Blog open to all young people and those trying to help and support them through psychological issues, mental health problems and crisis points in their lives. Provides expert knowledge, information and advice from informed practice, research and publication.
In Child and Adolescent Mental Health services it is a given that childhood experiences for good or bad influence the adult we become. Staff generally aspire to excavate childhood memories, examine early experiences, and study close attachments in order to begin to help a person understand themselves. Dreams can be analysed, behaviours interpreted, and relationships dissected in order to help a young person gain personal insight. Or others may tackle the presenting problem and focus on behavioural, active and cognitive interventions to try to help a young person's suffering and change aspects of their external life. Fidel Castro's reticence on the subject of his childhood, for many people who have tried, is intriguing.
Does this reveal an unhappy childhood, one concealing a hidden traumatic experience, ambivalent feelings towards his parents, or the overt repression of early internal conflicts that could explain his later life? Catholicism was a big factor in Fidel’s family, first in his father, Angel’s first marriage to Maria Reyes who was reportedly a firm Catholic and again in Fidel’s mother's life. Fidel's mother Lina Ruz Gonzalez was apparently a very strict, sombre Catholic, but there is evidence that she was also influenced by Santeria, a specific Afro-Cuban devotion to the saints who would be prayed to every day to fulfil her wishes. In Oriente province it was common-place for Afro-Cuban religions and cults to flourish with the slaves who brought with them their own spirituality, cults and voodoo ceremonies from Haiti and Africa. Fidel is open about his own superstitions, for example about the number 26.
The human mind is far too complex to draw a linear connection between a childhood event and a later adult action, there are many influences on the developing child and young person, external and internal experiences and a multitude of environmental variables, luck, chance happenings and random circumstances that go towards how we develop. My research however, does permit some reasonable speculation, informed by evidence and open to reasonable speculation or hypothesising.
Fidel's self-professed influences focus strongly on his Catholic upbringing and in particular the strict Jesuit college tutors, whom he cites as the source of his own personal self-sacrifice, absolute dedication to his ambitions and relentless perseverance in the face of adversity - more so in fact than any ideological mantra of Marxist-Leninism. Most of his formative political ideology relied very little on the Communist Manifesto, but more on the writings and actions of heroic revolutionary Cuban Nationalists such as Jose Marti.
The few details Fidel has shared about his early memories show a child playing happily in the fields, rivers and hills of his father’s sugar cane estate. He talks of his joy at being able to run free with plantation workers’ children, his friendships among Haitian immigrant labourers' children and the Cuban children descended from slaves. His love of the outdoors began very early in his life, riding horses or climbing mountains; the joy in his words as he describes those early images and memories is palpable.
An idealised childhood, growing up with privilege on his wealthy father's sugar cane estate? It's easy to see how some commentators have described him as spoilt, privately educated and the ultimate poor little rich kid who became the very opposite to his background due to guilt, or to spoil his parents' ambitions for him, or to indulge himself as arevolutionary dilettante. Castro’s name is synonymous with Che Guevara and their manifesto for egalitarian, humanistic struggles for liberation in Latin America of the many from the few in power.
Was he embarrassed and feeling guilty about his wealthy, privileged background which enabled him to attend elite schools to the extent that he swore to eradicate such inequality? This is far too simple an explanation. His childhood is one that was physically and psychologically tough, both at home and school, with frequent changes and disruptions in his schooling, and long periods away from home.
His Father was a hard, tough and dominating personality, who expected others to work as he had done as a poor, Economic migrant from Spain - relentlessly, compulsively, while enduring physical and emotional hardship. His temper was notorious and he often expressed a violent almost pathological hatred towards the Americans who controlled the sugar cane industry. He raged about their monopoly power and accused them of ripping him off in trading contracts. His was not a political ideological repugnance towards the Yanquis, simply that of a businessman who felt betrayed, cheated and perhaps humiliated and powerless.
Fidel was the middle child of three brothers and the eldest child was a sister, as he struggled through his early years with emotionally distant parents. Sibling rivalry and the 'invisibility' of being a middle boy meant he had to work hard to be noticed. What he did was to become aggressive, argumentative, and physically combative with authority figures especially teachers. During puberty he clearly experienced a strong Oedipal conflict with his father, manifested in a threat to burn down the house and soon after lead a strike by the estate workers for better wages!
As a youngster Fidel had an appendectomy and was seriously ill in hospital for 12 weeks. This would have been a significant psychological event, but masked by the medical concerns to manage the infection and subsequent fever. Medical treatment was still limited even for wealthy people and the possibility of death would have overwhelmed Fidel's fragile ego, deprived of immediate parental comfort and secure attachments. Alone, frightened and away from home- this was becoming a recurring feature in his early development as he was shunted between different schools and carers in Santiago and Havana, spending long periods away from his family.
In one of his memoirs Fidel recalls the death of an Aunt and the impact this had on his Mother. What he probably did not know is that his Father suffered the death of his own mother when he was a teenager, and that his first child a son, died an infant. So the Castro family narrative was strongly influenced by grief, loss and bereavement as Fidel struggled to discover and make sense of his own developing personality. At school he was bullied - ironically because to the wealthy Spanish colonial elite while he was rich enough to be there, nevertheless he was from peasant stock, prone to crude language, swearing, and culturally lacking in manners and etiquette.
They would also have been aware that he was born illegitimate, a hugely stigmatising and shameful position in the Conservative social culture of high society. His parents eventually married, but too late for Fidel to have suffered daily humiliation in his formative years. So he overcompensated for this social exclusion and feelings of inferiority by becoming a bully himself, picking fights with older, stronger boys and often losing. He threw himself into sports and was a National champion baseball player.
The picture that emerges is of a young person who had experienced a disjointed development in terms of physical location, education and socialisation. Lots of change is not the pathway to a settled, harmonious and integrated personality where Fidel could feel comfortable in his own skin, relaxed and at ease with himself. Instead he was constantly on his guard, defensive and socially awkward, especially with girls. He developed a thick skin - to an ordinary outsider he seemed a hard, angry teenager with a temper and easily provoked into fist fights.
Yet underneath was a little boy, fragile, vulnerable, frightened of change and feeling that he had little control over his life. A boy with tenuous secure attachments in a large family with whom he had less and less contact as he grew up. In early adulthood he found intimate personal relationships hard to sustain, very likely due to the claustrophobic experience in the closeted Jesuit boarding schools which probably distorted his sexuality and social skills, within their autocratic, male-dominated culture and overbearing religious orthodoxy. He was clearly most comfortable in the Macho world of Sport, Politics and later on among his cadre of Guerillas who risked capture, torture and death on a daily basis in their war against the puppet Cuban dictator.
The history of Cuba is sometimes written with a biblical reference to David and Goliath. In the Bible David defeated Goliath, so the similarity ends there, but it is noteworthy that Cuba, a small poor Caribbean island, has not been defeated by the American Goliath in 50 years of attempted invasion, blockades and Economic sanctions. The untold story of Fidel’s childhood will help you understand partly why this has happened, but it will reveal much more about what made the man who has been central to Cuba's story and how a fearful, lonely, anxious young man went on to become a legendary revolutionary Guerilla leader who liberated Cuba from American rule.
Welcome!This BLOG is one of many resources designed to offer free, open, evidence-informed advice and support for young people who find it hard to cope in living. In particular my aim is to reach out to troubled young people who are experiencing emotional or psychological difficulties in their lives. This may be due to a number of factors. You are not alone.
Many young people experience the very same feelings, thoughts and emotional pain you are suffering. Common factors present in troubled young people stem from parents fighting, separating or divorcing; or from bullying by peers or older people; or from physical, psychological or sexual abuse. Your difficulties may last a short time or they may have been with you for what feels like ages. You probably find it hard to express yourself verbally if you are depressed or full of anxious thoughts.
Others- whether friends, teachers or family cannot understand what is the matter and they will express frustration or even anger at your behaviour. You might feel ashamed of feeling suicidal or resort to self-harming in order to relieve the unbearable pressure inside you. Check out the resources, information and self-help advice and guidance - you have nothing to lose. You have taken a brave step in getting this far. Carry on, there is help for you.
What next? In the next few pages you will find numerous resources such as accurate information, tips, links to other support services and publications. My name is Steven Walker I have worked in public services with children and families for about 30 years. I started out as a Volunteer while at University. I am a qualified psychotherapist and social worker and I recently became a registered mentor. My speciality is Child and Adolescent Mental Health, so I have a lot of experience, knowledge and skills. But I don't know everything, and if this site cannot help you I provide details of others to access.
You need to feel comfortable with the kind of support you want and that is acceptable to your needs. Make the best use of this resource you can. I will regularly update with news, information and developments in this area of work either on the pages or blog. Please post questions whenever you feel the need. I will respond asap.
Steven Walker: Psychotherapist. MPhil, Child & Adolescent Mental Health; MSc, Social Work & Social Policy
Many psychological issues or mental health difficulties are more common than you probably think. Common mental health problems doesn't mean they hurt any less. What this means is that you are not alone and most professionals know this and can offer support. Latest data from the World Health Organisation suggests 1 in 10 children will suffer from a significant mental health problem before thy reach 18 years of age. 1 in 4 will suffer a problem that requires help from outside the family, although less serious. What is important is that if you feel you have a serious problem then don't let anyone try to persuade you that it isn't! Below are a selection of the most common problems faced by young people. The trends are that Anxiety, Depression, Self Harm and Eating Disorders are increasing- especially in economically advanced countries. Cyber-Bullying has been identified by a growing number of young people as the main threat to their emotional well-being and features as the first topic on this page.
CYBER-BULLYING The use of online technology is exploding worldwide and is fast becoming a preferred method of interacting among young people. While most online interactions are neutral or positive the internet provides a new means through which children and young people are bullied. A recent study discovered cyber-bullying to be a serious problem and some participants felt that it was more serious than ‘traditional’ bullying because of the associated anonymity. The findings revealed five major themes: technology embraced at younger ages and becoming the dominant medium for communication; definitions and views of cyber-bullying; factors unique to cyber-bullying; types of cyber-bullying and telling adults. Research suggests that cyber-bullying is increasing. A survey by the charity Beatbullying in 2009 found that nearly one third of all 11-16 year olds have been bullied online, and for 25 per cent of those the bullying was ongoing. Several recent studies confirm a worrying picture in which 18% of students in grades 6-8 said they had been cyberbullied at least once in the last couple of months; and 6% said it had happened to them 2 or more times. 11% of students in grades 6-8 said they had cyberbullied another person at least once in the last couple of months and 2% said they had done it two or more times.
19% of regular Internet users between the ages of 10 and 17 reported being involved in online aggression; 15% had been aggressors, and 7% had been targets; 3% were both aggressors and targets. 17% of 6-11 year olds and 36% of 12-17 year olds reported that someone said threatening or embarrassing things about them in e-mails, instant messages, web sites, chat rooms or text messages. Cyberbullying has increased dramatically in recent years. In nationally representative surveys of 10-17 year-olds, twice as many children and youth indicated they had been victims and perpetrators of online harassment in 2005 than in1999/2000.
The first modern research on bullying was carried out by Olweus on the incidence of bullying in Norwegian schools involving a nation-wide survey of over 140,000 junior and senior high school pupils (Olweus 1978). This pioneering work set a pattern for much of the subsequent studies in this area such as O’Moore and Hillary from Eire (1991), Rigby & Slee from Australia(1993) and Pepler et al from Canada(1993). There have been several locally based research studies in the UK including that based at the University of Sheffield and funded by Gulbenkian, ESRC and the Dept of Education. Other significant landmarks in this area of research include the creation of a Bullying help line by the Childline organisation in 1990, and in 1991 the delivery of a schools resource pack to every school in the UKby the Gulbenkian Foundation.
International comparisons are still rare in this area of research however one study analysed data from seven countries and found that while bullying was a universal phenomenon, it seems clear that there are cultural variations in the way that bullying is related to age, sex and social support. For example children in collectivist societies such as China tend to show more co-operative behaviour and less conflict than those in individualistic cultures such as Britain, Canada or the USA. What they all conclude is that cyber-bullying is on the increase, and it is more harmful than other forms of bullying and it can trigger mental health problems in victims, and result in depression, self-harm and ultimately suicide.
ADHD This is becoming a fast-growing problem since Psychiatrists first identified it about 30 years ago.It is characterised by developmentally inappropriate levels of inattention; impulsivity; and hyperactivity. In other words you might expect a really young child to be on the go a lot and exploring their world in a risky way. Parents can teach the young child how to avoid harm and be quiet and relaxed in social situations. But a person with ADHD finds this a challenge too far and cannot learn to manage impulsive behaviour. You will notice them- it's what they do. There is a well-documented gender bias of more boys than girls; no ethnic or cultural distinctions although UK prevalence much lower than China; and there is more prevalence among poorer families.Thre is a strong and ardent debate in the UK about the diagnosis of ADHD with many arguing it is over-diagnosed and used to just quiten and sedate young people while Psychiatrists argue the reverse- that it is under-diagnosed. Parents have cottoned on to ADHD and can pressure GP's to provide them with something to control their child. A chemical cosh may not be a great way to deal with what may be a parenting problem such as adult mental illness, separation/divorce, or poverty. Is it treating the symptom rather than the cause?
Causes: There is no single cause but research concludes that multi-causal factors include- genetic predisposition, brain damage and dysfunction, diet and toxic substances, environmental factors.
Treatments: Medication and psychosocial programmes employing behavioural and cognitive-behavioural strategies are the common strategies. Medication-psychostimulants such as Ritalin and Dexedrine have a focussing effect in that they appear to increase ability to sustain attention; decrease impulsiveness; and improve fine motor tasks. Physical hyperactivity subsequently declines but there is no increase in academic performance. Concerns-only 70 per cent show positive response; side effects include- anxiety, insomnia, irritability, weight loss, increased blood pressure. Since 1971 there has been a doubling of prescriptions every 4 years. Some research suggests that 30-50% of those prescribed Ritalin do not have ADHD, ddue to misdiagnosis, parental pressure. There is an underground/playground market in unprescribed Ritalin which some young people use to help them focus during pre-exam stress.
Anxiety problems Essential features: Distinguish between normal levels of anxiety and extreme and persistent reactions; among the most common emotional problems; little gender bias although evidence for more girls; developmentally there are different fears- 1-2 years: separation anxiety; 2-4 years: fear of animals and dark; 4-6 years: fear of ghosts, monsters and night sounds; 6-+ years: fear of death, injury, natural catastrophe 10+ years: fear of rejection by peers
Characteristics: stomach aches, headaches, muscle tension, sweating, jittery behaviour, feelings of choking, excessive worry.Generalized Anxiety Disorder (GAD)- typified by unrealistic and excessive anxiety and worry not related to a specific situation or external stress. Tension, nervousness, or being on edge. Present most days for more than 6 months and difficult to control.
Obsessive- compulsive Disorder (OCD)- recurrent obsessions or compulsions that are time-consuming, cause distress and lead to impairment in functioning. Typified by recurrent intrusive thoughts perceived as senseless and inappropriate causing marked anxiety. Compulsions are repetitive behaviours designed to reduce anxiety or distress.
Separation Anxiety Disorder (SAD)- manifested by obvious distress from and excessive concern about being separated from those to whom the child is attached. Typified by refusal to stay away from home; staying excessively close to a parent while at home; separation problems when starting school. Important to distinguish between developmental norms of separation anxiety and persistent, unrealistic concern going into late childhood.
School Phobia- fear and avoidance that is well circumscribed to the school environment. SAD child will avoid a variety of situations whereas the school phobic will fear and avoid school alone.
Assessment- In general assessment can be undertaken using self-report measures, structured diagnostic interviewing, and parent teacher ratings. There are several self-report scales- The State-Trait Anxiety Inventory (Speilberger et al 1970); Revised Children’s Manifest Anxiety Scale (Reynolds & Richmond 1985); Multidimensional Anxiety Scale for Children (March et al 1997); Child Behaviour Checklist (Achenbach 1991).
Prevalence- Fears and worries are common among children in community samples studies. Estimates are of 5-8 % meeting diagnostic criteria, slightly higher in mid-adolescence. Gender equal apart from adolescence when more girls. Cross cultural comparisons have shown similarity in need but higher rates of diagnosis for Black children.
Causes- Influenced by a variety of factors- genetic predisposition; parental mental illness; early trauma; cognitive and behavioural learning history; peer and familial inter-relationships.
Treatment- psychosocial approaches and medication are employed. Typically they use cognitive behavioural techniques to help children manage unwanted arousal with exposure to the feared or distressing situation. Helps children identify their anxiety-arousing thoughts, teaches relaxation responses, and provides strategies to moderate anxious arousal. About 70 % of children show marked improvement and further evidence suggest combining with parent training improves success rates.
Depression Only in the 1990’s did good evidence emerge that children were depressed before this it was a common assumption that depression was a problem limited to adults. Why was this? Loud and energetic problem behaviour was concentrated on by parents/teacheds and quiet (depressed) children ignored.
Essential features- subjective feelings of sadness/emptiness; observed looking tearful; diminished interest in most daily activities; weight loss/gain; insomnia; fatigue; agitation; feelings of guilt/worthlessness; inability to concentrate; thoughts of death, suicide, plan or attempt.
Prevalence-1% pre-school; 2% in middle childhood; 4-8% in adolescence. Children who meet criteria for other problems may also have depression as a secondary diagnosis. Some evidence that prevalence in modern children is increasing. Equal gender prevalence until adolescence when twice as many girls with depression.
Assessment- Measuring depression is nowadays thought to be more complex than it once was. As with anxiety mixture of self-report, structured interviews and parent/teacher rating scales used. But there is little consistency- especially marked differences between peer and teacher ratings and children’s own self-reports. Why is this?
Causes- No single environmental or genetic factor. Most research done with adults. Evidence that depression runs in families. Cognitive models of depression suggest that depression is linked to negative self views, the world and the future. When negative outcomes occur such as loss, separation and abuse, depressed children attribute them to internal, global aspects of themselves. Behavioural explanations emphasize problems in the child’s response to the environment- reduced positive reinforcement, limited pleasant events. One common model of understanding is that biological/genetic predispositions interact with family distress and cognitive distortions.
Treatment- NICE guidance 2005 suggests- mild depression should not be treated initially with anti-depressant medication; moderate to severe depression should be offered a specific psychological therapy such as CBT, interpersonal therapy or short-term family therapy
Cultural Diversity Racism and hostility to other cultures finds expresssion still in mental health services. Modern society is full of racism, xenophobia, anti-semitism, and islamophobia. The overarching context of mental health problems in young people is often forgotten as therapists, counsellors and psychologists set about focussing in on their task. One of the most important is also the one that is often absent from any assessment/diagnosis/understanding of why a young person develops mental health problems. In a multi-cultural, ethnically rich and increasingly diverse society we need to be alert to the variety of cultural contexts that young people come from and are influenced by. Religion and Spirituality are dimensions of cultural diversity which must be actively considered in order to practice in child and adolescent mental health services in a culturally competent way. This is not a manifesto for the promotion of religious belief- far from it, because we know that religious belief can herald a developing mental health problem or of itself, be indicative. But those trying to help troubled young people have tended to avoid the issue of religious belief. Why? Perhaps out of an unease that they were on problematic ground or entering a forbidden area? This is an error in the same way as if a therapist or doctor ignored a young person's social situation, or their parents' capacity to care. The belief systems of young people - whatever they are, should be acknowledged as part of their psychological make-up and be part of any helping and supportive strategy.The principles underpinning the counselling and psychotherapeutic helping relationship offer a complementary model to build on the capacity for healing that is associated with religious and spiritual experience.
They also fit with the concept of personal growth and social justice enshrined in psycho-social practice. It is suggested that religion and spirituality can be equated together or seen as quite distinct concepts. Spirituality, it is argued, refers to one’s basic nature and the process of finding meaning and purpose whereas religion involves a set of organized, institutionalized beliefs and social functions as a means of spiritual expression and experience. Many young people who report a lack of religious affiliation are equally happy to acknowledge a sense of spirituality. So it is important for those trying to help young people to distinguish between religion and spirituality. Assessment forms and models tend to ask about religion but not ask about spirituality. Religion and Spirituality have traditionally been separated in their application to an understanding of the human condition employed by counsellors and psychotherapists. It is as if our desperate need for recognition and importance has to be privileged over all other influences- particularly those that impinge on the realm of the unconscious and psychological. Some go further and suggest that religions typically act to increase anxiety rather than reduce it, or they are an instrument of oppression and control over women and the poor. The complexities and subtleties of different cultural manifestations of relationship dynamics are lost on those relying on media stereotypes drawn from extremist religious zealots. The central features of spirituality have been described as (Martsolf & Mickley 1998): Meaning- the significance of life and deriving purpose in existence Transcendence- experience of a dimension beyond the self that opens the mind Value- standards and beliefs such as value truth, beauty, worth often discussed as ultimate value Connecting- relationships with others, God or a higher power and the environment Becoming- a life that requires reflection and experience including a sense of who one is and how one knows
These spiritual needs can be explained in psychological terms as well. The conventional literature available to counsellors and psychotherapists can be used to explain these ideas in many ways using evidence from orthodox science and theories that have stood the test of time and served professionals well. Yet there is a lingering doubt perhaps that on deeper reflection the concepts of faith, purpose and the search for meaning are inadequately quantified in the language of scientific certainty that asserts they are just thought processes or embroidered survival needs. Even in this age of evidence-based practice we know that to ignore our intuitions and gut feelings risks denying us and the children and young people we aspire to help a most valuable tool.
It cannot be co-incidental that the further the human race moves towards scientific and rational certainty aided by the bewildering power of computers and technology able to explore and manipulate the biological foundations of life using genetic research, that people seem more determined than ever to seek answers to fundamental questions about existence whether from organised religions or alternative forms of spirituality. Jung believed that therapists needed to recognise the relevance of spirituality and religious practice to the needs and workings of the human psyche. He suggested that a psychological problem was in essence the suffering of a soul which had not discovered its meaning- that the cause of such suffering was spiritual stagnation or psychic sterility.
“Religions are psychotherapeutic systems in the truest sense of the word, and on the grandest scale. They express the whole range of the psychic problem in mighty images; they are the avowal and recognition of the soul, and at the same time the revelation of the soul’s nature” (Jung 1978).
Jungs concept of archetypes suggests that unconscious components of the psyche are revealed through dreams and phantasies at critical points of internal conflict. This transcendent process mediates between oppositional archetypes in order to produce a reconciling symbol. This experience enables children and young people to achieve gradual individuation and the revelation of the self. Some of the central experiences of individuation such as the hero’s journey, the metaphor of death and rebirth or the image of the divine child are paradigms of religious experience. They migrate into myths, fairy stories and legends, and are therefore accessible for work with troubled children and adolescents.
A sense of religion or spirituality has the capacity to inhibit or enhance culturally competent therapeutic work with children or young people. Children who choose to reject the religious practices of their parents may feel a sense of betrayal or anguish and be punished by parents feeling rejected. Vice versa young people who find religion a comfort in an atheist family will probably feel guilty and anxious and learn to hide their true nature. You may feel that an over-reliance on beliefs of this nature are symptomatic of a denial defence and a fatalistic outlook in your clients. On the other hand you may believe that having faith in something outside of themselves permits a child or young person to experience a sense of purpose and greater good that can enhance a therapeutic intervention. As a counsellor or psychotherapist you may also have religious beliefs or a sense of spirituality that helps you in your therapeutic work. It might also hinder your work if you encounter an atheistic belief system in a young person or a religious affiliation that contradicts your own. The evidence although yet to be fully developed, does suggest that acknowledging a sense of spirituality has a protective function against developing psychological problems. Children and young people who possess such a sense of spirituality are considered more resilient in the face of traumas including sexual abuse and less prone to mental health and adjustment problems in adolescence.
The problem with self-harm is not the actual selfharm/injury that you are engaged in. It's the stigma and peceptions of other people that is the main problem. It is their lack of knowledge, fear, anxiety and downright prejudice that prevents them understanding what you are going through and what help and support you are looking for. If parents, other adults or friends are prejudiced and blaming, then you have an uphill struggle in addition to sorting out the difficulty you are trying to cope with. Below are some of the common myths about self harm prevalent in the professional and public community:
Myths about self harm Adults who encounter self harm in young people and others can quickly react according to powerful beliefs that have built up overtime regarding this problem. These myths are enduring and probably influence many parents and professionals who are in a state of shock and disbelief when they first realise that a young person, for example, is self harming.
The young person is just attention seeking ! In fact evidence strongly suggests that deliberate self harm is done for the opposite reasons. It is usually a private act which is concealed and not disclosed to friends or family by young people with low self esteem who because of the stigma attached to self harm are unlikely to seek help. The last thing they want is for attention from anyone.
Self harm does not really hurt! It is also important to remember that every person has a different pain threshold. However, cutting or other acts of deliberate self harm does hurt although the initial pain sensation may be blunted by the intense emotions or associated drug and alcohol use. It seems that the sense of pain is very high by the time the young person is receiving treatment.
The seriousness of the problem is associated with the severity of the injury! There is no evidence to support this proposition. A young person who self harms in a minor way by superficial cutting may be feeling just as sad, depressed or suicidal as the young person who takes a serious overdose. Only teen-aged girls self-injure! Research over the past five years demonstrates that members of both genders, from six continents, and ranging in age from 14-60+ reported self-harming. Self-inflicted violence is just an attempt to manipulate others! Some people use self-inflicted injuries as an attempt to cause others to behave in certain ways. Most don't, though. It’s more important to focus on what it is they want and how you can communicate about it while maintaining appropriate boundaries. Look for the deeper issues and work on those.
Overview If you cause physical harm to your body in order to deal with overwhelming feelings, you have nothing to be ashamed of. It’s likely that you’re keeping yourself alive and maintaining psychological integrity with the only tool you have right now. It’s a crude and ultimately self-destructive tool, but it works; you get relief from the overwhelming pain, fear or anxiety in your life. The prospect of giving it up may be unthinkable, which makes sense; you may not realize that self-harm isn’t the only or even best coping method around.
For many people who self-harm, though, there comes a moment when they realize that change is possible, that they can escape, that things can be different. They begin to believe that other tools do exist and begin figuring out which of these non-self-destructive ways of coping work for them. How do you know if you or someone you know self-harms? It may seem an odd question to some, but a few people aren’t sure if what they do is "really" self-injury. Answer these questions:
Do you deliberately cause physical harm to yourself to the extent of causing tissue damage (breaking the skin, bruising, leaving marks that last for more than an hour)?
Do you cause this harm to yourself as a way of dealing with unpleasant or overwhelming emotions, thoughts, or situations (including dissociation)?
If your self-harm is not compulsive, do you often think about self harm even when you’re relatively calm and not doing it at the moment?
If you answer 1 and 2 yes, you are a self-harmer. If you answer 3 yes, you are most likely a repetitive self-harmer. The way you choose to hurt yourself could be cutting, hitting, burning, scratching, skin-picking, banging your head, breaking bones, not letting wounds heal, among others. You might do several of these. How you injure yourself isn’t as important as recognizing that you do and what it means in your life. Self-harming behaviour does not necessarily mean you were an abused child. It can indicate that somewhere along the line, you didn’t learn good ways of coping with overwhelming feelings. You’re not a disgusting person or sick; you just never learned positive ways to deal with your feelings.
How can I help myself ? If you are a young person who has already or is thinking about self harming, or if you know someone close to you who is self harming it is worth considering the following. The feelings of self-harm will go away after a while. If you can cope with your upset without self-harming for a time, it will get easier over the next few hours. You can:
a) Talk to someone- if you are on your own perhaps try phoning a friend. Telephone helplines and helpful contatcs are listed below. b) If the person you are with is making you feel worse, ask them to leave or go out. c) Distract yourself by moving about inside your home or outside, listen to some good music, do something harmless that really interests you. d) Try to relax- and focus your mind on something pleasant, perhaps an old memory from earlier in your life or a funny joke/situation you had with friends e) Find another way to deal with your feelings- squeezing an ice cube, or drawing red lines on your skin instead of cutting, use different pain such as eating a very hot curry. f) Try doing something completely different which is pleasant, or maybe write a note/diary entry explaining how you are feeling and explaining what is happening.
Advice for when you don't feel like harming yourself
When the urge has gone, and you feel safe, think about the times that you have self-harmed and what (if anything) has been helpful such as:
a) Go back in time and think about the last time you felt like self-harming. What stopped you? Think about who you were with, what was going on, how did you feel? What was it that made you feel like self-harming? Did it make you feel in control, powerful or give you a sense of relief and relaxation? Did it give you a sense of escape? What could provide you with the same feelings but without causing damage.
b) How did your friends react at the time? Could you have done anything else. What would your closest friend advise you to do? How would you convince yourself not to self-harm?
c) Make a visual or verbal recording. Talk about the good things about yourself- there must be at least one! If you cannot, then get a good friend to say what they like about you. When you start to feel like self-harming re-play this recording.
d) Make a plan for when the feelings to self harm begin to get the better of you. Phone that friend, have a few options in case they are not able to take your call. Discuss the best way to avoid self-harming with them, step by step, slowly let yourself believe you do not have to do it.
What if you still feel like self-harming?
a) Reduce the damage to your body by using a clean blade, and use shallow, less heavy strokes. b) Keep thinkming about the possible reasons why you are doing this and what else you might consider doing instead. c) Every so often re-consider your decision not to stop self-harming.
What can a young person do if they know someone who self-harms?It can be very upsetting to be close to someone who self-harms -but there are things they can do. The most important is to listen to them without judging them or being critical. This can be very hard if you are upset- and perhaps angry - about what they are doing. Try to encourage this young person to concentrate on their friend rather than their own feelings – although this can be hard. Encourage them to talk to their friend when they feel like self-harming. Try to understand their feelings, and then move the conversation onto other things.
Take some of the mystery out of self-harm by helping their friend find out about self-harm perhaps by showing them useful leaflets, or by using the internet or the local library. Find out about getting help - maybe suggest they go to see someone, such as their GP. Help them to think about their self-harm not as a shameful secret, but as a problem to be sorted out.
Try to be their therapist or counsellor (unless of course you are, and even then this should be a short-term plan). They need to see someone neutral in confidence.
Expect your friend to stop overnight- it is very dificult and takes time and effort. It will not be a smooth journey to stopping altogether.
React strongly with anger, hurt or upset- this is likely to make your friend feel worse. Talk honestly abou the effect it has had on you, but do this calmly and in a way that shows even as upset as you are your reactions are because you care abou them and their well-being.
Struggle with them when they are about to self-harm- it is better to walk away and to suggest they come and talk about it instead, rather than do it.
Make them promise never to do it again or make it a condition for maintaining your friendship. This is rejection and imposing conditions which will not help.
Make yourself responsible in some way for causing them to self harm or become the person with responsibility for stopping them. You need to get on with your life, and probably need to talk with someone trustworthy about how this has affected you.
Feeling Down Depression is a word that gets used a lot but while its a useful generalisation it conceals a wide range of very different states of mind. Most people feel low at times- its part of being human. These times can be very brief or they can become prolonged and recurring. If feeling low, weepy, hopeless, frightened, and anxious is a regular experience then you are depressed and there are ways of coping and a lot of help available. The tricky thing about depression is that it makes you feel unable to seek help or even admit your feelings to others. This is normal.
But a chance may come along that enables you to say something to somebody, or relate to another person suffering depression, or to acknowledge to another person how you feel. Not telling your parent/s is common - you are trying to protect them from the awful feelings inside you, but try not to worry- they are tougher than you imagine and most will want to help. Admitting you are feeling depressed is a first and very brave step. You already know who you can trust and who you feel safe with to discuss sensitive issues, so start with them. The provision of treatment for children and young people who get depressed is significantly limited by public stigma, our failure to detect or recognise depression, and the way that services are organised for young people. There is little doubt that children and young people are often unwilling to seek help because of the stigma associated with mental health problems. Moreover, the heterogeneity in the nature, course, and outcomes of depression in all age groups is likely to lead to poor recognition, especially amongst healthcare professionals in schools and community and primary care settings.
All this is made all the more complicated by the considerable variation in the local organisation of mental health services for children and young people. In any event, studies both in the UK and the USA have estimated that as many as 75% of children and adolescents with a clinically identifiable mood disorder remain undetected in the community.
There are self-help groups, books, magazine articles, drop-in centres, and informal places where sympathetic staff can help. Your GP, School Nurse, or College Counsellor might be helpful. See what feels right for you. You will be offered medication and counselling/therapy. These are the main options based on evidence of what works. You are unique so getting the right mix of medication and talking in confidence with someone may take a while to get right for you. What works for one person may not work for another.
You may even feel that you don't need outside help, or that taking more physical exercise works for you. You may decide to change some aspects of your lifestyle - less alcohol and drugs, less smoking or changing your eating habits. Making a new friend might make a difference. Sometimes small changes make a big difference. Experiment!
Eating disorders typically begin in adolescence and are increasing in young men. Body image is an increasing pressure on all young people but young women in particular are bombarded by glossy magazines, adverts, and clothing manufacturers to aspire to a certain image. When this is linked with normal developmental changes after puberty the mixture can be explosive and in certain youngsters, create the conditions for the onset of an eating disorder.
Assessment of your problem should be comprehensive and include physical, psychological and social needs, and a comprehensive assessment of risk to self. The level of risk to your mental and physical health should be monitored as treatment progresses because it may increase, for example, following weight change or at times of transition between services in cases of anorexia nervosa. For people with eating disorders presenting in primary care, GPs should take responsibility for the initial assessment and the initial co-ordination of care.
This includes the determination of the need for emergency medical or mental health assessment. Be very careful about the advice and information available on the internet which encourages weight loss and advises or even promotes anorexia as a life-style choice. It is not - it is an illness and can be managed, treated and sorted out.
Young people and, where appropriate, carers should be provided with education and information on the nature, course and treatment of eating disorders. In addition to the provision of information, family and carers may be informed of self-help groups and support groups, and offered the opportunity to participate in such groups where they exist. Workers should acknowledge that many people with eating disorders are ambivalent about treatment and recognise the consequent demands and challenges this presents.
Young people with eating disorders should be assessed and receive treatment at the earliest opportunity. Early treatment is particularly important for those with or at risk of severe emaciation and they should be prioritised for treatment.
Most people with anorexia nervosa should be helped in the community with psychological treatment provided by a service that is competent in giving that treatment and assessing the physical risk of people with eating disorders. If you require in-patient treatment you might be admitted to a setting that can provide the skilled implementation of re-feeding with careful physical monitoring (particularly in the first few days of re-feeding) in combination with psychosocial interventions.
Family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa. Feeding against your will should be an intervention of last resort in the care and management of anorexia nervosa. Feeding against your will is a highly specialised procedure requiring expertise in the care and management of those with severe eating disorders and the physical complications associated with it.
This should only be done in the context of the Mental Health Act 1983 or Children Act 1989 (UK). When making the decision to feed against the will of the patient, the legal basis for any such action must be clear.
As a possible first step, young people with bulimia nervosa should be encouraged to follow an evidence-based self-help programme. The course of treatment should be for 16 to 20 sessions over four to five months. Adolescents with bulimia nervosa may be treated with cognitive behavioural therapy (CBT-BN), adapted as needed to suit their age, circumstances and level of development, and including the family as appropriate.
For all eating disorders
Family members, including siblings, should normally be included in the treatment of children and adolescents with eating disorders.Family Therapy is the cardinal and optimum form of help and support because it brings together everyone in the family to harness their inner strengths to help change happen. Families and Parents know themselves better than anyone else so the therapy works by helping the Family support the young person in trouble.
Interventions may include sharing of information, advice on behavioural management and facilitating communication. In children and adolescents with eating disorders, growth and development should be closely monitored. Where development is delayed or growth is stunted despite adequate nutrition, paediatric advice should be sought. Professionals assessing children and adolescents with eating disorders should be alert to indicators of abuse (emotional, physical and sexual) and should remain so throughout treatment.
The right to confidentiality of children and adolescents with eating disorders should be respected. When working with children and adolescents with eating disorders social workers should familiarise themselves with national guidelines and their employers’ policies in the area of confidentiality. In the absence of evidence to guide the management of atypical eating disorders (eating disorders not otherwise specified) other than binge eating disorder, it is recommended to follow the guidance on the treatment of the eating problem that most closely resembles the individual person’s eating pattern.
CAMHS workers have the opportunity to employ communication and relationship skills in direct family support work, which they traditionally find rewarding and which service users find more acceptable than intrusive, investigative risk assessment (Crisp et al., 2003). The CAMHS role in multi-agency assessment and planning becomes significant in this context, where several perceptions can be expressed, based on diverse evidence and different levels of professional anxiety. CAMHS workers managing and supporting these processes with individuals or groups in planning meetings, case conferences or case reviews require advanced negotiation and decision-making skills, which are the hallmarks of professional training and supervision.
As the volume and complexity of family problems increases, there is concern the voluntary and nongovernmental sectors will be unable to match the level of skills to the level of need expressed and, therefore, creative ways of thinking are generating effective resources, such as the Family Group Conference approach to child welfare. Developed in New Zealand, it is based on a cultural-religious Indigenous concept among Maori people emphasising the relationship between celestial and terrestrial knowledge. According to Maori belief, the origin of the Family Group Conference was a rebellious initiative by the children of Ranginui, the great Sky Father, and Papatuanuku, the matriarch Earth Mother. Protected in a darkened cocoon by their parents, the children desired freedom to explore the outer limits of the universe. The family conference included close and distant relatives and grandparents, all of whom were regarded as part of a single spiritual and economic unity (Fulcher, 1999). Thus each Maori child’s cultural identity is explicitly connected to their genealogy or whakapapa. The Family Group Conference has been incorporated into mainstream child protection and adult mental health services in the UK and elsewhere, where extended family members are invited to participate in care planning and become part of the family support system rather than excluded from it (Brown, 2003; Featherstone, 2004).
Various initiatives aimed at children and their families living in disadvantaged areas are evidence of the practical implementation of the implicit preventive aspects of this policy, which was based on evidence of success from the US Head Start scheme (Gross et al., 1995). Gross et al.’s (1995) study demonstrated long-term reductions in antisocial activity, marital problems, child abuse, adult mental health difficulties, and unemployment in later life in a group of children who received the intervention, with a comparison group of children who did not receive the intervention. The Sure Start initiative was the British equivalent and the signature family support policy of the early 21st century. Recent research to evaluate its impact has produced positive findings (Hutchings et al., 2007). However, a systematic review of Family Group Conferences shows, to succeed as a family support intervention, they need to be part of a range of helping services and the start of a continuum of support (Schlonsky, 2010).
Impact of intervention
Measuring or quantifying the impact of preventive family support work is complex and achieving systematic results is expensive. Therefore, there is little in the way of evidence of long-term effectiveness in Britain or the rest of Europe. However, while outcome measures from various government projects are intangible (Robbins, 1998), there are signs small-scale social action projects could show changes in relationships between parents and professionals, as well as demonstrate how to work in partnership and engage positively with parents, all of which contribute to better family support and user-focused approaches.
The expansion of parent education or training programmes in the face of exponential demand for help from parents to deal with a range of child and adolescent difficulties from toddler tantrums to self-harm, suicide, and drug and alcohol addiction has meant this form of intervention is popular and expected to be offered as part of a repertoire of contemporary family support measures. Studies of parent education programmes, while limited in number, show they can be an effective way of supporting families by improving behaviour in pre-adolescent children (Lloyd, 1999; Miller & Prinz, 1990). They highlight the impact of group-based behaviourally oriented programmes in producing the biggest subsequent changes in children’s behaviour and are perceived by parents as non-stigmatising. Programmes where both parents are involved and which include individual work with children are more likely to result in long-term changes.
However, while enjoying a growth in popularity in Britain and other European countries, parent education programmes are generally not subject to rigorous evaluation (Donnellan, 2003, Nybell, Shook, & Finn, 2009). In a number of studies, fifty per cent of parents continue to experience difficulties. Further, it is not clear to what extent changes are due to the format or method of intervention, group support or practitioner skill. High attrition rates from some programmes are attributed to practitioner variables, such as their level of qualification and experience, and qualities such as warmth, enthusiasm or flexibility (Barlow, 1998). It may also be that some programmes are inappropriate for parents lacking motivation, especially when they are compelled to attend under the pressure of child protection concerns.
Few British studies have used randomised controlled trials. This inhibits identification of the most beneficial elements of a programme and, because most provision is geared to rectifying problems in disadvantaged groups, available research evidence reflects this bias. While over ten years old, those that have been conducted, nevertheless, have yielded important qualitative data from stakeholders’ perspectives (Ghate& Daniels, 1997; Morrow, 1998). It has been argued managerialist preference for evaluating work on the basis of the three Es (efficiency, effectiveness, and economy), which reflects service managers’ agenda for quantitative outcome measures, fails to reflect the whole picture (Leonard, 1996; Walker, 2001b). Others argue these data need to be supplemented with the three Ps (partnership, pluralism, and process), which better reflect professional social work principles seeking to incorporate service-users’ perspectives (Beresford, 2001; Dominelli, 2004; Powell& Lovelock, 1992). Further studies paying attention to normative models of parenting in the community would counter this bias by identifying skills leading to successful parenting and focus on what went right rather than what went wrong.
Effectiveness of family support
The literature on the effectiveness in family support tends to focus on the evaluation of specific service interventions but it should be acknowledged broader fiscal and social policies impact on children and their families and, therefore, contribute for good or bad to the context of children’s welfare in general, and family well-being in particular (Shaw et al., 2004). Recent research on child poverty ranked Britain bottom in a comparison of the current fifteen European Union countries with 32 per cent of children living in poor households (Crawford, 2006; Gilbert, 2003; Micklewright & Stewart, 2000). This is an important part of the equation of demand, needs, and resources when evaluating provision.
It has long been argued early intervention is the key to effectiveness because it stops problems getting worse when they become harder to tackle, and is more costly in terms of damage to children’s development, family relationships, use of scarce resources, and prevention of antisocial consequences in the long term (Bayley, 1999). However, Eayrs and Jones (1992) pointed out the accumulated evidence for the effectiveness of early intervention programmes is not as optimistic as was once hoped. On occasion there is the possibility such programmes can be damaging, deskilling parents and undermining their confidence. On the other hand, sixteen years ago a meta-analysis of early education interventions demonstrated children from disadvantaged backgrounds were less at risk from developing maladjustment, school failure, and delinquency after participating in these programmes delivered in an educational context (Sylva, 1994). More recent research supports this conclusion (Dolan, 2006). The location of family support is critical in engaging parents and children. Schools are emerging as an acceptable and accessible nonstigmatising venue for individual or group-based activity where attached social workers can engage in interprofessional work (Quinney, 2006).
A major review of consumer studies of family therapy and marital counselling analysed a variety of large- and small-scale studies, individual case studies, and ethnographic studies of specific therapeutic methods (Carr, 2000; Treacher, 1995). It concluded workers who neglected the service-user perspective and undervalued the personal relationship aspects of their family support work in favour of concentrating on inducing change ran the risk of creating considerable dissatisfaction among service users. This reinforced findings from an earlier study into the effectiveness of family therapy, which found advice and directive work needed to be balanced with reflective and general supportive elements typical of a professional social work approach (Howe, 1989). A subsequent meta-analysis of family therapy demonstrated effectiveness with specific problems, such as adolescent substance abuse and anorexia nervosa (Stanton& Shadish, 1997; Vostanis, 2007).
Systems theory can be useful in understanding the interactive nature of some family problems. It is also important in helping to take account of the natural history, social system, and environmental context of children’s problems in relation to their developmental stage. What becomes clear is there are no standardised ways of measuring childhood functioning or isolating all the family variables that can influence change. What is consistent is the general absence and rarity of service-user evaluation of, and involvement in, the design of family support (Statham, 2000). This further reinforces the need to establish professional social work methodologies, which incorporate shared social work values and preserve the cultural autonomy of groups in different societies. Taking the service-user perspective into account in determining effectiveness has become a feature of contemporary policy in social and health care contexts, but practice evidence does not support this policy aspiration (Barnes & Warren, 1999; Crawford & Kessel, 1999; Everitt & Hardiker, 1996; Kelson, 1997). In seeking to evaluate family support, it is problematic to define who the service user is. One of the challenges in defining effectiveness in family support interventions is clarifying for whom it is effective.
Family support usually means ‘mother support’ as fathers’ absence is a feature of the helping context, despite efforts to engage men in programmes to effect change. There is evidence of activity to engage men in work but what little has been undertaken has rarely been subject to rigorous evaluation (Holt, 1998). Mothers’evaluation of family support might differ in more or less ways than the evaluation of the children and or father irrespective of whether the focus of intervention was on an individual child, adult couple or the whole family (Walker, 2001d). A school-based behavioural problem might be resolved but at the expense of a deterioration in the parent-child relationship. Robust methods of differential evaluation by all participants, referrers, users, and providers would enhance the sophistication of up-to-date data on effectiveness.
•Etiology- unknown but there are associations with physical disorders (i.e. Rubella, MMR) suggesting organic pathology
•Definition- abnormal development of language and social relationships with ritualistic and obsessional behaviours (Kanner 1943)
•Failure to comprehend others feelings, lack of interest in imitative or social play, and inability to seek friendships or comfort from others
•Impairments in verbal and non-verbal communication and avoidance of eye contact
•Resistance to change and limited interests
•Difficulties in diagnosis- especially for pre-school age children
•Prevalence rates influenced by the complex classification systems for autism and conditions along the autistic spectrum
•Increased prevalence rates due to improved diagnosis
•Estimated at 7-17 per 10,000 children
•Onset at birth but unrecognized until 2/3 years
•Usually a delay between parent concerns and diagnosis
•The disorder occurs in boys 3/4 times more often than in girls
•First sign is lack of sociability
•By 3 years of age parents/health staff report language delay and lack of peer relationships
•Lack of empathy or capacity to reflect on social situations leads to isolation- reinforcing preference for solitary repetitive play
•Half of autistic individuals never speak- those that can show unusual use of language (i.e. intonation, stress, monotone)
•A significant proportion of autistic children have behavioural and emotional problems expressed in hyperactivity, short attention span, aggression, self-harm, anxiety/depression
•Autistic features are often present where there is a generalized learning disability
•Autism is on a spectrum of severity and is highly disabling. It is one of the least prevalent conditions seen in child mental health services, but because of the impact on family and social relationships it demands considerable resources.
•The outcome of autism is poor. There is deterioration in 50% of adolescents- some of which attributable to onset of epileptic seizures. In 30% there is some improvement in behaviour and functioning- usually when onset is later, where IQ is over 60 and speech developed by 5 years of age. This suggests early intervention is crucial.
•Multidisciplinary assessment should include:
•Neonatal history, Early development, Parental descriptions of behaviour, Observation with parent and siblings, Physical examination for tuberous sclerosis
•Information from GP, Health Visitor, Midwife, Nursery staff, Social worker
•Promotion of normal development- focus on cognitive, language and social skills
•Reduction of rigidity/stereotypy- gradual adjustment rather than total resolution
•Elimination of nonspecific maladaptive behaviours- (i.e. overactivity, aggression, sleep disturbance)
•Alleviation of family distress- practical support and learning problem-solving skills
•Special education provision
•Home based treatment- including family support, behavioural management, and drug treatment
•Physical therapies- usually prescribed following attempts to rectify problems with behavioural approaches
•Megavitamin therapy- B6 is reported to offer a small nonspecific benefit
•Medication- Haloperidol, Naltrexone, Tricyclic Antidepressants, and psychostimulants report success but with side effects
•Auditory integration training- focuses on reducing the hypersensitivity to sound which distresses 40% of individuals
•Secretin- a hormone treatment thought to improve behaviour
•There is no cure for autism however intensive, structured behavioural programmes have had beneficial effects
•Howlin & Rutter (1987) describe positive results from a home-based intervention consisting of behaviour modification, encouraging language and skill development, and psychological family support
•Rutter (1985) emphasises the importance of enlisting parents as co-therapists in behavioural treatments. Helping them learn problem-solving skills is important in their on-going management of current and future behavioural problems
•Several case studies (Celiberti & Harris 1993) describe success in helping siblings learn how to prompt and interact with their autistic sibling enabling them to elicit play and speech
Social skills training
•Despite a variety of approaches there is little evidence for benefit
•Groupwork appears to help with symbolic play and language development- in one study these gains were generalized outside the group (Kohler et al 1995)
•Parent support is critical in helping families develop problem-solving skills
•Parent support groups organised by statutory or voluntary agencies
•Multi-agency support must be applied- respite care, financial support, etc, to offer holistic care
•Benefit occurs when the child is offered a well-structured learning environment
•Individual needs must be addressed
•Special or mainstream school?- depends on the individual child and the individual school
•Parent/school collaboration crucial
•Definition- still confusion between Autism and Asperger’s in DSMiv and ICD10
•Asperger’s have better cognitive and communication skills but still poor social interaction and stereotyped interests
• Prevalence- estimated higher than for Autism, but little good evidence
•Normal intelligence but problems with social interaction
•More prevalent in boys
•Pedantic monotonous speech pattern
•Anxiety, low self-esteem and depression in adolescence
•No controlled studies for treatment to date (Szatmari 1991)
•Assessment needs to highlight strengths of child
•Parent education and support to help them understand and cope
•Early identification required to intervene with social & language skills
The importance of understanding the link between child abuse and mental health problems is paramount. InBritainat least one child dies each week as a result of adult cruelty. It has been estimated that about 5000 minors are involved in prostitution in Britain at any one time.Nearly 23,000 children were being looked after by local authorities for the year ending 2007. About 60 per cent of these children had been abused or neglected with a further 10 per cent coming from ‘dysfunctional families’ (ONS 2008). In 2007 there were over 300,000 children in need in England. Of these 69,100 were looked after in state care while the rest were in families or living independently. One quarter of all rape victims are children. 75 per cent of sexually abused children do not tell anyone at the time. Each year about 30,000 children are on child protection registers. Children with learning disabilities are at a greater risk of experiencing all forms of abuse and neglect. Recorded offences of gross indecency with a child more than doubled between1985-2001 but convictions against perpetrators actually fell from 42 per cent to 19 per cent. Fewer than one in fifty sexual offences results in a conviction.In 2007-08 there were 20,000 recorded sex offences against children (NSPCC 09).
Prevalence of abuse
Solid data about the prevalence of abuse is difficult to obtain but a reliable indication is that about 750,000 children will have been abused by the time they reach 18 years of age, with 400,000 having been sexually abused (Cawson et al 2000). This NSPCC research suggests that about 30 per cent of girls have been sexually abused and about 15 per cent of boys. Reductions in the length of time children spend with their names on child protection registers seem to imply that child abuse is decreasing- which is not the case, rather they illustrate the shorter time spent on registers consistent with the reported increase in de-registrations. In other words the government target for shorter registration periods may be being achieved, but the consequence is that risk is being hidden.
The problem with child abuse is the often hidden nature and secrecy surrounding it combined with societal ambiguity about state intervention in family life. Crude structural and organisational changes to the way child protection services are delivered are the institutional knee-jerk response to improving the safeguarding of children and young people in the wake of the damning Laming inquiry into the death of Baby P (2008), Victoria Climbie (DOH 2003) and The Bichard Report of the deaths of Holly Wells and Jessica Chapman (Home Office 2004). Every Child Matters: Change for Children (2004) established the new framework for building services around children in which previously separate services must work together in an integrated way.
Above all, these changes aimed to provide professionals with consistent ways of communicating about children’s welfare. In many ways it is the most important because organisational change of itself cannot bring about shifts in entrenched attitudes, beliefs, customs and vocabulary. And despite repeated child abuse inquiries citing poor communication between agencies as one of the major reasons why children have not been properly protected, it remains difficult to get right. Recent research also highlighted the paradox of the disproportionate investment in management performance recording templates, rigid timescales and IT systems resulting in a reduction in safety of systems and children rather than an increase in safety (Broadhurst & White 2009).
Despite the hyped publicity and modern media circus exploding around high profile child deaths, historically expectations of child protection staff have tended to be lower than they are nowadays. Up until 1914 around 250 children every year died in child protection cases that were known about – more perished without coming to the attention of professionals. By 1970 the number of deaths in child protection cases had shrunk but the impact of the cruel death of Maria Caldwell and the blaming of professional staff started a trend in public discourse that endures today. Ironically, the better social workers have become at protecting children and preventing their deaths, the more bitter the public and political outcry has become when this fails to happen (Ferguson 2007.) Poor inter-agency communication is usually cited in subsequent internal investigations and public inquiries.
Rather than trying to design ever more elaborate bureaucratic data systems, Reder et al (1993, 2003) suggest that agencies need to put greater effort into understanding the psychology of communication in order to improve it. This means more than superficial and tokenistic exercises hosted by agency managers, but a fundamental re-appraisal of the knowledge, values and personal beliefs held by every member of staff engaged in work with children and young people so that integrated working is actualised. The mental health and emotional well-being of children can be both a consequence of child abuse and a precursor. You must consider this aspect of your work in safeguarding children as much a priority as learning new procedures, computer data systems and legislative guidance.
Integrated working does not mean absence of disagreement- indeed the evidence suggests closer proximity with other agency staff accentuates differences between professionals. But this need not be a problem provided you work hard to appreciate each other’s perspectives and not be so certain of your omnicompetence. Thinking about yourself as an equal part of an integrated system, rather than as an individual agency representative is a crucial re-conceptualisation to make. Disagreement may actually be healthy and force staff to compromise or continue seeking a solution. At another level such differences between professionals may reflect the dynamics in the family situation which produce splits. The mental health of a young person at risk of abuse can find expression in other family members through a process of indentification and projection (Walker 2005).
Equally you should be wary of rushing too quickly to agreement and consider whether the multi-agency group are avoiding or denying some unanswered and complex issues because of the risk of exposing an argument. This could reflect the emotional dynamics within the family. Self awareness is one of the keys to managing the stress and strain inherent in working together to safeguard children. This requires skilled and highly developed supervision skills from line managers and a willingness to expose your practice to scrutiny and to engage in reflective practice (Walker & Thurston 2006).
CAMHS and child protection often seem to occupy different parts of child welfare services yet they are always linked in some way. By separating them institutionally and dividing staff who are often involved with a vulnerable family, government is not optimising the conditions for more effective child protection.
The much vaunted aim of joint working and closer collaboration has echoed throughout much of the past 30 years of public reports where young people have been killed by their parents/carers, when problems in communication between agencies have occurred. In fact it appeared much earlier in the 1945 inquiry report into the death of Denis O’Neill- often cited as the first child killed in the UK while subject to child protection agency involvement.
Guidance suggests that staff should receive more comprehensive safeguarding training that equips them to recognise and respond to a person’s welfare concerns. Thus the policy aspiration to foster closer collaborative working between agencies involved in safeguarding children faces serious obstacles.CAMHS staff receive separate child protection training and rarely work effectively with child protection social workers. Joint, multi-agency teams working from a single base would be a major step forward, but jealous budget holders and insitutional envy hampers this.
The principal reason given for failures in interagency cooperation is that one key individual within that system failed to fulfil their part of the process which resulted in a breakdown in the protective intervention. It is not the individual within the system but the structure of the system itself that is of key importance. That one individual within a system can be blamed for a child's injury denies the whole concept of collective interagency decision-making and responsibility. Agencies can fall into the convenient practice of finding a scapegoat reflecting a societal individualistic culture and the adversarial legal system: ‘In Britain, when things go wrong, the system encourages a blaming of individual agencies and practitioners’(Murphy 2000).
If better communication is to happen it is essential that the practitioner or agency concerned behaves in an assertive way by explaining the reasons behind a judgment or opinion to the rest of the interagency group. You must never attempt to take over another agency's role or sphere of activity. It is helpful to use the technique of predicting positive or negative outcomes for the proposed courses of action. Where possible, aim for compromise if not consensus. Where there is a sense that one side has forced a decision through, the probability of positive interagency cooperation being achieved around that decision is extremely low.
By being pro-active about potential problems and difficulties much goodwill can be generated and mis-conceptions dealt with before they occur during stressful situations. Acknowledging the powerful feelings aroused during this stressful work in a safe environment away from the front line with a neutral facilitator can be very helpful in reducing all sorts of barriers to better communication. These training experiences are not add-on extras or self-indulgent experiential exercises. They are the real process by which learning takes place, practice improves and clients are better safeguarded.
Skills and Knowledge for Safeguarding
This is an attempt to enhance integrated practice in safeguarding people. The main elements of the common core in which people who work with vulnerable people need to know about and become proficient in are:
Effective communication and engagement- includes establishing rapport and respectful, trusting relationships; understand non-verbal communication and cultural variations in communication; active listening in a calm, open and non-threatening manner; summarising situations to check understanding and consent; outline possible courses of action and consequences; ensuring people feel valued; understand limits of confidentiality and relevant legislation; report and record information.
Human growth and development- includes observing behaviour in context; understand developmental processes and mental health issues; evaluate circumstances in a holistic way and distinguish fact from opinion; know when to refer on for further support; demonstrate empathy and understanding; support the person to reach their own decisions; take account of different life styles; distinguish between organic disability and poor parenting producing delayed development; understand attachment patterns and the inter-relationship between developmental characteristics and being clear about your role and how to reflect on practice to improve it.
Safeguarding and promoting the welfare of the person- includes ability to recognise overt and subtle signs that people have been harmed by considering all explanations for sudden changes in mood or behaviour; involve parents/carers in promoting welfare and recognising risk factors; develop self-awareness about the impact of child abuse; build confidence in challenging oneself and others; understand legislation, guidance and other agency roles; share information in the context of confidentiality; appreciate boundaries of your knowledge and responsibility; Respond appropriately to conflict, anger and violence and understand that assumptions, values and prejudice prevent equal opportunity.
Supporting transitions- includes recognising changes in attitudes and behaviour; empathise and reassure to help the person reach a positive outcome; consider issues of identity and the effects of peer pressure; understand key areas affecting emotional well-being such as divorce, bereavement, puberty and family break-ups, primary to secondary school, unemployment, leaving home; disability and increasing levels of vulnerability; knowledge of local resources and how to access information.
Multi-agency working- includes effective communication by listening and ensuring you are being listened to; work in a team and forge sustaining relationships; share experience through formal and informal exchanges; develop skills to ensure continuity for the person; know when and to whom to report incidents or unexpected behaviour changes; understand how to ensure another agency responds while maintaining a focus on the persons best interests.
Sharing information- includes making good use of available information such as a common assessment; assess the relevance and status of different information and where gaps exist; use clear unambiguous language; respect the skills and expertise of others while creating a trusting environment and seeking consent; engage with people and their families to communicate and gain information; share confidential information without consent where a child is at risk; avoid repetitive questions and assessment interviews; appreciate the effect of cultural and religious beliefs without stereotyping; understand the Fraser principles governing young people’s consent; distinguish between permissive information sharing and statutory information sharing and their implications.