Introduction
Primary care has long been recognised for its role in managing adults with mental health issues. Consequently, the majority of Irish training schemes require General Practice (GP) trainees to complete an adult psychiatry rotation (four-six months dependent on individual training schemes) before working as a registrar in general practice. Research suggests that up to 40% of a GP’s patient contact time may involve managing mental health concerns, some of which may necessitate referrals to psychiatry services, including Child and Adolescent Mental Health Services (CAMHS) (McKay et al., Reference Mckay, Andretta, Cole and Clarke2020). Despite GP’s being regarded as the first point of contact for children and adolescents with mental health issues, General Practice is seldom discussed in the public discourse about how to manage the mental health crisis amongst this cohort apart from the ubiquitous suggestion ‘if you have any mental health concerns, talk to your GP’ (www.hse.ie, 2022). This issue is particularly pronounced in disadvantaged areas, where children are 4.5 times more likely to experience severe mental health problems compared to those in the highest socio-economic groups (McKay et al., Reference Mckay, Andretta, Cole and Clarke2020). However, the current waiting list for CAMHS is unacceptably long which deepens the gravity of the situation (Department of Children, E., Disability, Integration And Youth, 2023).
Studies suggest that the impact of the Covid-19 pandemic played a part in worsening of Child and Adolescent mental health. Between 2020 and 2021, CAMHS experienced a 33% increase in demand and the waiting lists for CAMHS has almost doubled from 2,755 in December 2020 to 4,434 February 2023 (Department of Children, E., Disability, Integration And Youth, 2023). This adds to the stress and anxiety these patients and their parents are experiencing who are awaiting appointment (McNicholas et al., Reference Mcnicholas, Reulbach, Hanrahan and Sakar2016). Irrespective of this, the demand for access to CAMHS needed to be examined in order to manage the situation effectively. GPs have previously reported feeling ill-equipped and under skilled to manage these patients due to sensitive and specialised care they require (Leahy et al., Reference Leahy, Schaffalitzky, Saunders, Armstrong, Meagher, Ryan, Dooley, Mcnicholas, Mcgorry and Cullen2018). One contributing factor to this issue may be the limited, if any, formal training or exposure to CAMHS provided to GP trainees in Ireland as part of their training.
Recent articles examine GP’s frustration with CAMHS in Ireland. They report unacceptably long waiting lists, no formal access to child psychology and increased demand in the private sector due to a failing service to provide assessment of need and access to multidisciplinary services (McNicholas et al., Reference Mcnicholas, Reulbach, Hanrahan and Sakar2016, Leahy & McNicholas Reference Leahy and Mcnicholas2021). Recent research carried out in Ireland assessing GP or GP trainees perspectives on CAMHS in Primary Care is limited. One study by Leahy et al. (Reference Leahy, Schaffalitzky, Saunders, Armstrong, Meagher, Ryan, Dooley, Mcnicholas, Mcgorry and Cullen2018) carried out in Ireland examined the role of the GP in providing early intervention for children with problems relating to their mental health via mixed methods investigations. One significant finding of the study was the low satisfaction rates among GPs regarding formal postgraduate training in Child and Adolescent Mental Health. The research concluded that there was a need to increased awareness of the link between the CAMHS and the role of the GP via the provision of more education to GPs and improving access to psychological treatments (Leahy et al., Reference Leahy, Schaffalitzky, Saunders, Armstrong, Meagher, Ryan, Dooley, Mcnicholas, Mcgorry and Cullen2018).
The Maskey report (2022) frequently emphasises the involvement of GPs in the care of children diagnosed with attention deficit hyperactivity disorder (ADHD) in Ireland. The report comments on failings such as lack of blood test monitoring, lack of monitoring of patients on psychotropic medication, poor correspondence between the CAMHS multidisciplinary team and their GP and patients being lost to follow up. By identifying these shortcomings, it highlights the key areas for improvement, primarily involving the implementation of a shared care protocol and enhancing communication between the CAMHS team and the patient’s GP (Maskey, Reference Maskey2022).
This study aimed to assess GP trainees’ training and confidence in assessing and managing children and young adults with mental health conditions in primary care. Majority of GP trainees are required to carry out a rotation in adult psychiatry as part of the Irish College of General Practitioners (ICGP) guidelines to become a GP in Ireland however there is no formal requirement for CAMHS training. Given the recognised increase in the number of children presenting to primary care with mental health concerns, it is important that GPs are competent in assessing these patients and formulating a timely and effective management plan. This study aims to examine potential gaps in knowledge among GP trainees regarding CAMHS and to assess their self-perceived confidence in managing child and adolescents with mental health issues in primary care.
Methods
This is a descriptive study informed by an online questionnaire . All third and fourth year GP registrars registered with the ICGP training schemes were invited to complete an online anonymous questionnaire. The survey was sent to the participants by the ICGP scheme administrators.
The online questionnaire consisted of 17 questions. Baseline characteristics were collected and questions assessed exposure to CAMHS training, confidence in managing key CAMHS issues in primary care, and knowledge of when to refer to specialty services. Questions were in the form of a mixture of multiple choice questions; yes and no answers; Likert scale; and some of the answers allowed for participants to give free text responses. Informed consent was a prerequisite to completing the survey. An information leaflet was provided to all participants to inform participants of the aims of the study prior to consent.
The areas of investigation were chosen based on current literature about CAMHS in primary care and The Mental Health of Children and Young people in Ireland Report published in 2023 by the Department of Children, Equality, Disability, Integration and Youth that accurately reflects the common child and adolescent conditions seen in Ireland (McGorry et al., Reference Mcgorry, Bates and Birchwood2013, Department of Children, E., Disability, Integration And Youth, 2023). The questionnaire asked specifically about the following: previous experience in CAMHS prior and during the GP training scheme; skills in assessing CAMHS and other mental health services in primary care; knowledge of the common clinical areas in CAMHS and the relevant pathways of referral; competence in CAMHS practice in primacy care; access to CAMHS and other community mental health services and the need for further training.
The option for the rating of knowledge, skills and competence was a Likert scale of one to five; 5- exceeds expectations or excellent, 4 – above expectations or very satisfactory 3- adequate/ meets expectation, 2- needs improvement or below expectations and 1- poor or inadequate. The sample consisted of 406 GP registrars enrolled on the ICGP training scheme in Ireland. The questionnaire was emailed to GP registrars via their scheme administrator in May 2022. A reminder email was resent six weeks after initial invite to those who has still not completed the questionnaire.
The results were analysed using quantitative methods while retaining the respondents’ anonymity. The analysis was conducted with an aim of identifying various patterns of response to particular areas of CAMHS and other youth mental health services in primary care including disability and primary care psychology.
Results
Among the 406 invited GP trainees, 60 completed survey, reflecting a response rate of 14.7%. Predominantly, 52 respondents fell within the age bracket of 30-39 years, while four individuals were under 30 years old, and an equal number were above 39 years. Females accounted for 50 out of the 60 respondents.
In terms of practice distribution, eight respondents worked in single-handed practices. 20 respondents worked in a small group practice (2 to 3 GPs) and 28 respondents worked in larger group practices comprising of 4 to 10 GP’s. Geographically, 42 trainees identified their practice locations as urban, with the remaining 18 trainees categorised their practice as rural. In delineating their training status, 33 respondents were fourth year registrars, 26 were third year registrars, and one respondent represented a second year trainee (Table 1).
Table 1. Participant characteristics
Six respondents had previous experience working in CAMHS prior to starting GP scheme while 54 has no experience before commencing the GP scheme. Of the six respondents who had previous experience; five of them worked in CAMHS as part of previous psychiatry job and one had a previous degree in the child and adolescent sector.
Seven respondents stated that they had experience in CAMHS during their GP scheme – three of whom stated they worked with CAMHS as part of psychiatry rotation and one respondent reported experience with CAMHS working on paediatric rotation. One respondent said ‘other’ and two respondents didn’t answer. Two out of the six respondents who reported experience during scheme said it was useful while four of the six reported they did not find it useful.
Competency in managing children and adolescents in common areas of CAMHS
When respondents questioned about rating their competency in managing children and adolescents in the seven common areas of child and adolescent mental health as listed below from 1 to 5; (1 = Unacceptable, 2 = Needs improvement, 3 = Meets expectations, 4 = Exceeds expectations, 5 = Excellent). Five out of the seven areas had a mode of 2 indicating a need for improvement. These five areas were; Disruptive behaviour/conduct disorders, Psychosomatic disorders, Eating disorders, Developmental Disorders and Gender Dysphoria / Gender Identity Disorder. Respondents most commonly rated themselves as meeting expectations in the areas of Emotional disorders and Self-harm and suicidal ideation (mode = 3) (Table 2).
Table 2. Competence in Child and Adolescent Mental Healthcare Services based on problem type (1 – unacceptable 2 – needs improvement 3 – meets expectations, 4 – exceeds expectations, 5 – excellent)
Knowledge in CAMHS common areas
When asked to rate their overall knowledge in various common CAHMS areas on a scale from 1 to 5, respondents predominantly rated themselves at 2 out of 5 (2 = Needs Improvement) for Aetiology of CAMHS problems, Nature and course of CAMHS problems, and Treatment and management of CAMHS problems. This collective mode of two signifies a recognised need for improvement in these specific areas. Conversely, GP registrars demonstrated satisfactory knowledge levels in Child development and Awareness of when to refer to Psychiatry services, as depicted in Table 3.
Table 3. Knowledge in specific areas of Child and Adolescent Mental Healthcare Services (1 – unacceptable 2 – needs improvement 3 – meets expectations, 4 – exceeds expectations, 5 – excellent)
Skills in CAMHS practice
GP Registrars most commonly rated their skills in the following areas as meeting expectations with a mode of 3: Communication with children and adolescents, Recognition of mental health problems, Management of mental health problems, Assessment of self-harm and suicidal risk. Areas that they felt their skills needed improvement was initiation of psychotropic medication and monitoring of Children and adolescents on psychotropic medication commenced by CAMHS (mode = 2).
Knowledge of CAMHS pathways and speciality services to refer children and adolescents
When asked how they would rate knowledge of what pathways and speciality services to refer children and adolescents to with the following mental health issues on a scale of 1–5 (1- Inadequate, 2- Below expectations, 3- Adequate, 4- Above Expectations, 5-Excellent), their knowledge of which pathways to refer for Neuro/Developmental Disorders, Mental health issues in children with disability and Learning disorders in addition to Conduct/ behavioural disorders and Gender dysphoria / Gender identification issues were all commonly rated as 2, indicating a level of knowledge below expectations. They commonly rated their knowledge of referral pathways for Emotional Disorders, Eating disorders and Self-harm/ suicide ideation as adequate (mode = 3).
Experience of accessing CAMHS services
GP registrars rated their experience of accessing specific CAMHS services as poor (mode = 1) for the following areas: Assessment of Need, Primary Care Psychology, Disability Services and CAHMS psychiatry OPD. Community sector organisations (e.g. Jigsaw) was the only service most commonly rated as satisfactory. See Table 4.
Table 4. Experience of accessing Child and Adolescent Mental Healthcare Services speciality services ((5 – excellent 4 – very satisfactory 3 – satisfactory 2- unsatisfactory 1 – poor)
Desire for further training in the area of CAMHS
Finally, when asked if they felt they would benefit from further training in CAMHS disorders as part of GP training, 55 participants said ‘definitely, 2 said ‘maybe’ and 3 said ‘no’.
Discussion
In this questionnaire study of GP trainees enrolled on an Irish training scheme, many of the respondents reported that they did not meet expectations regarding their confidence, knowledge and skills in important areas of child and adolescent mental health, disability and neurodevelopment disorders in primary care. Relatively few respondents had received training prior or during the GP training scheme and of the few who had training the majority didn’t perceive it as useful. A substantial proportion of GP trainees reported that they would definitely benefit from further training in these areas.
There was a variability of self-rated competence across different areas of mental healthcare problems in younger persons. The higher rating in emotional disorders and self-harm and suicidal ideation may be related to the fact that these disorders commonly overlap in adult psychiatry to which GP trainees have experience in, therefore they may feel more competent in dealing with these patients presenting with problems relating to these areas. Disruptive behaviour/conduct disorders and developmental disorders would not be classed as a common presentation in adult psychiatry hence this might explain the lower ratings in these areas as they are more specialised to child and adolescent psychiatry. A similar observation was made by Cockburn et al in a study that examined qualified GPs’ self-perceived competence in CAMHS (Cockburn and Bernard Reference Cockburn and bernard2004).
Respondents answered favourably when asked about their knowledge in Child Development and Awareness of when to refer to Psychiatry services. In contrast, areas that respondents self-rated poorly is in their rating of their knowledge of aetiology, nature and course and treatment and management of CAMHS problems in which they rated themselves as either ‘needs improvement’ or ‘unacceptable’. This reflects recent literature on GPs’ prescribing and monitoring of psychotropic medication and difficulty accessing CAMHS services in primary care (Moffat Reference Moffat2022, Maskey Reference Maskey2022).
The Maskey report highlighted this issue in relation to young people with ADHD in a particular health care district in Ireland. The report revealed that many GP’s were not carrying out the relevant blood tests and monitoring of children on psychotropic medications commenced by CAMHS despite letters been sent to them requesting it to be done. Recommendations were made regarding the creating of a shared protocol for CAMHS teams and GP in relation to the monitoring of patients on psychotropic medication (Maskey Reference Maskey2022). This raises the question as to why GP’s were not carrying out the relevant monitoring of these patients and whether there is an issue surrounding competency or knowledge in this area.
In relation to skills in children and adolescent mental health, the majority of respondents reported their skill level in three of the common areas as ‘meeting expectation’ which include communication with children and adolescents, recognition of mental health problems, assessment of self-harm and suicidal risk whist areas that reported a low rating of skill were initiation of psychotropic medication and monitoring of children and adolescents on psychotropic medication commenced by CAMHS. These responses mirror the previous low rating in relation to managing and treating children and adolescents with mental health problems. Reasons for this may be that Irish CAMHS guidelines recommend the use of psychotropic medication is to be initiated with caution in primary care and was historically perceived as being beyond the remit of the GP (O’Keeffe et al., Reference O’keeffe, Gavin, Cullen and Mcnicholas2013).
The area examining knowledge of CAMHS and other primary care referral pathways was rated as below expectations in the following areas: Neuro/Developmental Disorders, mental health issues in children with disability including learning disorders, Conduct / behavioural disorders and Gender dysphoria / Gender identification issues. Respondents rated themselves as meeting expectations or above in the areas of Emotional Disorders, Eating disorders, Self-harm and suicide ideation. This again reflects the common overlapping areas with adult psychiatry that GP trainees may have more experience and confidence in referring, as opposed to more CAMHS specific areas of psychiatry including learning and conduct disorders.
GP trainees’ experience of accessing CAMHS and other services including Assessment of Need, Primary Care Psychology and Disability Services were rated as unacceptable for the most part in contrast to community sector organisations (e.g. Jigsaw), which was rated as above satisfactory. The difficulties in accessing CAMHS is well cited amongst GP’s, and in particular the complexity of the different services and pathways to refer to (Leahy & McNicholas Reference Leahy and Mcnicholas2021, Leahy et al., Reference Leahy, Schaffalitzky, Saunders, Armstrong, Meagher, Ryan, Dooley, Mcnicholas, Mcgorry and Cullen2018, McNicholas et al., Reference Mcnicholas, Kelleher, Hedderman, Lynch, Healy, Thornton, Barry, Kelly, Mcdonald, Holmes, Kavanagh and Migone2021). It is estimated that less than a quarter of young people with a mental health problem receive any help from specialist services despite evidence that timely intervention can improve long term outcomes (Kessler et al., Reference Kessler, Amminger, Aguilar-Gaxiola, Alonso, Lee and Üstün2007). A study by Rocks et al., was conducted to evaluate the adoption of a single point of access (SPA) to streamline referrals to make the referral process easier for GPs and prompter for patients (Rocks et al., Reference Rocks, Glogowska, Stepney, Tsiachristas and Fazel2020). The respondent of this study share the same difficulties in accessing services thus indicating the need to streamline the referral process to make it more accessible and transparent for both GPs and patients.
The findings of this study show that GP trainees have limited experience in child and adolescent mental healthcare and as result demonstrate low ratings in self-perceived competence, knowledge and skills in common presentations that are seen every day in primary care. It supports the view that more training and exposure to this area is needed, preferably in the first two years of training so that registrars feel more confident and competent in managing these patients in a primary care setting. Recommendations to narrow the gap of knowledge should consist of firstly identifying the area as separate training specialty and incorporate it into every training scheme as a core competency that can be met via dedicated teaching and most importantly clinical exposure to child and adolescent mental health issues.
A training placement in CAMHS would serve as an excellent way for GP trainees to gain exposure and experience in managing younger people with mental health. Regular teaching provided by Child and Adolescent Consultant Psychiatrists and Child Psychologists to GP trainees would increase knowledge and improve competency levels. It would also enable better communication between CAMHS and primary care which could aid better access to speciality services and limit the need for referrals to CAHMS.
Finally, the implementation of a SPA referral system for children and adolescent mental health warrants strong consideration. It would make accessing speciality services more streamlined, cause less confusion and result in higher satisfaction rates amongst GPs and trainees. The current CAMHS system is under strain and struggling to meet the expectations of its patients, referring GP’s and the doctors and staff that work within the service (Doody et al., Reference Doody, O’connor and Mcnicholas2021, Leahy et al., Reference Leahy, Schaffalitzky, Saunders, Armstrong, Meagher, Ryan, Dooley, Mcnicholas, Mcgorry and Cullen2018, McNicholas et al., Reference Mcnicholas, Sharma, Oconnor and Barrett2020). With the advances made in primary care during the Covid-19 pandemic (MarkHennessy, Reference MarkHennessy2021), we now know that the Irish healthcare system has the capabilities to implement change when motivated to do so. This ability needs to acted on once again to bring about improvements that will serve GPs working in Ireland to manage the mental health of its younger population.
Although this study provides insight into GP trainee’s confidence and self-perceived knowledge and skills in manging younger patients with mental health issues, the limitations of the study are the low response rate which makes it less representative and in addition to this the questionnaire is based on self-assessment only. Previous studies looking at GPs knowledge and technical skills reveal relatively poor correlations between the results of self-assessment and more objective measures (Vermeulen et al., Reference Vermeulen, Tromp, Zuithoff, Pieters, Damoiseaux and Kuyvenhoven2014).
Therefore, further research with higher response rates are needed to establish GP’s competence in child and adolescent mental health with the use of more objective measures to accurately reflect their level of skill and knowledge. Pilot studies involving GP trainees carrying out rotations in CAMHS would be an effective way of determining if increased exposure to CAMHS would increase confidence in managing these problems in primary care. In addition, further research is needed to establish the need and desire for a single point of referral and a more streamlined referral process to CAHMS for GPs in order to improve their satisfaction rates with access to youth mental health services.
Conclusion
Current GP trainees in Ireland are lacking in confidence, knowledge and skills in many common areas of CAMHS. Reasons to account for this could be lack of experience working in CAMHS and difficultly access specialty services and complex referral pathways. Therefore, formal training needs to be provided to GP trainees during their training scheme to ensure they feel competent to meet the needs of younger patients presenting with mental health issues.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
None.
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 with the Helsinki Declaration of 1975, as revised in 2008. The study protocol was approved by the ethics committee of Research Ethics, UCD.
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