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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

17. Way attachment develops
YoungMinds Presentation
Way attachment develops

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

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

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

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

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

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

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

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

26. Proliferation of synapses

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

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

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

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

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

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

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

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

36. 85% of young people, parents GPs and teachers stated that this was their biggest concern. They also stated this was the subject that they felt least able to help with.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

58. youngminds Parents Helpline: 0808 802 5544 Tel: 020 7089 5050
Website: and
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