Looked After Young People and mental health Using a risk and resilience model to reduce self-harmful behaviour

Mental health: Definitions and context Today’s programme Mental health: Definitions and context Mental Health risk factors and Looked After Children Self-harming behaviour Resilience Framework and Looked After Children

Mental health: A definition ‘the strength and capacity of our minds to grow and develop, to be able to overcome difficulties and challenges and to make the most of our abilities and opportunities’ YoungMinds 2006

Think about the young people who you work with. Consider the following: How would you know if a young person’s mental health was good? How would they behave? Describe behaviour that would make you concerned.

Child Mental Health A capacity to enter into, and sustain, mutually satisfying and sustaining personal relationships Continuing progression of psychological development An ability to play and to learn so that attainments are appropriate for age and intellectual level A developing moral sense of right and wrong A degree of psychological distress and maladaptive behaviour within normal limits for the child’s age and context

Problems & Disorders Mental health problem A disturbance of function in one area of; relationships, mood, behaviour or development, of sufficient severity to require professional intervention. Mental disorder A severe problem (commonly persistent) or the co-occurrence of a number of problems, usually in the presence of several risk factors

A bio-psycho-social model EVENTS (what happens to us) NATURE (what we are born with) NURTURE (what we grow up with)

Prevalence among children aged 5 – 15 in the UK Mental or psychiatric disorder Risk factors but no obvious problems now Mental health problems 1.5 million or 10% 30,000 or 0.2% 3 million or 20% Severe disorder or mental illness

What are risk factors? Conditions, events or circumstances that are known to be associated with emotional or behavioural disorders and may increase the likelihood of such difficulties Risk is cumulative Risk is not causal but can predispose children to mental health problems

Risk and protective factors Risk Factors Protective Factors Seeking to reduce risk factors and increase protective factors. Reduce risk, increase resilience

Task Consider the following: What experiences may a child have prior to coming into care, that may effect their mental health?

Predisposing factors - child Genetic influences Low IQ and learning disability Specific developmental delay Communication difficulty Difficult temperament Physical illness, especially if chronic and/or neurological Academic failure Low self-esteem Risk is not cause and is not deterministic. It seems to be about clusters of risk factors and the balance between risk and resilience in C&YP

Predisposing factors - family Overt parental conflict Family breakdown Inconsistent or unclear discipline Hostile and rejecting relationships Failure to adapt to child's changing developmental needs Abuse - physical, sexual and/or emotional Parental criminality, alcoholism & personality disorder Parental psychiatric illness Death & loss - including loss of friendships

Predisposing factors - environment Socio-economic disadvantage Homelessness Disaster Discrimination Other significant life events Consider how we can seek to reduce, rather than increase these factors when a child is being looked after

YoungMinds Presentation Attachment Theory Attachment behaviour is defined as: The seeking of protection when anxious which is triggered by external threats or behaviours The person to whom a child is attached provides a secure base, a place of safety, warmth and comfort What do we know about these early experiences and how they can affect mental health? We know that attachment behaviour can effect our mental health and we know that our brain development is dependent on our early years experiences.

YoungMinds Presentation Attachment Theory A securely attached child feels confident that should they feel anxious, their parents will respond. Such security is brought on by interactions which are: Sensitive Regularly available and reliable Warm Responsive Consistent

Way attachment develops YoungMinds Presentation Way attachment develops

Secure and insecure attachment “A securely attached child is likely when faced with potentially alarming situations .... to tackle them effectively or seek help in doing so” Children whose needs have not been adequately met see the world as; ‘comfortless and unpredictable and they respond by either shrinking from it or doing battle with it.’ Bowlby (1980) Attachment and loss Vol. 3 and Bowlby (1973) Attachment and loss Vol. 2

Insecure Avoidant Caregiver subtly or overtly reject child’s attachment needs at time of stress Bids for comfort will be rebuffed Child keeps his/her attention directed away from their caregivers in an effort not to arouse anxiety and frustration In control because of the need for self reliance Comfort self rather than accept it from others In foster home, cause concern because they find it hard to trust carers with their feelings or let people get close At school some do well at school work some find it hard not to be ‘best’ and hard to allow teachers or other children to get close enough to build relationships In the community because for some there will be flashes of anger and a need to control other children and or be defiant of authority

Insecure Ambivalent/Anxious Caregiver will be inadequate at meeting child attachment needs (caregiver is passive, unresponsive and ineffective) Child’s strategy is to amplify attachment needs and signals in an effort to arouse a response (verbal and behavioural: bubbly affection to rage, anger, panic and despair. All experienced as controlling) Child may constantly feel that needs are unmet In foster care cause concern because they can provoke carers or wear them out. Their preoccupation with demanding but unpredictable birth families may also be a source of stress. At school lack concentration, restless, confused thoughts and stormy, love-hate relationships with peers and teachers In community they may take risks and needy angry and indiscriminate in relationships

Insecure Disorganised Child experiences the carer giver as ‘the source of alarm and its only solution’. (Children from abusive families) Child in these circumstances is unable to be guided by their mental model of the world because it offers few directions. Frightened, helpless, fragile and sad At risk of mental health problems or anti-social behaviour Cause concern In foster home because their behaviour whether this is secret soiling or aggression against family pets, is hard for carers to manage and for other children to live with At school because their bizarre behaviour, their tendency to be manipulative, aggressive or unable to think straight, makes both the interpersonal and academic aspects of school life a problem for them In the community, because they react with such helpless anger and/or distress to anxiety, that they may be unable to resist being drawn into self destructive or anti-social behaviours

In Essence… Attachment needs are activated during times of perceived stress (discomfort, environmental, danger, fatigue, illness) The child must either have these attachment needs met or find other ways to cope.

Adolescent attachment styles Compulsive self-reliance Distrusts relationships, avoids being rejected or relied upon. Prone to depression or psychosomatic symptoms. Compulsive care giving Actively involved in relationships but always as a care giver. Own parents unable to provide care but might have demanded it from child. Care-seeking Vigilant to signs of loss or abandonment. Constantly anxious. Parents probably unresponsive or threatened to leave family. Angry withdrawal Generalised anger towards attachment figure who is seen as unavailable.

Positive brain development The way a child is stimulated shapes the brain’s neurobiological structure. Experience has a direct impact on a child’s capacity for living, learning and relating as a social being. Early months and years experiences can have a direct effect on the developmenting brain

Early Brain Development We are born with most of the neurons (brain cells) we will ever own but; At birth the brain is 25% of its adult weight - by the age of 2 this has increased to 75% and by age 3 it is 90% of adult weight. This growth is largely the result of the formation and ‘hard wiring’ of synaptic connections Babies brains are both ‘experience expectant’ and ‘experience dependent’ So we know that those first two years are extremely important in brain development. Babies brains are waiting for things to happen so that they can change and grow because of these experiences.

Proliferation of synapses

The Learning Years: 5-10 Synaptic pathways that are regularly used are reinforced. This is the basis of learning. Reinforcement leads to permanent neurological pathways. Neural connections needed for abstract reasoning are developed Motor skills are refined

Adolescent Brain Development Brain development continues up to at least the age of 20 There is a significant remodelling of the brain in adolescence, particularly the frontal lobes and connections between these and the limbic system The frequency and intensity of experiences shapes this remodelling as the brain adapts to the environment in which it is functioning and becomes more efficient Frontal cortex is essential for such functions as response inhibition, emotional regulation, analysing problems and planning. Many of these aptitudes continue to develop between adolescence and young adulthood, whereas spatial awareness functioning and sensory functions (such as hearing and language processing) are largely mature by adolescence. So young people’s emotional regulation is still developing in adolescence Synaptic pruning is believed to be essential for the fine-tuning of functional networks of brain tissue, rendering the remaining synaptic circuits more efficient. This pruning occurs on the use it or lose it principle: this means that what adolescents do is critical to ensuring that circuits (or processing systems) which adaptive, rather than maladaptive, functioning strengthen and grow.

Emotional Functioning There is a mismatch between emotional and cognitive regulatory modes in adolescence Brain structures mediating emotional experiences change rapidly at the onset of puberty Maturation of the frontal brain structures underpinning cognitive control lag behind by several years Adolescents are left with powerful emotional responses to social stimuli that they cannot easily regulate, contextualise, create plans about or inhibit These changes in brain structure generate powerful emotional urges for sexual behaviour, independence and the formation of social bonds.

Impact of trauma In the face of interpersonal trauma, all the systems of the social brain become shaped for offensive and defensive purposes. A child growing up surrounded by trauma and unpredictability will only be able to develop neural systems and functional capabilities that reflect this disorganisation. Source: National CAMHS Support Service, Everybody’s Business

Traumatic stress When children and young people experience persistent stress they are likely to produce toxic amounts of cortisol which can have a detrimental effect on Brain function All major body systems Social functioning

Over production of stress hormones These functions may be diminished or lost: Ability to learn language and to speak Understanding feelings or having words to describe them Connection between how we feel and our sensory experience Empathy Control of impulse Regulation of mood Short term memory Enjoyment Think about a traumatic experience that you have had (maybe an accident that you didn’t expect e.g.: falling off my bike) What happened emotionally? Could you articulate? Could you recall exactly what had happened? When we experience significant stress, hormones are released and our body goes into fight or flight mode. The bits of our brain (and body) that are not essential to cope with the situation at hand, shut down. If this happens repeatedly during the brain developmental years, functions can be diminished or lost.

Reducing Risk Consider the different risk factors we talked about earlier and the effects of early years experiences What can you do to ensure that these risk factors are not increased once a young person is in care?

What worries us? Teachers, GPs, parents and young people were asked to rate the following concerns in order of how worried they would be if a young person they knew were affected by the following issues: HAVING RISKY SEX HAD AN EATING DISORDER BINGE DRINKING BEING BULLIED SELF HARM SMOKING USING DRUGS WAS A GANG MEMBER

85% of young people, parents GPs and teachers stated that this was their biggest concern. They also stated this was the subject that they felt least able to help with.

Self-Harm How would you define self-harm? What feelings arise when you think about self-harm? This subject can bring up many different thoughts and feelings for people. Some people have been directly affected by self-harm, or know those who have and people may be confused, upset or even angry about why people behave in this way. Part of this session aims to explore this in a little more depth and further understanding about what may cause people to harm themselves.

Defining Self harm When some people feel sad, desperate, angry or confused, they can hurt themselves. This is called ‘self-harm’. People can do this in a number of ways and for different reasons. People who harm themselves on more than one occasion may do so for a different reason each time. They may also harm themselves and not tell anyone about it NICE Guidance on Self Harm (2004)

truth hurts Young people who self-harm do so because they have no other way of coping with problems and emotional distress in their lives…. It provides only temporary relief and does not deal with the underlying issues.’ Truth Hurts, Mental Health Foundation (2006) http://www.mentalhealth.org.uk/publications/truth-hurts-report1/

How Common is it? In every secondary school classroom there will be two young people who have self-harmed

How common is it? Between 1 in 12 and 1 in 15 young people self-harm (truth hurts 2008) 7% of young people aged 15-16 in England self-harm (Hawton, et al., 2002) 37,000 young people presented to hospital in 2010/11 and many report previous episodes when they did not go to hospital (hospitals admissions statistics 2010) Inpatient admissions of young people under 25 for self harm have increased by 68% in the last 10 years (hospitals admissions statistics 2010)

The ONS report ‘Mental Health of Children and Young People in Great Britain, 2004’ found that: 28% of children aged 11-16, with an emotional disorder reported that they have self-harmed. This compares to 6% without an emotional disorder. 21% of children aged 11-16, with a conduct disorder reported that they have self-harmed. This compares to 6% without a conduct disorder. 18% of children aged 11-16, with a hyperkinetic disorder reported that they have self-harmed. This compares to 7% without this disorder. 25% of parents, who had a child with an autistic spectrum disorder, reported that their child had self-harmed, compared to on 2% whose children did not have the disorder.

Is there a link between self harm and suicide? While studies have shown that young people who self-harm are more at risk of suicide, people don’t necessarily self-harm because they want to take their own lives. The young people we work with describe self harm as a coping mechanism to manage overwhelming feelings; and young people who took part in this survey (TASH) describe it as a diversion of painful feelings.

Why do young people self harm? When considering why young people self-harm it is important to explore mental health more broadly and in particular, risks to mental health and we will do this shortly.

“I cut myself when I’m angry, it hurts but it helps my anger.” “The thoughts are in my head every day, I can’t take it. Cutting myself is the only way I can deal with him being around.” “I cut myself when I’m angry, it hurts but it helps my anger.” “ Cutting takes my mind off things, when I’m unhappy about myself, the way I am.” “I don’t really like school and nick off as much as I can. There’s always arguments at home so I go out and hang around with a group of lads and lasses. We all drink a bit; sometimes I cut my arm with a bit of broken glass. It feels good, but then I regret it the next day when I see the scar.” Young people have told us

Biological Effects of Self Harm Self harm can bring its own physical release. Neurochemicals can play an important role in self-harm. Endogenous opioids and serotonin may bring about a very positive feeling of calm and well-being. These chemicals are released particularly when the body is injured in any way. They produce insensitivity to pain which help the individual survive when faced with danger. It is likely that the body grows to expect a higher level of these chemicals.

Harm minimisation Taking control of their lives (helping to reduce risk taking behaviours) Developing more healthy ways of coping Increasing their self esteem Increasing their assertiveness in a positive way

what can we do to help? Listen non-judgementally Show care and respect Acknowledge emotional distress Explain what is going to happen next Help to them to get help to address the problems (referral) Be aware of your own capacity to help and make sure you have the opportunity to reflect

Advice for young people Prepare yourself with knowledge about self-harm before you talk to your friend. Stay calm and don’t over react. The person you are talking to is clearly upset or stressed. Being shocked or angry could make it worse. Talk it through with someone confidentially beforehand. This could be a parent or teacher, or even an organisation like ChildLine.  Offer advice about where to go. They could speak to a teacher, their GP or one of the organisation at the bottom of this page. Accept that they might not want to talk, but it’s important though for you to try and encourage the person to open up. This might take more than one conversation. If you are concerned that they might really hurt themselves consider explaining the situation to a teacher, parent or ChildLine so that you have support. It might feel like you are ‘telling’ on your friend but it’s important that they get support. Sometimes you will say the wrong thing. Don’t worry about it or let it stop you having a conversation. The most important thing is you show you care and keep talking to your friend. “Wait till I’m finished and calmed down...” Don’t try stop someone in the middle of self-harming as they will be in an agitated state. Be there for them to listen. Look out for signs and clues that someone is self-harming. Stay loyal. It’s important that your friend knows they can trust you, so don’t gossip about the situation your friend is in. Recovery takes time; so don’t hold yourself solely responsible for helping. Be there as a consistent support mechanism for them. Talk about thoughts and feelings rather than what they’re doing.

What is resilience? A model we recognise is useful with all young people and a way of supporting change for young people.

Resilient Children “can resist adversity, cope with uncertainty and recover more successfully from traumatic events or episodes” Newman, T (2002) What is resilience?

resilience Normal development under difficult circumstances. Relative good result despite experiences with situations that have been shown to carry substantial risk for the development of psychopathology (Rutter) The human capacity to face, overcome and ultimately be strengthened and even transformed by life’s adversities and challenges .. a complex relationship of psychological inner strengths and environmental social supports (Masten) Ordinary magic .. In the minds, brains and bodies of children, in their families and relationships and in their communities (Masten) Think about that person you know who has had very difficult upbringing, trauma etc but is doing ok. What contributed to their resilience? Lots of evidence to support that this is a helpful way to work.

Resilience in the child being female secure attachment experience an outgoing temperament as an infant good communication skills, sociability planner, belief in control humour problem solving skills, positive attitude experience of success and achievement religious faith capacity to reflect

Resilience in families At least one good parent-child relationship Affection Clear, firm consistent discipline Support for education Supportive long term relationship/absence of severe discord

Resilience in communities Wide supportive network Good housing High standard of living High morale school with positive policies for behaviour, attitudes and anti-bullying Schools with strong academic and non-academic opportunities Range of sport/leisure activities Anti-discriminatory practice

Resilience Framework. Groups Choose a section. What can you do?

Developing a self harm policy What do you think an effective policy would look like? Who would it target? What would it need to contain? How will you know that its having an effect? Which local services need to be involved in?

youngminds Parents Helpline: 0808 802 5544 Tel: 020 7089 5050 Website: http://www.youngminds.org.uk and Publications Training & Development: charlotte.levene@youngminds.org.uk