Introduction
Child and Adolescent Mental Health Services (CAMHS), the statutory body responsible for the provision of mental health services to children and young people (CYP) in Ireland under the age of 18 (Health Service Executive 2019), is overstretched and under-resourced (McNicholas Reference McNicholas2018). Referrals to CAMHS were increasing prior to coronavirus disease 2019 (COVID-19) and continued further post-pandemic (McNicholas and Moore Reference McNicholas and Moore2022). Waiting lists to access CAMHS have increased from 2 755 in December 2020 to 4 434 at the end of February 2023 (House of the Oireachtas 2023) with 682 CYP waiting more than a year for a CAMHS appointment as of April 2023 (Griffin Reference Griffin2023). Despite the increased demand and waiting times, funding, staffing and resources for CAMHS remain well below the recommendations set out in the nation’s mental health policy ‘A Vision for Change’ (Expert Group on Mental Health Policy 2006) and well below the European Union average (Irish Hospital Consultants Association, 2021). Acceptance rates across CAMHS vary significantly (38–81%) (Mental Health Commission 2023) with many CYP unable to access services increasing the likelihood of crisis mental health presentations.
Acute mental health crises including self-harm and suicidality in CYP in the United Kingdom (UK) and Ireland are increasing (Griffin et al., Reference Griffin, McMahon, McNicholas, Corcoran, Perry and Arensman2018), and rates of suicide attempts in CYP have escalated significantly since the COVID-19 pandemic (Wan Mohd Yunus et al., Reference Wan Mohd Yunus, Kauhanen, Sourander, Brown, Peltonen, Mishina, Lempinen, Bastola, Gilbert and Gyllenberg2022). CAMHS services operate only during working hours (09:00 a.m.–05:00 p.m. Monday to Friday), and there is a lack of both out-of-hours and crisis intervention services in Ireland. CYP suffering from a mental health crisis outside of working hours have limited mental health care options and often present to emergency departments (EDs).
The difficulties in accessing CAMHS and the lack of out-of-hours and crisis services have resulted in Ireland’s national police force, An Garda Síochána (GS), becoming increasingly involved as first responders to CYP experiencing mental health crises (Commission on the Future of Policing in Ireland, 2018). Section 12 of the Irish Mental Health Act (MHA) 2001 allows members of GS to bring a young person experiencing a mental health disorder where there is a serious likelihood of harm into custody, in the absence of a crime being committed and/or without having to make an official arrest (Mental Health Act, 2021). Additionally, section 12 of the Child Care Act 1991 allows members of GS to take a child to a place of safety when they have reasonable grounds for believing that there is an immediate and serious risk to the health or welfare of a child, and this is often applied in the management of mental health crises (Child Care Act, 1991).
Once in custody, GS members are obligated to have the young person assessed by a registered medical practitioner. If the medical practitioner believes that the young person is suffering from an acute mental health disorder, they can refer the young person for medical assessment and intervention to an approved centre. CYP are referred to either paediatric EDs if under 16 years of age or adult EDs if they are over 16 years of age. Many EDs have established links to a psychiatric team/department or a psychiatric facility. The parent/guardian of the young person often requests the assistance of GS.
There is a dearth of research regarding the GS’s ability to access child and adolescent mental health pathways. This study was the second of two qualitative studies which sought to gain insight on the pathways to CYP mental health care for GS. The first study explored GS’s perceptions and experiences of the systems in place to manage CYP experiencing a crisis mental health event once under GS’s supervision. The study highlighted that GS felt ‘fearful and unsure’ in their decision-making in responding to crisis mental health call-outs involving CYP and that CYP crisis mental health events were sources of significant psychological burden for GS (Rooney et al., Reference Rooney, Healy and McNicholas2021).
The principle aim of this study was to obtain insight from the medical and mental health professional stakeholders working in a paediatric ED regarding their experiences of CYP presenting with mental health crises being accompanied by GS. Challenges and opportunities associated with this pathway to mental health care for GS are considered.
Methods
Study design
This study adopted a qualitative research design and was the second of two data collection phases. In line with the social constructivism paradigm, a qualitative design was selected as it provided the exploratory capacity and flexibility needed to investigate individual experiences and how they create meaning to these experiences. The authors deployed an iterative phenomenological approach to interrogate the data and explore in detail how participants made sense of their individual experiences.
Data collection
The initial data collection (4 December 2019–2 March 2020) conducted semi-structured interviews with members of GS to explore the current care pathways of Irish CYP experiencing a crisis mental health event from the commencement of GS involvement through to the initiation of psychiatric care. An Expert Advisory Panel (EAP) comprised of leading experts in the fields of Child and Adolescent Psychiatry, Youth Justice, Mental Health, Policing and Social Policy offered guidance to study design. Panel members were invited to take part in an EAP meeting prior to data collection to discuss pertinent themes that had emerged from interviews with GS members and how these themes could inform interview schedules with medical and mental health professional stakeholders. The semi-structured interview schedule was devised by the researchers and informed by a literature review and feedback from the EAP meeting. The semi-structured interview schedule is included in Appendix 1.
The second phase of data collection was conducted from 7 September 2020 to 4 December 2020. Semi-structured research interviews were conducted with a convenience sample of medical and mental health professionals (n = 11) involved in child and adolescent pathways of accessing acute mental health care through GS. The interviews were conducted remotely by a member of the research team who is a criminologist with formal qualitative research experience. This research team member had no prior relationship with participants and was not an employee of the hospital. Participants included medical and mental health professionals working in a paediatric ED that serves children aged 0–16 years in Leinster Province and a social worker from Tusla Child and Family Agency (Leinster Province). The total interview time was 8 hours 50 minutes 36 seconds, and the average interview lasted 45 minutes.
Data analysis
All interviews were audio recorded with consent from participants and subsequently transcribed by the research team using Microsoft Word. Reflexive thematic analysis techniques were utilised to capture frequently cited and meaningful information that was relevant to the overall research questions (Clarke and Braun Reference Clarke and Braun2017). The software package MaxQDA was used to systematically organise and code transcriptions. All researchers were involved in data analysis. Member checking and triangulation were utilised as techniques to improve trustworthiness. The Standards for Reporting Qualitative Research (SRQR) was utilised by the authors during manuscript preparation to improve the transparency of the research (O’Brien et al., Reference O’Brien, Harris, Beckman, Reed and Cook2014).
Ethical considerations
Ethical approval was sought and approved from University College Dublin on 9 September 2019 (LS-19-73-Rooney-McNicholas). This was then followed up by obtaining approval from the Garda Research Unit, Tusla and CHI Crumlin.
Results
Participant demographics
Of those that agreed to take part, nine were female, and two were male with an age range of 28–56 years. The years of service ranged from 3 to 32 years with participants drawn from medical, mental health, nursing and social work professionals (n = 11).
Participants described varied and nuanced experiences of working with CYP presenting to ED with a mental health crisis involving GS. Additionally, participants provided key insights and recommendations into how identified challenges could be remedied. Four major themes were identified: (1) interagency working between GS and staff in the ED; (2) the ED setting in managing mental health crises; (3) unclear legislation, protocol and training; and (4) opportunities in care pathways. Details of major themes and subthemes are outlined in Table 1.
Table 1. Major themes and subthemes
GS, An Garda Síochána; ED, emergency department; CYP, children and young people.
Theme 1. Interagency working between GS and staff in the ED
Following referral by the GP of the youth to the ED, GS hold responsibility to ensure safe transport to the nearest hospital.
GS assistance in the ED
Participants highlighted the absence of a formal protocol outlining the need for GS to remain with the young person in the ED to facilitate assessment by medical professionals. In cases where the young person posed a risk to themselves or others, medical professionals are reliant on GS to assist with the management of the young person. Participants acknowledged that GS were generally very accommodating and helpful in this regard, often de-escalating situations that were potentially volatile. Participants also acknowledged the reality of GS being recalled to other policing duties.
[Doctor 2] Sometimes they just go, but if they have been very aggressive at home or if the Guards have built up a good rapport with the kid they will stay. And you know sometimes the Guards are called and told to come back to the station so they don’t have a choice, even if they did wish to stay, often times they will be called back.
[Nurse 2] It’s good, usually before we meet the child, they let us know how they think it might be best to approach the child you know in case they think they might become violent. They will usually come with us when we take the child to the room where they will be assessed.
Positive interagency rapport between GS and staff in the ED
Medical professionals reported positive interagency rapport with GS. They were mindful of the constraints in which GS work with regard to staffing, training and heavy workloads. Participants highlighted an awareness of the reliance on GS in the assistance of CYP mental health crisis assessments due to the unavailability of other services. Additionally, participants highlighted the shared difficulty of GS and the medical staff in managing unrealistic expectations of caregivers hoping for a quick solution for resolving crisis situations. Medical professionals reported gratitude for the assistance of GS and commended them for their conduct and support in difficult situations. Participants acknowledged the personal toll that working as first responders had on GS particularly with regard to the appropriate management of CYP with potential mental health crises without adequate knowledge and expertise.
[Psychiatrist 1] I think they are very good in terms of trying to de-escalate the situation, you know bearing in mind that some of these children would have assaulted members of the Guards and they are still there, still present and trying to de-escalate the situation with a great deal of grace that I don’t think I would have if somebody had just tried to bite me or whatever the case may be. I do think the way they manage it is very good.
Theme 2. The ED setting in managing mental health crises
Lack of appropriate clinical environment in the ED
Medical professionals highlighted that most CYP brought to the ED by GS are in a heightened and distressed state. There was a shared perspective amongst the medical professionals that the ED as a clinical environment was not appropriate for managing these CYP with mental health crises. The busy, unsafe and overstimulating ED with medical machinery, tubing and trolleys located in the assessment cubicles and throughout the corridors was recognised as a potential risk leading to further crisis escalation. High activity levels and workloads of participants were recognised and viewed as potential risk factors.
[Psychiatrist 1] The first feeling I have is just how utterly inappropriate it is for a child to be brought in by the GS to a medical hospital that is an inappropriate setting in terms of you know the environment. Like total sensory overload, you know it’s loud and bright, people are running around taking bloods, etc.
Medical professionals highlighted that there is no designated area or ‘safe space’ to assess and treat patients who do not require medical treatment (for physical illness or injury) but require careful, sensitive and therapeutic mental health assessment. Recourse to a ‘family room’, a resuscitation bay or on occasion a section in a corridor were viewed as both unsafe and potentially escalating.
[Nurse 3] And they also might arrive when we’re extremely busy and sometimes it might be hard to even find a single room space for them to have a chat, and they often end up in shared rooms or on corridors and I suppose yeah in the best of times our environment isn’t suitable to see these children.
Participants advocated strongly for a designated area for the safe assessment and management of a CYP experiencing a mental health crisis within both the garda station and paediatric ED.
[Doctor 2] I think having a separate area like a separate adolescent area to see these kids would be really helpful, you know so they don’t have to be seen in the main department.
Difficulty in maintaining safety in the ED
Participants highlighted that CYP in crisis could be highly distressed and unpredictable, posing a risk of harm to themselves and others as well as being a flight risk, requiring staff to be prepared to manage their own raised emotions, conduct a competent and skilled urgent care assessment whilst at the same time managing the expectations and emotions of the caregivers, fellow patients and other workers. Legitimate concerns were expressed by participants regarding the health and safety of the child and other ED attendees and staff. Furthermore, medical professionals are often required to de-escalate tensions between caregivers and children whilst concurrently carrying out an assessment and seeking background information. All medical professionals highlighted that these cases are time-consuming, requiring significant numbers of staff members to ensure the patient is managed appropriately and to maintain the safety of the ED. Inadequate facilities to de-escalate crisis situations sensitively and effectively and to maintain safety in the ED were recognised as ongoing concerns.
[Doctor 2] You know we have to think of the safety of the whole department as well so, whether these kids are going to be aggressive towards staff members or more importantly there are often much younger children here, you know it could spill out into the corridor. You know are they going to be a potential risk to other families and other children in the department.
[Doctor 1] I find that the Gardaí are quite helpful, they tend to stand back by the door, we would often ask our security Guards to come in as well, for the safety of the staff. Usually, one doctor would review the child and there would be two nurses and a shift leader would be present as well. It does tend to require quite a lot of staff.
Theme 3. Unclear legislation, protocol and training
Absence of formal protocol outlining the role of GS in the ED
Participants stated that there was an absence of formal protocols outlining the role of GS in the ED. They acknowledged that this could add to frustrations between the medical professionals involved and GS.
[Doctor 2] I have experienced a kind of a deer in the headlights effect where you can see that they don’t know what to do, you know they are standing there, and they feel totally superfluous when the assessment is being done.
Uncertainty in the legislation of mental health care pathways
Four participants interviewed expressed uncertainty regarding the legislation covering the care pathway of CYP presenting to ED with mental health crises through GS. They highlighted potential confusion from both participants and GS as to the application of the MHA for CYP presenting in such crisis. The participants felt that more training in mental health legislation including care pathways would be beneficial.
[Nurse 3] I think there’s a lack of knowledge and the, what’s a section 12 is that what they call it when they have to, like I wouldn’t know if that applies to a child I very much have a legal gap in my knowledge that I feel could be filled if that was possible and it would be great if there was a liaison with the actual Gardaí so we could kind of advance knowledge on that for both then, specialties then yeah definitely.
Lack of training of GS in managing CYP with mental health crisis
The personal toll of GS’s own mental health was recognised by the participants surveyed. Participants were aware as to how the lack of uncertainty about the GS role as first responders, their role in attendance in the ED, the optimal personal responses GS should engage with and the legal remit all contributed to personal challenges for the GS. Participants reported differences in GS responses to CYP, varying from a passive, cautious and hesitant approach to one that was more authoritarian and potentially escalatory. Six of the medical professionals recognised many members of GS found managing CYP with behavioural disturbances challenging. Participants highlighted that their commentary was not a critique but a recognition that GS may be unfamiliar and undertrained in managing mental health crises in CYP.
[Nurse 3] I actually find, just in general now and most of them are actually lovely, I do find a lot of them nearly wind up the children, as in they’re so no nonsense with them that it aggravates the child whereas we might have a kind of softly, softly, approach. If a child was cursing a Guard might give out to them, whereas a nurse just might ignore that you know and then they calm over time does that make sense? I do find in general though sometimes they can aggravate the behaviour, but I don’t think it’s on purpose I think it’s a lack of training or insight maybe?
Uncertainty around restraints of CYP
Participants surveyed were aware as to the potential for the existing uncertainty amongst GS staff about the appropriate and legal restraint of CYP in the ED and the additional personal stress this caused. This was proposed to be linked to a lack of training, a lack of mental health legislation training and procedure guidance. Participants recognised a dichotomy for GS of either being too heavy-handed with CYP and responding with physical restraint too quickly or being overcautious and hesitant with the need for ED professionals to directly guide, advise or request GS interventions.
[Doctor 2] If they bring a kid in who is being aggressive here, sometimes it can go either way. You know sometimes they stand back and don’t do anything at all which isn’t very helpful. But then sometimes they can also be a little bit heavy-handed and there have been times where we would have to say to them to lay off. I think the older kids they are maybe a little bit harsh on them, you know they don’t give them the level of understanding that perhaps they should. And then there are time where they are maybe a little bit too understanding, like I said they are being aggressive toward staff or aggressive towards their parents you know and if they are being particularly violent sometimes the GS have to be asked to restrain them which can be difficult.
The uncertainty of GS of the necessary physical restraint and restrictive practices to safely and effectively de-escalate a crisis balanced against unnecessary and excessive force was recognised as a source of personal stress for both GS and ED professionals.
Theme 4. Opportunities in care pathways
Crisis intervention teams
Medical professionals identified key insights into the opportunities that could remedy some of the issues that they had highlighted. One recommendation was to develop crisis intervention teams (CITs) which would provide a helpful and collaborative resource that could significantly improve the patients’ experience, promote interagency working and allow for skills to transfer across different groups of professionals.
[Psychiatrist 2] Just thinking about the US template around MH they have CITs so they would have access, maybe not to an emergency department, but access to community-based teams. Maybe that would be ideal, in my head.
Legislative and procedural clarity
Medical professionals recommended that an interagency protocol be developed to guide professional practice through the care pathways. This would enhance the understanding of what is expected of each discipline as well as help to identify where and when something has gone wrong, enhancing professional accountability and responsibility.
[Psychiatrist 2] I think the idea of uncertainty from a legal point of view you know a medical legal approach, it needs to be improved so that Guards and clinicians feel supported and know exactly where their powers lie when managing an adolescent who is presenting and isn’t under an involuntary order, because you know they don’t have a whole lot of power there.
[Tusla 1] The only joint protocol I know of is the ‘Missing from Care’ between Tusla and the Guards, and then there is a protocol for collaboration between the HSE and Disability Services but mental health no.
Enhance GS knowledge of mental illness
Medical professionals agreed that mental health professionals have an important role in training and upskilling first responders to enhance their knowledge of mental illness and unanimously voiced the benefits of the development and delivery of future training in this area. Additionally, mental health professionals should be involved in the development and delivery of future training in the area.
[Psychiatrist 2] I suppose so education sessions with the Guards around acute behavioural disturbances and mental illness on a very tertiary level.
Enhance interagency relationships and training
Most EDs felt that interagency training opportunities would strengthen interagency rapport and subsequently enhance collaborative working, information sharing and communication. Such views were informed by previous experiences of joint training and ‘eye-opening insights’ into other organisations, the different perspectives of professionals who work within them and the challenges they face.
[Tusla 1] I remember doing a training, a joint training between the Guards and the Social Work Department on domestic violence and it was amazing, and we were all kind of sitting there going ‘Jesus, I didn’t know that’s what you had to do’ and they were saying ‘oh we didn’t know that’s what you had to do and needed from us’ as a follow up.
Discussion
This study is the first to explore challenges faced by GS acting as first responders from the perspectives of medical and mental health professionals in the ED. It captures the experiences of both medical and mental health professionals working in a paediatric ED and responding to members of GS who attend with CYP with a potential mental health crisis. The study addresses a gap in the research of these complex care pathways as they present in an Irish setting. Specific challenges of the care pathway were identified as well as key recommendations to consider. The novel insights generated by the study offers a contribution to the limited knowledge base; however, further research is needed.
There was a consensus amongst the professional stakeholders that the ED is often not an appropriate setting for CYP presenting in crisis and the care pathway involving GS can be fragmented, convoluted and unclear. However, there are few other options given the lack of out-of-hours mental health services and crisis services for CYP in Ireland, despite being recommended in the nation’s mental health policies ‘A Vision for Change’ (Expert Group on Mental Health Policy 2006) and ‘Sharing the Vision’ (Government of Ireland 2020). Additionally, the long waiting lists for CAMHS and lack of primary care mental health services mean that many CYP experience severe delays in accessing appropriate services in a timely fashion (McNicholas Reference McNicholas2018). This risks symptoms escalation and contributes to public and family order situations requiring the presence and intervention by both GS and ED staff.
All the professional stakeholders acknowledged deficiencies in appropriate facilities for assessing CYP in crisis and poorly developed facilities to support their caregivers. This issue appears to be widespread with a recent UK survey finding only 23% of EDs contained a specialist psychiatric assessment room deemed private and meeting required safety criteria (Bolton et al., Reference Bolton, Palmer and Cawdron2016) and at odds with the Royal College of Paediatrics and Child Health published standards for the ED environment when assessing CYP with mental health difficulties (Royal College of Paediatrics and Child Health 2018). These include areas that are ligature free without moveable furniture and ED equipment.
Other jurisdictions have developed specialist psychiatry assessment rooms within the ED or separate psychiatric EDs for CYP (Brind’Amour, 2020). Nationwide Children’s Hospital in Ohio in the United States, developed a Psychiatric Crisis Centre (Nationwide Children’s, n.d.), which serves as a psychiatric ED, available 24/7 and separate to the main ED. The unit is dedicated for CYP experiencing a mental health crisis allowing assessment by a multidisciplinary team in a quiet and safe environment. In contrast to a typical and busy ED, the unit is secure and consists of many assessment rooms suitably furnished to create a comfortable and safe setting. A similar model was developed at Mental Health Fairview University of Minnesota Medical Center, which found in its first year of service, 60% more patients presenting in crisis were able to return home without a lengthy hospital stay (Fairview Health, 2023). Ireland’s New Children’s Hospital provides the opportunity to address recognised ED environmental challenges and develop suitably equipped and staffed EDs to allow therapeutic and safe mental health assessments.
The professional stakeholders in this study recommended the development of a multi-agency crisis intervention model of care specifically designed for crisis mental health management not unlike the recently commenced implementation of the Crisis Resolution Services as part of the HSE Mental Health Reform plans (Health Service Executive 2023). These are currently restricted to community adult mental health services (Health Service Executive 2023) and consist of two key components: the Crisis Resolution Team (CRT) and the Crisis Café. Despite the Crisis Resolution Services being a welcomed initiative, there is as yet no equitable service for children and adolescents.
In the UK, out-of-hours and crisis services to CYP are a policy priority with expectations that each National Health Service (NHS) trust provides 24/7 home crisis treatment. This has led to the development of CAMHS CRTs, which operate 24/7. The services are for CYP at risk of harming themselves or others and experiencing a mental health crisis. The CRTs can be accessed through self-referral or referral by health, social care or education workers and aim to assess a CYP within 4 hours of receiving the referral (National Health Service Nottinghamshire Healthcare, n.d.). The CRTs were developed so that CYP could access care close to home and avoid EDs as well as inpatient admissions (National Health Service, n.d.).
Initial service evaluations are positive with evidence of improved functioning at the end of treatment (Staite et al., Reference Staite, Howey and Anderson2022). Evaluation of adult CRTs has also been favourable with high patient satisfaction (Barker et al., Reference Barker, Taylor, Kader, Stewart and Le Fevre2011), reductions in admissions (Johnson et al., Reference Johnson, Nolan, Pilling, Sandor, Hoult, McKenzie, White, Thompson and Bebbington2005) and associated cost benefits (McCrone et al., Reference McCrone, Johnson, Nolan, Pilling, Sandor, Hoult, McKenzie, Thompson and Bebbington2009). Some less favourable outcomes (Tyrer et al., Reference Tyrer, Gordon, Nourmand, Lawrence, Curran, Southgate, Oruganti, Tyler, Tottle, North, Kulinskaya, Kaleekal and Morgan2010) suggest more research is required in the implementation of the CRT model especially with regard to CYP. Positive results would strengthen the rationale for implementing these services in Ireland.
Other approaches to reduce the number of police-directed mental health presentations at EDs include a model of collaborative work between police enforcement and mental health professionals. The South London and Maudsley NHS Foundation Trust’s Centralised Place of Safety provides immediate access to mental health staff for individuals detained under section 136 of the Mental Health Act 1983 (Healthy London Partnership 2017). Established in 2017, the service has significant positive feedback from patients, ED staff and police staff with evidence of a reduction in section 136 ED attendances (Healthy London Partnership, 2017; Kings Health Partners 2018). There standard of care set by this service was to ensure that those suffering from a mental health crisis are ‘treated by the right people, in the right place at the right time’ and more than 96% of patients are responded to within 30 minutes of arrival (Healthy London Partnership, 2017; Kings Health Partners 2018). These positive findings argue for a wider roll-out of the service and piloting in a younger cohort thereby increasing the accessibility to CYP.
Professional stakeholders in this study identified challenges for members of GS in de-escalating mental health crises and recommended interagency working and joint training programmes as methods to enhance GS understanding of youth mental illness. Such training programmes have been developed in the United States and recently piloted in the Midwest to police officers, with the aim of diverting youth with mental health problems from criminal and legal systems (Van Dijk and De Waard Reference van Dijk and de Waard1991). Crisis intervention team (CIT) training (CIT-Y) consists of 40 hours of training which include role playing, de-escalation techniques and exploring topics such as brain development, mental health in CYP, developmental disabilities and suicide risk (National Alliance of Mental Illness, 2009). Research has confirmed that CIT-Y is feasible and acceptable to police officers, enhances their knowledge of youth mental health and exerts a positive impact on officers’ behaviours (Kubiak et al., Reference Kubiak, Shamrova and Comartin2019).
In Ireland, GS recently announced a new mental health initiative where GS members will complete certified training courses with Mental Health First Aid Ireland (MHFA) including youth MHFA (St. John of Gods Hospital 2023). One of the aims of the initiative is to enhance GS understanding of mental illness and how to deal with members of the public experiencing mental health crises. Our study reported on uncertainties of GS in managing mental health crises, confusion regarding mental health legislation as it applies to youth and potential interdisciplinary tensions in the management of youth attending EDs. The proposed MHFA training should include presentations of youth with mental health illness.
Limitations
There is a paucity of research investigating the care pathways of CYP presenting with a mental health crisis involving the police service. Whilst this study makes a sizeable contribution to the research gap, the findings are only a starting point. The small sample size of stakeholders working in Leinster does not capture the experience of professionals working in other parts of Ireland. Quantitative studies will capture the extent of the problem. The sole ED in this study serves only under 16-year-olds; therefore, additional studies should be carried out in adult EDs to capture the experiences of care pathways involving youth aged between 16 and 18 years. This subsect of CYP often falls between the interface of child and adult mental health services. Data is emerging from other jurisdictions as to the potential benefits of dedicated crisis mental health services. Ireland should not lag behind these developments.
Conclusion
This study is the first study to explore the experiences of medical and mental health professionals working with CYP presenting with a mental health crisis to the ED following GS involvement. The study identified several challenges in the care pathway including the lack of appropriate clinical environments, challenges of GS in managing mental health crises in CYP and uncertainties around mental health legislation. The findings highlight the need for development of crisis services for CYP in Ireland as well as opportunities for youth mental health training to valued members in GS.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ipm.2024.20.
Financial support
Funding was obtained from the Policing Authority (An tÚdarás Póilíneachta).
Competing interests
Dr Laura Bond declares no conflict of interest. Dr Louise Rooney declares no conflict of interest. Dr Deirdre Healy declares no conflict of interest. Professor Fiona McNicholas declares no conflict of interest.
Ethical standards
‘The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.’
Ethical approval was sought and approved from University College Dublin on 9 September 2019 (LS-19-73-Rooney-McNicholas). This was then followed up by obtaining approval from the Garda Research Unit, Tusla and Children’s Health Ireland (CHI) Crumlin.
