DSM V

DSM V and CAMHS

 

The publication of DSM V in 2013 (The Diagnostic and Statistical Manual) used by Psychiatrists and others in CAMHS contexts to assess and diagnose troubled young people is a significant event. But even before it was published it was attracting controversy and criticism as its development was monitored. 70 per cent of the DSM V taskforce had commercial links to the pharmaceutical industry creating potential conflicts of interest. In addition, part of their taskforce membership was a mandatory nondisclosure agreement- effectively shrouding the whole process in secrecy and preventing any challenge from concerned clinicians.

Allen Frances, a former head of DSM IV issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle,...ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". (1). He stated that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process."

Robert Spitzer, the head of the DSM-III task force, also publicly criticized the way DSM V has been secretive and not open to scrutiny. (2). And Christopher Lane (3) former director of the Psychoanalytic Studies Program in the Psychiatry Department of Emory University, warned against the expansion of mental illness categories which were pathologising normal human experiences.

The British Psychological Society stated in its June 2011 response that it had "more concerns than plaudits" (4). It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflecting current normative social expectations". The BPS noted doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.

It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".

 

Who decides what is abnormal: the worker, parent or child? How is the notion of sufficiently marked or prolonged measured and against what standard? Mental illness takes us into the realm of medicine and clinical guidelines and diagnostic criteria usually applied to the most serious difficulties and those that are statistically rare. Whereas, at the other end of the scale, the terms emotional well-being or emotional literacy are becoming popular among the wider public and professionals even though it would be hard to find agreement about a definition of what these terms mean.

 

The behaviour and emotional affect of children and young people designated with symptoms of mental health difficulty can be considered in different ways within a variety of professional discourses. The dominant discourse is that of medicine and especially psychiatry, which continues to refine classifications of symptoms into universal descriptors. Yet behaviour and expressed emotions can be interpreted widely, depending on the theoretical base of the professional involved and the specific cultural and historical context of their manifestation.

 

Mental illness in young people was constructed in the context of a debate among

psychiatrists about the criteria for diagnosing specific mental health problems. Previously they had relied on a constellation of symptoms based on adult measures to distinguish children and adolescents whose condition was outside the normal experience. A significant study drew attention to the limitations in psychiatric diagnosis and, by implication, the medical model it embodies (5) This study found that not all children with symptoms of mental disorder showed marked impairment and, conversely, some children had significant psychosocial impairment without reaching the clinical threshold for diagnosis.

 

 

In 1952, when the APA's diagnostic manual first appeared, it was a small text that offered sketches of such traits as passive-aggressive personality disorder, emotionally unstable personality disorder, and inadequate personality disorder. It was seen more as a guide to psychiatry than as a definitive authority on everything pertaining to mental health. But in 1980, with publication of the third edition, which included more than 100 new mental disorders, quite a few of them still being contested. In 1994 DSM IV culminated in many disorders deleted, created or reorganised based on empirical research and literature reviews. The evidence base informing DSM IV included very little testimony from patients or service user organisations, and young people were not consulted at all.

 

For CAMHS staff the major changes in DSM V include the elimination of Asperger syndrome as a separate disorder, and merged under autism spectrum disorders (ASD). Under the new classification, clinicians would rate the severity of clinical presentation of ASD as severe, moderate or mild. But how are these terms defined? This change has been met with resistance amongst Asperger Syndrome specialists. There has been a proposal to increase the diagnostic criteria for the age when symptoms became present. The proposal would change the diagnostic criteria from symptoms being present before seven years of age to symptoms being present before twelve years of age.

 

The diagnosis of Bipolar Disorder in children is a controversial topic. While some believe the DSM IV criteria should be retained others have proposed other behavioral markers specific for children. The DSM-5 may include a new type of mood and conduct disorder, Disruptive Mood Dysregulation Disorder, as a replacement for most peadiatric bipolar diagnoses. Some prominent psychiatrists, such as Dr. Stuart Kaplan and Dr. Allen Frances, advocate applying less severe and better-researched diagnoses such as ADHD and Oppositional Defiant Disorder instead of Peadiatric Bipolar Disorder.

 

Another origin for controversy is the rise in the number of diagnoses in recent years, almost exclusively in the USA, with several possible causes for this increase. It has been argued that factors including biomedical reductionism, neglect of trauma and attachment factors, the symptom checklist but decontextualised model of psychiatry embodied in DSM, and the pervasive influence of the pharmaceutical industry, particularly in the US health system, have contributed to the epidemic of Peadiatric Bipolar Disorder.

 

Hypersexual Disorder is proposed as a new category. The diagnosis would apply when a person experiences several of the indicated symptoms (extreme amounts of time spent in the sexual activity, using the sexual activity in response to low mood or stress, failed attempts to reduce the behaviors, etc.). Moreover, it would apply only when the problem lasted six months or more, when a person experienced significant distress or impairment in major life areas because of it, and when the problem was not directly caused by medication or drugs, as well as other criteria.

It is proposed that the eight symptoms of Oppositional Defiant Disorder should be divided into the following categories: Angry/Irritable Mood; Defiant/Headstrong Behavior; and Vindictiveness. However, just as in the DSM IV, four of these symptoms need to be present to meet diagnostic criteria. The minimum four symptoms can come from all (or even just one or two) of the three categories. But who defines vindictiveness compared to say- retaliation, or an indication of persecutory child sexual abuse?

DSM V will have added to the diagnostic criteria for Oppositional Defiant Disorder stating that for children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months". But what does 'most' mean? For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months. The proposed change adds the criterion of frequency of symptoms and also delineates required frequency by the age of the child.

Gender Identity Disorder in children is another controversial area in DSM V. Transgender support groups and organizations believe it is unethical to even have a diagnosis of GID in young people. Other critics argue that it pathologises non-conformity with orthodox binary definitions of gender, stigmatises many children and fails to tackle homophobic prejudice and social intolerance of difference which are the real problems.

DSM V and all its predecessors are peppered with distinctions such as 'severe' 'major',  'superficial' and 'short-term', to try and help users place the young person into a pre-formed category. The problem is that these terms are rarely defined and by their nature are influencing the perceptions of psychiatrists and others tasked with assessing troubled young people. They force clinicians to find a category for the young person rather than permit a more personal, descriptive assessment. This means in the final analysis they are highly subjective. Labels stick and are usually linked to treatment including medication which can have profound side effects and imply that there is a biological element to a young person's distress. This risks ignoring the social construction of mental illness, the socio-economic context of racism, homophobia, poverty, poor housing, parental mental illness, unemployment and bullying.

Steven Walker, Systemic Psychotherapist

 

References

 1. Allen, F. (2009). A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences, Psychiatric Times, 26: 8

 

2. Carey, B. (2008). "Psychiatrists Revise the Book of Human Troubles". The New York Times. Dec 2008.

 

3. Lane. C. (2009). Bitterness, Compulsive Shopping, and Internet Addiction

The diagnostic madness of DSM-V. Slate Magazine, July 2009.

 

4.  British Psychological Association.(2011). Response to the American Psychiatric Association: DSM-5 Development. June 2011.

 

5. Pickles, A; Rowe, R; Simonoff, E; Foley, D; Rutter, M; and Silberg, J.(2001).Child Psychiatric symptoms and psychosocial impairment- relationship and prognostic significance. British Journal of Psychiatry, 179. 230-235

SUICIDE AND YOUNG PEOPLE

YOUNG PEOPLE AND SUICIDE

 

The numbers of those young people found to have committed suicide each year are a stark reminder of the painful human cost of mental illness. The loss of a young life is always shocking and distressing but in the case of suicide there is an added sense of despair and helplessness evoked. Suicide is now the second most common cause of death in young men and women in the UK.

The latest data from the Office for National Statistics (ONS) provides an opportunity to examine in closer detail what has been happening over the past 30 years, from 1981 to 2011. The official press release highlighted the recent jump in the annual number of suicides. There were 6,045 suicides in people aged 15 and over in the UK in 2011, compared with 5608 in 2010 – a rise of 437 people. The ONS figures showed that the UK suicide rate “increased significantly” from 11.1 deaths per 100,000 population to 11.8 deaths per 100,000 population. These statistics relate to the whole population, so it is worth noting that the corresponding figures for young people aged between 15 and 25 years were: 14.1 and 14.8 deaths per 100,000 population. Young people are thus more at risk of suicide than older people.

However closer analysis of the 30 year data reveals some worrying trends in the context of the current Economic crisis. For children aged 15-19 years there were on average more than 4 suicides every week, while for young people aged 19-25 there were 14 per week. Together on average nearly 3 young people between the ages of 15 and 25 committed suicide every day of the week.

In terms of the percentage of the young population this translates as a yearly average of over 5% per 100,000 for 15-19 year olds, and nearly 18% per 100,000 for 19-25 year olds. Put together the total number of suicides between 1981 and 2011 of young people between 15 and 25 years of age who committed suicide was 21,006. Or an average of over 700 per year.

These numbers disguise peaks, troughs and trends so further statistical analysis shows above average years as well as trends which can be calculated by regression analysis and other statistical models. For example there were 15 years out of the past 30 when the yearly average of suicides of young people was higher. Any link with other variables such as unemployment and economic recession could be useful for researchers and government planners in the Department of Education. The figures show that in the peak years of unemployment in 1983/84; 1992/93 and 2009/10 while there were higher than average numbers of suicides in young people, those years did not correlate with the highest numbers or averages over the past 30 years.

Another important variable is the relaxation of legal constraints related to alcohol availability and the increase in opening times for pubs and clubs which happened during the previous government's term of office. The link between alcohol, drug abuse and suicide is well established - whether it is perceived as a cause or effect phenomena. In other words a young person who is depressed may turn to alcohol and drugs to blot out their inner pain. Or excess drink and drug use could trigger a depressive episode combined with disinhibition.

Interpretation of these data is always problematic. For example the way Unemployment is calculated has been changed more than 30 times over this period of time by successive governments, making comparisons and extrapolation very difficult. The recording of suicides by coroners is also variable around the country and is understood to be an under-representation of the actual number of suicides in young people due to the lack of evidence in many unusual deaths of a corroborating note, or other indication of intent. Coroners are reluctant therefore to record an official suicide verdict where there is any doubt and also to protect the feelings of grieving parents and family.

Other factors associated with suicide can include parental mental illness, alcohol and drug abuse, childhood sexual abuse, a history of depression, early-onset psychosis, chronic neglect and poor attachment. All of these can be exaggerated by poverty, unemployment, poor housing, bullying and undiagnosed learning or developmental disabilities. Longitudinal studies conducted by Universities and Research Institutes can provide the fine grain needed to illuminate useful aspects from the raw data. However they are very expensive to undertake and sustain, and they can only offer interpretations based on the best available evidence and research methodologies.

The previous government launched the National Suicide Prevention Strategy  in 2002 with a target of reducing suicides by at least 20 per cent by the year 2010. This period combined with an unprecedented increased in NHS funding and specific hefty increases in CAMHS budgets. That target was achieved in terms of suicides in young people, and it happened to co-incide with a period of strong Economic growth. We are now in a period of Economic crisis combined with heavily-reduced CAMHS budgets. This does not bode well.

Steven Walker, Systemic Psychotherapist, Youth Enquiry Service, Essex.

Reference: Office for National Statistics, (2012). Suicides in the United Kingdom- 2011. London, ONS.

 

 

Social Exclusion and Mental Health

 

SOCIAL EXCLUSION & MENTAL HEALTH

SOCIAL EXCLUSION

The effects of social inequality- mental health problems affect 3x as many lower class children compared to higher class, 1 in 10 children suffer from a poverty related mental health problem, UK IS fourth from bottom of poverty league table, govt aim to abolish child poverty by 2021 has now been abandoned......

 

Mental health problems affect three times as many children in social class V (manual and unskilled) compared with those in social class I (professional) according to the authoritative Social Trends report (ONS 2012). It is important therefore to consider the external context of child and adolescent mental health problems and acknowledge that the impact of service provision in some families is mediated by factors such as unemployment, poor housing and poverty. They all contribute to the level of resilience and capacity for resourcefulness of children and families (Eamon 1994, Dunn 1999, Micklewright & Stewart 2000). A report on social inequalities from the Office for National Statistics revealed that one in ten children in the United Kingdom suffers from a poverty related mental health problem (HMSO 2000). According to other research the UK is fourth from the bottom of a list of relative poverty among the nineteen richest nations (UNICEF 2010).

 

The previous government target failed to reduce child poverty by a quarter by 2004, to halve it by 2010 and unlikely to have helped to abolish it by 2021. The calculations for defining poverty, relative poverty and absolute poverty are complex and subject to much statistical interpretation and debate. The current measure for calculating relative child poverty (defined as children living in households with incomes below 50 per cent of the national median) does not reveal anything about the depth of poverty. In other words every household below the 50 per cent threshold would be counted regardless of whether they were just below or in complete destitution. Also it fails to measure how long children have lived in poverty. This is important given the cumulative psychological effects of persistent social exclusion.

 

 Socially excluded children and their families

 

Black children- Govt inspections reveal inadequate assessment of the needs of black children and families: are your agencies following these recommendations?

 

Ensuring that services and staffing are monitored by ethnicity to ensure they are provided appropriately and equally

Involving ethnic minorities in planning and reviewing services

Training in anti-racist and anti-discriminatory practice

Investigating and monitoring complaints of racial discrimination or harassment

Explicit policies are in place for working with black families

 

Research by the NSPCC revealed (Barter 1999):

Racism and racial bullying are commonplace within the lives of ethnic minority children and young people

The most common expression of racism is through racist name-calling previously considered by adults as trivial but the impact is now known to be profound

Racial bullying frequently involves the use of violence

Violence against ethnic minority groups is persistent, patterned, and long-term in the way it affects individuals and the places where they live

 

Disabled children

Disabled children and those with learning difficulties are more likely to have mental health problems than other children. Disabled children and adolescents are twice as likely to have emotional and behavioural problems. There are a growing number of disabled children and young people living in the community who need high levels of support. Partly this is because more of these children are surviving infancy, and partly because there is no longer the assumption that disabled children should be cared for in hospitals or other institutions. Lone parents with disabled children, families from ethnic minorities, and families caring for the most severely disabled children have the highest levels of unmet need, and live in the poorest conditions. The mental health needs of disabled children are often masked by a narrow focus on their disability through a medical, rather than social model of disability. Behaviour causing concern can often be ascribed to the physical or intellectual disability rather than a separate psychological need.

 

Young Offenders

According to recent figures there were 11,500 young people aged 15 to 20 in jail in England and Wales in 2010, of those 90 per cent had a diagnosable mental health disorder, and many had substance abuse problems as well as personality disorders (Lyon et al 2010). 60 per cent had anxiety and depressive illness with 10 per cent suffering from a severe psychotic mental illness such as schizophrenia. 20 per cent of these young men and 40 per cent of young women will have attempted suicide prior to their imprisonment (Farrant 2001). Young offenders are among the most socially excluded groups in society and the evidence suggests that imprisonment simply makes matters worse not better. Within two years of release, 75 per cent will have been reconvicted and 47 per cent will be back in jail (Social Exclusion Unit 2002). If some of these young people become homeless or end up in insecure accommodation, they are between eight and 11 times more likely to develop mental health problems (Stephens 2002). Low take up of preventive mental health services among socially excluded families means that minor problems can develop into major problems. Over 90 per cent of recidivist delinquents had a conduct disorder as children

 

Looked After Children

Nearly 60,000 children were being looked after by local authorities for the year ending 2011. About 60 per cent of these children had been abused or neglected with a further 10 per cent coming from ‘dysfunctional families’ (DOH 2011). Abuse of this nature can lead to self-harming behaviour, severe behavioural problems and depression. Evidence confirms that the mental health needs of these children and young people are overlooked and that many have established mental health problems prior to coming into local authority care (Dimigen et al 1999). 38,400 of these children were in foster placements and 6,400 were in children’s homes, yet foster carers and residential staff are among the least qualified and supported people left to manage sometimes extreme behaviour. Specialist CAMHS services often decline to help because of the uncertain and possibly temporary nature of the child’s placement which contra-indicates successful intervention. The dilemma is that without input, placements often break down as carers cannot cope, invariably leading to more placements and further deterioration in the child’s mental health.

 

A recent research study emphasised the importance of a preventive approach with children in the public care system who are more likely to be excluded from school following emotional and behavioural difficulties (Fletcher-Campbell 2001). Teacher training that fails to adequately prepare newly-qualified staff to respond to the mental health needs of pupils is considered to be a factor in the increased use of school exclusions (OFSTED 1996).  Social workers using a preventive approach could be helpful to teaching staff and organise collaborative work aimed at preventing difficult behaviour escalating. Unless the mental health needs of these children and young people are addressed as part of a strategy that effectively nurtures children’s inclusion in school the risk of deterioration is high. The risk factors for looked after children are probably the most extreme of any socially excluded group, they include (Richardson & Joughin 2000):

 

Developmental delay

School failure

Communication difficulty

Low self esteem

Parent/carer conflict

Family breakdown

Rejection

Abuse

Parental mental illness

Alcohol/drug abuse

Poverty

Homelessness

Loss

 

Refugee and asylum seeking children
The number of applications for asylum from unaccompanied under 18s almost trebled between 1997 and 2011 from 1,105 to 3,469. DOH figures indicate that there were 6,750 unaccompanied asylum- seeking children supported by local authorities in 2001. Further evidence shows that many of these young people were accommodated and receiving a worse service than other children in need (Audit Commission 2000). Very little research has been done to ascertain the mental health needs of this group of children. However there is some evidence of the symptoms of post traumatic stress syndrome being present before they then experience the racist xenophobic abuse of individuals and institutions incapable of demonstrating humanitarian concern for their plight. This combination can shatter the most psychologically robust personality. It has been estimated that serious mental health disorders may be present in 40-50 per cent of young refugees (Hodes 1998).

         

DEFINING MENTAL HEALTH PROBLEMS

A mental health problem can be distinguished from the term disorder by the degree of seriousness and the length of time the condition lasts. The assumption is that most people will recognise these symptoms and understand they do not require specialist or intensive intervention. Mental health disorder has echoes of the concept of child abuse to social workers familiar with the Children Act definition and the concept of significant harm. Note the idea of abnormality of emotions and the notion of them being sufficiently marked or prolonged. This parallel is useful in as much as it reveals how imprecise these definitions are and how open they are to interpretation.

Who decides what is abnormal: the worker, parent or child? How is the notion of sufficiently marked or prolonged measured and against what standard? Mental illness takes us into the realm of medicine and clinical guidelines and diagnostic criteria usually applied to the most serious difficulties and those that are statistically rare. Whereas, at the other end of the scale, the terms emotional well-being or emotional literacy are becoming popular among the wider public and professionals even though it would be hard to find agreement about a definition of what these terms mean.

The behaviour and emotional affect of children and young people designated with symptoms of mental health difficulty can be considered in different ways within a variety of professional discourses. The dominant discourse is that of medicine and especially psychiatry, which continues to refine classifications of symptoms into universal descriptors (American Psychiatric Association 1994; WHO 1992). Yet behaviour and expressed emotions can be interpreted widely, depending on the theoretical base of the professional involved and the specific cultural and historical context of their manifestation.

Mental illness was constructed in the context of a debate among psychiatrists about the criteria for diagnosing specific mental health problems. Previously they had relied on a constellation of symptoms based on adult measures to distinguish children and adolescents whose condition was outside the normal experience. A recent study drew attention to the limitations in psychiatric diagnosis and, by implication, the medical model it embodies (Pickles et al. 2001). This study found that not all children with symptoms of mental disorder showed marked impairment and, conversely, some children had significant psychosocial impairment without reaching the clinical threshold for diagnosis.

If it is problematic to define mental illness or disorder, then it is equally difficult to define what is meant by mental health for children and young people. It can mean different things to families, children or professionals, and staff from different professional backgrounds might not share the same

perception of what mental health is. A multi-disciplinary group agreed (Health Advisory Service [HAS] 1995) that mental health in childhood and adolescence is indicated by:

•• a capacity to enter into and sustain mutually satisfying personal relationships

•• a continuing progression of psychological development

•• an ability to play and to learn so that attainments are appropriate for age and intellectual level

•• a developing moral sense of right and wrong

•• the degree of psychological distress and maladaptive behaviour being within normal limits for the child’s age and context.

Defined in this way, mental health is a rather ideal state, which depends upon the potential and experience of each individual, and is maintained or hindered by external circumstances and events. According to Hadfield (1975) the child who is mentally healthy ‘will obviously be both efficient and successful, for all his energies are employed to their full capacity. He will have a strong will and character, and be intelligent and moral’.

This dated, rather minimalist definition can be contrasted with a more fulsome contemporary definition of the HAS version offered by the Mental Health Foundation (1999) who suggest that children who are mentally healthy will have the ability to:

•• develop psychologically, emotionally, creatively, intellectually and physically

•• initiate, develop and sustain mutually satisfying personal relationships

•• use and enjoy solitude

•• become aware of others and empathise with them

•• play and learn

•• develop a sense of right and wrong

•• resolve (face) problems and setbacks and learn from them.

Mental health is also described as: ‘a relative state of mind in which a person…is able to cope with, and adjust to, the recurrent stress of everyday living’ (Anderson and Anderson 1995).

This definition of mental health introduces the idea of relativity and seems to advance the notion of coping with and adjusting to everyday living. Do Black children and young people have to cope with and adjust to the everyday stress of racism? Can mental health be achieved by tolerating unemployment, poor housing or social exclusion? Social workers practising in a psychosocial context will be attuned to the social dimension affecting children’s mental health. They need to consider how they define the terms mental disorder and mental health and whether their practice aims to help children and young people ‘adjust to the stress of everyday living’ or challenge those stresses within a personal helping relationship.

These definitions and the subtle distinctions between mental illness and mental health are important in the sense that they set the context for how social workers and others conceptualise difficulties experienced by children and young people. Examples later in this text will illustrate how education,

youth justice and social work staff can all offer quite different explanations for the same behaviour with significantly different outcomes to intervention. So it is very important to be as clear as you can be about what it is you are observing and what sources of knowledge are informing those perceptions. Acquiring a label of mental illness can not only be stigmatising in the short term but can have profound longer-term consequences for a young person in terms of relationships, employment, education and personal health or life insurance.http://www.youthangst.com

Posted 3rd January by steven walker

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SOCIAL EXCLUSION & MENTAL HEALTH

SOCIAL EXCLUSION

The effects of social inequality- mental health problems affect 3x as many lower class children compared to higher class, 1 in 10 children suffer from a poverty related mental health problem, UK IS fourth from bottom of poverty league table, govt aim to abolish child poverty by 2021 has now been abandoned......

Mental health problems affect three times as many children in social class V (manual and unskilled) compared with those in social class I (professional) according to the authoritative Social Trends report (ONS 2012). It is important therefore to consider the external context of child and adolescent mental health problems and acknowledge that the impact of service provision in some families is mediated by factors such as unemployment, poor housing and poverty. They all contribute to the level of resilience and capacity for resourcefulness of children and families (Eamon 1994, Dunn 1999, Micklewright & Stewart 2000). A report on social inequalities from the Office for National Statistics revealed that one in ten children in the United Kingdom suffers from a poverty related mental health problem (HMSO 2000). According to other research the UK is fourth from the bottom of a list of relative poverty among the nineteen richest nations (UNICEF 2010).

The previous government target failed to reduce child poverty by a quarter by 2004, to halve it by 2010 and unlikely to have helped to abolish it by 2021. The calculations for defining poverty, relative poverty and absolute poverty are complex and subject to much statistical interpretation and debate. The current measure for calculating relative child poverty (defined as children living in households with incomes below 50 per cent of the national median) does not reveal anything about the depth of poverty. In other words every household below the 50 per cent threshold would be counted regardless of whether they were just below or in complete destitution. Also it fails to measure how long children have lived in poverty. This is important given the cumulative psychological effects of persistent social exclusion.

Socially excluded children and their families

Black children- Govt inspections reveal inadequate assessment of the needs of black children and families: are your agencies following these recommendations?

Ensuring that services and staffing are monitored by ethnicity to ensure they are provided appropriately and equally

Involving ethnic minorities in planning and reviewing services

Training in anti-racist and anti-discriminatory practice

Investigating and monitoring complaints of racial discrimination or harassment

Explicit policies are in place for working with black families

Research by the NSPCC revealed (Barter 1999):

Racism and racial bullying are commonplace within the lives of ethnic minority children and young people

The most common expression of racism is through racist name-calling previously considered by adults as trivial but the impact is now known to be profound

Racial bullying frequently involves the use of violence

Violence against ethnic minority groups is persistent, patterned, and long-term in the way it affects individuals and the places where they live

Disabled children

Disabled children and those with learning difficulties are more likely to have mental health problems than other children. Disabled children and adolescents are twice as likely to have emotional and behavioural problems. There are a growing number of disabled children and young people living in the community who need high levels of support. Partly this is because more of these children are surviving infancy, and partly because there is no longer the assumption that disabled children should be cared for in hospitals or other institutions. Lone parents with disabled children, families from ethnic minorities, and families caring for the most severely disabled children have the highest levels of unmet need, and live in the poorest conditions. The mental health needs of disabled children are often masked by a narrow focus on their disability through a medical, rather than social model of disability. Behaviour causing concern can often be ascribed to the physical or intellectual disability rather than a separate psychological need.

Young Offenders

According to recent figures there were 11,500 young people aged 15 to 20 in jail in England and Wales in 2010, of those 90 per cent had a diagnosable mental health disorder, and many had substance abuse problems as well as personality disorders (Lyon et al 2010). 60 per cent had anxiety and depressive illness with 10 per cent suffering from a severe psychotic mental illness such as schizophrenia. 20 per cent of these young men and 40 per cent of young women will have attempted suicide prior to their imprisonment (Farrant 2001). Young offenders are among the most socially excluded groups in society and the evidence suggests that imprisonment simply makes matters worse not better. Within two years of release, 75 per cent will have been reconvicted and 47 per cent will be back in jail (Social Exclusion Unit 2002). If some of these young people become homeless or end up in insecure accommodation, they are between eight and 11 times more likely to develop mental health problems (Stephens 2002). Low take up of preventive mental health services among socially excluded families means that minor problems can develop into major problems. Over 90 per cent of recidivist delinquents had a conduct disorder as children

Looked After Children

Nearly 60,000 children were being looked after by local authorities for the year ending 2011. About 60 per cent of these children had been abused or neglected with a further 10 per cent coming from ‘dysfunctional families’ (DOH 2011). Abuse of this nature can lead to self-harming behaviour, severe behavioural problems and depression. Evidence confirms that the mental health needs of these children and young people are overlooked and that many have established mental health problems prior to coming into local authority care (Dimigen et al 1999). 38,400 of these children were in foster placements and 6,400 were in children’s homes, yet foster carers and residential staff are among the least qualified and supported people left to manage sometimes extreme behaviour. Specialist CAMHS services often decline to help because of the uncertain and possibly temporary nature of the child’s placement which contra-indicates successful intervention. The dilemma is that without input, placements often break down as carers cannot cope, invariably leading to more placements and further deterioration in the child’s mental health.

A recent research study emphasised the importance of a preventive approach with children in the public care system who are more likely to be excluded from school following emotional and behavioural difficulties (Fletcher-Campbell 2001). Teacher training that fails to adequately prepare newly-qualified staff to respond to the mental health needs of pupils is considered to be a factor in the increased use of school exclusions (OFSTED 1996). Social workers using a preventive approach could be helpful to teaching staff and organise collaborative work aimed at preventing difficult behaviour escalating. Unless the mental health needs of these children and young people are addressed as part of a strategy that effectively nurtures children’s inclusion in school the risk of deterioration is high. The risk factors for looked after children are probably the most extreme of any socially excluded group, they include (Richardson & Joughin 2000):

Developmental delay

School failure

Communication difficulty

Low self esteem

Parent/carer conflict

Family breakdown

Rejection

Abuse

Parental mental illness

Alcohol/drug abuse

Poverty

Homelessness

Loss

Refugee and asylum seeking children
The number of applications for asylum from unaccompanied under 18s almost trebled between 1997 and 2011 from 1,105 to 3,469. DOH figures indicate that there were 6,750 unaccompanied asylum- seeking children supported by local authorities in 2001. Further evidence shows that many of these young people were accommodated and receiving a worse service than other children in need (Audit Commission 2000). Very little research has been done to ascertain the mental health needs of this group of children. However there is some evidence of the symptoms of post traumatic stress syndrome being present before they then experience the racist xenophobic abuse of individuals and institutions incapable of demonstrating humanitarian concern for their plight. This combination can shatter the most psychologically robust personality. It has been estimated that serious mental health disorders may be present in 40-50 per cent of young refugees (Hodes 1998).

Posted 31st December 2012 by steven walker

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EATING DISORDERS

Eating Disorders

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.

Anorexia nervosa

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.


Bulimia nervosa

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.

Posted 31st December 2012 by steven walker

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Dec

31

DEPRESSION

Feeling DownDepression 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!

Posted 31st December 2012 by steven walker

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Dec

30

SELF HARM

SELF HARM

Why other people don't take self-harm seriously

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:

1. 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)?


2. Do you cause this harm to yourself as a way of dealing with
   unpleasant or overwhelming emotions, thoughts, or situations (including
   dissociation)?


3. 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.

Don't:

• 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.

Further resources:LifeSIGNS - Self-Injury Guidance & Network Support
www.lifesigns.org.uk


www.harmless.org.uk

www.mmha.org.au

www.selfinjury.org

American Self Harm Information Clearinghouse
521 Temple Pl
Seattle, WA 98122. Helpline: 206-604-8963.

www.youngminds.org.uk

www.headspace.org.au

Headspace National Office Australia, 47-51 Chetwynd Street, North Melbourne, Vic 3051.
Telephone: 03 9027 0100

www.samaritans.org.uk

www.nshn.co.uk

United Kingdom National Self-harm Network (NSHN)
PO Box 7264, Nottingham NG1 6WJ
helpline: 0800 622 6000

Posted 30th December 2012 by steven walker

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Dec

30

PSYCHOLOGICAL ISSUES

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.


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.

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 problemsEssential 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 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.

Posted 30th December 2012 by steven walker

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