Teenager’s case re-entered following placement breakdown amid risk-taking behaviour, judge has “no words” for her situation – 2024vol1#48

The Child and Family Agency (CFA) re-entered a case as a teenage girl’s placement had broken down. The girl had been engaged in risky behaviour and absconded regularly from her residential placement. An application for a referral to the Special Care Committee was being prepared. A regional chief officer for the CFA had been due to attend court to give evidence, unfortunately due to family circumstances she was unable to attend.

The girl had been received into the care of the State when she was a few months old. Her mother had been a child in care herself and gave birth to the teenager when she was 17. When the girl was born, she and her mother had been placed in a mother and baby unit, but her mother left the unit without the infant. On being received into care, she was placed with a foster family, with whom she remained until she was 18 months old. A full care order until she was 18 was then granted, and she was placed with a different foster family, where she remained until this broke down in the autumn of 2023.

She was placed in a facility run by a homeless charity in Dublin. During this time, she was involved in significant risk-taking behaviour which included meeting males that she had met online. The teenager made allegations of rape, sexual assault, being drugged and being assaulted. The teenager had absconded from this facility on several occasions.

According to the guardian ad litem (GAL) report on several occasions she was observed on the phone naked talking to an unknown male. She threatened self-harm by throwing herself in front of a car. A member of the public was concerned and called an ambulance. She was brought to a sexual assault treatment unit, claiming she was drugged and assaulted by a group of young males. She then left the facility to meet an unknown male. The GAL report also noted that she appeared to have a learning disability but had received no support for it.

The solicitor for the CFA informed the court the teenager had moved to a short-term residential unit in a provincial city, similar to the placement that the teenager had resided in in Dublin. The solicitor said that it was a better placement. The teenager had not absconded and appeared to have settled. She said the CFA were using this time to try to find a suitable long-term placement for her. Given the teenager’s presentation therapeutic assessment and intervention were unsuitable at this time.

The solicitor for the GAL said the situation was very fluid. The teenager needed a long-term placement that met her needs. The current placement was not as positive as the CFA had presented to the court. The teenager had already begun to meet men online in this placement and the GAL believed it was only a question of time before she began absconding from the placement to meet unknown males.

The GAL had said there needed to be parallel planning for the teenager, the CFA needed to secure a long-term placement for her and make an application for special care. The GAL said the CFA had not made an application for special care because there were already 10 children who had special care orders and there were no beds for them.

The judge said this was a daughter of the State, this child had been in the care of the state since she was four months old. In the care of the State she has been drugged, sexually assaulted, raped. The judge said: “I was incandescent with rage but now I despair, there are no words, no words. It simply cannot continue and all the while the CFA are celebrating a 10-year anniversary.”

The judge sought the attendance of a psychiatrist from the Child and Adolescent Mental Health Service (CAMHS) to explain why the service had stopped engaging with the girl when she was clearly at significant risk in the community.

The matter was adjourned for one week to permit the relevant chief regional officer of the CFA to address the court.

When the case resumed the solicitor for the HSE said the psychiatrist was present in court and had prepared a short note, but was uncertain of the evidence she was required to give. She wanted to help but was also apprehensive given the impact on other children as she away from her work.

The judge recounted the history and said the girl had been in care from a very young age. More recently, she had been transferred from her placement in Leinster to a placement elsewhere in the country “in an effort to remove her from males who appeared to be praying upon her.” She had undergone psychiatric assessment and was found not to have any mental health disorder and the advice at the time was that she was best treated in a community setting. Unfortunately, as soon as she was discharged from CAMHS she was found “wandering on a motorway semi-clothed to such an extent that the road had to be closed.”

It also appeared to the court that there had been at least one suicide attempt. As such, the judge said he had very significant concerns in relation to the girl and felt he had to put his best foot forward and issue a witness summons for the attendance of the psychiatrist. The girl had since been referred to the CAMHS service where she was now residing, but the judge considered this would not assist her as her treating doctors up to this point were all based in the CAMHS service in Leinster.

The solicitor for the GAL echoed the court’s concerns and said she had a number of questions for the psychiatrist in circumstances where it seemed the various CAMHS services “want nothing to do with her.”

Psychiatrist evidence

The psychiatrist said she only became involved in the girl’s care in 2023, but noted she was initially referred to the service in 2015 following concerns by her GP that she might be suffering from Attention Deficit Hyperactivity Disorder (ADHD). She was subsequently diagnosed with ADHD and her foster carers were referred to a parenting programme to help manage her behaviour at the time. Initially she was trialled on two separate medications for ADHD which she tolerated well, and between 2015 and 2016 her behaviour improved.

Unfortunately, in early 2022 the girl’s foster carers had begun to notice an increase in challenging behaviour and she was subsequently referred for further assessment. It was noted at the time that she was being aggressive towards animals, including the family dog. There were also behavioural outbursts at home. She was trialled on a low dose of anti-psychotic medication, but this was discontinued in late 2022 as she showed signs of regression on it.

The psychiatrist said she saw the girl for the first time in early 2023. A cognitive assessment was carried out and she was diagnosed with a borderline intellectual disability. She also underwent a speech and language assessment which showed a difficulty in her ability to use expressive language. She was last seen by the service in late 2023 when she stopped engaging entirely.

The teenager had initially been assessed by the liaison psychiatric service attached to CAMHS and she was not diagnosed with any identifiable mental illness at the time. She was not clinically depressed and there was no evidence of psychosis, but despite this she was still offered outpatient services. The court was told there had been multiple difficulties trying to get her to engage with the services offered, but that CAMHS continued to advocate the need for her to be prioritised for them.

The psychiatrist was asked about the possibility of involuntary detention of the teenager under section 25 of the Mental Health Act, 2001. She said in order to invoke the section there had to be evidence of an acute psychiatric disorder which would allow for the detention. However, the teenager was displaying psychiatric distress primarily as a means to express her difficulties in the transition from her previous placement and the move between counties. She said her behaviour was not attributable to a psychiatric disorder, but rather it was the instability of placements which had affected her.

She said the service had engaged the girl as best it could to date and that it had been “misrepresented” that it had not done so. The service was very limited in what it could offer the teenager given she had moved to a different province five weeks previously. An online service had been offered to her in recent weeks, which was not something usually done, but she had refused to engage with any online appointments that had been set up.

The solicitor for the GAL asked the psychiatrist whether or not the girl fit the criteria as suffering from a mental illness “given all we have heard about her presentation.” The psychiatrist said that she could not speak to what had occurred since late 2023 when the teenager stopped engaging with the service, but prior to that point, while she had a diagnosis of ADHD, she was not suffering from a mental illness which was amenable to treatment.

GAL solicitor: “Can you explain why?”

Psychiatrist: “ADHD is something which affects concentration and the ability to attend to things… It is not that it isn’t an illness, but she doesn’t have an inability to manage her emotions because she has ADHD… It can affect judgment and thinking, but in terms of her presentation the acts she did were done in a very rational manner, such as planning to do harm to others… She presents with difficulties which are long-standing and it is an attachment-based difficulty, which is common to children in care…”.

GAL solicitor: “So while she may be unwell, it’s not something which requires in-patient treatment?”

The psychiatrist said she had spoken with the CFA about the possibility of obtaining a secure placement for the girl, which she considered would be in her best interests. It was suggested that the psychiatrist was saying that the girl would benefit from a special care unit, but not a CAMHS unit. The psychiatrist explained that the inpatient care service provided by CAMHS was specifically for psychiatric care, which the teenager did not require. Instead, she needed a secure unit to give her stability and prevent her from absconding.

The GAL solicitor noted the teenager was currently engaging in very risky behaviour and since moving county she was also having suicidal thoughts, so it was clear there had been “an enormous escalation” since the service last saw her.

When pushed again on the question of whether the teenager was suffering from a recognised mental illness, the psychiatrist said it was hard to pass judgment except to expand on the point that the information from multiple colleagues and experts suggested that there was a thought process behind what the teenager was saying and doing. She said she did not think this was something being led by a mental illness such as psychosis or depressive illness, and on that basis she would not reconsider the diagnosis of ADHD.

The psychiatrist said a proposal had been made to transfer the teenager to a local service in the area she now was. Her view was it was unlikely she would be returning to her previous placement in the Leinster region, so it was not practical longer-term to continue to provide treatment to someone who was not in their catchment area. However, during the transition period, a block of short interventions via an online service would still be offered to her.

The GAL solicitor said the GAL was completely opposed to the file being transferred to a new service in circumstances where her present placement was only temporary.

Social Work Team Leader evidence

The team leader said the girl was in a more stable position since the last court date, but there were still major concerns. She was being monitored very well in her placement and the team was doing its best to keep on top of everything. A long-term placement that could manage the teenager’s challenging behaviours had yet to be identified and this was making matters more difficult. She was continuing to refuse medical help which was also complicating the situation.

Preparation work for a referral to the Special Care Committee had started, but this was a lengthy process involving “mammoth paperwork.” She said a family welfare conference, professional meetings and consultations with the experts involved in the girl’s care would have to take place. The intention was to progress the family welfare conference prior to the next court date.

The team leader said the main focus during a previous meeting with the professionals was to try to get CAMHS on the phone. The concern was that it was difficult to draw up and agree a safety plan without the involvement of CAMHS. She said invitations to various crisis meetings had been sent to CAMHS but they had not attended. The GAL solicitor suggested on that basis it appeared “none of them want anything to do with her.”

GAL evidence

The GAL said there had been a marked deterioration in the teenager’s behaviour. She was thought to be on the phone constantly to an unknown male, who appeared to be giving her advice. Although she was in a more stable place at the moment, things were not great. She said secure care was the only way forward and the only thing that could provide stability.

The girl had gone missing from her placement for a period of six days and told the GAL on her return that she had been staying in a house with a man and had engaged in sexual intercourse with him. In the GAL’s view, the girl was “disconnected in her reality and very down.” She said she was extremely worried for her.

Having heard the evidence the judge said it was paramount that the teenager was kept safe. He noted that CAMHS had made it clear they would not accept a referral under section 25 of the Mental Health Act, 2001, so the next step was secure care. The matter was put back for two weeks with liberty to apply if there was any further issue in the interim.