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All posts for the month March, 2016

In clinical psychology or mental health realms, when a young person deliberately causes harm to him or herself as a way of managing or communicating distress to others, we refer to this as self harm.  Self harm in times of distress most commonly includes cutting, burning, re-opening old wounds or head banging and the results can be superficial or very extreme and requiring hospitalisation. Self harm can also co-occur with other distressing conditions such as depression, anxiety, substance use and eating disorders. Whilst not all young people who self harm are suicidal, there is definitely an overlap and when someone is self harming, especially when they are causing extreme damage to themselves, there is an increased chance of accidental death.  So, it is incredibly important that any sort of self harm by a young person is given the appropriate response.

Whilst any self harm is concerning, the latest figures on mental health and young people in Australia tell us that rates of self harm are dramatically increasing.

If we look at people who have injured themselves and needed hospitalisation, the figures show that between 1996−97 and 2005−06, the hospitalisation rate for intentional self-harm among young people increased by 43{ba4639bc087185d97391fd5d15a50de89571c56f25425ee41c30a195518528de}, from 138 per 100,000 young people to 197. In 2010-2011, that number had increased to well over 600 per 100,000 young people.

Recently, the results of ‘Second Australian Child and Adolescent survey of Mental Health and Well-Being’ that surveyed over 6300 families and youths aged 4-17 were released.

As many as one in 10 teenagers – or about 186,000 – had engaged in some form of self-harm in their life, including a staggering quarter of teenage girls aged 16-17

….and those are the figures that those surveyed were willing to speak up about – Self harm is a very private behaviour that people may be reluctant to report.

Self harm can cause significant, long lasting body issues and it can also be really hard on friends, family and those who are aware of the self harm, but may feel powerless to stop a young person from hurting themself in that way.

When we look to the research to help us understand the problem of self harm the research includes mostly small studies. It also tells us that young people who self harm are a really diverse group and difficult to clump together. This heterogeneity means that what works for one young person who self harms may not work for another.  That means, we really need to carefully assess and understand each person who is self harming and find out what purpose it serves for them and then, how best to help them.

Self harm can serve many purposes for a young person.

It can be the way they:

  • regulate strong unpleasant feeling
  • control feelings of numbness or bring themselves back when they feel disengaged from their lives (dissociation)
  • test to see if they could suicide or kill themselves
  • try to feel in control over something
  • deal with internal conflict
  • re-directed aggression – if they are not comfortable being angry with others, sometimes they can turn that onto themselves
  • communicate and try to control of others
  • express and try to get rid of shame or guilt
  • seek out strong sensations or risk
  • deal with an underlying mental health or physical health condition

From my experience, I would say that it’s most likely that self harm in young people is the way they deal with negative or distressing feelings, especially when they themselves feel like nobody cares about them.

When you think about it, just about anyone is capable of self harm.  So – what stops us?

Most of us would have lots of barriers in place or lots of reason why we would not want to harm themselves – it hurts, it’s messy, it can scar, it would upset others or we might be concerned about what other people might think.

For a young person to harm and hurt themselves, one of the first things they need to do is push those internal barriers away.

The normal barriers that prevent us from hurting ourselves, can be overcome by a range of things and some in combination:

  • Alcohol and drugs can lower lots of barriers for lots of people. If a young person is drunk or under the influence of a substance that alters their thinking, they can push past the rational and logical reasons that would normally stop them form doing something.
  • Religion or cult involvement may sometimes encourage a young person to push themselves past lots of different barriers in order to reach some higher level of status or to be closer to a deity.
  • Impulsivity can mean that people can act without thinking. They can rush in and do things that they later regret because their ability to control and urge or an impulse is compromised
  • Grief can mean overwhelming emotions or a blunting of emotions. If they are overwhelming enough or sufficiently numbing, a young person may be able to push past the reasons not to self harm in an attempt to (in the case or overwhelming emotion) seek relief or (in the case of numbing) “feel” things again.
  • Social influences are especially strong for young people. If they want to fit into a group that are also hurting themselves, they may push past the rational reasons to seek a sense of belonging.  Sadly, there are numerous social media sites that encourage self harm or depict self harm as fashionable or darkly mysterious.
  • Practice can push away barriers to self harm. If a young person has previously experienced lots of piercing, tattoos or other experiences that involve discomfort in order for a specific outcome, it can be easier for them to push past the pain involved in self harm.
  • Being able to switch off from feelings can make it easier to decide to harm yourself. Switching off from feelings or dissociation can be something that young people learn to do if they have been in abusive or traumatic circumstances before.  It’s not always a conscious choice to switch off, but if they have dissociated before, then they can switch off again at other times.  That means they can switch off the reasons for not harming themselves.

When we are trying to help and support a young person who is self harming, we need to understand the purpose self harm has for them and how they push themselves past the internal barriers that would normally prevent them from self harm.

Self harm is often very private and very hard for young people to talk about.  Help is best left to qualified professionals, but – if you are a first responder – need to look at the safety needs first and avoid a million probing questions….those are best left til later, calmer and more professional circumstances.  I love this advice from Cornell about “respectful curiosity” and I’d encourage you to read it.

Professional treatment will consider the underlying concerns and the functions and put in place a safety plan for the young person.  Good treatment should assess dangerousness, suicidality and then go about trying to assist the person to be safer, to deal with problems that can be dealt with (problem solve), learn to communicate with others, learn to understand and sit with big emotions, and find other ways of dealing with distress.

Clearly, self harm in young people is not something to muck about with or to ignore.

For 24 hour support or crisis help:

  • Lifeline 13 11 14
  • Beyond Blue 1300 224636
  • Your local emergency services and hospital

For treatment, contact your GP or a registered Psychologist

For resources on how to help a friend… try this from Cornell.  If self harm is an issue at your school, or amongst the young people you care for, I’d love to come and talk with you some more to help you to help.

It’s very, very hard to learn new things when your brain won’t let you focus and won’t let your body be still.  ADHD is a syndrome that is brain-based and highly genetic.  It’s also a syndrome that gets bandied around lots – so much so that I think many teachers, and perhaps judges and legal representatives, roll their eyes when they hear about it.

Being able to attend well is yet another feature of our remarkable brains.  Paying attention is something we take for granted when it works well.  Without having a brain that can attend well, it gets harder to get started on a job, it can be difficult to keep focused, it can be hard to sustain effort, and very tricky to hold things in your memory long enough to work on them.  Attention can also have implications for our ability to manage our emotions and frustrations and to regulate or give ourselves feedback.   All of these brain functions depend on parts of the brain being structured and connected properly, both in physical structure plus in the ways that the brain’s chemicals move between and around these parts of the brain.

Properly diagnosis ADHD means that these executive brain functions are not working properly and that a child will need extra help to get things done. Attention Deficit Hyperactivity Disorder (ADHD) has three types an inattentive type, a hyperactive type and a combined inattentive-hyperactive type.

It is so very important that a very thorough assessment is done of a child with attention problems before we call it ADHD.

A child’s ability to attend can be affected by lots of things including brain injury and emotional trauma.  If you have been through a frightening situation, your brain will want to keep scanning the world for the next scary thing rather than learn how to do algebra.  When it comes to a child’s attention, we also need to check that the problems are not being caused by vision or hearing issues, autism spectrum concerns or by some other emotional issue or learning disorder (it can be hard to pay attention to reading if you are struggling with reading).  Simple things like sleep, getting the right amount of natural light, avoiding drugs and alcohol and having breakfast  can all aid attention and focus.  A gifted child might also have troubles maintaining attention if the work is so easy that they just feel like drifting off to think about something more challenging and exciting.  Diagnosing ADHD can also be made tricky because it can co-occur with many of these other issues.

On more than one occasion over my years of working with children, I have heard others say that the label of ADHD has been misapplied to a child.  Sadly, this can give those who genuinely have attention problems a bad reputation.

People will also often suggest that because a child can focus on a video game, that they do not have problems with attention.  It’s not that simple.

I’ve also heard people question whether properly diagnosed ADHD is really a problem or whether the child is just lazy or manipulative.  Is it that they can’t do it or that they won’t do it?  Sometime it’s a bit of both.  If it’s hard to do something, then we generally don’t like doing it.  It feels awful.  If we can help the child learn with the scaffolding they need, then learning becomes more pleasant and they will be less inclined to avoid it.

There are some things that make it harder for a child with attention problems.  If they really do not like a particular teacher or a particular subject, then things can get worse.  Children with attention problems seem to do better where teachers are perhaps a little firmer and confident.  They definitely do better when teachers understands their condition and work with them around the best ways to get things done.  It can help if they sit away from distractions and close to the teacher.

Children with attention problems really need help in being organised.  I remember watching one little fellow in a classroom.  He was sitting with his back to the board and the students were copying something the teacher had written onto a worksheet.  He sat down to start, but couldn’t find his pencil.  He decided to go and ask a friend if he could borrow one.  I watched him leave his seat and take a good five minutes to make it to his friends (so many distractions along the way), get the pencil, and then the long journey back to his spot, via his spilled lunchbox on the floor.  Of course, once he sat down, he had to keep twisting to read the board, remember what he had read, then turn back and write it down.  He was already behind his classmates in getting the work done and he was not going to finish it in the time allowed.  With a little more scaffolding (someone there ensuring he had what he needed, that he was sitting facing his work and the board, and that he had gotten started) could have made a big impact to how that lesson went for him.

BE VERY WARY – there are plenty of fad treatments and programs with little evidence to support them out there waiting for desperate parents and grandparents to part with hard earned coin to assist their struggling child.

The evidence-based treatment for thoroughly diagnosed ADHD involves a combination of medication to manage the brain’s functioning and therapy to address thoughts, organisation and coping strategies.  Medication should be carefully prescribed and monitored.  Through psychological therapy, a child can be assisted to build new skills and coping strategies and there are often associated emotional and interpersonal aspects of ADHD.

ADHD can co-exist with depression, anger and problems getting along with others so each of these problems should be monitored.  Of course, then, it makes sense that the medical practitioners and the psychologists should work closely together with each other, family and school.

So what do we need to do to help kids with attention problems?

  • We need to identify these children early so we can give them the appropriate scaffolding before they incorrectly learn that learning is too hard or too boring. We need to help scaffold them before life gets too messy and complex and they decide it’s all too hard and give up on learning.
  • Once identified, we need to give them proper assessments.
  • If the assessment is quick and a label given after just one appointment, then I would query the diagnosis.
  • Assessment should involve talking with the child, talking with the parents, testing the child using certain psychological tests, and where possible, watching the child in a learning situation.
  • Once identified, then medication may be appropriate.  Again, if you are going to medicate a young child, you want the diagnosis to be spot on and you want to be closely monitoring.  If the medicine is not working, then something is wrong with either the diagnosis or the treatment, or both.

We need to know the profile of the child’s brain functioning so that we can use the strengths and scaffold the weaknesses to help them chose subjects and set learning goals.

The profile of their executive abilities can also tell us what kind of help they need on a day to day basis in the classroom – extra help in organisation, monitoring to keep them engaged, proximity to the teacher, extra breaks to manage fatigue, give them extra reminders and warnings that topics are about to change, fidget toys – all strategies crafted to match the individual and their specific profile.

Overall, you can see that ADHD and attention problems should not be discounted merely because a child can attend to their favourite computer game.  Attention is needed across all of life’s activities.

The ideal solution to attention problems will likely involve medical intervention, special education accommodations and psychological intervention for support with understanding ADHD, problem solving, behavioural skills and mood monitoring.

Some kids are slow to warm up in company.  Some are content without too much interaction with others.   Other kids live in fear of having to speak or interact with others. It’s important that we understand the differences and preferences of children before we go rushing in to make them “come out of themselves” and be the “life of the party”.

From very early in a child’s life, we can get a sense of that child being a “people person” or not.  Some bubs love the smiles, noises and interactions from other happy faces.  Others are less sociable, perhaps even turning away from others and burying their face in Mum or Dad’s shoulder.  Some infants will need lots of social stimulation and love time spent with others.  Still others will be somewhere in between and once they have warmed up and feel secure they will turn out of their parent’s armpit and smile at others.

These ways that children interact from very early in their lives are referred to as temperaments.  Temperament is our own little style or our early preferences for interacting with the world.  Early in our lives we haven’t yet amassed enough aspects of ourselves to call it a personality, but we have our style of early behaviours and it affects us and the sorts of reactions we get from others.

If we are a sociable bub and our parent is more of a loner, we may be under stimulated or if our parent is really sociable and loves to entertain and spend time with other people and bub is not that way inclined, there can be distress.

We need to take into account a child’s temperament when we are planning how best to help them accommodate and feel comfortable in the big wide world. Those bubs with a less sociable temperament are often best paired up with other infants who are also a little slow to warm to others and they will need to be sure that they have their safe base with Mum, Dad or their carer being very close. Temperament can have a big impact on the sorts of adults infants will become.

A really big study of temperament was done here in Australia over a beautifully long period of time from around 1982 to 2000 called “The Australian Temperament Project”.  The project’s researchers looked at infants from their birth through to the ages of 17 or 18 to discover which parts of their temperament were sustained over the years and which styles and preferences faded or changes.

When it came to shyness, there were some factors that could lock in a shy temperament for a long period of a child’s life and some where a shy temperament disappeared over time.

Children who had been shy from very early in their lives but “grew out of” their shyness tended to have parents who did not make them feel guilty or anxious, were warm and nurturing, and, importantly, who did not push them to be independent too soon.

Others who were found to have not started off shy, but developed shyness over time, were those children who had been exposed to more physical discipline and were controlled with much guilt and anxiety.  Clearly, parenting style had some effect on the outcomes when it came to life long tendencies to be shy.

Some shy people are often referred to as introverts, but this is not always the case.  Introversion or Extraversion are aspects of personality and refer to our preferred way for taking information in from the world and the different things that give us energy or motivate us.

Introverts prefer going about the world with a focus on their ideas, memories and images rather than becoming excited or energised by being with, and interacting with, people in the world.

While shyness and introversion can both be associated with avoiding other people, with an introvert, it’s more a preference to go about the world concentrating on things and activities that do not always require contact with others.  It is very different from having a fear of socialising.

A child’s discomfort or distress with socialising has to do with how much they want or don’t want to be around others and how hard it is for them to actually be around others.

Introverts may not take up lots of social opportunities, but they can also tend not to actively avoid socialising.  Introverts are energised more by things and activities than they are by other people in a situation. They may prefer books or art or music, or even acting, to the actual social aspects of human company.

It also may be that some young people (and older ones, too) are shy or a little anxious in specific social situations and not with all social situations.

Some people may get extremely anxious in job interviews or in sporting situations.  Some avoid public speaking.  If a child’s happy lifestyle or personal goals do not require these things from them and they are happy, then these anxieties are not a big and chronic issue.  They may want to get some help and support about specific problems, like the job interview, as the need arises.

On the other hand, there is social anxiety, or social phobia, that is an excessive fear of speaking to or being with others.  Social anxiety or social phobia is typically something I start to see more in my practice as children become teenagers.  It seems the social burst that comes with puberty and the all-important focus shift to peers, seems to open any gap in shyness wider.  A teen brain brings with it the added harshness of being able to judge ourselves socially and, as if it is not already too hard for some kids to feel comfortable in social situations, this extra change in their biology and the biology of their friends, can mess further with their confidence.  It’s often the case that people who are very socially anxious may rely heavily on alcohol to relax them in social situations and this can be very risky.

The important thing about helping someone who is socially anxious is in understanding their perceptions of themselves.

Social anxiety often has a person caught up in their own thoughts about other people’s thoughts – the classic “I think that they think, that I should and they think…”.

Essentially, there is often a lot of automatic self talk that assumes that other people are judging them harshly and that they themselves are not going to meet a standard. The fear of making a social accident or slip-up becomes extreme.

Because someone with social anxiety finds it so hard to deal with their perception of others’ perceptions of them (it’s hard to write – image living with it!), they can start to avoid people.  It’s easier to try to get out of a social situation than it is to run the risk of doing something embarrassing.  People with social anxiety are often the ones checking the exits and thinking a lot about how they might be able to get away.

Those with social anxiety might fear the very signs that their body is anxious.  Many are concerned about blushing and what other people think about their blushing.  So much so, that their bodies normal anxiety reaction makes them blush. It can be a vicious anxious circle.

When treating social anxiety, it’s important that we get to the core idea that the person is concerned about – is it blushing, is it that they think they are boring, is it that they fear rejection???

Psychological treatment will help a young person with social anxiety to control the biology of their anxiety and then the flow of their automatic thinking.  Then we practice gently exposing them to some of the situations they may fear at a pace that is carefully planned.  If social anxiety gets so debilitating that it stops a person from functioning or contributes to them being depressed, then they should really seek professional help.

All up, if you have concerns about whether someone needs help with feeling comfy with others, first just check whether this is their preference or their fear.

If it’s their preference and you would like to spend more time with them, then plan something quiet and low key without too many other people.  If it’s a fear or if there has been a change in someone who was once bubbly and outgoing, but is now shy and avoidant, it’s best to get them to talk to someone professional.