Monday, 10 June 2013

Modern Psychological Issues


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.

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.

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.

Psychosocial approaches- teaching skills to pay attention, engage in self-control, reduce excessive activity, modify environment. Behaviour management, parent training, structured classroom programmes, cognitive training.

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.

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):

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.