How to help a child in crisis? – report from NIK’s expert panel on psychiatric and psychological care of children and youth

Pandemic, cyberbullying, growing pressure of the school and parental requirements – all this makes children more and more overwhelmed and unable to manage their emotions. “Help is there but the system needs changes” – this is how the expert panel on psychiatric and psychological care of children and youth, held in NIK’s headquarters, could be summed up. Prevention and education play an enormous role but the family and the child’s environment of origin are fundamental. The Polish psychiatry reform has been going on since 2019 but there is still a lot to be done. A project on children using psychological aid without parents’ consent has proven controversial. Besides, the meeting participants were not unanimous on whether teachers should be given the right to diagnose students for mental disorders. A point of departure for the debate were the results of NIK’s ad hoc audit.

“Overcrowded psychiatric wards, medical staff shortages and tragic statistics showing systematic increase in the number of suicides among the youngest ones are not only warning signs. This is a signal that we are running out of time if we want to avoid an outbreak of the epidemic of mental diseases” – with these words NIK President Marian Banaś opened the expert panel.

The Police data show that in the past five years the number of persons up to 18 years of age who committed suicide has increased by 9% and the number of suicide attempts has gone up by as much as 51%. In 2022, a tragic record of suicide attempts among children and youth was beaten. At that time, as many as 2037 young persons attempted to take their lives, including 150 deadly suicide attempts. It needs to be underscored that not all incidents are reported to law enforcement bodies so the data is underestimated.

NIK decided to take psychiatric and psychological care of children and youth under the microscope because of horrifying trends related particularly to young patients. In January this year, the NIK Branch in Poznań completed an ad hoc audit called Psychiatric and psychological care of children and youth in Wielkopolskie Province, based on which two planned audits were started: Psychiatric care of children and youth and Psychological and psychotherapeutic aid for children and youth. The planned audit results will be made public at the turn of the third and fourth quarter this year.

Key findings of NIK’s ad hoc audit included:  

• use of force against the law – one of the audit findings was related to the use of patient coercion, i.e. measures used against the will of persons with mental disorders, against effective principles. Coercion was used almost exclusively as the patients’ immobilisation. In a clinical hospital in Poznań the examined cases were related among others to uninterrupted immobilisation of patients for at least 100 hours. In 50% of cases coercive measures lasted from 160 to 1413 hours (63 days). Those patients were immobilised for 70% to 99% of the hospitalisation time, and the immobilisation was used multiple times. Coercive measures were used illegally. For instance, the use of force was prolonged without personal examination of the patient by a doctor. Also, it happened that patients were immobilised in the corridor without being shielded with a medical screen. In both audited hospitals the use of coercion was prolonged by doctors who were not psychiatrists, so they lacked formal rights to use it. With regard to the irregularities NIK has prepared reports to the District Commissioner for Professional Responsibility.
• children not picked up from hospitals – in two audited hospitals there were children whose hospital stay was prolonged not due to medical indications but because of legal problems as to where the patient should go after discharge. In one audited hospital the stay of at least four patients was longer than necessary. In case of one patient hospitalisation was prolonged by three months.
• lack of experienced psychologists and psychotherapists in both audited schools.
• long waiting time for psychological help – in the majority of cases the whole procedure – from submitting an application to getting an opinion or a statement – took over 61 days, and in extreme cases it was more than 201 days.
• architectural barriers and constraints:

1. in some cases psychological or pedagogical assistance was provided to young patients with mobility impairment at the car park, under the facility’s windows because a patient could not be carried into the building;
2. in one case a patient in the wheelchair was carried into the facility by his/ her parents with the personnel’s assistance;
3. the facility rooms were not soundproof, so the talks held there could be heard in the waiting room;
4. sensitive data was not protected properly. In one case the students’ data was stored outside the facility in a school dormitory which was accessible to third parties (the room was closed only in the course of NIK’s audit);
5. in view of the above NIK has prepared a report to the Personal Data Protection Office.

• problems of new district psychological and pedagogical counselling centres:

1. only one of 14 psychotherapists hired in the centres was certified;
2. availability of psychological or psychotherapeutic care for new patients was limited considerably. As much as 90% of patients were persons in therapy.

• low availability of medical entities: staff shortages were one of key issues. As a consequence, young patients had to use mental health facilities for adults. In 2020-2022, the number of minors who used medical services in those facilities doubled.
• limited availability and high demand for treatment in a clinical hospital - in 2020-2022, in K. Jonscher Clinical Hospital the planned treatment waiting time reached 262 days. On the other hand, emergency admissions, without the need of queuing, made up 95% (1603 patients). The NIK audit showed, however, that hospital beds of young patients were placed in corridors. That was against the law and did not guarantee respect for the patients’ intimacy and dignity. Besides, 11% of teenagers were kept in hospital wards for adults.

According to the meeting participants the mental health crisis among children and youth is made up of diverse factors, such as: student burnout resulting from high requirements of schools, parents’ excessive ambitions mixed up with their helplessness towards children, uncontrolled access to social media and pressure of the internet. Forced isolation during the pandemic also took its toll.

Main conclusions of the meeting participants:

• parents of children in crisis often do not cooperate with relevant bodies. For instance they fail to pass on recommendations prepared by psychological and pedagogical counselling centres to education facilities. As a consequence, the child does not receive essential support, which may have a tragic ending.
• children should be heard, cared of, feel safe and secure and have space for development – these are fundaments that will give children the strength needed to overcome difficulties and crises. A lot of parents cannot talk to their children while setting high requirements to them at the same time. Helping children build adequate self-esteem is pivotal.
• prevention is the key. A stay in the psychiatric ward does not always help. Psychological or psychiatric care is not needed in many cases. Family, friends and teachers should build a strong bond with the child and react fast if necessary. “Studies show that a single reaction of an adult – a sensible, conscious and empathetic reaction -may stop the child from committing suicide” – one participant said. Supporting children in their environment of origin is absolutely crucial. “No psychologist will ever replace a parent” – another panelist stated.
• the State Secretary in the Ministry of Education and Science urged the panelists not to spread false information that the state does not support psychiatric and psychological care of young persons – because it does. The Minister argued that thanks to the amount of PLN 1.87 billion provided by the minister only this year the employment of specialists (psychologists, pedagogues and therapists) in schools and kindergartens went up by nearly 100%: from 22 thousand to 41 thousand. The ministry representative also presented detailed data concerning financial aid provided by the ministry: 35% of children in the system receive psychological and pedagogical support and the subsidy for children with special education needs this year is PLN 13 billion.
• the issue of children from 13 years of age using psychological services without their parents’ consent caused major controversies. Its supporters argued that the consent would help children receive essential help, e.g. in case of their parents’ divorce, when one parent does not agree to the child’s therapy or when the child is afraid to admit to his/ her problems. On the other hand, the opponents claimed for instance that the solution does not make sense because the parents will learn – sooner or later – that their minor child is covered by psychological support or therapy.
• a member of NIK President’s Social Advisory Council and the President of Adam Smith Centre stated that in case of violating constitutional rights, personal inviolability in particular, institutions such as the Commissioner for Patient’s Rights, should file reports to the prosecutor’s office. “Some of these pathological phenomena would not take place, or their scale would be smaller, if the persons who infringed personal inviolability were convicted” – the panelist stated.

NIK organised the expert panel on psychiatric and psychological care of children and youth to listen to opinions of specialists and practitioners. The meeting was to show if the direction taken by NIK in its planned audits is justified. The results of both planned audits on psychiatric and psychotherapeutic care will be published at the turn of 3^rd and 4^th quarter this year.