target dates in the Programme for Government. However, I will ensure that undertaking the work that is required to obtain the additional beds will be a top priority for me and my Department.

I am aware that there is a shortage of staff trained in dealing with adolescents with mental illness. Dealing with such adolescents requires specific skills, and there is a clear requirement to understand the needs of adolescents and how those needs can be met. Training staff to develop the appropriate skills is the key to the development of an effective and efficient service. The Department has examined training necessities. There are four new trainee consultant psychiatrists who specialise in child and adolescent psychiatry coming forward each year, and the intention is to have up to 20 consultants by 2008.

There are 17 nurses involved in university training in child and adolescent psychiatry, and each year six social workers are trained in child and adolescent psychiatry. I take the point that the matter goes beyond consultant psychiatrists and that there is a need for other specialist trained staff. The resources to establish the 10 additional beds have been allocated to the health and social services boards.

The Department of Health, Social Services and Public Safety is reviewing the many comments that were received following the circulation of the report on 15 January to the Health, Social Services and Public Safety Committee, the boards and trusts, the relevant professional groups, voluntary agencies and user and carer groups. Most of those who have replied to date are content with the proposal that there should be two child and adolescent mental health units - one in the east and one in the west - although some replies advocated one regional unit. A working group representative of all interested parties will determine the preferred provider, or providers, in a way that will take account of health and social needs, accessibility and equality.

I have secured resources of £1 million to provide the 10 additional adolescent psychiatric beds and a further £1 million for 35,000 additional consultations for all age groups, including adolescents, with community mental health teams. I see that as a start, but I accept that much more is needed, and I will continue to do my best to ensure that the needs of this particularly disadvantaged group of young people are met.

I thank the Minister for her attendance and her interest. I hope that we can sustain all the developments that she mentioned in the coming years. I acknowledge the goodwill of the Department and, in particular, the Minister, but I am troubled by a feeling of déjà vu. I was one of a group of people who were involved in a similar debate 15, 16 or perhaps 17 years ago, when there was no service. That debate led to the setting up of the young people's centre run by Dr Ewan McEwan in College Gardens. I do not think that we have made enough use of him, but I will leave that matter for the moment. I also want to thank Mr McMenamin, Dr Hendron, Dr Adamson, Mr Berry, Ms Ramsey, Mr Ford, Ms McWilliams and Mrs Robinson for taking part in the debate: I am heartened.

I became involved with the subject simply because I still try to do a bit of general practice, and I noticed a significant increase in the number of teenagers with a degree of distress and mental illness. Mr McMenamin became involved in the debate because of the approaches made to his constituency office. I subsequently learned that the demand for adolescent psychiatric services has increased by about 50% in the past 12 months. We are all well-intentioned, and we pay lip service to children's issues in the Assembly from time to time. Adolescents may not be the babies or young children on whom we usually focus our attention, but these bigger children - 13 to 18-year-olds - are, in many ways, just as vulnerable.

Adult psychiatric services have undergone a major revolution in the past 20 years. Many people who were previously institutionalised now live fairly stable lives in hostel accommodation. Child psychiatry has been around for a while, and although it leaves a bit to be desired, there certainly seems to be a reasonable service. I emphasise that good-quality mental health provision is a much wider issue than just the elimination of the gross illness that strikes us so dramatically. There is a lot of illness and poor mental health that we never see. We are, perhaps, dealing with the tip of the iceberg.

Adolescents in psychiatry, by and large, have been falling between two stools. I do not want to repeat what has already been said about teenagers being shoved into adult beds when it is totally inappropriate. In other cases, child psychiatrists have seen some individuals but not others. It is very much on a grace-and-favour basis.

The serious point that has emerged here that frightens me is that, in some cases, up to 20% of young people in parts of the community can be affected. Perhaps briefly, if only for a few weeks, they have a dip, a point of stress or illness. Adolescents have the same range of mental illness that adults have. However, these illnesses are further compounded by the stresses and strains of growing up and of being a teenager.

It is a very specialist field, and one that we, collectively, at a political level, have severely neglected. There is one small unit serving Belfast and it struggles along with one consultant and a handful of dedicated staff. Recently, I understand, a consultant has been appointed in Lisburn, but that service is limited and, to a large extent, is fairly disconnected from the Belfast service. The problem is that we need a vision for the whole regional service. It is not acceptable to have a bit of a service in Lisburn and a bit more in Belfast or a bit in north and west Belfast, and a bit in south-east Belfast. This service needs to be regionalised and must be a comprehensive, seamless service that works and delivers the best possible support it can to these vulnerable people.

We need all of the components, and I agree with many of the structures that the Minister has outlined. We need the proper outpatient, day-care and in-care patient level of service. However, I emphasise that the in-care level needs to be subdivided because the illnesses and the types of problems are very different. It encompasses such a wide range, as the Minister outlined - for example, we have some very timid and nervous people perhaps suffering from anorexia and others who are psychotic and quite aggressive. It is difficult, or certainly not good for either party, to mix them. Some are drug addicts or are perhaps going through a withdrawal phase when they could become quite psychotic. Many have been sexually abused and, as a result, are disturbed - that is perhaps one of the biggest groups. Others have been mentally and physically abused. I do not want to lay a lot of emphasis on the issue, but some would perhaps be sexually aggressive and a serious threat to the more vulnerable female patients that might be there.

Also, without being sensationalist, we do have situations where adolescents have been involved in murders and are caught up in a whole forensic web and legal matters. It is impossible to put all these elements together in one comfortable unit. There are many experts out there, but we need to be able to get it together.

I want to echo something that Ms McWilliams said earlier. She said that we do not have the research, the quality of information or the reliable statistics on which we can build a service, and we badly need that. The structures of the service need not only to be comprehensive and coherent but also adaptable to individual needs. I suggest that a community-based service should be located in every trust and alongside that perhaps a degree of day care.

I am glad I heard someone mention 25 beds, which is an increase on the 16 that we should have by December 2001. I would like to see us setting ourselves a goal of 25 beds. However, the 25 beds will be totally inadequate if they cannot be subdivided into small units of twos and threes. I favour one regional unit because we are not going to be able to bring the proper therapeutic support to two or more centres.

There is a severe danger in shoving a load of disturbed teenagers in to one big place in that some of them could make others worse. They must be housed in comfortable, apartment-sized units where compatible people can fit together, and within that, there needs to be a proper therapeutic structure.

It would probably be very narrow to look at Belfast only; I would apply a similar theory across the board. In the Eastern Board area we probably need one adolescent psychiatrist and one child psychiatrist for every trust, and perhaps two other consultants at a central level. Those at a consultant level should be fully supported by specialist nurses, because well-trained nurses can be every bit as useful as - and in some cases more useful than - the psychiatrist or the medically trained person.

There are a number of other things that I would like to mention, but I do not want to go on. I am very glad to have been able to participate in the raising of this issue today. However, I am concerned about the need for an adolescent drug and substance abuse service. We have a service for people who are 20 - certainly 18 - or older, but we do not have one for adolescents. We have no eating disorder service for people who are 17 or younger. There is no support service for adolescents who have been sexually abused. Edinburgh has been mentioned as a best-practice model. Edinburgh is good, but I think that we also have a jewel in the crown in our own centre in College Gardens, if it could only be expanded. The fact that we do not have a forensic service for adolescents was mentioned earlier. Someone should be looking at the interface between the law and psychiatry.

Having said all that, Mr Deputy Speaker, I want to draw your attention to the fact that we have brushed only the tip of the iceberg. There are many young people out there that never quite come up on the screen. There are young people out there who are labelled as being educationally difficult, and they fall within the remit of the education boards or become statemented. Many of those children are semi-disturbed, or quite a bit more than semi-disturbed, but not disturbed enough to annoy the rest of us, and we tend to ignore them. There is a major problem out there, and until we get on top of it, we will be doing our young people a major disservice.

Mr Deputy Speaker, I want to thank you, the Minister and others who facilitated this debate.

<< Prev