A Guide to the Mental Health of Children and Young People 9781911623915, 9781911623908, 1911623915

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A Guide to the Mental Health of Children and Young People

A Guide to the Mental Health of Children and Young People Q&A for Parents, Caregivers and Teachers

Dr Meinou Simmons Oxfordshire CAMHS Outreach Team

University Printing House, Cambridge CB2 8BS, United Kingdom One Liberty Plaza, 20th Floor, New York, NY 10006, USA 477 Williamstown Road, Port Melbourne, VIC 3207, Australia 314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre, New Delhi – 110025, India 103 Penang Road, #05–06/07, Visioncrest Commercial, Singapore 238467 Cambridge University Press is part of the University of Cambridge. It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning, and research at the highest international levels of excellence. www.cambridge.org Information on this title: www.cambridge.org/9781911623915 DOI: 10.1017/9781911623908 © Meinou Simmons 2023 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2023 A catalogue record for this publication is available from the British Library. ISBN 978-1-911-62391-5 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

Contents Acknowledgements Preface

vii ix

Part 1. What Affects Children’s and Young People’s Mental Health?

1

Introduction to Part 1 and Key Definitions

3

1. Biological Processes Affecting Mental Health

9

2. Lifestyle Factors Affecting Mental Health

26

3. The Impact of Relationships on Mental Health

71

4. Stressors Affecting Mental Health

89

5. Vulnerability of Special Groups

129

6. Promoting Mental Health and Resilience and Preventing Ill Health: A Summary

153

Part 2. Strengthening Relationships with Children and Young People and Giving Support

159

7. Looking after Yourself

161

8. Connecting with Children and Young People

166

9. Supporting Partners and Co-Parents

173

10. Creating a Network of Support

178

11. Positive Parenting Strategies

184

12. Helping Children and Young People to Manage School

194

13. Building Resilience and Strength

201

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Part 3. What Are the Common Mental Health Difficulties in Children and Young People and How Are They Managed? What Can You Do to Help? 205 Introduction to Part 3

207

14. Difficulties with Mood: Depression; Mood Swings and Emotional Dysregulation; Bipolar Disorder

217

15. Difficulties with Worries and Anxiety

246

16. Difficulties with Self-Harm and Suicidal Thoughts

260

17. Difficulties with Trauma and Post-Traumatic Stress Disorder

274

18. Difficulties with Anger and Behaviour

284

19. Difficulties with Attachment

298

20. Difficulties with Autism and Neurodevelopmental Difficulties including Tics

306

21. Difficulties with Attention and Activity Levels

323

22. Alcohol- and Drug-Related Difficulties and Disorders

338

23. Difficulties with Eating

353

2 4. Difficulties with Body Image and Body Dysmorphic Disorder 374 25. Difficulties with Perfectionism, Obsessions and OCD

382

26. Difficulties with Losing Touch with Reality (Psychosis)

391

27. First Aid for Mental Health

400

28. Mental Health Teams: Who Works in Them and What Are the Types of Specialist Teams?

406

Concluding Remarks Index

411 413

Acknowledgements This book started out as a maternity leave project when I was expecting my third child, but then kept me busy for a good while afterwards! First, I would like to thank my husband, Sam, and my three children for their love, support and patience. My husband also gave me many useful suggestions in the final draft of the book. I am also indebted to family members, colleagues and friends who gave their time to read the manuscript and provide me with useful comments and suggestions to improve the book. I am very grateful to my former colleague, consultant child and adolescent psychiatrist Dr Anne Stewart, who gave me very helpful developmental points, which have considerably improved the book. My sisters, Lidewei and Kiersten, and my uncles, David and Gerry, gave me their perspectives on drafts of the manuscript, which prompted improvements. Dr Nick Hindley and Dr Marta Costa, who are colleagues in my consultant peer personal development group in Oxford, also gave me some useful suggestions. Finally, I would like to thank the anonymous peer reviewers who also gave useful improvements, as well as the editorial team at Cambridge University Press, who have supported the project since its inception. I would also like to say a special thanks to Julene Knox for her excellent copyediting. 

Preface Why Was This Book Written? As a practising child and adolescent psychiatrist with a special interest in mental health education, I have noticed a growing general awareness of mental health issues in children and young people. This awareness is important as it is alerting ever more people to the monumental scale of mental health difficulties in the next generation. However, developing awareness of youth mental health is only the first step in giving helpful support to children and young people. Unfortunately, I have heard from many parents, caregivers and teachers that they don’t feel they have the skills, knowledge or training to look after children’s and young people’s mental health. This contrasts sharply with their confidence in sorting out physical health problems. Yet we know that developing brains and minds need looking after and nurturing in the same way that developing bodies do. This book tries to help bridge the gap of confidence and understanding many of you face when dealing with youth mental health issues. Although I know there are now many web-based resources bursting with mental health advice, I am aware that it can sometimes be a minefield to find reliable and useful information online. So, this book is meant as a starting point of information and advice. I give links to other reliable information resources including books and websites for those who want to dig deeper. I hope the book will be useful for both those of you dealing with current difficulties as well as those of you who want to develop a more general understanding of the topic.

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Preface

My aim is to help you to develop an understanding of factors which have an impact on children’s and young people’s mental health and give you some strategies for offering and accessing support when difficulties arise. I hope it’s useful.

How Is This Book Structured? This book has three sections: ➣ Part 1 discusses some important factors that affect children’s and young people’s mental health and wellbeing, including exercise, diet, social relationships and technology. ➣ Part 2 focuses on how to strengthen your relationships with children and young people and give them useful support. ➣ Part 3 explains some common mental health difficulties and disorders in young people, how we diagnose and manage them, and how to support children and young people with these issues.

How Can This Book Be Read? While some people may prefer to read this book cover to cover, you do not need to do so. If you prefer, you can read or consult each sub-section separately.

Part 1 What Affects Children’s and Young People’s Mental Health? In Part 1 of this book, I’ll look at various issues that can affect children’s and young people’s mental health. In the introductory chapter I first look at some key definitions including mental health, wellbeing and disorder. Then each of the main chapters in Part 1 looks at important factors affecting mental health. In Chapter 1 I look at a range of biological processes which affect children’s and young people’s mental health including attachment; genes and inheritance; the developing brain; and puberty. In Chapter 2 I go on to explore lifestyle factors which have a significant impact on children’s and young people’s mental health, including sleep; nutrition; exercise and movement; technology; bullying and academic pressures; and alcohol and drugs. In Chapter 3 I discuss the impact of relationships on mental health and look in more detail at family relationships; social and peer relationships; and romantic relationships and sex.

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In Chapter 4 I look at a range of issues that increase stress for children and young people, known as stressors. These stressors include abuse and neglect; adverse childhood experiences (ACEs); trauma; bereavement and parental separation; and, finally, the impact of COVID and other global public health issues on mental health. In Chapter 5 I look specifically at vulnerability of special groups who are known to have an increased risk of mental health issues. Although I don’t cover all possible vulnerable groups, I examine a few important examples including intellectual disabilities; young people with gender identity difficulties and different sexual orientations; young people with additional physical health needs and illnesses; young carers; and, finally, other vulnerable groups. Chapter 6 provides a summary of the previous chapters in Part 1 to draw together threads of important factors which have an impact on children’s and young people’s mental health.

Introduction to Part 1 and Key Definitions In this section I introduce common terms including mental health, mental wellbeing and mental disorder. I look at how common youth mental disorders are and explain how we assess them. Finally, I consider how to support children and young people with mental disorders.

What Is Mental Health? What about Mental Wellbeing, Mental Fitness and Mental Flourishing? ➢ Mental wellbeing, also often known as mental fitness, describes your mental state, i.e., how you are feeling and how well you can cope with day-to-day life, which can change quickly. Mental and physical fitness are of equal importance. ➢ Mental flourishing is the state of experiencing positive emotions, psychological and social functioning, most of the time, and enables you to engage with a meaningful life (1). Its opposite state is languishing, where people may describe their lives as ‘hollow’ or ‘empty’. ➢ Mental health, according to the World Health Organization (WHO), is ‘a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ (2). Mental health is a longer-term state than mental wellbeing or fitness and tends to change more gradually.

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How Are Mental Health and Wellbeing Linked? Mental health and wellbeing are linked and are overlapping concepts, but they are not the same. ➢ If you experience difficulties with mental wellbeing for some time, you are more likely to develop mental health problems. For example, children who live in very deprived communities with little support are much more vulnerable to mental health problems than those from welloff communities and with good support from parents and caregivers. ➢ If you already have a mental health problem, like bipolar disorder, you are more likely to have periods of low mental wellbeing. However, it’s also worth noting that people with mental health problems can also have times when they experience positive wellbeing. In our example, the person with bipolar disorder can have periods when their wellbeing is very good, for example in between episodes of illness. That’s why aiming to improve mental wellbeing is important whatever your mental health status.

Which Factors Can Affect Mental Wellbeing and Mental Health? Several factors can affect mental wellbeing and mental health: ➢ Positive mental wellbeing is influenced by lifestyle factors like sleep, diet and exercise, positive relationships as well as school and home experiences. Children who develop in lower-stress environments will generally be more able to experience positive mental wellbeing. ➢ A mixture of inherited and environmental factors can interact to cause mental health problems. For example, when a parent has alcohol problems, the child has an increased risk of mental health problems. However, the child’s risk of developing mental health problems is also influenced by other factors, such as their genetic makeup and their

Introduction to Part 1 and Key Definitions

available support. This illustrates the complex interplay of both genes and environment which make up an individual’s risk of mental health difficulties. ➢ Many factors are common to both mental wellbeing and mental health. For example, severe early attachment difficulties, stress and trauma, and poverty and inherited factors can affect both mental health and mental wellbeing. A 2016 UK study by Patalay and Fitzsimons looked at predictors of mental illness and wellbeing in 11-year-olds (3). It showed that mental wellbeing was predicted by aspects of a child’s social life and relationships, such as bullying, and perception of feeling connected to others at school. On the other hand, other factors such as underlying health problems are more likely to predispose to mental health disorders. Mental health disorders are also strongly affected by other important factors, such as inheritance.

What Is a Mental Health Disorder? What about a Mental Condition? There is often confusion around whether to use the term ‘mental disorder’ or ‘condition’. A good rule of thumb is as follows: ➢ A mental health disorder is a behavioural or mental pattern of symptoms that causes significant change which can impair functioning. There is a noticeable step change in functioning from a period of being well to being mentally ill. For example, you can have an episode of depression where you become unwell and struggle to function, after which you recover. ➢ A mental health condition is a term used for in-born difficulties such as autism and ADHD where the brain is wired up differently. There isn’t a significant step change in functioning from being well to being unwell. Instead, the brain is on a different developmental pathway to what is typical, and a condition will evolve over time. There isn’t a specific cure for mental conditions such as autism.

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What Proportion of Young People Have a Mental Health Disorder? ➢ 1 in 6 children and young people (aged 5–19 years) in the UK in 2021 had at least one mental health disorder (4). ➢ 50% of mental disorders develop by age 14. This shows why investing in young people’s mental health is so important and has long-term implications.

How Do Mental Health Professionals Assess Someone’s Mental Health? ➢ Mental health professionals are trained to assess a person’s mental state. This includes assessing how someone looks, speaks, understands and behaves. We ask questions about mood, thoughts and the person’s ability to understand experiences. ➢ Observation of play and behaviour is often more helpful in younger children than asking direct questions. ➢ Taking a history of a child’s or young person’s difficulties is a core part of a mental health assessment. There is a systematic format for the process of gathering information which involves getting key information from the young person or child themselves, if possible. ➢ Gathering information from significant adults around the child is a crucial part of the assessment. ➢ We also look at a child’s or young person’s ability to function or do the activities needed to manage at school, family life or friendships.

How Can You Best Support Children’s Mental Wellbeing? ➢ You can help children and young people develop positive mental wellbeing and learn coping skills for managing stress.

Introduction to Part 1 and Key Definitions

➢ Firstly, ensure children’s basic needs are met, including offering supportive care and providing them with enough food, shelter, rest, security and warmth. Maslow, a psychologist writing in 1943, famously set out a pyramid of basic needs. Food, water, rest, warmth and safety are at the bottom of the pyramid and being able to think creatively is at the top (5). ➢ Attend to the child’s inner psychological needs. What makes each child tick? Understanding this is an evolving process and the best approach is to listen to the child and try to make sense of their thinking. ➢ Read and understand helpful materials. By reading this book you are one step ahead. You can also consult useful online resources, for example the Royal College of Psychiatrists’ website www.rcpsych.ac.uk to support positive mental health and wellbeing.

KEY POINTS

•

We should help our children and young people to aim for a state where their mental wellbeing is flourishing. We can also help equip young people to positively manage mental health difficulties and disorders.

•

Mental health and wellbeing are different but overlapping concepts. Mental wellbeing describes your mental state and can change quickly. Mental health describes a longer-term measure of mental functioning. Even if you are mentally unwell you can still improve your wellbeing, for example by looking after your sleep and diet and by developing positive relationships.

•

It is common for young people to struggle with their mental health. Half of mental disorders start in adolescence.

•

To look after children’s mental health, it is important that we meet both their basic psychological as well as their physical needs.

References (1) Mental Health Foundation of New Zealand. 2010. Flourishing, Positive Mental Health and Wellbeing: How Can They Be Increased? Available at https://archive.mentalhealth.org.nz/assets/Flourishing/

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A Guide to the Mental Health of Children and Young People Flourishing-and-Positive-Mental-Health-Dec-2010.pdf#:~:text=Flourishing %20is%20useful%20descriptor%20of%20positive%20mental%20health,and %20positive%20social%20functioning%2C%20most%20of%20the%20time (2) World Health Organization. Regional Office for Europe. 2019. Mental Health: Fact Sheet. Available at https://www.euro.who.int/__data/assets/ pdf_file/0004/404851/MNH_FactSheet_ENG.pdfUnlinked (3) Patalay, P., and Fitzsimons, E. 2016. Correlates of Mental Illness and Wellbeing in Children: Are They the Same? Results from the UK Millennium Cohort Study (PDF). Journal of the American Academy of Child and Adolescent Psychiatry 55(9), 771–783. (4) NHS Digital. September 2021. Mental Health of Children and Young People in England. 2021 – Wave 2 Follow Up to the 2017 Survey. Available at https:// digital.nhs.uk/data-and-information/publications/statistical/mentalhealth-of-children-and-young-people-in-england/2021-follow-up-to-the2017-survey (5) Maslow, A. 1943. A Theory of Human Motivation. Psychological Review 50, 370–396.

1 Biological Processes Affecting Mental Health In this chapter we discuss a range of biological processes and factors which affect youth mental health including attachment, genes and inheritance, the developing brain and puberty. We think about how gaining a better understanding of children’s biology can allow you to better support your children’s mental health.

Attachment Building strong bonds between children and their caregivers is likely to be the most important factor in protecting children’s mental health and wellbeing. Nurturing children through their early years is a crucial but often under-appreciated task. Research shows that attachment difficulties underlie many mental health problems. Attachment is the emotional bond between baby and parent or caregiver. All baby animals (including our children!) have evolved to attach to their main caregivers to protect themselves from threats. The psychoanalyst

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John Bowlby developed the theory of attachment to help explain why infants become so distressed when separated from their parents. This section on attachment gives a brief overview on the topic. (Please note, I discuss specific difficulties with attachment in Part 3 of this book.)

Why Is Attachment Important? ➢ A baby needs a strong and supportive relationship with at least one main caregiver for their healthy development. The caregiver is usually the biological parent but can be another adult who takes on the parental role. ➢ A caregiver meeting a baby’s needs is not just about providing the baby with food: it is also about providing emotional comfort. Important experiments with monkeys in the 1950s led by Harry Harlow, an American psychologist who pioneered work on separation anxiety, which separated baby monkeys from their mothers paved the way for humans developing a better understanding of the importance of early attachment relationships. These experiments showed it is the sensitive response and security of the caregiver that are more important for the baby’s development than the caregiver just providing food. If the caregiver is sensitive to the baby’s needs, and is consistently there for them, the baby will use the caregiver as a secure base from which to explore in a healthy way, and then follow a path of healthy emotional development. ➢ As the baby develops, they learn they will be supported and contained when they express their emotions, rather than abandoned. No caregiver is perfect and fully sensitive all the time; but the important thing is to be sensitive and consistent with caregiving most of the time. Hence, a key part of this relationship is helping children to learn to regulate their emotions. ➢ A secure attachment relationship helps our children to develop emotionally and socially, including in their future relationships. It gives the child an internal working model of relationships, which helps them to develop future healthy relationships.

Biological Processes Affecting Mental Health

Is There a Biological Change in Our Bodies Which Helps Us with Attaching to Our Children? ➢ There are chemical changes within our bodies in response to having children. ➢ Oxytocin is an important bonding hormone produced in the base of brains of new parents. Mothers produce oxytocin in labour, breastfeeding and positive touch. Oxytocin helps with birth, bonding, attachment, trust and social interaction. ➢ The more oxytocin produced in mothers, the more attachment behaviour a mother shows, and the more oxytocin in turn produced by the infant. ➢ Fathers and adoptive mothers who show attachment behaviour towards their babies also produce oxytocin.

Are There Different Attachment Styles or Behaviours? What Are They? ➢ Mary Ainsworth was a skilled researcher and colleague of John Bowlby who looked at attachment behaviours in young children (1). She set up experiments where she separated babies from mothers for a short time. She then came up with different categories of attachment behaviours based on how babies responded to their parent leaving the room and then reuniting with them. She described the following main attachment styles: – Securely attached babies got upset when their parent left the room but could still easily be comforted upon their parent’s return. Ainsworth found that about 70% of babies showed a secure attachment style. – There were the following sub-types of insecurely attached babies: 1. Anxious (or ambivalent) babies became extremely distressed when their parent left the room and could not easily be comforted when they returned. 2. Avoidant babies didn’t seem distressed when their parent left them, and actively avoided contact once the parent returned.

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3. Disorganised babies displayed a variety of odd, unusual, contradictory or conflicted behaviour when the parent left them and returned. This style was described after the other two styles above and is more common where the parent has been abusive or neglectful in some way to the child. ➢ The attachment style of the babies is closely related to relationship patterns in the home. The securely attached children had parents who were responsive to their needs. The insecurely attached children had parents who didn’t respond to their needs or were inconsistent in their care.

What Happens If Attachment Is Not Secure? ➢ The caregiver’s sensitivity to the child has a significant impact on the attachment relationship. However, there are also several other factors which affect this relationship, including factors within the child, the parent and the environment. ➢ If attachment early in life is not secure, children are at increased risk of problem behaviours and mental health conditions. This is an important reason why children adopted into the most loving and stable homes are still at higher risk of mental health problems and often need more specialist support to help them cope in the future than those who had experienced secure attachments. ➢ Attachment disorders can happen when there have been significant problems with the attachment relationship developing (see Chapter 19 in Part 3). ➢ If a child develops a strong internal working model of relationships, they have a better chance of developing strong relationships in adult life.

How Do Attachment Behaviours Change with Age? Attachment develops with age, brain development and social experiences:

Biological Processes Affecting Mental Health

➢ Young children gradually learn that their caregiver will return after separation. It is normal for securely attached babies and toddlers to be clingy to their caregiver and show distress on separation: hence settling into nursery can be tough. ➢ As children reach early primary school age, most of them trust that their caregiver will be there for them, but the goal is still to keep carers close. If there is a change at home – for example a new baby is born – the attachment system is disrupted, and the child may need extra support to get back on track. ➢ By late primary school age, children become more independent from caregivers and can self-regulate their emotions better, so the important thing is for caregivers to be available when needed. A child will manage longer separations if they are secure in knowing parents will be there for them when needed. ➢ By teenage years, if the attachment system is secure, children can gradually explore who they want to be and develop their independence if they have adequate caregiver support to do so. Triggers which could upset the system include an attachment figure becoming less available. Parents separating or a parent having to put energy into elderly relatives could cause this.

How Can You Nurture Healthy Attachment with Your Child? The most important way you can help your children is to be consistently physically and emotionally available to them. This availability will need to continue and adapt throughout the child’s development. Here are some important principles you can follow at different stages: ➢ With babies and young children, you can follow their lead and play with them, and ensure they have stable and secure care. Showing you are attentive to your baby’s cues and responding appropriately in a sensitive two-way interaction is known as ‘serve and return’. This is a tennis analogy: the baby serves their cue, and you respond sensitively, which shows the baby they are important and that what they do counts as it is worth responding to.

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➢ As children get older, it is important to show them you are always there for them and will provide them with a secure base. You should try hard to listen to them and play with them and let them know you are always there for them. Play is the way children work through their feelings, so playing with them helps strengthen our bonds. ➢ In teenagers the attachment relationship may be at threat as children grow up and develop independence. The important thing is to try and listen to what your children’s changing needs are so that you can continue to nurture the relationship.

KEY POINTS

• • •

The attachment relationship between caregiver and child is central to a child’s healthy development and is a crucial factor in supporting their positive mental health and wellbeing. There are different types of insecure attachment, all of which can be problematic for children’s emotional development and their ability to form future relationships. There may be challenges to the attachment relationship as children grow up. If you try to provide your children with a secure base from which to explore, you can help them with their social and emotional development and their gradual development of independence.

References (1) Ainsworth, M., Blehar, M., Waters, E. and Wall, S. 1978. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum.

Genes and Inheritance We all inherit a set of genes, which have a significant influence on our mental health. In fact, our genes can predict about half of our longer-term health outcomes, with factors in the environment predicting the other half. But it’s

Biological Processes Affecting Mental Health

not simply a question of nature (genes) or nurture (environment) affecting how we turn out. The picture is made more complicated by the fact that genes and environment can also interact. Environmental factors can change which genes are ‘switched on’ and at what stage in life this happens. So, how we eventually turn out is a complex mix of inheritance and environment. When it comes to understanding our children’s inheritance and our impact on their development, we can use the analogy of being their gardeners. Our children can be thought of like seeds, which already contain the genetic blueprint to become beautiful plants. We cannot change who they are or their genetic makeup, or what type of plants they will grow into, but we can nurture them and provide them with the best environment we can so they can thrive. So, we can do our best to help them make the best of whatever genetics they have inherited to positively influence their mental health.

What Are Genes? ➢ Genes are individual units of inheritance passed down from both parents. Genes affect all sorts of characteristics from what we look like to our personality and how our brains are wired up. Even if we inherit a particular gene, it may not be switched on, so we only see the products of a small proportion of our genes. ➢ The Human Genome Project, which is trying to decode all the genes in human DNA, estimates that humans have up to 25,000 genes. This accounts for the huge variation between people!

Does Nature or Nurture Have More of an Impact on Our Mental Health? Can a Fault in a Single Gene Cause Mental Illness? ➢ Both nature (inheritance) and nurture (environment) are important. The contribution of each depends on the health condition and individual circumstances. Genes and environment also interact with each other in a complex way.

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➢ For example, many young people with depression have inherited an increased tendency to become depressed. However, trigger factors are also very important and can make a young person more likely to become depressed at a certain time, for example after a relationship break-up or bullying at school. ➢ Some physical health conditions such as cystic fibrosis or sickle cell disease are caused by a fault in a single gene. In mental health, however, single gene disorders are rare. Many different genes as well as our personality influence our susceptibility to mental health difficulties. That’s one reason why mental disorders are often so complex and can vary so much between individuals.

What Is Epigenetics and Is That Also Important? For those who want to know more detail about how the environment can alter genes here’s a basic outline: ➢ Epigenetics is the study of how environmental changes can alter the physical structure of genes, which means that genes can be turned on or off due to chemical changes that attach to genes. These chemical changes can be permanent or temporary and can even be passed on to the next generation. Life experiences, nutrition and exposure to toxic chemicals can all cause chemical changes to the structure of genes. ➢ Trauma and child maltreatment can cause epigenetic changes. For example, in one study of people with post-traumatic stress disorder, those who had experienced abuse as children had up to 12 times more epigenetic changes than non-maltreated individuals (1). ➢ As the environment can alter genes, we now understand it’s not just a question of nature or nurture, but also nurture’s impact on nature. This is helpful for you to know as you can see how important a positive nurturing environment is for your children and their long-term mental health.

Biological Processes Affecting Mental Health

KEY POINTS

• •

•

We inherit our genes from our parents. These genes affect many different processes in our bodies, for example what we look like and how we behave, including our vulnerability to mental disorders. Our inheritance in conjunction with a range of environmental factors influence our susceptibility to mental health disorders. Many different genes are involved in causing vulnerability to common mental conditions, as well as environmental factors. Environmental changes, for example life experiences, can alter the structure of genes by switching them on or off.

References (1) Mehta, D., Klengel, T., Conneely, K. N., et al. 2013. Childhood Maltreatment Is Associated with Distinct Genomic and Epigenetic Profiles in Posttraumatic Stress Disorder. Proceedings of the National Academy of Sciences of the USA 110(20), 8302–8307.

The Developing Brain Our amazingly developed brains set us apart from other mammals. Although we share around 99% of our DNA with chimpanzees, the main difference between our species is in the development and size of our brains. We have many more nerve cells in our brains than chimps and other mammals. As each nerve cell can interact with many other nerve cells, we can start to understand the complexity of human brains. As well as being the control centre for movement, sensations, vision, ­language and thinking, the brain is also the seat of all our mental and emotional processes, so understanding the brain helps us understand the mind and our mental health too.

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In this section I explain how and when the brain develops, and I discuss how we can influence our children’s brain development and their risk of mental health difficulties.

What Is Special about Human Brains? When Do They Mature? ➢ The prolonged developmental process and complexity of human brains is what sets humans apart from other mammals. ➢ Brain development goes through many stages. The process starts early on in the developing embryo and then there are further important leaps in brain development in the first few years of life. One of the most important stages in brain development is the process of creating, strengthening and shedding connections in nerve cells. ➢ Human brains don’t fully mature until we are around 25 years old. So, although we legally become adults at 18, our brains still have quite a lot of maturing left to do.

Are Children’s Brains Like Mini Adult Brains? Why Is This Important? ➢ A child’s brain is very different from an adult brain. The young brain goes through considerable developmental change through childhood. This helps explain why children and young people think and behave differently from adults. ➢ It’s helpful to understand that children are functioning in different mental worlds from adults, due to the huge difference in our brains. We can’t expect children to behave or react similarly to adults. As adults we often forget how long it took us to learn how to self-regulate our emotional state, and hence we place unrealistic expectations on children. ➢ Rather than discussing feelings, children often need to play them out to work through them.

Biological Processes Affecting Mental Health

➢ We need to take greater care when using medication in children and young people than in adults. Children may respond differently to medicines as their bodies are immature and their brains are still developing.

What Is the Process of Brain Development? ➢ In the womb: The brain first develops in the areas most needed for survival functions like breathing, or reflexes. The higher regions that control thinking and reasoning are still primitive. ➢ In the first few years of life: There is a huge increase in the number of connections within the brain. Some brain connections get stronger while others are discarded through a process called ‘pruning’. This is like a complicated electricity station that sends extra-thick cables down commonly used routes but cuts out less-needed pathways. Children’s brains have less white matter (which is the stuff that wraps around nerve cells) to ensure clear transmission, so electrical signals in children’s brains are therefore slower at processing information. ➢ By age 3: The brain has almost reached adult size. The growth in each region of the brain depends on receiving stimulation, which spurs activity in that region. So, learning really does increase brain development! ➢ In teenage years: After another growth spurt, there is a second process of pruning connections paired with significant chemical changes. The front areas of the brain (involved in impulse control and planning) are underdeveloped relative to other areas. This helps explain why young people often take more risks and tend to act impulsively and hence their car insurance premiums tend to be much higher! Change also happens in the emotion centres of the brain as teenagers learn to regulate their emotions through puberty.

Which External Factors Can Affect Brain Development? ➢ Before birth: While a baby is in the womb the brain is already developing. The food a pregnant woman eats will give energy to the baby’s

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developing brain. Various risks and injuries in pregnancy can affect the brain too, such as from infections, chemicals, including from smoking or alcohol, nutritional deficiencies or when pregnant mothers experience stress, trauma or mental health conditions like depression. Premature birth can also affect the baby’s brain. ➢ After birth: Children exposed to high stress levels, head injuries, infections or toxic chemicals are more susceptible to mental disorders and difficulties with brain functioning. We can help protect and nurture our children’s brains by giving children a stable and supportive environment.

How Can the Brain Change in Response to the Environment? ➢ The brain’s ability to change in response to stimulation is known as ’plasticity’. The extent of this ability to change depends on the part of the brain and the stage of development. So, the richer the experiences we can introduce to children, the more we can stimulate their brains to develop and grow. But we don’t always need to structure learning. We can also help children learn creatively by providing them with a safe environment to explore and play. ➢ The brain can keep changing and building new pathways, as we keep learning throughout our lives. So, if we can give children the example of remaining curious and being open to learning new things, we can also keep building new connections ourselves, which is protective for our own brains.

What Is a Growth Mindset? How Does This Fit with the Brain’s Ability to Develop? ➢ Growth mindset refers to the belief that you can improve intelligence, ability and performance, as brains are constantly evolving

Biological Processes Affecting Mental Health

and adapting to challenges. It was a theory developed by Carol Dweck, an American researcher. (See the Resources section below to read more information on growth mindsets.) ➢ The opposite of growth mindset is fixed mindset, which is the belief that a person’s talents are set in stone. ➢ Dweck proposed that children’s learning capabilities could improve if they engage in the right behaviours for stimulating their brain and building new connections. This theory fits in with the model of an adaptive developing brain. ➢ It is important to help children and young people believe they can keep learning whatever their abilities. If children label themselves as ‘no good’ at something, the chances are they will not try to develop these abilities, and this will also have a negative impact on their brain development and their mental health. They will get stuck into fixed thinking patterns which will not allow for positive brain development.

KEY POINTS

•

Children’s and young people’s brains look and function very differently from adult brains.

•

The brain keeps developing into our mid-twenties: with major ‘leaps’ in development happening in the first few years of life as well as adolescence.

•

A teenager has a relatively underdeveloped front part of their brain, hence young people engage in more risk-taking and can be more impulsive.

•

We can protect children’s brains through good nutrition, healthcare and by providing them with a secure, safe and nurturing environment.

•

Brains have an ability to change and adapt in response to stimulation. We can help children develop their true potential by fostering a growth mindset.

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Useful Resources Books ➢ Inventing Ourselves: The Secret Life of the Teenage Brain written by Sarah-Jayne Blakemore (Random House, London, 2018) is an excellent introduction to how teenage brains work. Prof. Blakemore is a leading UK researcher on the adolescent brain. She has many publications to her name and has also written an accessible book on the topic. ➢ Mindset – Updated Edition: Changing the Way You Think to Fulfil Your Potential (Robinson, London, 2017) is a helpful book written by Carol Dweck, the pioneering researcher who first wrote about growth mindsets. Her work has been extremely influential in modern educational thinking.

Puberty Puberty is the transformation of children’s bodies into adult bodies, so they can reproduce in the future. Hormones, which are the body’s chemical messengers, trigger and coordinate the process. Puberty can often be tough for our young people due to years of swinging hormones and periods of mismatch between the brain, hormones and growth. With so many changes happening together, it’s not surprising there is often a significant impact on young people’s mental health and wellbeing.

What Are Common Anxieties That Come with Puberty? Girls ➢ Breast development can cause anxieties as it’s common to have breasts of different sizes. Girls also may worry about the ‘lumps’ under the nipple. It is common for early developers to be self-conscious about breasts.

Biological Processes Affecting Mental Health

➢ Premenstrual syndrome is very common and can cause several emotional and physical symptoms including mood swings, tiredness, headaches, bloating and cramping. Some girls notice their mood drops significantly before their periods, so I often ask girls with mood difficulties to track their moods along with their periods. ➢ Periods can be painful and often difficult to manage if heavy, and some girls with heavy periods can lose a lot of blood and may become anaemic, causing tiredness.

Boys ➢ Voice changes happen as the voice box grows larger and thicker and the vocal cords lengthen. Boys can become self-conscious when their voice squeaks or ‘cracks’ during this process. ➢ Wet dreams are caused by ejaculation not urination and may cause embarrassment in boys. They are a normal part of maturing and aren’t necessarily sexual dreams. ➢ Erections can happen spontaneously and unexpectedly during puberty, which can be quite embarrassing, especially if they happen in public. ➢ Breasts can get tender and swell in boys during the early years of puberty. This may be a worry for boys, but you can reassure them that the changes generally disappear after a few months and don’t develop into true breasts.

How Else Can Puberty Affect Children’s Mental Health? ➢ Puberty can be a long, painful and confusing process over which the young person has no control, which can cause anxiety. ➢ There is an increased risk of some mental health disorders during puberty, including depression, anxiety and eating disorders. Many serious

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➢ ➢

➢

➢

mental health conditions also have their onset during adolescence. Roughly half of mental health problems start by age 14 and around 75% have started by the early twenties. Late as well as early developers can also be at increased risk of feeling insecure about their bodies. Mood swings caused by hormone fluctuations are common during puberty, because the body is adjusting to changing sex hormone levels. Sleep disruptions due to hormone changes can affect mood and anxiety. Early school starts that don’t fit with teenagers’ natural sleep rhythms can make it difficult for them to recover from disrupted sleep. Emotion regulation is often a struggle for teenagers as the brain is still emotionally immature and often out of step with all the physical body changes.

How Can You Support Young People through Puberty? ➢ Talk about puberty as a normal stage of development and discuss puberty openly before it happens. Having several conversations from an early age tends to be more helpful than waiting to have a big talk when children may have already heard misinformation elsewhere. Remember to discuss the brain and emotional changes as well as physical changes. ➢ Make sure young people get the practical help they need in advance, and they know who to go to for support at any point. For example, a girl may need help with accessing and understanding how to use sanitary protection, keeping track of periods, and how to manage pain. This is often easiest with someone of the same gender as they can support with their personal experience, so it may be helpful for single parent households to enlist someone to mentor the young person of the other gender to the parent.

Biological Processes Affecting Mental Health

KEY POINTS

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Puberty is the transformation of children’s bodies into adult bodies capable of reproducing. It is kickstarted by hormone cascades that affect cells throughout the body and brain.

•

Puberty can be a difficult time for many young people. The physical changes can be scary and painful. It’s not always easy to predict which young people will struggle the most with the changes. Supportive preparation can be very helpful.

•

Puberty can affect mental health in many ways, so trying to support positive mental fitness is important. The risk of mental health difficulties increases significantly as young people develop, so it’s important to be on the lookout for difficulties around this time.

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2 Lifestyle Factors Affecting Mental Health In Chapter 2, I explore some lifestyle factors that have a significant impact on our mental health, including sleep, nutrition, exercise and movement, technology, bullying and academic pressures, and alcohol and drugs.

Sleep Many of you, especially if you have ever had to care for newborn babies, will be able to relate to what it’s like to be severely sleep deprived and the huge impact this has on your mood and overall functioning. You won’t be surprised to know that sleep is one of the most important determinants of being in good health. Sleep also has an important function in brain health and repair. Almost all mental disorders also have an impact on sleep. So, sleep and mental health go hand in hand. Many children and young people struggle with sleep at some stage. Fortunately, we now know of a range of strategies that can improve sleep, and I will share them with you in this chapter.

Lifestyle Factors Affecting Mental Health

How Important Is Sleep? ➢ Sleep is vital for our brains and bodies to both function and repair. Sleep is not just ‘dead’ time or even relaxation time. Sleep deprivation increases the risk of many physical and mental health conditions, for example anxiety. ➢ Several studies have also shown a direct relationship between the number of hours slept and both lifespan and health-span (which is the number of healthy years we live). Matthew Walker, an international sleep scientist, explains all the vital functions of sleep eloquently in his book Why We Sleep (1).

What Happens When We Sleep? ➢ A good night’s sleep helps the brain repair and reboot itself. Sleep helps us to lay down memories and improve concentration and learning. Sleep also helps with creativity, problem solving and emotional regulation. ➢ Our brains go through different stages of sleep. We need to get into a deep sleep state for the repair and reboot processes to work properly. ➢ The total night’s sleep is made up of four to six rounds of a sleep cycle, each one lasting around 90 minutes. ➢ There are four main stages of sleep, in which the brain goes through different patterns of activity as follows: – –

–

Stage 1: The falling asleep stage. This takes 1–5 minutes at the start of the night. The body and brain activities start to slow. Stage 2: The body enters a more relaxed state with slowed breathing. Brain activity slows, but there are some bursts of activity. This lasts 10–25 minutes in the first cycle, and this stage can get longer during the night, and can take up to half of a total night’s sleep. Stage 3: Deep sleep. The body relaxes further and breathing slows down more, and the brain’s electrical pattern changes. This stage lasts around 30 minutes in the first cycle but gets shorter in the following

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–

cycles. This stage is important for restorative sleep, and we spend most of our time in this stage during the first half of the night. Rapid eye movement (REM) sleep. In this stage the eyes move quickly although the rest of the body is temporarily paralysed. REM sleep is essential for brain functioning including working at processing memories, and vivid dreams may occur. The first REM stage may only last a few minutes, but the time spent in REM sleep gets progressively longer through the night and can last up to an hour towards the end of the night.

Is Lack of Sleep Associated with Health Problems? Sleep guidance for children compiled for the American Academy of Sleep Medicine (2) found that reduced sleep is associated with poorer overall health and quality of life in young people: ➢ Mental health: Although both too little and too much sleep have an impact on mental health, the most convincing evidence is that too little sleep is associated with poor mental health outcomes. In teenagers less than 8 hours sleep is associated with increased behaviour difficulties, suicide attempts and substance abuse. In school-aged children, at least 9 hours of sleep was associated with better behavioural functioning. ADHD symptoms were worse in those children with less than 8 hours sleep. Sleep deprivation is directly linked to increased anxiety according to a recent study by Matthew Walker (1). ➢ Memories and emotions: Rapid eye movement (REM) sleep helps process and take the emotional charge from memories. Most REM sleep happens in the early hours of the morning and if children miss out on it they are more likely to suffer from the impact of stress and trauma. ➢ Brain functioning: There is a strong relationship between sleep and children’s ability to process information, language, memory, emotional regulation and reactivity.

Lifestyle Factors Affecting Mental Health

➢ Physical health: Short sleep duration is associated with an increased risk of obesity and high blood pressure as well as problems with the immune system. Too little or too much sleep can also disrupt appetite and metabolism including longer-term risk of diabetes. Several studies show that lack of sleep in adults is linked to physical health problems including obesity, cancer, heart disease, diabetes, dementia, immune system problems and reduced fertility as well as mental health problems like depression and anxiety.

How Much Sleep Do Children and Young People Need? ➢ Children and young people need different amounts of (minimum) sleep depending on their age. The table below shows how much sleep is needed for different ages according to the American Academy of Sleep Medicine (3). Who?

How much sleep needed per 24 hours?

Infants (4–12 months)

12–16 hours including naps

Toddlers (1–2 years)

11–14 hours including naps

Pre-schoolers (3–5 years)

10–13 hours including naps

Primary school age children (6–12 years)

9–12 hours

Teenagers (13–18 years)

8–10 hours

Adults

7 or more hours

➢ Some people need more sleep than others. The amount of sleep you need varies according to different factors, including culture, environment and the individual’s brain. This also applies to children, so it’s important to check how much sleep your child needs. Your child may not be getting enough sleep if they are tired in the daytime, feel unrefreshed when they wake up or if tiredness stops them functioning properly.

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➢ There is a complex balance between the pressure to sleep and the pressure to be alert. This balance helps decide how well and how much we sleep. The pressure to sleep builds up with the number of hours we are awake, our exposure to darkness and our physical tiredness. However, on the other hand, stress, inactivity, daytime naps and screen-time can increase our state of arousal, which will counter sleep by keeping us alert. ➢ We all have natural preferences for when we sleep. ‘Night owls’ naturally prefer to stay up late and wake up later, and ‘early morning larks’ prefer early mornings and earlier bedtimes.

Why Do Teenagers Struggle to Get to Sleep at a Reasonable Time and Wake Up for School? ➢ Teenagers’ body clocks go through a phase of being more shifted towards a ‘night owl’ pattern. They find it difficult to switch off until later in the evening and want to get up later in the morning. ➢ Many teenagers build up a sleep debt if they are regularly having to wake before they are ready, for example due to an early school-day.

How Can You Help Young People Improve Their Sleep? Here are some sleep hygiene tips: ➢ Explain why sleep is so important for the brain. Children do better at school and have healthier bodies if they give themselves enough sleep opportunity. Many health experts now recommend using an alarm as a reminder to get to sleep rather than to wake up. ➢ Keep to a consistent bedtime, even at weekends. The body clock works best following the same routine, so it doesn’t have to keep resetting. It’s best to try and keep to roughly the same bedtimes throughout the week. Although teenagers may struggle with routines, a tip is for them to use their phones to ping themselves a reminder to start their wind-down and put

Lifestyle Factors Affecting Mental Health

➢

➢

➢

➢

➢

the phone to bed. You can work out a reasonable bedtime depending on the child’s age and need for sleep: this will gradually change with age and having later bedtimes for older children is helpful. It may, however, be useful to let teenagers have a lie-in at the weekend if they have built up a sleep debt due to enforced early mornings through the rest of the week. Keep bedrooms calm screen-free zones. Bedrooms should be calm, quiet and dark, and set up for sleep. Screens are best kept out as they stimulate our brains and counteract the natural signals trying to wind-down, even with the blue-light filter on. I often advise families to make ‘phone-beds’ in the living room. The constant vibrations, alerts and beeps will be somewhere else! Encourage a wind-down routine up to an hour before bed. A relaxing routine in the hour leading up to sleep can help to send signals to your brain to prepare for sleep. This routine could include a warm bath (which helps by dropping body temperature and relaxing muscles), reading, doing puzzles and listening to audio books, podcasts and relaxing music. If listening to audio books or podcasts, devices could be put just outside the door of the bedroom, so they are used simply for the audio rather than visual function. Encourage exercise, so that young bodies are physically tired at bedtime. Children need to be physically tired enough at bedtime to switch off, and unfortunately this is often difficult to achieve with our increasingly sedentary lifestyles. You can do some exercise at home, such as dance workouts, trampolining, running up and down stairs, skipping. The target is to get the heart rate up. It’s important, however, to avoid strenuous exercise too close to bedtime, as it can be too activating. Try to get exposure to natural light in the daytime and reduce exposure to artificial light late in the evening. This helps with the body’s natural production of sleep hormones, which will help give our brains the signals to switch off earlier. Good advice is to try to go outside as much as possible during the day, then switch off bright lights in the evenings. It may be helpful to use a dimmer switch, screen filters or blue-light filtered glasses. Avoid meals, heavy snacks, alcohol and caffeine late in the evening. Food before bed gives you a burst of energy and wakes up your digestive system when you want to signal it to shut down. It’s still common for school pupils to cram for exams with caffeinated drinks and

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snacks. However, both alcohol and caffeine can disturb the quality of sleep, and often have a hangover effect the next day. ➢ If sleep is still a problem, see your GP. Poor sleep may be due to a sleep disorder or may be secondary to another health problem, for example depression or a thyroid problem. Specialist sleep clinics can assess for specific sleep disorders in children. ➢ Sleeping tablets tend to be a last resort, as they rarely work well in the longer term. Sometimes sleep medications like melatonin may be helpful for children stuck with sleep difficulties in combination with ADHD and autism, especially when other medication may be affecting sleep.

KEY POINTS

•

Getting good-quality sleep is vital in keeping your body and brain healthy and can also prevent a range of long-term health problems.

•

We all vary as to how much sleep we need, but most of us need a minimum amount to function and this varies according to age. It’s important to know the minimum amount of sleep children need as they develop. We also have different sleep preferences of being ‘night owls’ or ‘morning larks’ and most teenagers go through a phase of being night owls.

•

Technology is one of the biggest modern threats to getting good-quality sleep, and it’s best to switch off devices in the hour before bed. A good house rule is to put phones and devices to bed in the kitchen/living room at night.

•

Sticking to a consistent routine of going to bed the same time each night is important. Setting a bedtime reminder alarm is often more effective than having a wake-up alarm.

•

Getting natural daylight exposure outdoors as early as possible in the day is important in waking us up and resetting our body clocks. Reducing bright lights in the evenings and keeping bedrooms dark is also helpful for our sleep–wake cycles.

Lifestyle Factors Affecting Mental Health

•

Exercise can promote sleep as it helps the body to become physically tired. However, if you exercise too close to bedtime it can stop you sleeping.

•

Other sleep tips include building in a wind-down routine before bed, which can consist of having a bath, reading a book, listening to soothing music, audio books or podcasts and avoiding heavy food, caffeine and alcohol before bed.

References (1) Walker, M. 2018. Why We Sleep: The New Science of Sleep and Dreams. London: Penguin Books. (2) Paruthi, S., Brooks, L., D’Ambrosio, C., et al. 2016. Consensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion. Journal of Clinical Sleep Medicine 12, 1549–1561. http://dx.doi.org/10.5664/jcsm.6288. (3) Paruthi, S., Brooks, L., D’Ambrosio, C., et al. 2016. Recommended Amount of Sleep for Paediatric Populations: A Statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine 12, 785-786. https:// doi.org/10.5664/jcsm.5866.

Useful Resources Web-Based Resources ➢ The Sleep Charity (www.thesleepcharity.org.uk) is a UK-based charity run by volunteers with lots of useful tips and resources, including free downloadable information and guides for all ages, for example a free e-book for teenagers and detailed information for children. The charity runs workshops and a Sleep Advice Service between 7 and 9pm from Sunday to Thursday on 03303 530 541.

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➢ Cerebra (www.cerebra.org.uk) is a UK-based charity aimed at families of children with brain and neurodevelopmental conditions. It has a Sleep Advice Service where parents can get free consultations around sleep. It also has a free downloadable Sleep Guide and sleep cards available through the Cerebra website which can be useful to anyone, not just those with brain conditions at: https://cerebra.org.uk/wp-content/ uploads/2020/03/sleep-guide-june19-low-res.pdf ➢ The American Association of Sleep Medicine (www.sleepeducation .org) has a useful sleep education section with advice on children’s sleep, including guidelines on how much sleep different aged children need.

Books ➢ Matthew Walker, a world-famous British sleep researcher, has written accessible and informative books about sleep. His first, Why We Sleep: The New Science of Sleep and Dreams (published by Penguin Books in 2018) is an international bestseller. ➢ Chasing the Sun: The New Science of Sunlight and How It Shapes Our Bodies and Minds is a book written by award-winning British science journalist Linda Geddes. It explains very clearly how to improve our sleep rhythms by getting more light in the day and dark towards sleep-time. This was published by the Wellcome Collection in 2019.

Food and Nutrition Most people realise how important a healthy diet is for a healthy body, but did you also know how important it is for a healthy mind? There is now increasing research in nutritional mental health. This research is starting to show just what an important impact food has on our mental health. I will outline some of the main principles around this in this chapter. A key ­principle to remember is the more unprocessed food we all eat, the better for our bodies and brains. I will also give some further advice around feeding children and young people to optimise their mental health.

Lifestyle Factors Affecting Mental Health

What Does a Balanced Diet Mean? The UK government regularly updates guidance on a balanced diet, based on information from the Scientific Advisory Council on Nutrition. The Eatwell Guide gives the latest guidance as follows (1): ➢ One-third of our diet should come from fruit and vegetables. Variety is best as this will provide the mix of different nutrients we need. ➢ One-third of our diet should come from starchy carbohydrates found in bread, rice and pasta: wholegrain is best. ➢ The remaining third is made up of dairy (or dairy alternatives), a portion of protein in each meal (e.g., meat, fish or pulses/beans), unsaturated oils and fats (like olive oil) and few high fat/sugar/salt foods (e.g., crisps and biscuits). ➢ Drink six to eight cups of water or water-based drinks a day.

Do the Same Principles for a Balanced Diet Apply to Children Too? According to the UK Eatwell Guide (1) there are modifications we need to make for children as follows: ➢ Children have different energy needs according to their age and gender: Girls and women need less energy than boys and men. There is also a sliding scale in energy needs according to age: from 1-year-old children, who need over 700 kcal per day, to adults and children over 11, who need 2,000–2,500 kcal per day. Be guided by your child’s appetite. If a child’s appetite seems very reduced it may be worth getting help through the GP. ➢ Children under 2 have special nutritional needs. NHS websites and health visitors will provide useful advice here. ➢ Between the ages of 2 and 5, children should gradually move to eating the same foods as the rest of the family in the proportions shown in the Eatwell Guide.

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➢ If children have a balanced diet, they shouldn’t generally need extra supplements, except vitamin D, which would benefit most people in non-tropical countries. ➢ Children should have less saturated fat than adults. However, a lowfat diet isn’t suitable for children under 5. ➢ No more than 5% of the energy children consume should come from processed sugar as it increases the risk of obesity and tooth decay. I know this is difficult to achieve when so many children’s snacks, like yoghurts and juices, are full of sugar!

What Are Good Principles for Food and Mental Health? The Mental Health Foundation put together a guide called ‘Food for Thought: Mental Health and Nutrition Briefing’ (2), which has updated evidence on the link between food and mental health. Here are some guiding principles you should follow for children: ➢ Eat and drink regularly. Children’s brains need regular energy intake, and young people’s moods can swing up and down if they get hungry. Complex carbohydrates like wholegrain pasta and vegetables are the best slow-release source of energy. Water is important for all body processes and children often need reminding to drink enough in the day. ➢ Eat a range of foods including as many unprocessed foods as possible. We need about 40 key nutrients for a balanced diet, and deficiencies can be harmful to children. Fruit and vegetables are associated with better mental wellbeing. It’s better to get nutrients from foods, but a general vitamin supplement can be helpful for children who refuse to eat a balanced diet. The main supplement almost everyone in the Western world needs is a vitamin D supplement as most of us are deficient and it’s an important vitamin to keep bones, teeth and muscles healthy. ➢ Think about optimising gut health. Modern research shows the gut and brain health are closely linked. There is increasing research that we need to feed the gut microbiome, which is the sea of good bacteria we carry in our guts to promote good health and digestion. If we eat foods that include

Lifestyle Factors Affecting Mental Health

a range of fruit and vegetables that feed the good bacteria in our guts (known as pre-biotics), we aid our digestion. This can help with mood and mental health. Foods that are high in fibre and wholegrains are digested more slowly, which helps to protect our guts, while highly processed foods with refined fibre can strip away the good bacteria from our guts. ➢ The Mediterranean diet has the best evidence base for its impact on our mental health. It is made up of fresh fruits, vegetables, wholegrains, pulses, nuts, olive oil and fish. An interesting study called the SMILES (Supporting the Modification of lifestyle in Lowered Emotional States) Trial conducted by the Food and Mood Institute in Australia in adults with depression (3) found that participants who had a dietary intervention had a much greater reduction in their depressive symptoms over the three-month period, compared to those who got social support. A further trial in children found better overall diet quality is related to more positive mental health in pre-adolescent children (4).

Which Components of Food Are Most Important for Your Mental Health? ➢ Try to eat a variety of foods. Cutting out major food groups can mean you don’t get enough nutrients. So, people with strict diets that exclude major food groups need to be careful they don’t miss out on essential nutrients. ➢ Vitamins and minerals are important for brain processes. As an example, vitamin D deficiency is linked with depression in adults (5). Vitamin B and C deficiency can make mental health disorders worse. There are a range of different B vitamins, most of which we can get through a balanced diet, with fruit and vegetables being the richest sources. However, vegans may not get enough vitamin B12 in their diets as it’s mostly found in meat, fish and dairy sources, so they may need to take a supplement to prevent anaemia. ➢ It is important to get a diverse diet, including lots of vegetables as well as protein sources. Nutrients including iron, iodine, zinc, selenium and magnesium are important for brain functioning.

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Iron is a key nutrient and many people who don’t include iron-rich foods may not be aware that it is a common cause of tiredness. Omega 3 and omega 6 fatty acids are also essential as we can’t make them ourselves, so we need to get them from our diets. The table below includes some example foods and effects of deficiency which you may find helpful to reference if you are worried about dietary intake (2). Nutrient

Example foods

Deficiency

Iron

Red meat, pulses, dried fruits, nuts, green leafy vegetables, seeds.

Tiredness due to anaemia; behaviour problems.

Omega 3 fats

Oily fish, nuts and seeds, fortified food, green leafy vegetables.

Poor concentration and attention; mood swings and irritability; tiredness and poor sleep.

Omega 6 fats

Poultry, eggs, nuts and sesame seeds, cereals.

Poor concentration and energy.

Vitamin C

Citrus fruits, berries, broccoli.

Weakness and tiredness. Can worsen mental health conditions. In extreme cases can cause scurvy.

Vitamin D

Sunlight, oily fish, meat and eggs.

Deformities like rickets, bone pain. Depression in adults (5).

Which Foods Can Have a Negative Impact on Mental Health? ➢ Some foods trick the brain into releasing chemicals which can make mood go up and down, for example caffeine, so it’s best not to have too much of them. ➢ Some foods stop the brain getting the nutrients it needs from other foods, like saturated trans-fats such as palm and corn oil found in

Lifestyle Factors Affecting Mental Health

processed foods like cakes and ice-cream, so over-eating these foods can block good nutrients getting through. A systematic review conducted by O’Neil et al. in 2014 (6) showed that unhelpful dietary patterns are linked to poorer mental health in children and adolescents. ➢ Foods with lots of colours and additives may have a negative effect on the brain and mental health and can affect hyperactivity. Many parents of children with ADHD have learnt this through experience.

How Can We Promote a Healthy Eating Pattern? You can’t control everything children and young people choose to eat, but you can influence some choices, especially when at home. ➢ Make healthier food available at home, by stocking up with fruits and vegetables ready for snacking (e.g., cutting up carrot, celery and pepper sticks with hummus) and not having too many crisps and chocolates in the cupboards. ➢ Model positive eating patterns. Try to have three meals a day with limited snacks in between, which is the healthiest pattern for teens and adults. Young children with small stomachs may need to rely more on snacks to keep them going. ➢ Encourage a good breakfast. Many young people often skip breakfast, which means they frequently lack the energy needed for their brains to function properly for the morning of school. The brain takes up to half of the body’s energy needs, so fuelling it for the day is a good idea. Many cereals have a very high sugar content, so porridge is a healthier alternative. Recent studies have shown that a higher-protein breakfast in adolescents can improve the feeling of fullness, positive eating behaviours in the day and weight control (7). ➢ Eat together as a family at the table where possible. Eating together is important for our mental and emotional health as well as setting up good eating habits. The dinner table is often one of the only times we can sit together and talk in the day. Removing screens during shared meals also helps you concentrate on chewing food properly.

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KEY POINTS

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Eating healthily is important for long-term physical and mental health. The UK government Eatwell Guide can offer a helpful starting point. Poor diet is linked to poor mental and physical health outcomes.

•

We all need a balanced diet with a range of vitamins and minerals for positive brain health. The more whole, unprocessed foods we eat, the better.

•

As children grow their energy requirements change. Children will need more energy at growth spurts. Notice if a child’s appetite changes significantly and get help for this.

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You can promote a healthy eating pattern by stocking up on healthy snacks and not buying too many unhealthy ones. It is helpful to model positive eating patterns, provide a good breakfast and aim to eat together as a family as often as possible.

References (1) Public Health England. 2016. The Eatwell Guide booklet. Available at https:// assets.publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/742750/Eatwell_Guide_booklet_2018v4.pdf (2) Mental Health Foundation. 2017. Food for Thought: Mental Health and Nutrition Briefing. Available at www.mentalhealth.org.uk/sites/default/files/ food-for-thought-mental-health-nutrition-briefing-march-2017.pdf (3) Jacka, F., O’Neil, A., Opie, R., et al. 2017. A Randomised Controlled Trial of Dietary Improvement for Adults with Major Depression (the ‘SMILES’ Trial). BMC Medicine 15(23). https://doi.org/10.1186/s12916-017-0791-y. (4) Dimov, S., Mundy, L., Bayer, J. K., et al. 2019. Diet Quality and Mental Health Problems in Late Childhood. Nutritional Neuroscience. (5) Anglin, R., Samaan, Z., Walter, S. and McDonald, S. 2013. Vitamin D Deficiency and Depression in Adults: Systematic Review and Metaanalysis. British Journal of Psychiatry 202(2), 100–107. doi:10.1192/bjp. bp.111.106666.

Lifestyle Factors Affecting Mental Health (6) O’Neil, A., Quirk, S., Housden, S., et al. 2014. Relationship between Diet and Mental Health in Children and Adolescents: A Systematic Review. American Journal of Public Health 104(10), e31–e42. (7) Leidy, H., Ortinau, L., Douglas, S. and Hoertel, H. 2013. Beneficial Effects of a Higher-Protein Breakfast on the Appetitive, Hormonal, and Neural Signals Controlling Energy Intake Regulation in Overweight/Obese, ‘BreakfastSkipping’, Late-Adolescent Girls. American Journal of Clinical Nutrition 97(4), 677–688.

Useful Resources Web-Based Resources ➢ The UK government website has the latest dietary guidance recommended by nutritional experts. Available at www.gov.uk/ government/publications/the-eatwell-guide ➢ The Association of UK Dieticians has lots of useful fact sheets, including on the links between food and mental health. Available at www.bda.uk .com ➢ The Food and Mood Centre based in Australia has conducted and planned several research studies on the impact of food on mood and mental health. Available at https://foodandmoodcentre.com.au/ ➢ The International Society of Nutritional Psychiatry is mainly based in Australasia and aims to research the impact of nutrition on mental health. Available at www.isnpr.org

Exercise and Movement The human species has evolved to be mobile, and we know that movement and exercise have huge benefits for both mental and physical health. Unfortunately, in the modern world staying still has become the default position. In many schools, children sit in classrooms all day with ­minimal

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opportunities to move. It doesn’t get easier as we get older, as many of us move into jobs where we work at computers all day, and there’s no requirement to move. So, we need to push ourselves out of our default position to move and exercise. There is increasing evidence to show how important exercise is in mental health. I know from my own personal experience how vital exercise is for my own mental health: without being able to run and walk regularly I would struggle. In this section we discuss some of the benefits of exercise for mental health and give some ideas of how to get our children and young people moving.

How Much Exercise Is Recommended According to Current UK Guidance? The UK government Chief Medical Officer published the following Physical Activity guidance (1) for different age ranges: ➢ From 1 to 5 years: Aim for an average of 180 minutes of physical activity per day. This can include a range of activities, from messy play to climbing, games and outdoor play. ➢ From 5 to 18 years: Aim for an average of 60 minutes of physical activity per day. This can include active travel, dancing, climbing, playing and sports. ➢ For 18 years and over: Do at least 75 minutes of vigorous exercise per week or 150 minutes of moderate intensity exercise per week.

How Can Exercise Help Mental Health? There is now very good evidence that exercise is beneficial for our mental health. Although the bulk of the research comes from studies in adults, there is increasing evidence that exercise has a positive benefit across the lifespan (2). Here are some of the ways exercise can be helpful for mental health:

Lifestyle Factors Affecting Mental Health

➢ Exercise increases the volume of some brain regions by improving their blood supply. One important area is the hippocampus, which is involved in memory, emotion regulation and learning. ➢ Exercise improves mood by increasing endorphin and endocannabinoid levels, the body’s own feel-good chemicals. ➢ Exercise has been shown to reduce the risk of developing depression (3). ➢ Outdoor exercise can improve the ability to concentrate and improves ADHD symptoms (4). ➢ Increasing your heart rate can reduce stress by stimulating brain chemicals which can make you think more clearly in stress. ➢ Exercise can boost self-esteem and sense of achievement. ➢ Exercise improves sleep, provided it’s not too close to bedtime. ➢ Exercise done with other people can provide social connection and can help with social skills, which is beneficial to mental health.

How Can You Encourage Exercise in Children and Young People? Most people struggle to fit regular exercise into their life. Here are some tips to try and encourage children and young people to exercise: ➢ Make it fun. Think creatively and make up some games related to your child’s interests. I have been on various Lego-themed forest adventures with my kids! ➢ Show you prioritise exercise too. If you show your children you exercise regularly, this is one of the most powerful teaching tools. So, it’s time to think about scheduling in some movement yourself if you don’t already. ➢ Talk about playing together rather than exercising! We don’t want exercise to turn into a chore. Offering to play a game together in the park may be more appealing to many young people than suggesting going for a run. ➢ Use the outdoor spaces around you. You don’t need money or much equipment: the main thing is to create opportunities for children and young people to be outdoors. For younger children, running about in the

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park is often good. For older children and teenagers, encouraging outdoor time through walks, runs and bike rides is good. Social media tools such as Strava can motivate some young people. ➢ Consider enlisting the help of a four-legged friend. People with dogs tend to be healthier as they need taking out each day. If you can’t get a dog, you could buddy up with someone who has one or consider a scheme such as ‘Borrow My Doggy’ (www.borrowmydoggy.com).

What Are Some Tips for Young People Who Find It Hard to Get Started? ➢ Set goals and build up slowly. If you don’t exercise regularly yet, you could start with aiming for once or twice a week. Try to build regular movement breaks into your daily activities too. ➢ Try to set up regular ‘dates’ for exercise and put them on your calendar or phone. Planning something in often helps with followthrough. With my kids, sometimes planning to do junior parkruns together (www.parkrun.org.uk), which happen at a set time every Sunday morning, has been helpful. Booking in timed swim sessions has also worked well for us, with agreed play-time for the second half of the session. ➢ If you add exercise to another activity you already do, it is more likely to stick. For example, if you already get the bus to school/college, could you get off a stop or two earlier and do a brisk walk at the end? Some people do press-ups each time they brush their teeth! ➢ Exercise with other people to help you keep going. A simple way to do this is to join a sports group or club. If that’s not practical, try meeting with a friend: you are less likely to cancel the activity if you are letting someone down. ➢ Consider using rewards. We all like incentives! For example, a bike ride can earn you the chance to watch a TV programme. With parkruns, kids can earn wristbands after a set number of runs. ➢ Use technology creatively. There are lots of fitness apps and gadgets that may appeal, for example the Fiit app or Wii fit. YouTube is a great resource with a wealth of brilliant home workout videos, including Cosmic Yoga and Joe Wicks. Watch out for the privacy settings on certain apps for young people.

Lifestyle Factors Affecting Mental Health

Are There Dangers of Some Young People OverExercising? How Can You Help Them? ➢ Yes: there is a sub-group of young people who struggle to get the balance right and eat too little and exercise too much for their energy needs. Some may go on to develop eating or physical health problems, and may be at higher risk of developing other mental health problems. ➢ You can help young people set up a safe exercise programme and talk with them about their energy needs for exercise. A sports coach may be able to help with this. They may also need professional psychological support to look at any underlying difficulties.

Which Exercise Is Right for Your Child? How Can Children Be Supported for Their Mental Health in Sports Clubs? ➢ Do some ‘matchmaking’ and find out which physical activity suits your child. Not every child enjoys traditional sports like football but activities like martial arts, cycling and swimming can be equally good. You may need to try several before your child ‘clicks’ with something they really enjoy. ➢ The Faculty of Sports and Exercise Medicine has put together recommendations for sports clubs to ensure good mental health for children (5). The UK charity Mind has also set up a toolkit for sports clubs and organisations that want to support the mental health of members and coaches. It introduces the idea of mental health champions and offers guidance on setting up a mental health champions scheme (6).

KEY POINTS

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Exercise is just as important for mental health as for physical health. It boosts brain connections and reduces the risk of mental health problems. It also helps you learn life skills such as communication and discipline, and gives you the opportunity to build real-life connections in an increasingly ‘virtual’ world.

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As PE and outdoor activities at school have been squeezed out of curricula, it’s important to consider how to keep children and young people moving in a fun way. Think about how to set up opportunities for outdoor time and invest in all-seasons gear.

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Can you find a sport to suit your child’s needs? Spend a bit of time ‘matchmaking’ and trying things out until you find something that suits your child.

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Be creative with ways to help young people who aren’t exercising to get started, like using goal-setting and rewards and exercising with others. On the other side of the coin, be aware of those young people who may be over-exercising, and how to help them get the balance right.

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Talk to sports clubs about the Mind toolkit to help support the mental as well as physical health of their members.

References (1) UK government. 2019. UK Chief Medical Officer’s Physical Activity Guidelines. Available at https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/832868/ukchief-medical-officers-physical-activity-guidelines.pdf (2) Biddle, S., and Asare, M. 2011. Physical Activity and Mental Health in Children and Adolescents: A Review of Reviews. British Journal of Sports Medicine 45(11), 886–895. (3) Schuch, F., Vancampfort, D., Firth, D., et al. 2018. Physical Activity and Incident Depression: A Meta-analysis of Prospective Cohort Studies American. Journal of Psychiatry 175(7), 631–648. (4) Wooley, H., Pattacini, L. and Somerset-Ward, A. 2011. Children and the Natural Environment: Experiences, Influences and Interventions – Summary. Natural England Research Reports, Number 040. Available at publications.naturalengland.org.uk/file/61087 (5) Faculty of Sport and Exercise Medicine. The Role of Physical Activity and Sport in Mental Health. A Faculty of Sport and Exercise Medicine UK Joint Position Statement with the Sports and Exercise Psychiatry Special Interest Group of the Royal College of

Lifestyle Factors Affecting Mental Health Psychiatrists. Available at www.fsem.ac.uk/position_statement/ the-role-of-physical-activity-and-sport-in-mental-health/ (6) Mind. 2021. Available at www.mind.org.uk/about-us/our-policy-work/sportphysical-activity-and-mental-health/resources/toolkit-for-the-sport-sector/ ?msclkid=e8ad3d16cd4011eca221581cbfbecdc7

Useful Resources Web-Based Resources ➢ The Royal College of Psychiatrists has produced a guide called Exercise and Mental Health for Young People. Available at www .rcpsych.ac.uk/mental-health/parents-and-young-people/young-people/ exercise-and-mental-health-for-young-people

Technology The explosion of the digital world has probably been the single biggest change to our children’s upbringing compared to our own. Some people call the younger generation ‘digital natives’, as they have been raised with technology, while the older generation are known as ‘digital immigrants’, having come to it later. Just because children and young people know how to use technology well doesn’t necessarily mean they are using it safely or are in control of their use. If there are concerns about children’s and young people’s technology use, there may also be a detrimental impact on their mental health. So, it’s our responsibility as adults to try to exert some control and offer screen hygiene advice and support. However, it’s important to take a balanced approach and consider both positives and negatives of technology. It’s helpful to spend time considering the content and type of technology consumed rather than just the amount. If we support children and young people to make good digital choices, there is likely to be a positive impact on their mental health and learning.

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Is Technology Bad for Mental Health? ➢ The evidence for how technology impacts on mental health is only just starting to emerge. As technology is still changing so rapidly, research can’t keep up with all the changes. But recent research suggests we should take a balanced approach: weighing up both potential harms and benefits. ➢ Although it is difficult to show there is a causal link, there have been concerns about how the rise in mental health problems in young people is associated with increased technology use. Some evidence has connected harmful screen use to certain mental health difficulties, and young people who consume social media excessively are more at risk. ➢ A recent large Oxford study by Prof. Przybylski of over 120,000 adolescents showed that moderate use of digital technology is not intrinsically harmful and may be advantageous. Both little and no use of technology are associated with lower wellbeing (as they may be ‘left out’ socially) and very high use is associated with a small but measurable negative influence. Also important is what kind of technology is used and when it is used (1). ➢ In general, the evidence is mixed: there are benefits as well as disadvantages. It is not all bad, but people are starting to realise the content of what we consume is very important.

Potential Positives for Mental Health ➢ Technology can break physical boundaries. We can now connect with people across the world to share information and support. Technology has been helpful for many people’s mental health throughout the COVID-19 pandemic as it has allowed many families and friends to stay connected. ➢ Young people can find like-minded people much more easily online. This is particularly helpful for young people with less common conditions, for example those with gender difficulties.

Lifestyle Factors Affecting Mental Health

➢ We can learn interesting things and keep up with the latest updates, which were previously inaccessible. Families can access relevant information online, especially if they use websites from reputable sources, and many children and young people have been able to engage with online learning or access entertainment when there was very little else to do. ➢ Technology can offer new creative and innovative outlets for young people to explore, including art, photography, writing and storing information. They can share and showcase work, which can lead to positive wellbeing. ➢ Some websites, apps and resources offer helpful mental health tools. As an example, Moodgym was initially an online resource designed to help those in rural Australia prevent and manage depression and anxiety using psychology tools. It is now globally available for a fee (2). There are many similar resources available online, including self-harm monitoring apps, and tools to connect with therapists or to access online therapy.

Potential Negatives for Mental Health ➢ Time online may detract from time spent experiencing the real physical world and undertaking healthy activities such as playing outside. ➢ There is a danger of consuming too much technology and developing addictive-like behaviours. There has been a recent explosion in accessible technology designed by large unregulated companies to keep people hooked to maximise profit. Certain vulnerable young people, for example those on the autistic spectrum, are more susceptible to excessive screen use. Adam Alter gives some helpful insights in his book (3) about how games companies keep people hooked, and these are useful for parents to be aware of. These include: 1. The principle of variable reinforcement, commonly used in slot machines and now increasingly used in most computer games. Variable reinforcement means you sometimes win a prize, but more often you lose. Research shows having a pattern of occasional and unpredictable ‘hits’ is a most powerful reinforcer to repeat behaviour.

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2. There are no natural ‘stop points’ in many computer games. If you were reading a book or comic you would naturally stop at the end of a page or chapter, but computer games are designed to just keep moving on, so children and young people playing them may find it very difficult to stop. 3. Games companies can use data from millions of users to keep refining their product in increasingly skilful ways to create experiences to hook people, so it’s no surprise that our vulnerable young people become so easily captivated. ➢ If people don’t have enough face-to-face interactions, their social skills and ability to connect with others can be affected. The quality of real-life connections is generally better for our mental health than we get from online social media contacts. ➢ There is a lot of misinformation online, which leads to young people getting inappropriate or harmful advice, for example sites that promote self-harm. Many forums designed to help those with certain mental health problems can be hijacked by those who share tips to maintain unhealthy behaviours, for example around disordered eating. ➢ Many children may be exposed to violent and sexual content before it is appropriate for them, for example pop-ups flashing up on sites like YouTube. Internet predators often know how to unlock information from social media sites. ➢ Cyber-bullying can spread through networks quickly and can be harder to escape from than physical bullying. Some young people have become severely mentally unwell, and inquests of several youth suicides in the last few years have uncovered cyber-bullying as an important contributory factor. ➢ There is pressure to post the best side of oneself online, which provides a false sense of reality. When young people then compare themselves with others, this often leads to them feeling inadequate. For example, in the Prince’s Trust 2019 UK survey of 2,162 young people (4), 57% reported that social media create an overwhelming pressure to succeed; 48% said that they felt more anxious about their future when seeing the lives of their friends online.

Lifestyle Factors Affecting Mental Health

What Do Mental Health Professionals Tend to Advise? Most mental health professionals take a balanced approach and current advice tends to be: ➢ Moderate technology use balanced with having frequent time in nature. The UK Chief Medical Officer emphasised the importance of taking a break and moving in her 2019 report (5). Encourage non-screen activities and being ‘unplugged’, i.e., leaving the phone behind where possible. ➢ Use pre-agreed limits of digital content and time. Try to negotiate screen-time and content in advance in a way that considers the child’s developmental level: teenagers can have longer than young children. It’s helpful to decide in advance what you think is a sensible limit for your child. Set down clear boundaries that prioritise school-work and other pre-agreed activities. It can be helpful for young people to use an audible stop timer. ➢ Monitor parental controls and content. Parents can monitor time and content by putting parental controls on screens. See guidance on keeping safe online in the section below. Some families make use of tracking devices if they are worried where young people are. ➢ Discuss online safety and the sharing of personal information. Talk to young people about what to do if they see something stressful online and explain that people are often not who they say they are online. It’s helpful for young people to know that when they share personal data, they then lose control of it, and it can be shared widely and used to bully or groom them. A good guide is that if young people are not happy for the adults around them to see an image, it’s probably not safe online. It’s common for teens to share images of their private parts to their girl/boyfriend (known as ‘sexting’), which they need to know can then be shared via social media and may be difficult to erase. ➢ Try to ensure young people don’t take screens to bed and to the dinner tables if possible. Screens are the biggest current threat to young people’s sleep. The Royal College of Paediatrics and Child Health recommends screens should be avoided an hour before bedtime (6). If you

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think this is too harsh, many people use the rule that all screens are put in a phone-bed in the kitchen or living room 30 minutes before bedtime. It also makes for good habits if screens go in a box during dinner. ➢ It is useful if schools can help young people learn screen hygiene and safety using Case Examples of young people who learn to stay safe online.

What Should You Do If a Young Person Seems to Have Lost Control over Screen Use or Seems Stuck? ➢ Discuss screen use with them. Does the young person see their use as a problem? Do they feel in control of their use or are addictive behaviours creeping in, like getting withdrawal symptoms without their devices? ➢ Encourage doing some activities without screens. Can the young person cope if they don’t take their phone to their bedroom? Can they put some barriers to prevent instant accessibility of apps, for example removing apps from their home screen, or setting a minute timer delay when they click on an app? ➢ If you continue to be worried, seek professional help. Go to the GP if you think there is an impact on the young person’s mental health and request a referral to a local mental health service. If you are concerned about gaming addiction, there is also now a UK National Centre for Gaming Disorders in London (7).

What Are Some Key Messages about Keeping Safe Online? It is helpful for you to give all children and young people the following key messages, especially when they have their own phones or devices: ➢ Do not give your name, address, contact details or school name to people you don’t know, even if you have talked to them a lot.

Lifestyle Factors Affecting Mental Health

➢ Never arrange to meet someone you have met online, unless you are with an adult. It’s a warning sign if someone asks to meet you alone. ➢ Never tell anyone else your log-in details or passwords. Change them regularly. ➢ Let your parents or caregivers know what you are doing online. Parents or caregivers will have to check your browser history and social media pages regularly to check you are safe. Avoid sites that focus on the following: body image; exploring means of self-harming; porn sites; inappropriate images. ➢ Criminal charges can be brought against people who carry out crimes online. The police have ways they can track people, so don’t hesitate to contact them if you are worried someone may be targeting children or young people you know.

Where Can You Find Further Guidance on How to Keep Safe Online? It’s important for adults to prioritise getting accurate information in the fast-changing landscape of online safety. Although there is a digital generational divide, children and young people need guidance around digital access and how to use devices safely and remain in control. Young people are often the most vulnerable groups. Here are some organisations which have put together online guidance for parents and caregivers: ➢ The UK National Society for the Prevention of Cruelty to Children (NSPCC) is a good place to start to look for advice. Their guide to online safety for parents/caregivers is helpful and is available at www.nspcc.org .uk/keeping-children-safe/online-safety/ ➢ Net Aware is an updated site managed by NSPCC and O2 explaining apps and sites young people use: www.net-aware.org.uk ➢ Thinkuknow is an online education programme for families from the National Crime Agency’s CEOP command. You can also report incidents directly to them. Available at www.thinkuknow.co.uk/ ➢ Parent Info is a site set up by CEOP and Parent Zone with advice for families: https://parentinfo.org

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➢ Safer Internet Centre was set up through the European Commission. It provides information, has a helpline and hotline: www.saferinternet.org .uk/ ➢ Internet Matters is an online educational website set up through industry partners BBC, Google, BT, Sky and many more who provide information to families about staying safe online: www.internetmatters .org/about-us/

KEY POINTS

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Technology is such a fast-moving field that the research hasn’t yet had a chance to provide conclusive advice on its longer-term impact on mental health.

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Most professionals advocate taking a balanced approach to technology which encourages some safe use, with agreed limits and controls. The important message is to take control of technology before it starts to control you.

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Some positives of technology include its ability to break down physical boundaries and connect with like-minded people as well as being a depository of helpful resources.

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Potential disadvantages of technology include a lack of physical connectedness; possible addiction, cyber-bullying and grooming; spreading of misinformation and harmful content.

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Guidance for parents and caregivers includes to moderate digital use and balance it with other activities; monitor time and content of use; discuss safe use; use parental controls; take care with sharing information; encourage screen-free zones in bedrooms and at dinner tables.

References (1) Przybylski, A., and Weinstein, N. 2017. A Large-Scale Test of the Goldilocks Hypothesis. Psychological Science 28(2), 204–215. (2) Moodgym, Australia, by e-hub Health Pty Ltd. Available at www.moodgym .com.au

Lifestyle Factors Affecting Mental Health (3) Alter, A. 2018. Irresistible: The Rise of Addictive Technology and the Business of Keeping Us Hooked. New York: Penguin Random House USA. (4) Princes Trust. 2019. The Prince’s Trust eBay Youth Index. Available at https://www.princes-trust.org.uk/about-the-trust/ research-policies-reports/youth-index-2021/youth-index-2019 (5) United Kingdom Chief Medical Officers. 2019. Screen-Based Activities and Children and Young People’s Mental Health and Psychosocial Wellbeing: A Systematic Map of Reviews. Available at https://assets.publishing.service.gov .uk/government/uploads/system/uploads/attachment_data/file/777026/UK_ CMO_commentary_on_screentime_and_social_media_map_of_reviews.pdf (6) Royal College of Paediatrics and Child Health. 2019. The Health Impacts of Screen Time: A Guide for Clinicians and Parents. Available at www.rcpch .ac.uk/resources/health-impacts-screen-time-guide-clinicians-parents (7) NHS: Central and North West London NHS Foundation Trust. National Centre for Gaming Disorders. Available at www.cnwl.nhs.uk/services/ mental-health-services/addictions-and-substance-misuse/nationalcentre-behavioural-addictions/National-Centre-for-Gaming-Disorders

Useful Resources Web-Based Resources ➢ See the last section of this chapter under the heading ‘Where Can You Find Guidance on How to Keep Safe Online?’ for a list of useful online information web-based resources for parents and caregivers. ➢ The Royal College of Psychiatrists produced a recent report examining technology use and its impact on mental health entitled ‘Technology Use and the Mental Health of Children and Young People’ (CR225) in January 2020. Available at www.rcpsych.ac.uk/docs/default-source/ improving-care/better-mh-policy/college-reports/college-report-cr225.pdf ➢ 5Rights Foundation exists to make changes to the digital world to ensure it caters for children and young people: https://5rightsfoundation .com/about-us/ ➢ MindEd is a useful mental health educational website that has training resources for schools and families on digital risk and resilience: www .minded.org.uk

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Bullying and Academic Pressures Although schools aim to be happy and supportive environments, it is common for children to experience some difficulties along the way. Sadly, many children and young people experience bullying at some stage or struggle with academic pressures. Challenges at school can affect mental health. If you understand these challenges in some detail, you may feel better equipped to support children and young people.

Bullying No one wants their child to be involved in bullying, but unfortunately it is a very common childhood experience. You can help children by being there for them and offering support when the going gets tough. Bullying is behaviour by an individual or group, repeated over time, which hurts someone else. It includes name calling, hitting, pushing, spreading rumours, threatening or undermining someone.

What Are Signs a Child or Young Person May Be Experiencing Bullying? Children are often reluctant to tell adults they are being bullied for different reasons: they can blame themselves, feel ashamed or may not want to worry their parents. Here are some common signs you may spot in a child or young person who is experiencing bullying: ➢ Not wanting to go to school. Younger children may complain of tummy aches or headaches to avoid school. It may be helpful to spot if there is a pattern to this happening, for example complaining of a stomach ache on a certain day of the week. ➢ Having more injuries than you may expect. Be aware that clothes can hide bruises. ➢ Personal belongings getting broken or lost more than you would expect without an adequate explanation.

Lifestyle Factors Affecting Mental Health

➢ Displaying withdrawn behaviour or other behaviour changes, for example irritability or aggression towards others, which is more common in children who struggle to express their feelings verbally. ➢ Struggling with school-work. Grades may start to worsen, or a child or young person may complain work is too hard. ➢ Reduced social contacts and friendship changes. Children and young people may isolate themselves more and go out less.

What Are the Effects of Bullying? The effect of bullying on a child or young person can depend on a range of factors including their personality and resilience, the severity and frequency of bullying and the availability of supportive adults. Here are some common effects of bullying: ➢ Increased risk of mental health problems including depression, anxiety and self-harm. ➢ Difficulty with relationships, including friendships. ➢ Difficulties settling at school or extra-curricular activities. Children and young people may start to try to avoid school and activities they previously enjoyed. ➢ Struggling with academic work due to difficulties with concentration and worries.

Who Gets Bullied? We can’t always predict who will get bullied. However, there are some features in children and young people which come up more commonly, including: ➢ Often children with a visible difference or those who struggle to stand up for themselves are targeted. ➢ Children with both mental and physical health vulnerabilities are particularly at risk.

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Why Do Some Children Bully Others? Bullying behaviour can stem from: ➢ Children’s own difficult experiences. Children and young people who bully others have often had difficult childhood experiences themselves, including abuse and neglect. Hurting others may be the child’s only way of dealing with difficult feelings, mirroring how some of their important adults also respond to stress. That’s why demonising the bully without considering their own background can be misguided. ➢ Some children with low self-esteem hold the mistaken view that bullying will earn them respect or friendship.

What Should I Do If I Think My Child Is Bullying Others? ➢ Try to talk to them in a non-confrontational way about what they are doing. ➢ Discuss the importance of treating others with kindness and respect, whatever their background. Try to get them to see things from others’ perspectives, for example asking, ‘Imagine if you were that person, how would you feel if someone did that to you?’ ➢ If they need help with working through their own issues, think about how they may access appropriate support through a mentor, school-based counselling or a referral to mental health services.

What Should You Do If You Think a Child or Young Person Is Being Bullied? There are several ways we can offer support to a child or young person. These include emotional and practical support as follows:

Lifestyle Factors Affecting Mental Health

Emotional Support ➢ Let the child or young person know you are there for them. See if they will open up to you. If not, try to find another trusted adult who they may feel comfortable talking to. ➢ Check on how they are regularly. If you are worried about their mental health, it is important to help them get further support if needed. ➢ Try to support the child or young person in making connections with friends and family and other sources of positive support. ➢ Distract them with activities they used to enjoy or get excited about.

Practical Support ➢ Ensure children and young people are safe online by checking their browsing history and social media sites with their consent. Ask them periodically what is going on online too. ➢ Prevent ongoing access to online abuse by trying to put a block on social media accounts that seem to be harmful. You can report online bullying on the social media site or app in question and create blocks. Childline (www.childline.org.uk) has specific guidance on how to do this. ➢ Keep evidence of the bullying, for example through a diary or screenshots so that the issue can be dealt with using factual information rather than hearsay. ➢ Report bullying to school as schools have a responsibility to deal with it. All schools should have a published bullying policy. It is often helpful for teachers to quietly alert other staff to keep an eye on the situation until they catch it happening, rather than confronting the bully. According to the Department for Education’s guidance (1), as well as within school, head teachers have the legal power to make sure pupils behave outside of school premises (state schools only). This includes bullying that happens anywhere off the school premises, for example on public transport or in a town centre. ➢ You can report issues that involve crimes to the police or antisocial behaviour coordinator, for example in the event of violence, physical or sexual assault, or theft, and if bullying occurs because of race, gender or sexual identity, which could include the illegal sharing of (or a threat to share) naked images of a young person.

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What If the School Fails to Deal with the Problem Helpfully? ➢ If your child or young person is experiencing bullying at school and you think the school is not taking enough action, you can write to your local authority and remind them that they have a ‘statutory duty’ to ensure all children in their schools are always safe (2). You can find template letters on the National Bullying helpline website (www .nationalbullyinghelpline.co.uk). ➢ Changing schools is a last resort, as it can often bring another set of difficulties with it, such as struggling with being the ‘new’ person and getting used to new systems. However, it may sometimes be necessary and helpful to avoid persistent bullying behaviours that schools struggle to stop.

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Bullying can be very challenging to manage and can have a significant impact on mental health. It’s important for supportive adults to learn to spot the signs of bullying and know how to support children and young people through these experiences.

Academic Pressures Like many adults, young people can struggle to get their work–life balance right: either working too much or too little. Although we want young people to develop a positive work ethic, some can lose their sense of perspective and become consumed by academic pressures, which may come at the expense of their mental health and wellbeing.

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Do Many Young People Struggle with Academic Pressures? ➢ A 2017 survey carried out by Young Minds found that 80% of young people surveyed said that exam pressure had a big impact on their mental health, while 96% said that exam pressure affected their mental health (2). In addition, 82% of teachers said the focus on exams has had a disproportionate effect on the wellbeing of their students.

Why Do Some Children and Young People Get Overwhelmed by Academic Pressures? There are several factors which may contribute to a young person feeling overwhelmed including: ➢ School systems which involve high-stakes examinations at key stages can lead to a build-up of stress at focal points. ➢ Children and young people who find learning a struggle, either due to mental health needs or learning difficulties, may fear they can’t keep up. ➢ Children and young people with perfectionist personality traits are particularly at risk of getting overwhelmed by pressures. ➢ School cultures with a strong academic emphasis but without sufficient access to support systems may pose a particular risk. ➢ Family cultures focused on academic results can build unachievable expectations for young people. This is particularly the case with highachieving parents who have themselves received positive rewards conditional on their academic successes. They may unwittingly prioritise academic success above wellbeing, which can make young people feel undervalued if they struggle to meet expectations.

When Is It Time to Step in? Here are some clues a child or young person may be struggling with school pressures:

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➢ They may be reluctant to go to school and complain school is too hard. ➢ They are putting more and more time into homework, at the expense of family, friends and other activities. ➢ There may be an impact on appetite and sleep. They may be staying up late to work and getting nightmares. They may try to exert some control over their eating, developing unhealthy eating patterns. ➢ They may display changes in behaviour and mood. ➢ They may have increased stress levels and complain of headaches or tummy aches. ➢ They may clam up and not want to talk about school or exams. ➢ They may get angry with themselves for little mistakes.

What Can You Do to Help? There are various ways you can support children and young people. Here are some suggestions: ➢ Encourage the child or young person to recognise the importance of getting a healthy work–life balance and offer some support in helping them redress this. It is useful if parents and caregivers can model a healthy work–life balance themselves. Academic work is only one part of a balanced life. ➢ Talk to school staff about how they support a healthy work–life balance. Schools should be alert to children and young people who are struggling and promote a nurturing ethos. ➢ Prioritise basic needs such as diet, sleep and exercise. It’s important to get to bed on time, to try to eat regular healthy meals and build in some daily exercise. You can find more information in the relevant chapters in this book. ➢ Use weekly schedules to plan in other activities, which you can increase over time. This may include helping children and young people to spend more time with family, encouraging social activities with friends and trying to help them get back into interests which may have dropped off. ➢ Managing perfectionist traits. Some children and young people may find self-help books or a referral to therapy useful to help realise that work can be ‘good enough’ rather than perfect. ➢ If a child or young person has got really stuck, they may need extra support from mental health services.

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KEY POINTS

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Schools aim to be supportive environments that nurture emotional and social development, but sometimes challenges get in the way of this.

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Children and young people may struggle to get their work–life balance right. They may need help in getting support, for the sake of their mental health and wellbeing.

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Academic pressures can become intense for many young people. It is helpful if we can sense when young people may be getting overwhelmed. We can then give them some support in trying to redress the balance, for example with sleep, food and exercise and helping them manage perfectionist traits.

References (1) UK government website. 2022. Bullying at School. Available at https://www .gov.uk/bullying-at-school/bullying-outside-school?msclkid=9deb29d3cd6a 11eca07adb050ff3713d (2) Young Minds. 2017. Wise Up – Prioritising Wellbeing in Schools. National Children’s Bureau, London. Available at https://youngminds.org.uk/ media/1428/wise-up-prioritising-wellbeing-in-schools.pdf

Useful Resources Web-Based Resources ➢ The National Bullying Helpline is a UK charity that offers support around all types of bullying. It has a helpline (0845 225 5787) and website: www.nationalbullyinghelpline.co.uk/ ➢ Bullying UK, part of Family Lives, is a charity that looks at how to offer support to all victims of bullying: https://www.familylives.org.uk ➢ The National Society for the Prevention of Cruelty to Children (NSPCC) has some useful information around supporting children who have been bullied: www.nspcc.org.uk/

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Alcohol and Drugs The negative impact of drugs and alcohol on adult mental health is now well known. The impact of drugs and alcohol on children’s and young people’s mental health is significantly greater. This is because alcohol and drugs can directly alter the way children’s and young people’s brains develop and therefore function. Many young people go through a risk-taking phase as they forge their own identities and take steps towards independence. Experimenting with drugs and alcohol can often be part of this phase, and for some young people drug and alcohol use can become problematic. I explore the impact of problematic drug and alcohol in more detail in Part 3 of this book. In contrast, this chapter focuses on how alcohol and drugs can affect mental health and wellbeing.

Alcohol Is There UK Guidance around Alcohol Use in Young People and Its Effects on Health? In 2009, the Chief Medical Officer of England published the first official guidance on alcohol aimed at children and young people (1). Some recommendations were: ➢ The healthiest and safest choice was for children to remain alcohol free up to age 18. ➢ There is evidence that drinking at a young age, particularly heavy or regular drinking, can result in physical or mental health problems, impair brain development and put children at risk of alcohol-related accident or injury. It is also associated with missing or falling behind at school, violent and antisocial behaviour, and unsafe sexual behaviour.

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What Are the Risks of Alcohol for the Brains, Minds and Bodies of Young People? The adult body can only process about one unit of alcohol per hour before it gets intoxicated. Young people can often process less than this depending on their age and genetic makeup. Risks of alcohol are: ➢ Short-term risks: Disinhibited behaviour which leads to poor social judgement, difficulty concentrating, poor coordination and reduced perception. ➢ Longer term: Alcohol can shrink the brain and ability to learn, remember and concentrate. It has a negative impact on mood and other mental health symptoms. ➢ Binge drinking: Can lead to alcohol poisoning, which is a medical emergency that needs urgent treatment in hospital.

How Can You Educate Your Child about Safe and Legal Alcohol Use? It’s important to talk to young people about their vulnerability and safety when drinking alcohol: they are more likely to experience an assault or crime when drunk, which also puts their mental health more at risk. It may be helpful to consider the following points: ➢ Model safe and responsible drinking, then young people are more likely to follow your lead. ➢ It’s against the law for those under 18 to buy or drink alcohol in restaurants, pubs and clubs. There is never a safe or legal reason to drink alcohol and drive. ➢ Help young people recognise the signs of alcohol poisoning and when to get help. This is useful for young people to be aware of when they are out with friends. ➢ Explain that it is important to drink slowly, rather than binge drinking, alternating alcohol with food and water. Try to make sure young

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people don’t go out on an empty stomach and recommend that they eat something when they meet friends for a drink. ➢ Plan to avoid problems around safety when young people drink, including making sure young people can get home safely and have people they trust with them. Make sure young people have the numbers of their friends’ parents so they can reach them if they need to. ➢ Be aware of safe drinking limits and the units of alcohol in different drinks. The current UK guidance is 14 units/week for adults over 18, and if 15- to 17-year-olds do drink alcohol they should limit drinking to no more than one day per week. Remember: a standard 175 ml glass of wine, a standard can of 5.5% lager or a pint of beer are all at least 2 units. You can find full guidance on the NHS website (2).

Drugs How Do Drugs Affect the Brain in Young People? ➢ Drug use can interfere with the developing brain. Adolescence is a critical period for brain development and drugs can alter how the brain develops. ➢ Drug use can affect problem solving and decision making. Young people can make risky decisions, which can affect their physical and mental health. For example, getting involved in unsafe sex and not being aware of road safety in the normal way can have repercussions on both physical and mental health. ➢ Drugs and alcohol have a range of effects on emotions. For example, we know that alcohol and cannabis have depressant effects. ➢ Many drugs and alcohol have an addictive potential. ➢ Many drugs can make mental health problems worse and trigger episodes of certain conditions. We now know about the strong link between cannabis and psychosis (see below) in vulnerable young people.

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What about the Links between Recreational Drug Use and Mental Health? ➢ There is evidence to suggest that young people who use recreational drugs have an increased risk of suicide, depression, psychotic symptoms and disruptive behaviour disorders.

What about Cannabis and the Link to Mental Health? ➢ There is special concern about the impact of cannabis in those with underlying mental health vulnerabilities. ➢ Heavy cannabis use (especially skunk) increases the risk of mental health problems including anxiety and low mood, impaired memory and psychotic symptoms such as hallucinations and paranoia. In fact, a study has shown that if you administer THC, one of the active chemicals in cannabis, to a person, you can cause psychiatric symptoms (3). ➢ Cannabis can also cause psychological dependence. This is when a person feels they need the drug to feel good and start to depend on it psychologically. This contrasts with physical dependence, where the body has a chemical need for the drug.

Are Many Other Drugs of Abuse Linked to Mental Health Symptoms? ➢ Yes. Several other drugs of abuse are also linked to mental health symptoms. There is more information on this topic in Part 3 of this book. As well as cannabis, other drugs can directly cause psychosis and induce a schizophrenia-type reaction, including amphetamines, LSD, ketamine and phencyclidine (PCP).

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Are There Any Tips for Helping Young People Understand the Impact of Drugs and Alcohol? ➢ Talk to young people about drugs and alcohol before they go to secondary school. It is highly likely that many young people are exposed to drugs in secondary school, and they will come across inaccurate information from peers. There is a very helpful book which can guide you on this topic called The Drug Conversation by Owen Bowden-Jones (4). ➢ Help build on young people’s self-esteem, so they feel confident in their ability to make their own decisions. You can help with this from a young age by encouraging them to make safe choices independently. ➢ Keep clear boundaries about what is acceptable behaviour and the possible consequences of making potentially harmful choices. Young people who know the rules and consequences for different choices are more likely to learn to make clearer decisions. If you explain what is behind your rules, they are more likely to follow. ➢ Discuss the impact of drugs, alcohol and tobacco on issues that are important to young people, for example physical appearance (e.g., on websites like drinkaware.co.uk). ➢ Young people may also not be fully aware of the impact of drugs and alcohol on their mental health. It may be helpful to look on websites such as Get Smart About Drugs (5), which outlines other young people’s experiences of drugs and alcohol. Young people generally relate better to hearing other people’s experiences rather than being told why not to do something. ➢ If you think your child has a problem with drugs or alcohol, you can get further information in Part 3 of this book.

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Drugs and alcohol use can have a direct impact on mental health and wellbeing. We know many young people do experiment with these substances, but we can try and educate them about safety and the impact of their choices.

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Although abstinence from alcohol is safest for young people, it’s helpful for young people to be aware of how to minimise risks if they do drink alcohol. Adults can help by modelling safe drinking; ensuring young people are aware of the law and units per drink; and how to look after themselves and their friends when drinking.

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We can help talk to our young people about how drugs can affect them. Tips include starting the conversation before children get to secondary school; looking up people’s stories around drug use; and keeping clear boundaries.

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There is a link between cannabis and mental health difficulties, particularly in those with brains already vulnerable to mental disorders. A sub-group of young people have a higher risk of paranoia and psychosis, especially if they use skunk (a potent form of cannabis). There are other drugs which can also have a similar impact on the developing brain.

References (1) UK Department of Health. 2009. Guidance on the Consumption of Alcohol by Children and Young People. A Report by the Chief Medical Officer. Available at https://webarchive.nationalarchives.gov.uk/20130103185806/ http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_110258 (2) NHS website. April 2018. Alcohol Units; Alcohol Support. Available at www .nhs.uk/live-well/alcohol-support/calculating-alcohol-units/ (3) Hindley, G., Beck, K., Borgan, F., et al. 2020. Psychiatric Symptoms Caused by Cannabis Constituents: A Systematic Review and Meta-analysis. Lancet Psychiatry 7(4), 344–353. doi:10.1016/S2215-0366(20)30074-2. (4) Bowden-Jones, O. 2016. The Drug Conversation. London: Royal College of Psychiatrists Publications. (5) United States government, Drug Enforcement Administration (DEA) website. Get Smart About Drugs. Available at www.getsmartaboutdrugs.gov/ consequences/true-stories)

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Useful Resources Web-Based Resources ➢ Talk to Frank is a UK website written for young people which has encyclopaedic information about the impact of drugs and alcohol on the body and mind. There is also a helpline for confidential advice (0300 1236600). Available at www.talktofrank.com/ ➢ Healthtalk (www.healthtalk.org) is a web-based project which has produced online films with people with various health conditions. There is a section on the impact on drug use in young people at https://healthtalk .org/drugs-and-alcohol/overview ➢ Get Smart About Drugs is the US Drug Enforcement Administration website. It aims to educate on the use of drugs and contains lots of useful information for parents and caregivers: www.getsmartaboutdrugs.gov/

Books ➢ The Drug Conversation by Dr Owen Bowden-Jones, a psychiatrist specialised in supporting people with drug and alcohol problems, is an extremely informative book written for parents about how to talk to young people about drugs. It also has lots of useful information about drugs and uses many Case Examples. It was published by the Royal College of Psychiatrists publications in May 2016.

3 The Impact of Relationships on Mental Health Having good relationships is one of the most important ingredients of positive mental health. People who feel more socially connected to family, friends or their communities are also often happier, healthier and live longer. Loneliness is a key predictor of poor mental and physical health. It can lead to problems with sleep, immunity and increased stress. However, loneliness can sometimes be hard to spot: you can still be lonely if you appear to be connected to several online networks. It’s the quality and types of connections we have that are more important than the quantity. The UK Campaign to End Loneliness brings together current research and data on this issue and produced an informative 2020 report (1). So, how can you help young people to develop healthy relationships? In this chapter I look at family relationships, social and peer relationships and romantic relationships.

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Family Relationships Our first relationships start in the family. Modern families take many forms, which can include single or two parent families, blended families (i.e., stepfamilies joining together), adoptive and foster families and cross-generational families. Whatever the family composition, the main role of parents and caregivers is the same: to provide children with longterm support, love and guidance. As mentioned in Chapter 1, the attachment relationship children have with their parents or caregivers is instrumental in determining their longer-term mental health outcomes. Moreover, family relationships are important as they become the models for all future relationships. However, as most parents would agree, navigating family relationships is one of our hardest tasks.

How Important Are Family Relationships to Our Mental Health? ➢ We know that family relationships are central to positive mental health and wellbeing. Family relationships have been one of the top three concerns reported to Childline in the last few years, reflected in the Childline 2018/19 annual report (2). ➢ A 2015 survey of 4,500 children across 11 Child and Adolescent Mental Health Services found that family relationship problems were the single biggest presenting problem (3).

What Are Some Benefits of Positive Family Relationships? Children with positive family relationships have: ➢ stronger relationships with others; ➢ improved ability to regulate emotions and respond to stress;

The Impact of Relationships on Mental Health

➢ improved self-esteem; ➢ better social and academic outcomes; ➢ stronger intergenerational relationships, for example with grandparents; ➢ improved recovery when they develop mental health problems.

How Can You Try to Build in More Positive Family Time? It is often difficult in busy lives to find family time, but if you can prioritise it, it can help you to develop positive relationships with children and other family members. Here are some strategies you could try: ➢ Aim for regular sit-down meals together. As discussed in Chapter 2, it’s helpful to aim for face-to-face connections without screens and request that phones are put away during meals. ➢ Prioritise family gatherings such as birthdays. You could also let teenagers know that their attendance would be highly valued, even if they only go for a short time. ➢ Think about which relationships need more support within the family, and how to nurture them. You don’t always have to do everything together. It’s important to be sensitive to the changing needs of different family members as times change. ➢ Set up regular family activities. Family activities could be planned in at least weekly for younger children, such as a park trip. The frequency is likely to reduce as children get older, but you can still aim for family time with teenagers. Having a walk together or playing a board game is a good way to start. ➢ Encourage children and young people to connect with extended family when possible. For many young people extended family can provide helpful support when their relationship with their parents gets tricky.

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How Can Adults Best Model Positive Relationships? Children and young people learn the most from adults around them: by watching and following patterns of behaviour. So, here are some tips to model positive relationships: ➢ Keep the communication channels open. No topic should be ‘off limits’ in terms of what children and young people can ask their parents and caregivers, although it is helpful for adults to have some conversations separately from children and know how to signal this to one another. ➢ Model sorting out difficulties through problem solving and compromise, as this has a positive impact on young people (4). It also helps preserve children’s security by increasing their confidence that any difficulties between their parents will be managed in a way that supports family harmony. It also reduces the likelihood of aggression. ➢ Practise listening rather than passing judgement. A good rule of thumb is to listen twice as much as we talk: we have two ears and only one mouth for good reason! ➢ Apologise when we make a mistake. If you don’t come from a family culture of apologising this may feel uncomfortable at first, but if you can get used to taking responsibility for your mistakes and saying sorry it gives children a great example. ➢ Try to make some individual time with each family member every week. With young people you don’t always need to make a date to spend time with them: chatting while giving them a lift can work just as well. I have noticed my children really benefit when I try to spend individual time with them.

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There’s no such thing as a ‘typical’ family nowadays: the modern family can involve many types of set-up. The quality of relationships matters more than who is in the family.

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Building positive family relationships is important for many reasons, including supporting positive mental health, developing self-esteem, emotional regulation and in building other strong relationships. Good relationships can also help us recover quicker from problems. Some tips to help families build relationships are prioritising family meals, setting up family activities and connecting with extended family. Adults can model positive relationships by practising constructive conflict, listening and being open, apologising for mistakes, problem solving and compromising. Try to spend some individual time with each of your children every week if you can.

References (1) Campaign to End Loneliness. July 2020. The Psychology of Loneliness: Why It Matters and What We Can Do. Available at www.campaigntoendloneliness .org/wp-content/uploads/Psychology_of_Loneliness_FINAL_REPORT.pdf (2) Childline. 2019. Annual Review 2018/19. Available at https://learning.nspcc .org.uk/media/1898/childline-annual-review-2018-19.pdf (3) Wolpert, M., and Martin, P. 2015. THRIVE and PbR: Emerging Thinking on a New Organisational and Payment System for CAMHS. New Savoy Partnership Conference, London, 11 February. (4) Goeke-Morey, M., Cummings, E., Harold, G. and Shelton, K. 2003. Categories and Continua of Destructive and Constructive Marital Conflict Tactics from the Perspective of U.S. and Welsh Children. Journal of Family Psychology 17(3), 327–338. doi:10.1037/0893-3200.17.3.327.

Social and Peer Relationships Human survival has always depended on our ability to connect with others: our ancestors could not survive alone, so they developed social skills to learn to connect with others. Although our dependence on others for survival has reduced, we still need others to meet our emotional and so-

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cial needs. Imagine how our life would be without social contact. Many ­parents appreciated the important social function of school in the first COVID lockdown in 2019. As young people develop greater independence through their adolescence, friendships and peer relationships take centre stage, and parents often feel pushed aside. As peer relationships are so important to young people, it’s not surprising these can have a huge impact on mental health and wellbeing, especially if young people feel excluded from their peers. So how can we help young people navigate social and peer relationships in a positive way?

What Are the Benefits of Social Relationships for Children and Young People? Social relationships can be beneficial for children and young people in several ways. Many appreciate this without you needing to explain it to them. However, some children and young people may find social relationships tricky, and it may be helpful to discuss some advantages of friendships with them: ➢ Friends offer loyalty, reassurance and support. Friends can encourage each other, especially through difficult times. ➢ Sharing activities together is often more fun than doing them alone. It gives you a feeling of connectedness with others, which meets your emotional needs. ➢ Young people develop social skills with others through friendships, including empathy, and listening to others, sorting out differences of opinion and managing conflict. These are important life skills. ➢ Being accepted by a friendship group helps young people develop their self-esteem and sense of identity as well as an understanding of when it is safe to trust others and disclose personal information.

The Impact of Relationships on Mental Health

What Is the Impact of Loneliness on Young People? It is important to try and prevent loneliness in young people for several reasons, including: ➢ Loneliness is a predictor of poor mental and physical health. It can lead to disrupted sleep, increased stress hormones and poor immune function. Loneliness is also a risk factor for antisocial behaviour, depression and suicide. ➢ You can still be lonely if you are connected to online networks. Feeling connected depends on the quality and type of relationships. Many young people describe feeling lonely and empty despite having more online friends than ever before.

How Can Parents and Caregivers Try and Encourage Positive Relationship Choices as Their Children Develop? ➢ Model keeping positive relationships yourself. This includes talking positively about other people when they are not with you and considering how you support your own friends. You can discuss how you are navigating your own relationships with your children. ➢ As children develop into their teens, continue to try to get to know who your children’s friends’ parents are. It’s not necessary to become best friends, but it can be helpful to make positive links with other parents and caregivers, so you can pick up when you hear a young person needs more support. It may also be helpful to understand acceptable boundaries within different families. ➢ Encourage extra-curricular interests which can help develop alternative social networks from school. Sports, music groups and

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Scouts, Guides, Cadets and Woodcraft are clubs which help develop social relationships where children can show another side to themselves than at school. Children and young people can also gain a sense of being part of another community.

Which Groups of Children and Young People Tend to Struggle More with Peer Relationships? ➢ Children and young people who are or who feel different in any way often feel excluded. ➢ Children with physical and mental health vulnerabilities and special needs can struggle with peer relationships and may find it very hard to fit in with peers.

How Can You Help Young People Develop Positive Social Skills? Some young people learn social skills more instinctively than others. Those that need more support in learning how to communicate appropriately and in navigating social relationships (such as young people with autism) may find online resources helpful, for example those put together by the National Autistic Society on making friends (www.autism.org.uk). School ‘sunshine’ groups set up by pastoral staff may help children develop social skills too. It may be helpful for supportive adults to consider practising the following skills with children who may need some extra guidance: ➢ Practise greetings. Learn how to greet people courteously by saying ‘Hello’ and ‘How are you?’, waving, smiling and trying to give eye contact. ➢ Practise listening and turn-taking. Explain the importance of listening to others and using non-verbal cues such as nodding as well as taking turns speaking in conversation.

The Impact of Relationships on Mental Health

➢ Explaining the importance of personal space and tending to personal hygiene. Explain that everyone has a personal ‘circle’ around them that others shouldn’t enter without permission. Also discuss the social importance of keeping clean. ➢ Practise using manners and being polite. Remind children to use please and thank you: politeness is a form of respect. Practise eating with cutlery quietly and waiting for others before eating. Practise waiting in queues. ➢ Encourage respectful play. Providing the opportunity to play with others is important. However, for some children this needs quite a lot of supervision until they learn the rules for respectful play, including waiting for your turn and learning that you don’t always win in games. ➢ Encourage using words to express emotions and needs. If a child is hurt, encourage them to say how they feel; if they snatch or push, encourage them to ask for what they need. You can use role-play to help children understand this. ➢ Learn to treat others in the way you would like others to treat you. We use the term mentalisation to describe the skill of being able to put yourself in someone else’s shoes. If you can mentalise you are more likely to be able to form positive relationships with others. We can encourage young people to reflect on how their actions may affect others, for example by saying things like: – ‘How would your brother feel if he saw that you had broken his model?’ – ‘If X were here now what could you do to make him feel better?’ – ‘If X were sitting in that chair now what do you think he would say?’

How Can You Encourage Children to Think for Themselves Rather Than Following the Crowd? It can be difficult for children to think independently as peer influences can be very difficult to resist! However, if you try and instil independent thinking in children it will help them to learn how to make their own choices. Examples of this include: ➢ Talk through the choices open to a child or young person before they do something with friends. This is particularly relevant where peer

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influences are likely to be strong. Practising using a ‘pros and cons’ list can be helpful. It’s important to consider the repercussions of personal choices and how to be assertive if the situation feels uncomfortable or unsafe. ➢ Encourage reflection after returning from activities in which young people feel they didn’t make positive choices due to peer influences.

What If Young People Fall out? Relationships are not all plain sailing: every relationship will have ups and downs. Here are some tips to manage falling-outs: ➢ Talk through what happened in a falling-out. Were there factors which may have made it difficult to manage the relationship positively? Some children may have background difficulties which affected the relationship, for example attachment difficulties or autism. ➢ Help young people take responsibility for their own behaviour and apologise for mistakes. It’s very difficult to behave respectfully all the time: the important thing is to be able to reflect on when we are less respectful to others and then apologise. ➢ Explain that although many break-ups are reparable; sometimes they are not, and in unhealthy relationships being apart may be for the best. Even if you as an adult felt your child’s friendship was mostly a destructive one for your child, your child may still have viewed the relationship as valuable. They may need to go through a grieving process to help them move forwards in a healthy way, and they may need your support with this.

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Humans have evolved to be social creatures: we derive emotional support from relationships, which has a positive impact on mental health. Social and peer relationships can have several benefits, including having fun, developing social skills and feeling connected with others. Loneliness, on the other hand, can be destructive to our health.

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•

•

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We can help young people develop positive relationships by supporting them to engage in extra-curricular activities, modelling respectful relationships ourselves and by getting to know other young people’s parents to develop support networks. Some children will need more support with social skills than others. We can help young people with skills such as practising greetings, understanding personal space, conversations and supervised play. Helping children learn to put themselves in someone else’s shoes is a key skill in relationship building. We can help support children and young people if they fall out to repair friendships. How much help they need will depend on their age and maturity. If relationships aren’t reparable, we can also support young people through break-ups, and later reflect on possible difficulties.

Romantic Relationships and Sex As young people grow up, many will start to have romantic relationships, which is a step towards adulthood and independence. But managing these types of relationships can be tricky and there are often significant effects on mental health and wellbeing. Parents and caregivers can often minimise potential negative effects on mental health if they help young people understand the features of healthy romantic relationships or how to seek help if there are problems, and support young people in navigating these relationships.

What Potential Issues Can Romantic Relationships Bring between Young People and Supportive Adults? Having romantic relationships is often an integral part of young people growing up and developing their identity. However, things are not always plain sailing, and the following issues may arise:

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➢ There may be a difference between a young person’s physical and emotional maturity and young people may need adult support in negotiating these relationships. This is especially the case if there are differences in age or maturity between the partners. ➢ Young people and parents can both feel unprepared when intimate relationships form. If this is the case, it is important to discuss how to manage this openly. Helping young people to regain control by helping them assert their needs is useful. ➢ Young people may start to become more emotionally distant from family members as they get closer to their partners. Adjustments in other relationships may become necessary.

What Are Some Developmental Patterns of Relationships as Young People Mature? ➢ It is common for late primary school age children to start talking about having romantic feelings for others. ➢ About 1 in 3 young people report sexual relationships before age 16 according to the British National Survey of Sexual Attitudes and Lifestyles (1).

What Are the Benefits and Pitfalls of Romantic Relationships for Mental Health in Young People? Having romantic relationships can have positives as well as potential difficulties in terms of the impact on mental health. Benefits of romantic relationships include: ➢ They can be exciting and pleasurable to experience, with a positive impact on wellbeing. ➢ They may help develop an adolescent’s self-identity, functioning and social inclusion.

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➢ They can offer positive support, especially in managing challenges. ➢ They allow rehearsal for how to have a close confiding relationship in adulthood. Young people can learn helpful skills like mutual trust and managing conflict constructively.

Some difficulties of early romantic relationships include: ➢ Some studies have found increased levels of stress, anxiety and depressive symptoms among adolescents who have had romantic experiences. ➢ Getting into a sexual relationship before they are emotionally mature enough can increase the risk of mental health difficulties. ➢ Getting too intensely involved with a partner at the expense of friendships can get in the way of building supportive networks and broader social skills, and it can also be difficult to pick up the pieces after a break-up. ➢ If relationships are unbalanced in any way, for example if one partner is controlling, a young person may not have the ability or skills to manage this, which can affect their mental health. ➢ If one partner has mental health difficulties, this can be challenging for the other partner to manage, and it may also increase their risk of mental health difficulties.

What Are the Important Features of Healthy Intimate Relationships? It is important to help young people understand how to build a healthy relationship. Here are some important features in healthy relationships, based on US government advice (3): ➢ Treating one another with respect, trust and honesty. ➢ Giving each other space and respecting each other’s individuality. Each partner should keep their own friends and hobbies and not have to change who they are to fit someone else’s expectations.

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➢ Open communication involving listening and problem solving, compromising and disagreeing respectfully. ➢ Valuing consent and not pushing the other person to do anything outside their comfort zone, for example sexually. ➢ Finding healthy ways to express anger. This involves talking through difficult feelings and knowing when to find personal space to calm down.

What Are the Warning Signs That a Relationship Is Harmful to a Young Person? Many young people find themselves trapped in controlling or harmful relationships. It is important to be aware of the following warning signs that a relationship may be causing harm. The following is based on the US Department of Health and Human Services advice (2): Controlling behaviour with rules of what the partner can/can’t do. Aggressive or intimidating behaviour towards their partner. Disrespectful behaviour or making fun of their partner. Having a high level of dependence on the partner with loss of their own identity. For example, a young person may be unable to make decisions without their partner. ➢ Evidence of physical or sexual violence in the relationship. You may notice bruises on the young person, or their partner may display rough or possessive behaviour.

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How Can You Help Young People in Controlling or Unhealthy Relationships? ➢ Explain your concerns to the young person. You could discuss the features of coercive relationships using examples from the media. ➢ Help the young person stay connected with others. It is important to try and maintain other supportive relationships.

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➢ Discuss how the young person can get support and think through next steps together. Supportive adults should be able to help the young person take back control. If this is not possible, please seek professional help. Coercive relationships are now legally recognised, and the police can become involved to help protect young people, especially if there has been violence or controlling behaviour (3).

Are There Helpful Tips for Talking about Safe Sex with Young People? ➢ Start introducing the idea of consent and healthy relationships from a young age. You could start by naming body parts correctly, then discussing that the body parts under your child’s underwear are private and no one should touch them without consent. At late primary school age you could then move on to discussing puberty as a pathway to sexual maturation. ➢ Most young people want to understand about sex and relationships from their parents/caregivers, and it’s helpful to share accurate information before playground rumours start creating misunderstandings. It is normal to feel awkward talking about sex, but the more you talk about it the easier it will get. ➢ Cover a range of topics (not all at the same time!). Suggestions are: – making decisions and the importance of informed consent; – ensuring both partners feel ready before they have sex; – information about sexual preferences; – for older adolescents: discussing safe places to have sex, pornography, contraceptive choices and STIs and risky sexual practices including chem-sex (when people take drugs to enhance sex). ➢ Let your child know you want them to feel safe in asking questions and confiding experiences. ➢ Use resources and books to help you, such as in local sexual health clinics, which also offer regular screening. The BBC and NSPCC both have good online resources in the UK. ➢ Find out how the school is covering sex education, for example are modern issues around texting sexual images, up-skirting and grooming covered?

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What about Exposure to Pornography? ➢ Many of you will be surprised at how early children and young people are exposed to pornography. A large UK survey commissioned by the NSPCC and Children’s Commissioner carried out in 2016 (4) showed most young people have been exposed to pornography by mid-adolescence. Exposure may have come through accidental clicking on pop-ups from other websites, which then rouses curiosity. So, it is helpful to try to be aware of what young people are doing online and have conversations about this too. A good rule in general for technology exposure is not to allow pre-teens access to their own devices without caregivers being present. ➢ The problem with pornographic exposure is it creates a false idea of how real sex happens: Over half of boys in the above survey who viewed pornography think it is realistic. Rather than sex happening as part of a loving intimate relationship, pornography shows a false idea of sex, focusing on penetrative sex with men treating women as submissive objects. Many young women report their partners expect them to perform as pornography models do. Accessing pornography can also become addictive to some young people.

What Is the Impact of Difficult Sexual Experiences on Young People’s Mental Health? ➢ A difficult sexual experience, for example sex where they have not given consent or sexual assault, can be very damaging for young people’s mental health. Young people can suffer invisible mental ‘scars’ and this can make them anxious and often wary and even lose confidence in getting intimate or having a relationship again. They may also be at increased risk of post-traumatic stress difficulties or anxiety and depression. ➢ Specialist therapy can often be helpful in supporting these young people.

The Impact of Relationships on Mental Health

KEY POINTS

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Romantic relationships can be positive experiences for young people, but they can also be difficult to negotiate. As there can be both positive and negative effects on mental health, it’s important to view them in a balanced way and see them as opportunities to develop. It is important for young people to understand what a healthy relationship is. Supportive adults should be aware of warning signs that a relationship is unhealthy and know how to support young people if they are concerned. Start talking about sex early on and have open conversations that allow for discussion. It’s helpful to be aware of the almost ubiquitous exposure to pornography at secondary school age and the false idea this gives young people about sex.

References (1) The British National Survey of Sexual Attitudes and Lifestyles. 2010–2012. National Surveys of Sexual Attitudes and Lifestyles 3. Available at www .natsal.ac.uk (2) Government Office of Population Affairs, US Department of Health and Human Services. Teenage Dating and Romantic Relationships Risks. Available at www.hhs.gov/ash/oah/adolescent-development/healthyrelationships/dating/teenage-dating/index.html (3) Youth.gov. Characteristics of Healthy and Unhealthy Relationships. 2020. Available at https://youth.gov/youth-topics/teen-dating-violence/ characteristics (4) Martellozzo, E. , Monaghan, A., Adler, J., et al. 2016. ‘I Wasn’t Sure It Was Normal to Watch It …’ A Quantitative and Qualitative Examination of the Impact of Online Pornography on the Values, Attitudes, Beliefs and Behaviours of Children and Young People. London Middlesex University. Available at www.mdx.ac.uk/__data/assets/pdf_file/0021/223266/MDXNSPCC-OCC-pornography-report.pdf

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Useful Resources Web-Based Resources ➢ The National Society for the Prevention of Cruelty to Children (NSPCC, www.nspcc.org.uk) is a UK-based charity with lots of helpful information and a telephone and online helpline for children and families. It has useful resources on how to talk to children about sex and healthy relationships. ➢ Brook (www.brook.org.uk) is a UK-based charity which runs several sexual and wellbeing services across the UK aimed mainly at young people. It also provides education and professional training. There’s also lots of excellent, up-to-date information on the website. ➢ Barnardo’s (www.barnardos.org.uk) is a UK children’s charity set up to protect and support children with helpful information about how to keep safe and healthy, including a Family Space with information on different age ranges for parents and carers. It has also launched a schools education programme on healthy relationships called ‘Real Love Rocks’.

4 Stressors Affecting Mental Health In Chapter 4, we look at a range of stressors (things that can cause stress) that affect children’s and young people’s mental health. In the first section I consider the term ‘stress’ and its impacts on the body and brain. I then go on to examine important forms of stress that can affect children and young people as they develop, including abuse and neglect, adverse childhood experiences (ACEs), trauma, bereavement and parental separation and, finally, the impact of COVID and other global public health issues. Different forms of significant stress can have both a short- and longer-term impact on children’s and young people’s mental and physical health. Indeed, many adult mental health difficulties can be traced back to childhood stressors. However, the news is not all bad: children and young people are resilient and strong, and if given additional support, love and guidance when under stress, they can often learn to develop through and beyond stress and learn new coping strategies.

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Stress We can all recognise stress. Stress is a response to a perceived threat or demand that is triggered by a stressor or threat. Our bodies then produce a stress response. What is less commonly known is what a lasting impact prolonged stress has on our mental and physical health. Stress can trigger and worsen many health conditions. Critical factors are the dose and length of stress experienced. This section gives a brief outline of stress and some strategies to help children and young people manage it.

Are There Different Degrees of Stress? Yes: the dose of stress we experience often determines how harmful it is. Like medication, a small dose may be helpful and protective, but an overdose is often harmful. We can classify stress according to the dose as follows: ➢ A small amount of stress can be positive and can help you perform better, for example performance stress can improve your performance at presentations and tests. In children a secure attachment to caregivers is the key to helping them cope with manageable stress in a positive way, for example with their first day at nursery. Indeed, managing stressful events helps build children’s and young people’s coping skills and independence. ➢ Tolerable stress involves more serious but manageable stress. Children and young people can tolerate a higher dose of stress if they have enough support from a caregiver and the coping skills to manage it. The body systems usually adapt to stress but can then return to normal afterwards without long-term damage to the body’s stress-response systems. There may be some impact on mental health, and children and young people may need extra support to get through stressful times successfully.

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➢ Chronic stress is much more difficult to manage and recover from and has a lasting impact on mental and physical health. Chronic stress involves prolonged activation of the stress-response system without the protective effects of caregiver support to buffer the stress. In other words, this is an overdose of stress. Classic examples are children exposed to ongoing abuse and neglect who don’t have adequate support systems to help them manage.

What Happens to the Body in Stress? ➢ The hormones adrenaline and cortisol activate the response to stress. ➢ The heart starts pumping faster, and lungs breathe more quickly so we can get out of danger. ➢ The muscles tense up so we can move quickly. ➢ The liver starts making more free sugar, which our body can use to burn energy. ➢ The gut and all non-essential systems shut down to prioritise getting energy to the essential body systems needed for survival.

Although it is normal to get these bodily responses to stress for brief periods in reaction to everyday life stress, there is cause for concern if these symptoms keep going for prolonged periods and start to interfere with our ability to get on with life.

What Causes Us to Experience Stress? ➢ There’s no straightforward answer: different things will trigger stress in different people. It’s important to help young people find out what their own triggers are. ➢ However, there are underlying factors in children which increase the risk of stress, such as trauma.

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Why Is Too Much Stress Bad? Continuous activation of stress hormones has a negative effect on most of our body systems, including the following: ➢ Stress affects the developing brain in a way that can alter its structure and function. The brain gets stuck into hyper-alert mode, and many pathways less essential to survival, for example those involved in learning and memory, are weakened. The reward system in the brain can’t function properly. Use of unhealthy coping strategies, such as using alcohol and drugs, can also lead to physical changes which have a knock-on effect on brain functioning. ➢ Inflammation in our body increases, including in blood vessels, which in the longer term can increase the risk of clotting, making heart attacks and strokes more likely. Chronic inflammation is also now known to be an important trigger for many mental disorders, including depression and anxiety. ➢ The immune system is suppressed: we are more likely to get sick from infections and other illnesses. ➢ The muscles become tense, which increases the risk of pain, headaches and muscle problems. ➢ Gut function can change, resulting in diarrhoea and tummy pains, which are associated with chronic stress. Stress is linked with negative changes in gut bacteria, which can also influence our mood and mental health.

How Can You Tell Stress Is Becoming a Problem? ➢ Stress may become a problem if a child or young person is experiencing it more often than you would expect and if it is starting to affect how they manage at home or school. ➢ Children may not always be able to tell you how stressed they are, but signs to look for include appearing tense and irritable with frequent anger outbursts.

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What Is the ‘Stress Bucket’? The ‘stress bucket’ is an idea first conceptualised by Brabban and Turkington (1) that may help young people understand stress. It goes like this: ➢ You can visualise yourself as a stress bucket that collects all sorts of stressors, just like a bucket collecting water. ➢ The size of the bucket depends on the number of problems you are exposed to: if you have more difficulties your bucket is bigger as there are more potential stressors to take in. ➢ Stress fills the bucket like water. You need to empty your stress bucket every so often by releasing water from holes or a tap, using stress-management strategies to stop it overflowing. ➢ You monitor the amount of water filling the bucket to make sure the bucket doesn’t overflow. You can use self-monitoring strategies to check you are coping and the water level isn’t getting too high.

Stressors fill the bucket,e.g., exam stress, parents ex arguing, bullying ar a rg

Bucket Bu B u filling up as stressors pour in

H Healthy stress level with good balance of water fflowing in and out

Holes in the bucket are coping mechanisms to help reduce stress, so water flows out, e.g., music, exercise and positive support networks

Figure 1:  The stress bucket

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What Can You Do to Help Children and Young People Manage Their Stress? The following stress-management strategies may be helpful: ➢ Find a way children and young people can learn to self-monitor the amount of stress they experience. Filling in charts of their stress levels, learning to communicate their feelings when under stress and understanding what their body does when stressed can help them to learn to self-monitor stress levels. ➢ Encourage time outside in nature. It could be a forest walk, a trip to the park or time spent in the garden. Nature brings about a reduction in stress. Fractals are repeating geometric patterns found in trees and flowers and have been shown to bring down stress levels by up to 60% (2). If you struggle to get outside, you can still get a soothing effect by having pictures of nature indoors. ➢ Getting enough sleep is key. (See Chapter 2: Sleep section for detailed sleep advice.) Keeping to a consistent bedtime routine is a helpful first step. Avoiding screens before bed and at night and maximising natural daylight exposure in the daytime are important. ➢ Exercise is a great way to reduce stress. The positive effects of endorphins can help counter the effects of the stress response. Exercise also helps sleep, if done well before bedtime. ➢ Breathing exercises, visualisation, mindfulness and yoga can be very helpful. One breathing technique helpful in children is to get them to hold up their fingers on one hand and then count along each finger in turn: first to breathe in for 3, hold for 4 and breathe out for 5 on each finger. Many apps and podcasts are available to help with breathing and mindfulness. ➢ Spending time with loved ones. Enjoyable social activities are great antidotes to stress. ➢ Find creative outlets, for example art, dance or listening to or playing music. ➢ Contact with animals can help bring down stress, hence the increasing interest in pet therapy in hospitals and care homes.

Stressors Affecting Mental Health

➢ Model calm problem solving when things get tricky. We are our children’s role models. If we can show how to compromise and solve problems effectively, children are more likely to follow suit.

What If Stress Is Getting out of Control? If stress is too much to manage at home, you can ask for further help as follows: ➢ You can ask for support from the GP or school counsellor in the first instance to help steer you towards other stress-management strategies. ➢ If stress becomes more ongoing and difficult to manage, you can ask for a referral to Child and Adolescent Mental Health Services.

KEY POINTS

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Stress is our body’s way of responding to a perceived threat or ­demand. Our body systems go into fight or flight mode to help us escape danger when under stress.

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There are different degrees of stress: a small amount of stress can be positive and can aid performance; a moderate amount of stress may challenge us but is tolerable; a chronic overdose of stress can be toxic. We usually recover from tolerable stress if there is adequate support around us, but chronic stress can cause long-term problems.

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Chronic stress can have a lasting impact on bodies, increasing the risk of physical and mental health problems.

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Stress-management strategies include maximising time outdoors in nature; breathing and meditation; exercise; spending time with loved ones.

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The stress bucket analogy may help young people visualise our ­capacity to manage stress and find outlets if stress is starting to overflow.

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If stress is getting out of control it may be time to get more help. The GP or school counsellor are helpful first ports of call.

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References (1) Brabban, A., and Turkington, D. 2002. The Search for Meaning: Detecting Congruence between Life Events, Underlying Schema and Psychotic Symptoms. In A. P. Morrison (ed.) A Casebook of Cognitive Therapy for Psychosis (Chap. 5, pp. 59–75). New York: Brunner-Routledge. (2) Taylor, R., Spehar, B., Wise, J., et al. 2005. Perceptual and Physiological Responses to the Visual Complexity of Fractal Patterns. Journal of Nonlinear Dynamics, Psychology and Life Sciences 9(1), 89–114.

Abuse and Neglect The 2018 government report, ‘Working Together to Safeguard Children’, defines child abuse as ‘a form of maltreatment of a child’. It goes on to say ‘somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm’ (1). High-profile cases of children exposed to horrific abuse come up in the media every so often. But many other forms of abuse are common and not always easy to spot, especially in children who have other vulnerabilities. Although abuse and neglect are more common in households where there is insufficient care and support, children can experience abuse when they come from loving, caring backgrounds, sometimes without the knowledge or understanding of parents or caregivers. It is important that all adults are aware of how to safeguard children and prevent harm where possible. This is because abuse and neglect also have a profound effect on children’s developing bodies and brains and can increase the likelihood of mental health difficulties and disorders.

How Common Are Abuse and Neglect in the UK? ➢ The Crime Survey for England and Wales estimates that 1 in 5 adults have experienced abuse before age 16, which is around 8.5 million people, so this is not a rare problem (2). However, it is difficult to get exact figures as many cases of child abuse remain hidden.

Stressors Affecting Mental Health

➢ In the year ending March 2019, Childline delivered almost 20,000 counselling sessions to children in the UK where abuse was the primary concern. Almost 50,000 children in England alone were looked after by their local authority because of their experience or risk of abuse or neglect.

How Does Abuse Affect Young People’s Brains and Mental Health? ➢ Young people who have been abused suffer from raised stresshormone levels for long periods, which puts their stress-response system out of kilter. This makes them much more vulnerable to mental health conditions, including depression, anxiety and personality difficulties.

What Are the Different Types of Child Abuse? The four traditional main categories of abuse are: 1. Physical abuse includes any way of physically causing harm to a child or young person, such as hitting, punching, kicking, as well as making up symptoms of an illness or causing a child to become unwell. 2. Sexual abuse is when someone is forced or tricked into sexual activities. There are two types: contact and non-contact abuse. Contact abuse involves physical contact, and can be touching, kissing, oral sex or penetration. Non-contact abuse is where the child is abused without being touched, for example, a child being exposed to pornography. 3. Emotional (or psychological) abuse is any type of abuse that involves the continual emotional mistreatment of a child, and can involve deliberately trying to scare, humiliate, isolate or ignore a child. 4. Neglect is the ongoing failure to meet a child’s basic needs, for example by leaving them hungry or dirty, without proper clothing, shelter, supervision or healthcare. This can put children and young people in danger and can have long-term effects on their physical and mental wellbeing.

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Are There Other Types of Abuse? This section may be more relevant to school staff and other professionals rather than parents and caregivers. The NSPCC now includes additional types of abuse which it may be helpful to be aware of (3): ➢ Bullying is behaviour that hurts someone else, and cyber-bullying is when it is done online. ➢ Child sexual exploitation is when a child is given things in exchange for performing sexual activities. It is a type of sexual abuse. ➢ Child trafficking (or modern slavery) is where children are tricked, forced or persuaded to leave their homes and are moved and then exploited, forced to work or sold. ➢ Domestic abuse is any type of controlling, bullying, threatening or violent behaviour between people in a relationship. Over 1 in 4 people in the UK will have been exposed to domestic abuse. Witnessing domestic abuse also counts as child abuse. ➢ Female genital mutilation is when a female’s genitals are deliberately altered or removed for non-medical reasons. This is still common practice in some cultures although high-profile campaigns are working to try to educate people to change this practice. ➢ Grooming is when someone builds a relationship and emotional connection with a child or young person so they can manipulate, exploit and abuse them. Grooming often happens online, and young people may be tricked into unbalanced relationships. ➢ Non-recent abuse is when an adult was abused as a young person. The effects of this can last a lifetime. Past abuse can make an adult much more likely to get into unsafe relationships (2) and enter into a cycle of intergenerational abuse. If parents have been abused themselves, they also may find it more difficult to deal with or even pick up abuse in children. ➢ Online abuse is abuse that happens on the Internet.

Stressors Affecting Mental Health

Do Abuse and Neglect Affect Developing Brains? Can Support Reduce These Effects? ➢ Children who have been abused or neglected show decreased activity and connections between parts of the brain. This is an active area of research. ➢ Studies which looked at children in institutions, like the Romanian orphanages of the 1980s where children were neglected and left in their cots alone all day, showed these children were at high risk of a host of disorders, including behaviour and psychiatric problems and developmental delays (4). However, the research showed that if these babies are taken into foster care or adopted at an earlier age, their brains have a better chance of catching up than if they remain in institutions for longer. This ties in with what we know about the protective effect of secure attachment on brains.

What Are the Longer-Term Effects of Abuse? It is important to note that children will vary in how they respond to abuse: not all children will have the same difficulties, and some children may not have longer-term problems. However, longer-term effects of abuse and neglect can be wide-ranging and can include: ➢ Emotional difficulties, such as anger, anxiety, sadness or low self-esteem. ➢ An increased risk of mental health difficulties, including depression and anxiety, eating disorders, self-harming and post-traumatic stress disorder. ➢ Drug and alcohol problems and self-harming behaviours are more common. ➢ Increased risk of physical health problems. ➢ Difficulties with building relationships and parenting their own children, due to the impact on trust and self-esteem. Thus, this has a

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trans-generational impact on children of people who have been abused. ➢ Risk of becoming the victims of future abusive relationships. It is difficult for young people who have been abused to judge how best to protect themselves and how to set appropriate boundaries in future relationships.

What Should You Do If You Suspect a Young Person Is Being Abused or Neglected? If a child talks to you about abuse or neglect, here are some helpful responses: ➢ Listen carefully to what the child is saying. Listening and telling children you believe them is one of the most powerful actions a supportive adult can make to a child. ➢ Let the child know they have done the right thing by telling you and tell them you will take it seriously. Try to make notes as soon as you can after the conversation, so you get the details right. ➢ Emphasise the abuse is not their fault. Young people are often confused about what has happened to them, and it is common that they have been led to believe they brought the abuse on themselves. ➢ Don’t confront the alleged abuser. This can put children at risk, and it is best left to skilled professionals who have the right tools and backup to deal with an abuser. ➢ Be open and honest and explain to them what you will do next. Let the child know their safety is your main concern. Explain that you cannot promise to keep things secret as you will have a duty to pass on information to protecting agencies. ➢ Report what the child has told you as soon as possible. In the UK, social care services via Multi-Agency Safeguarding Hubs are the first agency to contact. In the UK you can find information on this process on your local council website.

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Are There Any Tips about Caring for Young People Who Have Been Abused? Young people who have been exposed to trauma and abuse have more vulnerable mental states. Ways to help include: ➢ If you are worried about the immediate risk to a child, for example if you are concerned about abuse happening again, or if a crime has been committed, you can report it directly to the police. ➢ If you think a child or young person is at risk or being abused or neglected, contact Children’s Social Care at the local council (www.gov.uk/report-child-abuse-to-local-council). If you don’t know where the child lives, contact your own local council, the NSPCC or the police for advice. In the UK the NSPCC helpline team can support you with reporting abuse by putting together and sharing a report with social care services. They can be contacted at 0808 800 5000 or fill in an online form at www .nspcc.org.uk/keeping-children-safe/reporting-abuse/report/. ➢ Try to find out whether the abuse has been reported and has stopped. If there is any doubt, a referral to social care services would be a helpful step. ➢ Check that children are kept safe with multi-agency support, if needed. Usually, social care services will be the lead agency, and they have various stages of support depending on the level of concern. In cases where there is a high level of concern about the child’s ongoing safety a Child Protection Plan is put in place and different professional groups may be asked to contribute to core group meetings. ➢ Ensure the child or young person has access to at least one trusted adult who they can talk to and who is aware of how to access further specialist mental health support if needed. ➢ Consider how to support the family environment. Practical steps to support can often make a huge difference. ➢ Give the child or young person emergency helpline numbers they may be able to contact whenever needed, for example Childline (currently 0800 1111).

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➢ Encourage children and young people to have a creative outlet, for example through music or art, which can help build their resilience. Voluntary sector organisations are often helpful. ➢ Check which local specialist support services are available and how young people can access them. You may need Child and Adolescent Mental Health Service support if mental health needs are ongoing. There are also different types of therapeutic services that can help young people who have been abused and neglected. Social care teams are often aware of what is available. ➢ Children may find therapy helpful, for example play therapy, family therapy, psychology or psychotherapy. These may be set up through social care or mental health services. However, it’s imperative that the child or young person is safe and well supported at home and is mentally ready first. If therapy starts at the wrong time for the child, this can have detrimental consequences for their mental health. ➢ School support staff may need some information, so that school support plans can be put in place.

KEY POINTS

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Abuse and neglect are common and all around us. Current estimates are that 1 in 5 adults have experienced abuse or neglect at some point.

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The four traditional types of child abuse are physical, sexual, ­emotional abuse and neglect. There are now several other categories of abuse listed by the NSPCC, including child sexual exploitation and trafficking.

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If you suspect abuse in a child, report it to social care services or the NSPCC. If there is immediate harm to a child or a crime has been committed, contact the police.

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Abuse and neglect have long-term effects on young people including on their mental and physical health. Abuse can also affect how the brain develops. Effects can be minimised by strengthening supportive relationships.

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People who have been abused or neglected can be supported in different ways. Social care services are often the lead agency. It is important for young people to have a trusted adult, and access to specialist services if needed. Therapy may be helpful, but only if and when a young person is ready and adequately supported.

References (1) HM government. July 2018. Working Together to Safeguard Children. Available at https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/779401/Working_Together_to_ Safeguard-Children.pdf (2) UK Office for National Statistics. January 2020. Child Abuse Extent and Nature, England and Wales: Year Ending March 2019. Available at www.ons.gov.uk/peoplepopulationandcommunity/ crimeandjustice/articles/childabuseextentandnatureenglandandwales/ yearendingmarch2019#:~:text=1.,years%20(8.5%20million%20people) (3) National Society for the Prevention of Cruelty to Children (NSPCC UK). Types of Abuse. Available at www.nspcc.org.uk/what-is-child-abuse/ types-of-abuse/ (4) Mackes, N., Golm, D., Sarkar, S., et al. 2020. Early Childhood Deprivation Is Associated with Alterations in Adult Brain Structure despite Subsequent Environmental Enrichment. Proceedings of the National Academy of Sciences of the USA 117(1), 641–649.

Useful Resources Web-Based Resources ➢ The National Society for the Prevention of Cruelty to Children (NSPCC) website (www.nspcc.org.uk) has a treasure trove of information about abuse and neglect with lots of helpful definitions and a guide to UK child protection services.

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Adverse Childhood Experiences (ACEs) Adverse childhood experiences (ACEs) are traumatic events that happen in childhood that can lead to an increased risk of several mental and physical health conditions.

What Are the Different Types of Adverse Childhood Experiences (ACEs)? ACEs are traumatic events occurring before age 18 and can be split into the following categories: ➢ Abuse and neglect. (Please see the previous section for more information on this topic.) ➢ Household challenges, including domestic violence; drug and alcohol misuse; parental mental illness or separation; bereavement or having a parent in prison.

How Were ACEs Discovered? What Is the Relationship between ACEs and Life Outcomes? ➢ The original ACE Study was conducted in America between 1995 and 1997 and included over 17,000 adults (1). ➢ The researchers found a strong direct relationship between the number of ACEs adults had experienced during their childhood and negative health outcomes. The results have been the springboard for new research and thinking as there are huge public health implications. ➢ People with four or more ACEs are: 4.5 times more likely to develop depression; have 14 times the number of suicide attempts; 11 times the level of intravenous drug use; and are 4 times as likely to have had sex by age 15.

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How Do ACEs Affect Our Brains and Bodies? ➢ The trauma of negative experiences directly affects the brain, including regions involved in learning, and the processing of rewards and fear. ➢ Trauma also affects hormonal stress responses.

What about the Impact of ACEs on Mental Health Outcomes? We now know that ACEs increase the risk of the following mental health outcomes (2): ➢ ➢ ➢ ➢ ➢ ➢

Depression and anxiety. Post-traumatic stress difficulties. Behavioural difficulties, including aggression. Self-harm and attempted suicide. Social isolation. Becoming a victim in future relationships.

How Can You Reduce the Impact of ACEs? You can significantly reduce the risk of the impact of ACEs on a child’s or young person’s life by trying to boost their resilience or coping skills. Here are some useful strategies to help with this: ➢ Ensure children have access to stable, nurturing relationships. Having an ‘always available adult’ they can turn to for support whenever needed is a key protective factor. ➢ Support parents and encourage them to develop core parenting skills. Parenting programmes that teach parenting skills as well as how parents can take care of themselves build resilience within the family.

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➢ Use strategies to help with children’s social and emotional development. This includes helping children learn about how to express their feelings and how to develop empathy, for example through nurture groups in schools. ➢ Increase support to infants and young children in higher-risk families. Children are resilient and strong. Their brains are still developing and can be influenced in positive ways, so intervening early with support tailored to the child, for example using an appropriate therapy or intervention, can change the course of children’s lives. ➢ Help children and young people develop strategies to manage stress. Basic strategies include paying attention to self-care, exercise and diet. (See earlier section on Stress within this chapter for further information.)

KEY POINTS

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Adverse childhood experiences (ACEs) include traumatic events that occur before the age of 18, such as abuse, neglect and other household challenges. ACEs can have a negative long-term impact on children’s and young people’s physical and mental health.

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There is a strong relationship between the number of ACEs and their impact on health outcomes: those who have been exposed to more ACEs are at increased risk of negative mental and physical health outcomes.

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We can work together to change children’s and young people’s risk of negative outcomes by intervening early to support them. Examples of helpful interventions include providing at-risk families with parenting and community support; ensuring children have positive attachment relationships (including having access to an always available adult); as well as building up emotion-regulation and social skills.

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There is reason to be hopeful. Children’s and young people’s brains are still developing into early adulthood. We can help change the course of children’s development by offering positive support.

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References (1) Centers for Disease Control and Prevention (CDC USA). Available at www .cdc.gov/violenceprevention/aces/index.html (2) Felitti, V., Anda, R., Nordenberg, D., et al.1998. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine 14(4), 245–258. doi:10.1016/ s0749-3797(98)00017-8.

Childhood Trauma Childhood trauma underlies a wide range of different mental health difficulties and disorders. Understanding the impact of childhood trauma is a rapidly expanding field and overlaps strongly with research into adverse childhood experiences (ACEs) and stress. However, trauma can include different experiences apart from ACEs, and hence merits its own section.

What Is Trauma? ➢ Trauma is caused by an event that a child finds overwhelmingly distressing or emotionally painful and often results in long-lasting mental or physical effects. ➢ How trauma affects a child or young person will vary by their age and stage of development.

How Can Trauma Be Classified? The type, complexity and dose of trauma are important. Although trauma can be classified in a variety of ways, a simple classification is as follows: ➢ Acute trauma results from a single incident, for example the experience of a natural disaster like a flood or earthquake; a road traffic accident; a medical procedure; witnessing a single act of violence or sexual abuse.

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➢ Chronic trauma is repeated and prolonged. Many children’s experience of trauma in the family home, for example domestic violence, is chronic. Chronic exposure to illness and traumatic grief can also come under this category. Prolonged separation from a caregiver can lead to chronic trauma. ➢ Complex trauma is exposure to varied and multiple traumatic events. Children and young people exposed to extreme traumatic events, including wars or terrorism, often experience complex trauma. Many children and young people who have struggled with severe physical or sexual abuse through their development can also experience complex trauma.

What Are the Effects of Severe Trauma on the Developing Brain? ➢ When a child experiences trauma, their brain enters into a heightened state of stress and the primitive centres of the brain (including the area known as the fear centre) are overactivated. The child will often struggle with being calm and feeling safe. ➢ Children are particularly vulnerable to trauma because of their rapidly developing brains. Growing brains can carry lasting imprints of trauma due to the overactivation of pathways relating to stress. ➢ The higher centres of the brain, including the thinking centres and the emotion-regulation centres, are underactive. The child often struggles with concentration, learning and managing emotions.

What Are Some Longer-Term Mental Health Impacts of Trauma? ➢ Increased risk of depression and anxiety. ➢ Behaviour problems.

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➢ The child can get into a prolonged heightened state of stress, which is harmful to the body and brain’s development. ➢ Difficulties with managing relationships.

How Can You Help Young People Who May Have Been Exposed to Trauma? At Home ➢ Help the child or young person feel safe. Support them to create their own safe space at home where both their basic and psychological needs can be met. ➢ Ensure a supportive adult is available to listen to the young person whenever needed. ➢ Refer children and young people for an assessment for psychological support, for example through a Child and Adolescent Mental Health Service. It’s important to make sure they are ready and well supported before embarking on any trauma work, otherwise it can be harmful. Other forms of therapy that don’t directly address the trauma could be available.

At School ➢ Talk to pastoral staff at school and think about how to put together a trauma-sensitive support plan. ➢ Ensure the child has access to a safe quiet space they can go to whenever they need to. ➢ Ensure the child has access to a trusted staff member for support when needed, for example a mentor or counsellor. ➢ Request trauma-specific training for support staff. ➢ Consider setting up coping skills resources for children and young people in vulnerable groups in consultation with mental health professionals. This could include setting up a quiet room with play equipment, introducing mindfulness sessions or self-care skills sessions.

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Is There Reason for Hope? What Is Post-Traumatic Growth? ➢ There is growing interest in the field of post-traumatic growth. There is emerging evidence that many people may experience positive growth after some types of trauma. According to Tedeschi and Calhoun (1), after trauma, people may find a new appreciation for life, develop more meaningful relationships, feel more empathy for others’ suffering or have an increased sense of personal strength. ➢ However, it’s important to emphasise that children and young people are likely to need a significant amount of support in their development prior to being able to experience post-traumatic growth. Also, the dose and complexity of trauma experienced will determine whether growth is possible. ➢ Supporting children and young people to reframe their life’s journey as a story where change, upset and learning is an inevitable part of development can often offer hope.

KEY POINTS

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Trauma is caused by an event that is overwhelmingly stressful or painful. It can be acute, chronic or complex.

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People experience trauma from a wide range of triggers from v­ iolence, abuse and accidents to separation from caregivers.

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Trauma has a lasting impact on the brain and body and increases the risk of many mental and physical difficulties, including depression, anxiety, behaviour difficulties and chronic stress.

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We can help young people recover by trying to ensure they feel safe and having a trusted adult available who can listen to them. We can make schools more trauma-sensitive through training, ensuring access to safe spaces and mentors.

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It is hopeful that many young people do manage to achieve some post-traumatic growth after trauma, especially if they have had positive support.

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References (1) Tedeschi, R., and Calhoun, L. 2004. Posttraumatic Growth: Conceptual Foundations and Empirical Evidence. Psychological Inquiry 15, 1–18. http:// dx.doi.org/10.1207/s15327965pli1501_01.

Useful Resources Web-Based Resources ➢ www.childtraumarecovery.com is a British website written by a group of UK-based researchers who study childhood trauma. It has lots of useful advice around how to support children and young people who have experienced trauma. ➢ Young Minds, a UK youth mental health charity, has produced a helpful guide on trauma for parents and carers. Available at www.youngminds.org .uk/young-person/coping-with-life/trauma/ ➢ The National Child Traumatic Stress Network (www.nctsn.org/) is an American organisation which has helpful information about resources and treatments for childhood trauma.

Books A Terrible Thing Happened by Mary H. Holmes (Magination Press, Washington, DC, 2000) is a book that helps children with trauma by telling a story about a racoon who witnessed a traumatic incident. He struggles with behaviour and then is able to talk through his difficult feelings with a trusted adult (an art therapist). Recommend age range: 4–8. Please note further resources are available in Part 3 of this book in Chapter 17: Difficulties with Trauma and PTSD.

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Bereavement and Parental Separation Bereavement Going through a bereavement of someone close to us is often one of the most difficult life events we all have to deal with. My own personal experience of losing my father and aunt when I was young had a profound impact on me. It is likely that you too will have experienced your own significant bereavements. If you haven’t yet been able to process your grief, you may find this a difficult topic to read about right now: if so, please don’t feel you have to read this section until you are ready. If a child or young person experiences the death of someone close it is usually a devastating experience. According to the UK child bereavement charity Grief Encounter, 1 in 29 children suffer the death of a parent before they are 16. The impact of loss and the process of grief on a young person’s mental wellbeing and health can vary hugely depending on the age and maturity of the child and the strength of their relationship with the deceased. On a positive note, most children and young people are resilient, and can recover even from major life events with appropriate support. It’s important, however, to know how to access professional help to support a young person’s mental health if you need it.

How May the Death of a Loved One Be Experienced by Children and Young People? ➢ The death of someone close is often a major life event that can lead to a grieving process in children and young people. ➢ There may be significant psychological trauma in some children, depending on the circumstances, especially in those who are already vulnerable.

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What Factors May Affect How a Child or Young Person Responds to Major Life Events Including the Death of a Loved One? Children and young people can vary hugely in how they deal with life events like losing a close relationship. Factors which may affect their coping include: ➢ Developmental stage and maturity. As children grow, their brains are developing in tandem with their level of understanding of the world. A 5-yearold will have a very different concept of loss compared with a 17-year-old. ➢ The quality and strength of the relationship. Experiencing the death of a parent will be a different experience from losing a more distant relation, such as an elderly relative. The quality of the relationship will also impact on how the loss is experienced. ➢ The degree of support at home and in school. A child with a high level of support will often be able to manage their loss better. ➢ The child’s resilience and coping skills. Children and young people who have developed positive coping skills will often manage better. Those who have experienced other traumatic events will find it harder to build coping skills.

How and Why Do Children Experience Death Differently from Adults? ➢ Children may not fully understand their loss or be struggling to process it. Children may behave in puzzling ways or appear to ignore their loss. For example, it is common for children to jump between talking about their loss and other mundane things, such as ‘Why did mummy have to die? Can I have a biscuit now?’ This switching between emotional states may be a protective mechanism to process painful emotions in manageable doses.

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➢ Children may find it difficult to put their experiences into context, so they may become completely overwhelmed by the loss of a loved one, and not understand how life can fit together without them. For many children, having the space to talk about how they understand their loss with a supportive adult can be helpful. ➢ Children may have limited language, so find it difficult to process emotions verbally. Working through their emotions through play or artwork may help them move forwards.

At What Age Do Children Start to Understand Death? ➢ Children under 5 do not yet understand that death is final and inevitable. ➢ Between 5 and 9 years old, children generally start to gain further understanding of the inevitability of death, but this may include fantasy elements. ➢ From age 10, children tend to gain a fuller understanding that death is universal and irreversible. ➢ From mid to late adolescence, young people develop a deeper understanding of death in terms of the contextual and relational factors.

What Are the Stages of Grief in Young People? Although children may go through different stages of grief, depending on a range of factors (including their level of understanding, maturity and the type of loss), older adolescents tend to go through the traditional stages of grief in a similar way to adults. These five main traditional stages of grief were first explained by Elisabeth Kubler-Ross in her 1969 book On Death and Dying (1) and are as follows: 1. Grief starts with denial when we refuse to believe the reality. 2. This shifts to anger, which can be directed at the person who died for leaving us, or others for not having saved them.

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3. The third stage is bargaining, for example we may bargain with God or a higher power to try and bring the person back. 4. The fourth stage is depression, when the reality of living without our loved one sets in. 5. Acceptance is the final stage of coming to terms with the loss.

How Can Children Be Helped through Grief? Specialist counselling services for children can be valuable in helping them manage their grief. Depending on their age and understanding, children may go through different patterns of grieving, but many children may follow these steps: ➢ Understanding what death means and being able to recognise when it has happened. It is often helpful for children to be guided through this process using books or video clips (e.g., those recommended on the Cruse website: www.cruse.org.uk) which can be pitched at their age and level of understanding. Once children develop some understanding of the irreversibility of death or loss it is also important for them to understand the rest of their family isn’t in immediate danger. ➢ Understanding the reality of death and accepting the emotions that go with it. Although the reality is painful, we should not give children false hope that a loved one may return after death. Children can process the truth if it is explained with sensitivity and may get confused if you try to avoid the truth. It is helpful for children to understand they can keep their memories alive of their loved one, but that grieving may trigger a range of emotions. ➢ Reorganising a child’s sense of identity and moving on. The child can manage other relationships without being too afraid of others’ deaths. They can still remember their loved one, perhaps using photos or books to talk about memories, and feel that they can move forwards with their grief.

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What Strategies Are There to Help Children and Young People Manage Grief? Depending on the child and the circumstances, some of the following strategies may be helpful: ➢ Make sure children have a close confiding relationship with a supportive adult and they have the space to talk when they are ready. Ensure parents and caregivers also have access to support. ➢ Explain that death is not their fault. Children and young people may experience feelings of guilt they can’t put into words. ➢ Give clear answers to questions and age-appropriate explanations of what happened that children and young people understand. Use clear language like ‘death’ rather than using the term ‘loss’, which is ambiguous. Do not give false hope. Specialist grief and family counselling services have good resources and booklets (see Useful Resources at end of this chapter). ➢ Give space and time to grieve but ensure children don’t become too isolated. ➢ Try out strategies to help children learn to manage strong emotions when they are struggling, for example relaxation exercises, mindfulness, talking to friends and support groups and trying to continue hobbies where possible are important. ➢ Lower expectations for behaviour and school-work for a while. Children may find it harder to talk about their loss and may express difficult feelings with challenging behaviour and find it hard to concentrate. Schools may be able to make some allowances. ➢ Give children and young people spaces and opportunities to talk in an open-ended way. Grief counselling may be helpful when they are ready to access it. ➢ Encourage play and creative expression. Music and art can be therapeutic. ➢ Some children and young people may need a higher level of support through mental health or bereavement services. This is especially the case if grief is complicated, death was sudden or happened to someone very close.

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When May a Child Be More Likely to Get Stuck in Their Grief and Need Extra Help? A child getting stuck in loss/grief may be more likely if: ➢ The death or loss was sudden or unexpected. ➢ The relationship with the person was complicated or extremely close. ➢ The child is unable to access adequate emotional support, for example if the surviving parent is lost in their own grief or is mentally unwell. ➢ The child didn’t have a secure attachment relationship. ➢ The child experienced trauma, for example abuse. ➢ The child is mentally unwell.

What Should You Do If You’re Worried a Child or Young Person Seems Stuck in Their Grief or Loss? ➢ Seek professional help if a child or young person is stuck in their grief. Complicated grief can exist in all ages and can lead to mental health problems like depression and anxiety. You may see prolonged changes in behaviour, or the child may struggle to function with everyday activities. The GP is often the first port of call, and they may refer on to a children’s mental health service or specialist bereavement service. ➢ Check how supportive adults are coping in the household, including surviving parents, as this will have a knock-on impact on how children are managing. There are local and national bereavement services available for adults, such as CRUSE (www.cruse.org.uk).

Parental Separation Most people find the ending of long-term relationships a painful process, which becomes more complicated when children are involved. Deciding to separate from a co-parent is often a very difficult decision. However, if parents separate in a way that keeps the children’s best interests in mind,

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it can often be a more positive choice for a family than children living in a toxic atmosphere. Parental separation is also a very common childhood experience: about 1 in 3 parents in the UK with children separate before their children are 18. According to official UK government statistics in 2017/18, this equates to around 3.5 million children (2). The impact of parental separation can vary considerably depending on a range of factors. An important one is how the process is handled and what supports are available to the children. It is very helpful if parents can work together to sort out contact arrangements that are in the best interests of the children. We advise parents to keep their own disputes or anger about the other parent separate as this will also help the child to maintain their own relationship with the other parent.

What Are the Most Common Worries of Children of Separated Parents? Children of separated parents may have the following worries: ➢ The separation was somehow their fault, or they could have done something to prevent it. Despite parents going to great lengths to reassure children, this is a common worry. ➢ Worries about not being able to see one parent. This is a real concern which, despite efforts of families, often becomes the reality. ➢ Worries about conflicts continuing. Often parents get into very real conflict, and children may be drawn into disputes, even when parents try hard to avoid this.

Are Children from Separated Families Disadvantaged? ➢ Divorce and separation can increase vulnerability to mental health problems.

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➢ On the other hand, exposing children and young people to environments where there are prolonged toxic disagreements can often be more damaging to mental health than parents separating. When children witness destructive conflict, some may experience increased worries and hopelessness, putting them at risk for depression and anxiety. Other children may act out in an aggressive manner, which increases their risk of behaviour problems (3). ➢ The impact of parental separation on mental health depends on several factors, for example the quality of the relationships between children and parents, underlying mental health vulnerabilities, circumstances of the separation and exposure to conflict.

How Can You Support Children If You Do Decide to Separate? ➢ Try to keep a rule of not saying negative things about the other parent in front of the children. This is where having other supportive relationships where you can express your anger away from the children is helpful: if you need help with this it may be useful to get counselling for yourself. If parents can remain civil and respectful to one another and discuss adult issues separately, they may be able to reduce the negative impact of the separation. Mediation can often be helpful if communication is difficult. ➢ Prioritise what is in the children’s best interests throughout the separation, especially with respect to maintaining contact with both parents when this is safe. We see many children and young people in mental health services who do not have a relationship at all with one parent. This lack of contact may not be deliberate but may be the result of conflicts between adults. Children often mourn the loss of a parental relationship. ➢ Children and young people often blame themselves for their parent’s separation. Even when parents think they have explained that children were not involved in any way in their decision to separate, you often need to spell it out several times in different ways to convince children. ➢ It’s important to remember children can experience grief from a range of losses, for example if contact is lost with a parent who moves abroad, a grief process may also start.

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KEY POINTS

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Many children unfortunately experience the loss of someone close either through death or moving away. One in three parents with children separate before their children are 18.

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It is common for children and young people to go through an ­adaptation or bereavement process following a loss before they can move on.

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Older adolescents tend to go through the traditional stages of grief in a similar way to adults. Children, however, may go through different stages of grief, depending on a range of factors including their level of understanding and maturity and the type of loss.

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It is helpful to give children and young people the space and time to grieve and to provide them with clear answers and the tools to help them recover. Giving false hope or ambiguity about loss can often be detrimental to recovery.

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It’s important to seek professional help if the child seems to be stuck in their grief. This is more likely if a child is otherwise vulnerable, the loss was severe, sudden or unexpected, or there’s not enough additional support around them.

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Parental separation can be less harmful to mental health than toxic destructive conflict. If we handle separations as positively as possible, mental health outcomes improve.

References (1) Kubler-Ross, E. 1969. On Death and Dying. New York: The Macmillan Company. (2) UK government, Department for Work and Pensions. 26 March 2020. Official Statistics. Separated Families’ Population Statistics: April 2014 to March 2018. Available at www.gov.uk/government/statistics/ separated-families-population-statistics-april-2014-to-march-2018 (3) Cummings, E., and Davies, P. 2002. Effects of Marital Conflict on Children: Recent Advances and Emerging Themes in Process-Oriented Research. Journal of Child Psychology and Psychiatry 43(1), 31–63.

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Useful Resources Web-Based Resources ➢ Cruse is one of the largest UK bereavement charities and has some helpful resources for children at www.cruse.org.uk/ ➢ UK child bereavement charities include Winston’s wish (www .winstonswish.org) and Grief Encounter (www.griefencounter.org.uk). They provide support and information to families where children have experienced the death of a loved one. ➢ Gingerbread (www.gingerbread.org.uk/) is a UK charity that supports single parent families with advice on coping with separation. ➢ The National Society for the Prevention of Cruelty to Children (NSPCC) has helpful advice pages on dealing with separation and divorce in a way that keeps the children’s interests at the centre. Available at www.nspcc.org.uk/keeping-children-safe/support-for-parents/ separation-and-divorce/ ➢ Relate (www.relate.org.uk/) is a UK-wide counselling service which provides family counselling and advice on understanding children’s feelings and behaviours during separation. ➢ Citizens Advice (www.citizensadvice.org.uk/) is a UK charitable organisation which can give advice to parents if their relationship breaks down and child maintenance payments.

Books ➢ Muddles, Puddles and Sunshine: Your Activity Book to Help When Someone Has Died by Diana Crossley and Kate Sheppard (Hawthorn Press, Chicago, 2001). This is aimed at helping primary school aged children process their loss and move forwards. ➢ The Sad Book by Michael Rosen (Walker Books, London, 2004). This is a very helpful book Michael Rosen wrote after grieving for his son. He uses his own experience to talk about loss in a simple but understandable way.

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➢ The Invisible String by Patrice Karst (Little, Brown Readers US, 2018) is a book aimed at primary school aged children. It has a lovely story about how children will always keep an emotional bond with people close to them, even through loss.

The Impact of COVID and Other Global Public Health Issues The COVID-19 pandemic took the world by storm in early 2020 and has had wide-ranging effects on us all, including causing significant deteriorations in many health outcomes. It has become clear that in addition to the direct impact on physical health, COVID also has had a significant impact on children’s and young people’s mental health, particularly in increasing their anxiety and stress levels. Mental health services have seen an unprecedented increase in demand, with some service areas and patient groups more affected than others. We are still in the process of trying to work out how to move forward from all of these changes and support children and young people in the best way we can. In this section I reflect on what we know so far about COVID and how we can learn from this and other similar public health issues, and how we can offer support moving forwards.

How Has the COVID Pandemic Impacted on Children’s and Young People’s Mental Health? ➢ A large national UK survey tracking children’s and young people’s mental health showed a significant increase in mental health difficulties between 2017 and 2021, which covers the period of the COVID pandemic (1). Rates of mental health disorder in children aged 6–16 increased from 1 in 9 to 1 in 6. Around 4 in 10 children reported their mental health had deteriorated between 2017 and 2021. Although this study can’t show a causal relationship between COVID and mental health,

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➢

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it was the largest single change affecting the UK population in this period, so is likely to be a major contributor. The COVID pandemic didn’t affect everybody’s mental health in the same way: some people were affected more severely than others. In children’s and young people’s mental health services, we found that many children struggled emotionally with being away from school for extended periods, especially without the social interactions of peers and other supportive adults. However, other children for whom school is very difficult found being more home-based a welcome relief. Co-space (2), a large study run from Oxford University based on parent reports of symptoms, looked at changes in children’s mental health symptoms from March 2020 to January 2021. It found that during the pandemic, behavioural, emotional and restless/attentional difficulties in children increased in lockdown. This was especially the case in primary school aged children. More secondary school aged girls experienced emotional problems than in previous months, especially with mood and anxiety difficulties. Children with special needs and those from low-income or single adult households had elevated mental health symptoms throughout the pandemic. The pandemic increased the inequalities in society, especially the life chances and risk of mental health for those less well off. A report by the Children’s Society in 2020 (3) explains this well. There was a disproportionate impact on UK black and ethnic minority families. Many families were pushed into poverty as parents lost their jobs, and children in struggling households had much less support from other agencies and informal networks. The lockdowns reduced the buffering effects of schools in helping to keep an eye on and support disadvantaged children. This was especially the case for children exposed to domestic violence, abuse, neglect and parental mental health problems. Children without access to reliable technology and knowledge at home fell increasingly behind peers. It continues to be difficult to address the learning gaps that resulted from the COVID lockdowns. Many children lost family and friends to COVID, leaving many people managing grief together without the usual support mechanisms. Long COVID has also been a significant problem for many families.

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➢ Children and young people had to adjust to extended periods without face-to-face social contacts. Lack of contact was difficult for many children to manage, especially younger children and those without the skills to take part in online education. Many children struggled with behaviour and difficulties with social skills.

Were There Groups of Children Whose Mental Health Seemed to Be Particularly Affected? ➢ Some children and young people found their anxiety levels heightened by the pandemic, especially those with pre-existing anxiety difficulties and physical health vulnerabilities. ➢ Some children, especially those with other risk factors, for example previous trauma or family difficulties, found their mood dropped significantly and was difficult to shift as the pandemic went on so long. The impact of a sustained low mood is an increased risk of future mental health difficulties. ➢ Many children and young people with OCD found it much harder to manage their condition in the pandemic, especially if obsessive thoughts related to germs or cleanliness. ➢ The number of children with eating disorders significantly increased (4). The impact on eating disorder services was significant, with many UK services struggling to cope with the increased demand.

How Can You Help Children and Young People Understand a Global Pandemic without Them Getting Too Unduly Worried about Them? ➢ Try and be honest about what is going on and explain why things are happening in age-appropriate terms, but without overwhelming children with unnecessary details or anxieties.

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➢ Many of the mental health charities, for example Young Minds (www.youngminds.org.uk), have produced helpful guides on managing COVID for children and young people that are freely available online. The publisher Nosy Crow published a free book (illustrated by Axel Scheffler) on their website (see Useful Resources below).

How Can You Help Children and Young People Stay Mentally Well during Difficult Periods like Lockdowns? ➢ Maintain a positive relationship with children. Investing in the caregiver–child relationship is more important than struggling to meet all the school’s learning outcomes at home. Many caregivers found that they didn’t transition well to the role of teacher, and children found it difficult to see their caregivers as teachers. ➢ Follow children’s interests and help them explore these themselves with support. Sticking doggedly to a dry curriculum can be a motivational challenge for parents and children alike. Children will learn more if there is time to explore their own passions. ➢ Prioritise each child getting some individual time with a significant adult each week. This could be with a grandparent if parents are very busy, and can also be done remotely, but they may need help in setting sessions up. ➢ Aim to exercise every day for the benefit of everyone’s mental as well as physical health. Children will sleep much better at night if they are physically tired, and a break from screens is also helpful. Getting out of the home is also very helpful for parents and carers. ➢ Try to keep the connection with extended family and friendship networks to reduce isolation and improve support. Set up videoconference or phone meetings or outdoor meet-ups. While virtual contact isn’t the same as face to face, it is often better than no contact. However, for younger children virtual contact may need to be brief and tightly structured.

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➢ Don’t be afraid to contact organisations for extra help. For example, if a child seems to need someone outside the family to talk things through, ask school for support through their pastoral care system. If things do seem to be getting worse, get in touch with the GP. Most organisations in health and social care found a way to offer support to those that needed it during COVID.

What Should I Do If a Child Seems to Need Additional Mental Health support? ➢ In the first instance, see your GP, and request a referral to mental health services. Mental health services still run throughout pandemics. They are key frontline services, although the models of care shift to more digital work.

What Are the Longer-Term Impacts of COVID and Global Pandemics? We are not yet fully aware of all the longer-term impacts of COVID. However, Young Minds has carried out various surveys throughout the pandemic to look at the impact on children’s and young people’s mental health and wellbeing, and their fourth survey, carried out in early 2021, showed two-thirds of young people felt that COVID would have a longterm negative effect on their mental health (5). It is likely that longer-term impacts may include the following: ➢ Physical health difficulties, including long COVID, may impact on families. If parents are unwell this affects children’s wellbeing. ➢ Many families will have experienced multiple losses, including deaths in their network, job losses and separations. Inequalities will have widened due to losses happening disproportionately among those more disadvantaged. ➢ The impact of losing many months of school or nursery education has yet to be fully understood. There is likely to be more of an impact on younger children in terms of their social skills and confidence.

Stressors Affecting Mental Health

➢ The pandemic may have enabled some positive changes to take place as we have all had to re-evaluate our priorities, and there has been a shift of focus in caring for the environment. ➢ Public health issues are now increasingly at the forefront of government thinking, and society’s appreciation for healthcare has improved. People are now increasingly aware that health underpins all else. Many people have gained a better view of what is important to them and have shifted their priorities. Many parents and caregivers are more available to their children as they work in an increasingly digital and blended way, and extended families have set up better digital connections. There are now more choices of different service provision due to increased digital availability. It’s important to always look for silver linings with children and young people, even when everything seems bleak.

KEY POINTS

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The COVID pandemic caused a deterioration in many children’s and young people’s mental health and had a particular impact on overall levels of stress.

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Unfortunately, the pandemic widened inequalities, which had a particularly negative effect on many deprived groups of children and young people.

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Some children with pre-existing mental health difficulties, for example anxiety and OCD, low mood, eating disorders and past exposure to trauma, found their difficulties increased.

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It’s important to be sensitive and thoughtful about how to talk to c­ hildren about the impact of COVID and use positive resources to help you.

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Important ways you can help children struggling in pandemics include prioritising your relationship; trying to maintain 1:1 time; building in time outdoors and keeping in touch with social and family networks.

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It is likely there will be long-term impacts associated with the COVID pandemic that are yet to be fully established. However, many important lessons have been learnt through the pandemic experience which may be helpful for other public health issues.

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References (1) NHS Digital. September 2021. Mental Health of Children and Young People in England 2021 – Wave 2 Follow Up to the 2017 Survey. Available at https:// digital.nhs.uk/data-and-information/publications/statistical/mentalhealth-of-children-and-young-people-in-england/2021-follow-up-to-the2017-survey# (2) Co-Space Study. University of Oxford. Available at https://cospaceoxford .org/ (3) The Children’s Society. 2020. Impact of COVID-19 on Children and Young People. Available at www.childrenssociety.org.uk/information/ professionals/resources/impact-of-COVID-19-on-young-people (4) Jayanetti, C. 21 February 2021. NHS Sees Surge in Referrals for Eating Disorders among under 18s. The Observer. (5) Young Minds. Coronavirus: Impact on Young People with Mental Health Needs. Survey 4: February 2021. Available at https://youngminds.org.uk/ media/4350/coronavirus-report-winter.pdf

Useful Resources Web-Based Resources

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The publisher Nosy Crow has produced a helpful e-book entitled Explaining Coronavirus to Children, which is freely available online at https://nosycrow.com/blog/ released-today-free-information-book-explaining-coronavirus-children-­ illustrated-gruffalo-illustrator-axel-scheffler/ The UK charity Young Minds (https://youngminds.org.uk/) has a wealth of useful resources on dealing with COVID.

5 Vulnerability of Special Groups Some special groups of children and young people have much more of an uphill struggle in their everyday ability to manage than their peers due to a range of underlying vulnerabilities. These children and young people often build up impressive strengths and coping skills through their experiences. However, they also tend to have a greater risk of mental health difficulties and disorders. Special groups we discuss here include young people with intellectual (learning) disabilities; gender identity difficulties and those of different sexual orientations; young people with physical health difficulties including chronic health problems; and young carers. In this chapter we outline some of the reasons why children and young people in these groups may have more mental health difficulties. Although this list of children and young people with vulnerabilities is not exhaustive in its scope, it highlights some important themes and issues.

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Intellectual/Learning Disabilities The terms intellectual disabilities and learning disabilities are often used interchangeably in similar contexts. The Royal College of Psychiatrists faculty in this field is now known as the Faculty of Intellectual Disabilities. However, there are resources under the term ‘Learning Disabilities’ on the same website. There are around 286,000 children (180,000 boys, 106,000 girls) age 0–17 in the UK with an intellectual disability (1). According to MENCAP, a leading UK-based learning disability charity, a learning or intellectual disability is: ‘a reduced intellectual ability and difficulty with everyday activities – for example carrying out household tasks, socialising or managing money – which affects someone for their whole life. People with this disability tend to take longer to learn and may need support to develop new skills, understand complicated information and interact with other people’ (1). It is well known in the sphere of mental health that those with intellectual disabilities are generally at increased risk of mental health and neurological problems. An important UK-based study for example found that more than a third of children with intellectual disabilities also have a mental health disorder (2). Unfortunately, this group of children and young people also have the double disadvantage of finding it much harder to communicate their difficulties and needs. So, accessing appropriate support and treatment can also be tricky. This field is an important one. So, if this is an area where you would like more detailed information, it may be helpful to turn to the Royal College of Psychiatrist’s website (www.rcpsych.ac.uk/mental-health/problems-­ disorders/learning-disabilities). Other specialist third sector intellectual disability organisations, such as MENCAP (1), also often have useful information.

Vulnerability of Special Groups

What Is the Difference between the Terms Disability and Impairment? ➢ Impairments are things which happen to our bodies or minds that can be problematic. Disabilities describe the extent to which having an impairment leads to disadvantage and discrimination. ➢ Nowadays there is a move towards using the term ‘impairment’ rather than disability. However, the term ‘disability’ is still used as a descriptor and most UK services and classification systems are based on it.

How Are Intellectual Disabilities Classified? ➢ The traditional classification systems were based on Intelligence Quotient (IQ) as follows: Mild (IQ 50–69); Moderate (IQ 35–49); Severe (IQ 20–34) and Profound (IQ below 20). However, we now consider this classification outdated. ➢ There is a move towards using classifications based on levels of adaptive functioning, as this gives us a better idea of the amount of support needed. Severity is quantified according to level of functioning.

What Causes Intellectual Disabilities? Intellectual disabilities may be caused by a variety of factors which can affect the brain when it is developing. These factors can happen before birth, during birth or after birth. Here are some examples of common causes: ➢ Before birth: While the brain is developing in the womb, there can be disruptions to normal development if the mother suffers from accidents, infections or illnesses or because of inherited factors. ➢ During birth: If the baby is born too early or the birth is traumatic, the brain is more likely to be at risk of bleeding and not getting enough oxygen. ➢ After birth: Exposure to certain childhood illnesses, seizures, accidents and toxic chemicals may affect the developing brain.

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Why Can It Be Difficult to Pick up Mental Health Problems in Children and Young People with Intellectual Disabilities? There are several reasons why it is harder to pick up mental health problems in this group including: ➢ Behaviour difficulties are thought to be due to the child’s intellectual disability rather than a mental health difficulty. This is known as clouding, which means people don’t tend to look beyond the intellectual disability for an explanation. ➢ Children with intellectual disabilities may present with a more unusual pattern of symptoms than expected for their age. ➢ Medicines taken for physical health problems may mask mental health symptoms.

Which Factors Affect How a Child Presents with a Mental Health Condition? The presentation of mental health problems in people with an intellectual disability will depend on: ➢ The cause of their intellectual disability: Some disabilities make people more vulnerable to certain difficulties, such as anxiety. ➢ The severity of impairment and ability to communicate: A child with a more severe impairment will struggle to put words to their distress. ➢ Personality factors: Children with intellectual disabilities will have their own personality styles and patterns of relating to others. ➢ Cultural factors: For example, religious or cultural practices may affect how families present and what they perceive as requiring support. ➢ Environmental factors: Changes to the environment, for example school changes, can have a profound impact on children’s ability to cope (3).

Vulnerability of Special Groups

How Can You Help? ➢ Find ways to aid communication, including allowing more time, using simple language, using open questions and using visual aids (e.g., cards with different facial expressions on them). ➢ Listen carefully to caregivers or anyone who knows the young person well to find out what the young person is usually like and if there have been any changes in behaviour. ➢ Use behaviour charts to track behaviour changes and when they happen. Is there any pattern? It can be helpful to use charts to also track more subtle changes over longer time frames. ➢ Think about possible changes which could trigger mental health problems. Internal changes include pain, medication, puberty onset, illness or missing home. External changes include bereavements, changes in staff, routines, moving home or school and class changes. ➢ Consider requesting an educational psychology assessment to better understand the child’s full learning profile. If there isn’t enough support at school and the work is not at the right level, children’s mental health may suffer. It may be that an Education, Health and Care Plan is also needed so that targeted resources can be put in place.

How Can Parents Access Additional Help or Support? ➢ Consider which school resources could be helpful. Special schools are equipped to manage a range of mental health difficulties. Mainstream schools may need to adapt their resources for the needs of specific children. For example, counsellors may need to go on more training. If you think your child has an intellectual disability but isn’t getting the support they need, you can request application for an Education, Health and Care Plan and educational psychology assessment. (See Part 2, Chapter 12 on helping to manage school for more details.)

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➢ Local and national third sector charitable organisations for children with intellectual difficulties can often offer support to families (including the telephone peer support of parents who have been through similar issues before) and may have guides and support workers to work with children and young people. ➢ Many mental health services have specialist intellectual disability teams or staff but generally only deal with those at the more severe end of the spectrum. However, most general youth mental health teams will deal with those with mild–moderate intellectual disabilities and can consult with more specialist colleagues if helpful.

KEY POINTS

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Intellectual (or learning) disabilities are lifelong conditions that affect the ability to learn and manage activities.

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Intellectual disabilities may be caused by different types of damage to the brain before, during or after birth.

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Classification systems are moving towards categorising the severity of intellectual disabilities based on the child’s level of adaptive ­functioning rather than IQ.

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Children with intellectual disabilities have much higher rates of mental illness than those without.

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Appropriate and prompt support for children and young people with intellectual disabilities who are struggling with mental health is very important. Different skills may be needed. Mental health services can provide specialist support.

References (1) MENCAP UK website. Available at www.mencap.org.uk/ learning-disability-explained/what-learning-disability (2) Emerson, E. , and Hatton, C. 2007. Mental Health of Children and Adolescents with Intellectual Disabilities in Britain. British Journal of Psychiatry 191(6), 493–499.

Vulnerability of Special Groups (3) BOND: Better Outcomes New Deliveries. A Consortium led by Young Minds. Children and Young People with Learning Disabilities – Understanding their Mental Health. Available at www.mentalhealth.org.uk/sites/default/files/ children-and-young-people.pdf

Useful Resources Web-Based Resources ➢ The Royal College of Psychiatrists’ website: www.rcpsych.ac.uk/ mental-health/problems-disorders/learning-disabilities. This site also signposts to the Books Beyond Words series, which contains a collection of books written in pictorial form for children and young people with learning disabilities. ➢ Young Minds, a leading UK child mental health charity, in association with an organisation called BOND (a disability and development organisation), has produced the very useful PDF leaflet available on the Mental Health Foundation website: BOND: Better Outcomes New Deliveries. A Consortium led by Young Minds. Children and Young People with Learning Disabilities – Understanding Their Mental Health. Available at www.mentalhealth.org.uk/sites/default/files/children-andyoung-people.pdf

Vulnerable Young People with Gender Identity Difficulties and Different Sexual Orientations (LGBTQ+) Although society has become more inclusive of a range of different identities in recent years, people who identify with different sexualities or who have gender identity difficulties are still often stigmatised and have a much higher risk of mental health challenges than the general population. It is worth noting that having gender identity difficulties is not a mental disorder but it increases the risk of mental health difficulties.

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What Is Sexuality? What Is behind the LGBTQ+ Label? Sexuality describes how someone expresses themselves in a sexual way: it is inborn and not a choice. Part of sexuality is sexual orientation, which refers to who you’re attracted to, and who you want to have sex with. Heterosexuality means being attracted to the opposite gender, and is the most common sexual orientation, but there are a range of different orientations, some of which are described below: ➢ Lesbian/gay (LG) people are attracted to the same gender as themselves. ➢ Bisexual or bi (B) people are attracted to more than one gender. ➢ Transsexual or trans (T) are people who emotionally and psychologically feel they are the opposite gender from their birth sex. ➢ Queer (Q) covers all non-heterosexual identities. Some people choose this identity as they don’t feel other identities fit them properly. ➢ Plus (+) was a category set up to ensure all gender and sexual identities are covered, as many people use other non-standard terms to describe their sexuality.

What Terms Are Associated with Gender Identity and Dsyphoria? ➢ Sex describes the biological difference between male and female. ➢ Gender describes the attitudes, feelings and behaviours that a given culture associates with a person’s biological sex. ➢ Gender identity is a person’s deeply felt, inherent sense of their gender. People with gender identity difficulties or gender dysphoria do not feel comfortable with the sex they were assigned at birth. ➢ Gender diversity is the extent to which a person’s gender identity, role or expression differs from norms for people of a particular sex. It replaces the old terms ‘gender conforming/non-conforming’, as it tends to be less stigmatising. ➢ Gender expression is an individual’s presentation, including physical appearance and behaviour that communicates aspects of gender. Some

Vulnerability of Special Groups

people feel their gender is on a moveable spectrum, and they prefer to express themselves as ‘gender fluid’ or ‘non-binary’, i.e., somewhere between male and female.

What Is Known about Children with Gender Dysphoria and How They Develop? There are two broad groups of children and young people with gender dysphoria, as follows: ➢ The first group is where young children identify strongly with being the opposite gender to their birth sex. While some of these children hold on to these feelings, a significant number will go on to change their minds about their gender identity as they grow up, with many later coming out as homosexual or bisexual. ➢ The other group is where young people first sense a dissatisfaction with their gender in adolescence. This second group tends to have a higher rate of their feelings about their gender staying the same. However, it’s worth noting that young people whose difficulties are more closely linked to wider identity disturbances through adolescence are more likely to alter their views on their gender identity. ➢ Hence, although children and young people may appear very fixed in their gender identity at one stage, their views may evolve and change. This doesn’t detract, however from the distress children and young people feel when they experience gender dysphoria.

What Are the Special Mental Health Concerns for LBGTQ+ Young People? ➢ The survey ‘Life in Scotland for LGBT Young People’ carried out in 2017 with 684 young people found that 84% of LGBT young people had at least one mental health problem or associated behaviour;

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half had experienced suicidal thoughts. Almost all trans young people felt that they had experienced a mental health difficulty (1). ➢ Stonewall Scotland’s school report in 2017 (2) surveyed 402 LGBT young people aged 11 to 19. It found that nearly all young people who identified themselves as trans (96%) had deliberately harmed themselves at some point and more than 40% had at some point attempted to take their own life. This compares to a quarter of lesbian/gay/ bi young people.

Why Do Young People Experience Such Challenges? ➢ Public attitudes and the day-to-day experiences of young people are still often negative, although this is changing with public education campaigns. ➢ Social isolation and lack of support networks. Online networks and forums can sometimes improve this. ➢ Bullying and experiencing hate crime are common experiences for people with these difficulties, which can sometimes be severe. ➢ Provision of support services is patchy and often under-resourced.

What Can Parents Do to Help? ➢ Give yourself time to think, reflect and discuss with people you trust. It can take a while to get your head around these issues if they are affecting a child or young person close to you. You may well have conflicting thoughts around these issues. Some parents report going through a process akin to grief as they wrestle with the changes in their child’s identity. Look for support from online parent support groups, for example Mermaids (https://mermaidsuk.org.uk/). If your co-parent is struggling, try to offer them support. It may be helpful to access counselling or to see professionals involved in your child’s care separately.

Vulnerability of Special Groups

➢ Listen to the young person’s concerns and try to understand their perspective. Emphasise to young people that you will go on loving and supporting them whatever their sexual or gender identity. Help them think through issues like who they want to tell and when, whether they would like to change their given name or pronoun and consider any practical support they may need. ➢ School meetings can be helpful between parents and school to discuss how the school can be supportive. This can be particularly useful for transsexual young people. It may be helpful to plan for when the young person can switch their identity/name/role and how school staff can support this. Consider discussing access to gender-neutral changing rooms and toilets. ➢ Help young people connect with support networks and local support groups and organisations. However, it is important to check first that online communities and resources are useful before committing to their membership. ➢ Seek professional help if needed. Talking to a counsellor can be beneficial. For those who show signs of mental health difficulties, go to the GP in the first instance as the young person may need a referral to Child and Adolescent Mental Health Services.

Are There Specialist Services for People with Gender Identity Difficulties and What Do They Offer? ➢ Many countries now have specialist services for under 18s with gender identity difficulties. The UK has a national treatment service called Gender Identity Treatment Service (GIDS) (www.gids.nhs.uk) at the Tavistock Clinic in London with a base in Leeds, and satellite clinics in other areas. This service has seen a huge surge in referrals in recent years, so wait times are often long, hence the service is trying to do more joint and consultation work with local services. There is updated information on the ‘News’ section of its website (3).

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➢ Specialist clinics often provide detailed assessments of gender and sexual identity together with mental health needs. Many young people need therapeutic psychological support. Reversible hormone blockers are sometimes offered to those young people who remain very fixed in their gender dysphoria (post 16). This is currently a hotly debated topic, partly due to the lack of clear data on the numbers and characteristics of children and young people whose gender dysphoria may alter as they become adults. ➢ Irreversible treatments for people to transition to the opposite gender including surgery are only offered to adults over 18 in the UK. However, some countries do offer irreversible treatments to young people.

KEY POINTS

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Young people of different sexualities and those with gender identity difficulties have a higher risk of mental health challenges including increased risks of self-harming and suicide.

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It is important for families and schools to try and gain an ­understanding of issues facing young people and offer appropriate support. Specialist third sector organisations often have useful ­information available for schools. School meetings may be helpful.

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Some young people with gender identity difficulties may benefit from professional support, for example counselling or referral to mental health services.

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Many countries also now have specialist services for those with gender identity difficulties which can provide a range of assessment and treatment options, including reversible hormone blockers. They may work in conjunction with local mental health teams.

Vulnerability of Special Groups

References (1) Life in Scotland for LGBT Young People. Analysis of the 2017 Survey for Lesbian, Gay, Bisexual and Transgender Young People. Available at www .lgbtyouth.org.uk/media/1354/life-in-scotland-for-lgbt-young-people.pdf (2) Stonewall Scotland. School Report 2017. Available at www .stonewallscotland.org.uk/school-report-2017 (3) Gender Identity Development Service, UK (GIDS). The Tavistock and Portman NHS Foundation Trust. Available at https://gids.nhs.uk/about-us

Useful Resources Web-Based Resources ➢ The UK National Gender Identity Service (GIDS) located in the Tavistock Clinic in London (https://gids.nhs.uk/). The website contains information about gender identity issues, and how to make a referral to the specialist clinic. ➢ Mermaids (https://mermaidsuk.org.uk/) is a UK charity that supports young people with gender identity issues, and their families. ➢ Gendered Intelligence (www.genderedintelligence.co.uk) is a registered charity that exists to increase understanding of gender diversity and improve the quality of life of those who self-identify as trans. ➢ Galop LGBT+ (www.galop.org.uk) is a UK-based anti-violence and abuse charity offering support for people in the LGBT+ community. ➢ Stonewall (www.stonewall.org.uk/) is a UK-based charity which offers information and support for lesbian, gay, bisexual and transgender young people. It undertakes campaigns and research.

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Children and Young People with Physical Health Needs and Illnesses Some children and young people experience a heavy burden of physical health difficulties, some of which are more clearly visible than others. Life can be incredibly hard for these children and young people, and there is an inevitable impact on their development and ability to function with peers. Although many such children and young people develop huge levels of internal strength through their experiences, they also require a high level of support. These children and young people also experience a greater risk of mental health difficulties and disorders than their peers. According to the UK Family Resources Survey 2015/16 (1) around 7% of children have a disability. As physical and mental health are very much intertwined, the impact of physical health difficulties can have a significant knock-on effects on mental health. There is research to show that the rates of depression and anxiety are much higher in these groups.

Which Types of Physical Health Difficulties Can Children Experience? Children and young people can experience a wide range of physical health difficulties. Certain health conditions in children are inherited, such as Downs syndrome, certain heart conditions or cystic fibrosis. Other conditions are caused by environmental factors, for example car accidents or birth trauma/prematurity. There are two broad categories of children with physical health needs: ➢ Physical disability: for example, blindness and deafness; brain impairments; muscular dystrophy; spina bifida; paralysis following injury. ➢ Chronic physical illness: this includes respiratory conditions like asthma, heart conditions, diabetes.

Vulnerability of Special Groups

Why Are Young People with Physical Health Needs More at Risk of Mental Health Difficulties? Young people who are managing physical health conditions are more at risk of mental health difficulties for several reasons, as follows: ➢ Having physical health needs often makes a child or young person feel different and stand out. Children and young people can feel lonely, misunderstood by others and, as with any difference, can be bullied. ➢ Children and young people can be excluded from activities if they are unable to do things with their peers, especially if they must miss school or other activities. ➢ The physical health condition can have direct mental health symptoms, including tiredness and low energy levels. ➢ Medications can have troublesome side effects, including making young people feel tired or sick. Some medications can cause mental health complications like anxiety. ➢ The impact of managing physical illness and having to do daily medical treatments can be significant on children and young people. The rates of anxiety and depression are higher in children with chronic physical illness. Contemplating a future of physical health problems and medical care can also be difficult for young people. As an example, children with type 1 diabetes must plan everything they eat, test blood sugar and inject insulin up to several times a day. They attend regular check-ups and carefully monitor eyes and kidneys. The focus on eating as well as the associated difficulties with managing a medical illness can lead to an increased rate of eating difficulties including insulin restriction, with greater risks of complications. They have a higher risk of depression and emotional disorders.

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What Can Schools Do to Help Support People with Physical Health Needs? ➢ It is often helpful for school Special Educational Needs Coordinators (SENCos), school nurses and support staff to understand the health needs of the children in their care and consider, together with caregivers, the possible impact on the child’s schooling. ➢ Schools can make individual action plans, which should be reviewed regularly. ➢ Liaise with hospital schools if needed.

What Can Supportive Adults and Parents Do to Help? ➢ Be aware that the child may need extra support and guidance from family to negotiate both their physical and mental health needs. You may need to be extra patient and resourceful to help your child manage: think of ways in which activities can be adapted so your child can take part. You are your child’s advocate before they can advocate for themselves. But watch out that you are not transferring too much of your own anxiety onto your child. ➢ If there is any impact on schooling, try to meet with your child’s teacher at the start of each academic year and go through a written plan of support if your child needs it. The child’s medical team may provide backup and helpful resources. ➢ Encourage positive friendships. Being physically unwell can be very isolating, so nurturing relationships with kind, positive individuals can be extremely helpful and protective for mental health. ➢ Consider applying for financial benefits if you are putting in added time and resources. The cost of bringing up a child with a disability is around three times as much as one without. In the UK you can get further advice around benefits from Citizens Advice (www.citizensadvice.org.uk).

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What Support Is out There? ➢ Many children and young people have access to support from a specialist medical team. These teams often include psychologists and specialist nurses who may provide young people with ongoing support. ➢ There are often local support groups for families with physical health conditions. Ask your medical team what is available in your area. ➢ There are several national specialist charities with support for almost every health condition you could imagine, no matter how rare. These charities can provide families with support and advice. ➢ There are also internet forums for young people and their families to connect with other young people with similar conditions. This can be especially helpful if the young person doesn’t know anyone else or is unable to meet anyone else with their condition. ➢ Child and Adolescent Mental Health Services including hospital psychiatry liaison services can also help offer support if needed. It is useful if they can link in with physical health teams and provide joint care.

KEY POINTS

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People with physical health needs are at an increased risk of mental health difficulties for several reasons, including: the impact of their condition on their ability to function; direct effects of their condition on mental health, including tiredness; difficulties and side effects of medication.

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There are many types of medical condition. It is a good idea for school support staff to try to understand how the medical condition impacts on an individual child’s schooling and their mental health, and to create written support plans that are reviewed at regular intervals. It is often helpful to link in with specialist medical teams where possible.

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There are various avenues of support for these children and young people, including specialist nurses and psychologists in medical teams, local support groups, national charities and forums. If a child’s mental health is at risk, consider liaising with their medical team first and then if needed requesting a referral to mental health services.

References (1) Family Resources Survey. 2015/16. UK government, Department for Work and Pensions. Available at https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/600465/familyresources-survey-2015-16.pdf

Useful Resources Web-Based Resources ➢ Almost all physical health conditions have UK-based charities and organisations which offer information and support to people with these conditions. One example specific to children is the charity Children with Cancer UK (www.childrenwithcancer.org.uk). Many also have forums and specific support for children and young people. As there are so many organisations, they will not all be listed here.

Young Carers Young carers are children and young people under 18 who provide regular or ongoing care and emotional support to a family member who is physically or mentally ill, disabled or misuses substances.

Vulnerability of Special Groups

Children and young people who devote their lives to caring for others make huge personal sacrifices to shoulder the responsibility of care, which takes an inevitable toll on their mental health. Carers are often one of the most neglected and under-supported groups. Young carers themselves are also one and a half times more likely to have a disability, long-term illness or special educational needs. When adults become carers, they are often able to make a conscious choice to take on this role. However, many children and young people end up in a carer’s role, generally because there is no one else available. There is usually a knock-on effect on every aspect of the young person’s functioning, including their mental and physical health, and most importantly the chance to enjoy their childhood. It is therefore important to recognise and support young carers.

Which Types of Problems Do Young Carers Support? ➢ In a Children’s Society report looking at young carers and who they care for, over half came from single parent families; 50% said they were caring for someone with a physical health problem; 29% for a person with a mental health problem; 17% for someone with a learning difficulty; and 3% for someone with a sensory impairment (1).

How Many Young Carers Are There in the UK? ➢ UK census data in 2011 showed there were 166,000 young carers in the UK. However, the Children’s Society estimates that around 800,000 children and young people in the UK are young carers (2). ➢ There is a difference between the actual figures and census data. This is because many children are hidden from the official statistics for various reasons, including shame and stigma, fear of being put into care and not seeing themselves in the role of carer.

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What Are Some Effects of Being a Young Carer? ➢ Mental health effects: young carers are twice as likely as young people generally to report a mental health condition. Girls are more vulnerable than boys. They are more likely to suffer from anxiety, stress and depression. ➢ Social difficulties: which may contribute towards feelings of isolation. ➢ Physical health effects: for example, increased tiredness and experiencing stress-related physical problems. ➢ Educational effects: missing school and missing out on qualifications and job opportunities. ➢ However, many young people often find some positive benefit in their caregiving experience (3).

What Can Make a Young Carer More Vulnerable to Difficulties? ➢ A young carer becomes vulnerable when the level of caregiving and responsibility to the person in need of care becomes excessive or inappropriate for that child, risking affecting their emotional or physical wellbeing or educational achievement and life chances.

What Support Is Available for Young Carers? As many young carers are ‘under the radar’ of support services, it is important to be aware that there are different avenues of support, including: ➢ Local council and social care support: In the UK local councils have a duty to carry out a carer’s assessment if there is an appearance of need. There is more detailed information about accessing this on the NHS website (4). Councils are encouraged to follow a family approach and look at whether the young person wishes to continue caring and whether it is appropriate for them to do so; the impact of care on the young carer;

Vulnerability of Special Groups

and how support can be provided. Social Services often also have carers’ support teams and workers. ➢ Young carers’ groups and organisations: They are often organised by national charities, for example Carers UK (www.carersuk.org) and may link in with social care services. ➢ School-based support: If schools are aware of young carers, they may be able to offer extra mentoring and support. ➢ Mental health support: Young carers should have priority in accessing counselling and mental health services as they are vulnerable.

KEY POINTS

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Young carers are children and young people under 18 who provide regular or ongoing care and emotional support to a family member who is physically or mentally ill, disabled or misuses substances.

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There are many more children and young people in a young carer role than we are aware of through census data.

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Young carers have poorer health and education outcomes than their peers.

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Young carers are twice as likely to suffer from mental health outcomes and are more likely to be depressed and anxious. It is important that young carers can access appropriate mental health support if needed.

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There are different avenues for support for young carers including through local councils and social care services, young carers’ groups and school-based support. However, many young carers still struggle to access support.

References (1) Dearden, C., and Becker, S. 2004. Young Carers in the UK: The 2004 Report. London: Carers UK and the Children’s Society. Available at www.lboro.ac.uk/ microsites/socialsciences/ycrg/youngCarersDownload/YCReport2004[1].pdf

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Useful Resources Web-Based Resources ➢ Young Carers Development Trust is a national UK organisation specifically aimed at tackling the lack of opportunity experienced by many young carers due to their caring responsibilities. There are links to helpful information on their website: www.ycdt.org.uk ➢ Carers Trust is a well-known national carers’ organisation for carers of all ages. However, there is useful information specific to young carers on the website too: https://carers.org/

Other Vulnerable Groups The following groups of young people may also be more vulnerable to mental health difficulties.

Looked after Children ➢ A child or young person who is cared for by their local authority is known as a ‘looked after’ child. They might be living in a children’s home, with foster parents or in some other family arrangement.

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➢ Looked after children are much more vulnerable to mental health difficulties than those who are not in care. According to a UK national guidelines evidence summary (1), the overall conclusion from many studies carried out over the last 50 years is that around 45% of looked after children in the UK have a diagnosable mental health disorder and that up to 70–80% have recognisable problems.

You can read about why these children are more vulnerable in the sections on attachment, trauma and adverse childhood experiences (ACEs) in an earlier section of Part 1 and there is a section on attachment difficulties and disorders in Part 3 of this book.

Children and Young People Who Have Experienced High Levels of Discrimination ➢ Racism is an important example here and is unfortunately still endemic in many parts of the world, including the UK, and often still under the radar of those in authority. ➢ Schools are now getting better at tackling discrimination and are legally required to have a discrimination policy in place. However, discrimination is still a common experience in children and young people and can particularly impact on self-esteem, increase the risk of anxiety and depression. ➢ A useful resource for parents and teachers on race and discrimination is Dr Pragya Agarwal’s book Wish We Knew What to Say: Talking with Children about Race, published in 2020 by Dialogue Books.

Children and Young People with Neurodevelopmental Conditions, including Autism ➢ Autism can affect almost every area of functioning, including the ability to manage emotions, interact socially and have relationships, manage school, and eat and sleep.

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➢ For children and young people with autism, navigating a world that isn’t set up to consider their needs can be stressful. They have a higher rate of mental health difficulties. ➢ The challenges of autism are discussed further in Part 3 of this book.

References (1) National Institute for Health and Care Excellence (NICE). 20 October 2021. Looked-After Children and Young People. NICE guideline [NG205]. Available at www.nice.org.uk/guidance/ng205/

6 Promoting Mental Health and Resilience and Preventing Ill Health: A Summary This chapter gives a summary of the factors affecting children’s and young people’s mental health covered in Part 1 of this book. My aim is to help parents, caregivers and other significant adults develop their understanding of the factors that can affect children’s and young people’s mental health and ways they can provide support in these areas.

Biological Processes ➣ Attachment: Secure attachment has a lasting and protective impact on children’s development and mental health. So, trying to make sure we have secure attachment relationships with our children is one of the best ways of protecting their mental health and building their resilience.

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➣ Genes and inheritance: Understanding the building blocks of our inheritance (DNA) helps us understand key aspects of who we are, as well as our risks of mental health difficulties. Our genes can be altered by our environment. ➣ The developing brain: Our amazingly complex human brains keep growing and changing throughout our development into our mid-twenties, so it’s important to stimulate children’s brains and develop a growth mindset. ➣ Puberty is a process driven by hormones to transform children’s bodies into fully mature adult bodies through several stages. It’s an amazing time of change but can also be challenging for young people’s mental health, especially as brain development may lag behind physical changes.

Lifestyle Factors ➣ Sleep: Getting enough sleep is critical for children’s and young people’s mental and physical health and development. When we sleep our brains can restore and regenerate, which is important for mental health. ➣ Diet: Good nutrition has a key impact on mental as well as physical health. The field of nutritional psychiatry is starting to produce evidence that nutrition can have a significant positive effect on mental wellbeing and support those with mental disorders. It is helpful to be aware of the important building blocks of good diet and to offer children unprocessed foods wherever possible. ➣ Exercise: Our bodies have evolved to move, but as movement is no longer essential for survival, many people have got out of the habit of moving, which has a negative impact on our mental as well as physical health. Encouraging children and young people to exercise and move regularly in a way that fits in with their lives is important for both their long-term physical and mental health. ➣ Technology: Rapidly changing technology has been the single biggest change in the last generation. Recent research shows a mixed picture, with some benefits as well as disadvantages. An important principle is that we stay in control of technology before it controls us through excessive use and addiction. As caregivers, we need to explain safe use, set clear

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boundaries and monitor children’s and young people’s internet use carefully, and support them if they run into difficulties around their use. ➣ Alcohol and drugs: These are mind-altering substances which have a major impact on mental as well as physical wellbeing. It’s important for young people to be aware of risks and for adults to understand how to support young people and get specialist help when needed.

Relationships ➣ Family relationships: Relationships with our family are our first and often longest-lasting. Close family relationships are protective for positive mental health and wellbeing. Conversely, difficulties in family relationships can lead to vulnerabilities in mental health. It’s important to nurture our family relationships and seek help if needed. ➣ Peer and social relationships: Humans are hard-wired to be social animals and to depend on others. But peer relationships prove difficult for some children and young people to navigate and they may need support in managing them. Learning social skills can be challenging but social relationships can have a positive impact on our mental wellbeing. ➣ Romantic relationships and sex: The process of exploration of early romantic relationships is often exciting but may also be a challenging experience. There may be an impact on mental health and young people may need guidance and support around managing relationships and understanding the components of safe relationships.

Stressors ➣ Stress: Stress is one of the most significant factors affecting our mental and physical health. Many major health problems start with stress. By understanding the biology of stress, including triggers and how to manage them, we can help protect children and young people from their negative effects.

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➣ Bullying and academic pressures: Although most children and young people are happy at school, bullying and high academic pressure can be bumps on the road for many young people and for some others they can make life intolerable. It is important for families to try to work with schools to help children and young people with these issues. ➣ Abuse and neglect: The four traditional forms of abuse are physical, sexual and emotional abuse and neglect. As many children and young people are at risk of experiencing abuse and neglect at some point in their development, we need to be vigilant to the signs of abuse and learn how to report it and support them to help to protect their mental health. ➣ Adverse childhood experiences (ACEs): These are traumatic life events which occur before a child turns 18 and can increase the risk of both mental and physical health problems. It is important to be aware of how to support these children and young people who have experienced ACEs. ➣ Trauma: Trauma can be very difficult for children and young people to manage, especially if chronic or complex, and can have a significant influence on mental health. It’s helpful for adults to be aware of the impact of trauma and how to support young people who have been through difficult traumatic experiences. ➣ Loss and separation: Children and young people who go through bereavements or parental separations will have their own needs and vulnerabilities that require support. Children and young people will go through different grief processes depending on their level of maturity. A parental separation, however, can often be less traumatic than experiencing chronic toxic disagreements in the home. It’s important to remember that the child’s age and maturity will affect their understanding and their coping and remind the child or young person they are not to blame. ➣ Special groups: Some groups are more vulnerable to mental health difficulties, for example children and young people with intellectual disabilities or physical health problems, young carers and children and young people with sexual and gender identity difficulties. It is important to consider the special needs and risks of these vulnerable groups.

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Part 1 of this book has outlined some major factors which can impact on children’s and young people’s mental health and wellbeing. Some areas are more modifiable than others: you can’t change the genes children inherit or some of the trauma they may experience. However, there are several areas which you can influence, the most important of which is creating strong and lasting attachment relationships with them, as this probably has the most significant impact on their mental health. I hope this section of the book has also helped you understand the other areas of children’s and young people’s lives where you have a possible influence, and which also can affect their mental health, for example diet, sleep, exercise and technology.

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Part 2 Strengthening Relationships with Children and Young People and Giving Support Part 2 is dedicated to understanding how you can support yourself and other caregivers, and how to strengthen your relationship with your child or young person and ensure there is adequate support around them, which will have a positive impact on your own mental health. Chapter 7 outlines the importance of looking after yourself, which underpins everything else, as without self-care it’s not possible to care for others. Chapter 8 focuses on your connection with your child or young person using a range of communication strategies. Chapter 9 discusses the importance of supporting your partner or co-­ parent and gives suggestions for how to do this. Chapter 10 describes how to create networks of support for your child or young person and how to visually map these out.

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Chapter 11 outlines some important parenting strategies. Chapter 12 explains how to help children and young people manage school, and how to get support if there are school-related difficulties. Chapter 13 explores how to help children build their resilience and strengths.

7 Looking after Yourself Prioritising looking after yourself and your own health is essential if you have caregiving responsibilities: you won’t have the energy or resources left to support others if you are not meeting your own needs. By learning how to care for yourself you will find you are better able to help children and young people. Modelling self-care is also one of the best ways of influencing young people to engage in self-care. If you don’t look after yourself, a key risk you run is of burnout, which can put you out of functioning for a while. Burnout is a state of exhaustion caused by excessive and prolonged stress and happens when you feel overwhelmed, emotionally drained and unable to meet constant demands. As the stress continues, you begin to lose the motivation that led you to become a parent or caregiver. So, looking after yourself and avoiding burnout is very important for you as well as your whole family.

Why Isn’t Always ‘Putting the Children First’ the Best Strategy? Neglecting yourself may work for a short time but doesn’t work long term: you may burn out. Think of the practical advice on planes to put on your own oxygen mask before you put on anyone else’s. In the same way we

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need to protect our own mental health needs before we support children’s and young people’s mental health. Children take more notice of what you do than what you tell them they should do. Do as I say not as I do doesn’t tend to work! If children see you looking after yourself and your mental health needs, they are more likely to follow you.

What Can You Do to Look after Yourself? ➢ Try to take some time out away from the family each week. Family life can get very intense, especially if you are the main caregiver. Getting out of the house is important and takes you away from the long list of things that need doing at home. Single parents could club together with a similar household, so each adult gets a regular break. ➢ Make sure you sleep for 7–9 hours if you can. Sleeping is vital to mental health and wellbeing: it is when the brain repairs and restores itself. Good rest improves all health-related outcomes. It can be difficult to get enough sleep with very young children, but once the family has a good bedtime routine, you should also try and prioritise your own sleep. Forget the extra tidying up. A good start is to keep electronics out of your bedroom and trying to build a relaxing sleep zone in your bedroom. ➢ Eat slowly, not just on the go. It’s often all too easy to just snatch high-energy snacks on the go but take time to think about what you eat and sit down and chew food properly. Could you batch-prepare some good-quality foods and freeze portions if you don’t have time to cook every evening? Try to consciously buy healthy snacks and keep a fruit-bowl filled to snack on. ➢ Build a network of supportive people who you can ask for help if you need (see Chapter 10 for more information). Invest in your friendships and family and don’t be afraid to ask for help. ➢ Take some time to go outside every day. There are mental health benefits to spending time outdoors in nature, even if it is just having a warm drink outside or walking around the block. Exposure to sunlight

Looking after Yourself

early in the day helps set our biological clocks, which improves sleep and exposes us to much-needed vitamin D. ➢ Can you go back to something you loved doing before you became a parent? Did you used to play a musical instrument or sing? Or perhaps enjoy art, crafts or reading novels? There are so many hobbies that we as parents tend to give up once pulled into the whirlwind of parenting. If you start something with someone else with a similar interest, you are more likely to keep each other going. ➢ Book some things into your calendar ahead of time that you can look forward to in the next year. This is especially important in the winter months when seasonal impact on mood is common. ➢ Make time for regular exercise. This will have a positive impact on both your physical and mental health.

How Can You Get Support for Your Own Needs? Don’t be afraid to ask for support if you need it: it’s a sign of strength to ask for help. There are many informal avenues of support, including through friends and family, which can be helpful for some people. However, for many people, professional support or support from third sector organisations can be valuable as it’s also impartial. Here are some professional sources of support to consider: ➢ GPs can help with both physical and mental health problems. They can refer on to specialists if needed and often signpost you on to other community support. ➢ Community counselling and psychological support. These may be advertised locally or in health centres. Community psychology services often have their own websites, which often accept self-referrals. ➢ Social care support. If you find things are really getting on top of you, Social Services may be able to help. Removing children from their families is a last resort. It’s much more likely you will be offered support to help you manage, for example through an Early Help Assessment in the UK.

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➢ Psychotherapy may be a possibility if you feel you have more deeprooted psychological problems relating to your own early attachment difficulties or childhood experiences. Psychotherapy may help you understand more about your unconscious drives, which may underlie some of your mental health and parenting difficulties. It is not a quick fix and needs long-term commitment to see longer-term changes. It can be expensive as few forms are available on the NHS. ➢ Local and national charities, support groups for mental health/ vulnerable groups. If you have a specific difficulty, the chances are there is a UK charity which offers support! Don’t forget mental health helplines like the Samaritans in the UK where staff are always available to talk things through if they are getting too much for you.

KEY POINTS

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Looking after yourself isn’t selfish: it is the only way you can begin to look after others. Modelling self-care and looking after your own mental health is also the best way children can learn to prioritise their own needs.

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Parents and caregivers who don’t practise self-care are at risk of ­mental health difficulties as well as burnout. Burnout happens when you feel overwhelmed, emotionally drained and unable to meet constant demands, and can affect your parenting.

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Ways to improve self-care include taking regular time out for yourself; getting enough sleep and paying close attention to how you eat; ­staying in touch with friends/family and asking for support when needed; going outdoors when possible; exercising regularly and trying to find time for your own interests.

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If you need support, it’s important to know how to access help for yourself. You can find support through professionals, including GPs, counsellors and social care services. Psychological support can also be very useful.

Looking after Yourself

Useful Resources Web-Based Resources ➢ Young Minds, a UK charity aimed at mental health support for young people, has a section of its website entitled ‘The Parent’s Guide to Looking After Yourself’. Available at www.youngminds.org.uk/parent/ parents-guide-to-looking-after-yourself/ ➢ The Anna Freud Centre is a UK-based institute of mental health for children and families. There is useful information on self-care for parents on its website: www.annafreud.org/parents-and-carers/ self-care-for-parents-and-carers/

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8 Connecting with Children and Young People If you connect with children and young people in a meaningful way, you are in a much better position to support them through their challenges, including with mental health. Unfortunately, it’s all too easy to lose your connection as children and young people develop, and it’s not always easy to repair lost connections. But strategies which help with communication and empathy can help us connect and reconnect after challenges.

How Can You Connect with Children and Young People? Connecting with young people is an art that needs constant attention: ➢ Good communication and empathy will help us connect with young people. ➢ Tune in with the young person’s age and developmental stage. Your connections with children and young people will evolve and change as they grow and develop. Think about how they respond to different people

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in their lives. Are there tips you can take away from people who you see engaging well with children and young people?

What Is Empathy? ➢ Empathy is the ability to sense other people’s emotions as well as imagining what they might be thinking or feeling. Another way of putting it is getting into someone else’s shoes and walking around in them to see how the world looks different. It’s a difficult exercise but one that’s worth doing every time you struggle to make a meaningful connection.

How Can You Show Empathy? ➢ As adults we often spend a lot of time enforcing rules for children, but how much time do we spend imagining what it is like for someone very young trying to do something hard for them? To do this, you need to listen to the child’s story and try to imagine how it feels for them. ➢ Next time you sense your young person is finding something hard, show the child you are really listening by making empathic statements which summarise how you imagine it must feel for them in that situation. But remember to always check it out first as we can only ever guess how someone else feels. For example: ‘If someone shouted at me like that, I would feel really angry. How did it make you feel?’

How Important Is Non-Verbal Communication? What Can We Do to Improve It? A high proportion of what we communicate is non-verbal: studies show that up to 80–90% of what we convey is non-verbal. So, it’s a good idea to be aware of what both we and others are conveying non-verbally. Here are some non-verbal aspects of communication to be aware of:

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➢ Eye contact is crucial in connecting with others in a meaningful way. Being on our phones and devices often gets in the way of maintaining eye contact. You should aim for a natural amount of eye contact: too intense eye contact and staring isn’t helpful either. Often side-on (e.g., if you are sitting together in a car) rather than face-to-face communication feels more comfortable for young people. ➢ Body posture: An open posture where we are sitting up and keeping arms and legs uncrossed shows we are interested and present. Try to work out what young people want to convey with their posture and if they look tense or relaxed. ➢ Facial expression of emotions: Smiling can have a positive impact on your own mental wellbeing and those around you. Smiles are infectious too! Facial expressions can tell us a lot about underlying emotions. Even flickers of emotion called micro-expressions can convey clues about how we feel. If you can learn to detect a range of facial expressions, it will better help you understand your children. ➢ Tone, pitch and volume of voice: As parents we can often end up using nagging or irritable voices. If in doubt, it can be helpful to try to lower the pitch and volume of your voice: you can sound harsh and high-pitched without thinking about it. Talking too loudly can escalate into shouting exchanges, which are stressful. But if you can be aware of the tone of your voice and show warmth and interest, young people are more likely to open up. ➢ Movement and gesture: We often speak with our hands and bodies as well as our voices. Certain cultural groups tend to use their hands more expressively than others, but many of us use gesture without being fully aware of it. It’s helpful to bring your own use of gesture more into your conscious awareness and think about what you are conveying. If you increase your awareness of gestures, you can also detect young people’s distress, anxiety and other emotions more easily.

What about the Importance of Touch? There is a growing field of research looking into the importance of touch in positive mental health and childhood development. Nerve endings

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that detect touch are linked into the brain and nervous system and can help to calm you down and bring about reductions in stress hormones. Mammals show licking and grooming behaviours as part of bonding. In humans, touch is a key part of relationship building and connecting. Here are some helpful tips about healthy touch: ➢ Touch must be consenting on both sides for it to be OK. Different children will have different thresholds for what kind of touch they will accept and when. Children and young people who have been abused may be more wary and less comfortable with touch. Children on the autistic spectrum often need to initiate physical contact on their own terms, and struggle with uninvited touch. ➢ We know about the importance of skin-to-skin contact for newborn babies. Massage can also be a very positive and powerful way of bonding with babies and children and can help with tummy pains. Many colicky babies can be soothed by massage. ➢ A hug can be soothing in many different situations and can often say much more than words. If your children accept hugs, try and hug them every day if you can. ➢ Holding hands is not only a way to keep young children safe: it’s also a way of connecting and can help children and young people feel loved and supported. ➢ Playful activities such as tickling and rough and tumble play can be a fun way for families to enjoy physical play together. Laughter is an important positive way of connecting too. It’s key to set out clear rules, though, so people don’t get hurt.

What about Play and the Creative Arts? ➢ Many younger and less verbally inclined children tend to communicate through play or through creative methods. If you take time to play with youngsters or watch them play you will learn a lot about their internal worlds and what they are trying to communicate. Many children and young people find creative expression in art, drama

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and music valuable, and it can provide them with an expressive voice. In fact, play, arts and music therapies are often important treatments in many mental health facilities.

How Can You Improve Your Verbal Communication? ➢ Telling children and young people that you are available to listen is crucial. There are many barriers to listening properly. We are often so absorbed by our own problems that we aren’t available to hear children fully. Try to take some time each day to listen to your child without interruptions or judgements. Then summarise in your own words what you think they are telling you, commenting on how they may feel. Try not to have your phone on you. ➢ Use open communication with young people. To encourage open communication, it’s important to be open yourself, by being honest about what and how you feel, naming your feelings rather than blaming others. So ‘I’m feeling quite tired tonight so I’m afraid I won’t have the patience for playing that game … ’. ➢ Choose your words carefully. As parents it’s easy to subconsciously follow patterns and phrases of words that we may have heard as children. It’s important to think about these phrases and replace them with more sensitive language that helps connect with children. It’s also important children don’t feel blamed, as this will affect their self-esteem. ➢ Think about your use of open and closed questions. Open questions are those that allow an open-ended answer, for example ‘Tell me about how you found the trip … .’ They are helpful in most situations to gain your child’s perspective. Closed questions, such as ‘Did you like that?’, will often only get a ‘yes’ or ‘no’ answer. Sometimes they may be the only way of getting a child to speak and can help you get a specific piece of information. However, be aware that closed questions can steer children to choose an answer they don’t mean and can also lead to missing out a lot of what is behind what’s going on.

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What If Young People Don’t Seem to Want to Communicate Much with You? Young people can often frustrate us with how little they talk. The following strategies may be helpful to keep connecting with them: ➢ Showing children and young people our love is unconditional and that we still value spending time with them whether they want to talk or not is important. Building in some individual time with each child every week helps nurture relationships. Talking while doing something else (like going out for a walk or driving) is often an easier way of opening up than being face to face. ➢ If the young person is shutting themselves away, explain to them you are concerned about them and the impact on their mental wellbeing and would appreciate them keeping in touch every day. Can you work out a way together that allows them to spend time with the family? Are there things you can do that would feel less intrusive? ➢ Some young people respond well to written or other non-verbal communication using notes, letters, emails or texts. You could also consider creative strategies to help enable communication, for example music, art or other strategies. I have had young people who use fridge magnets or Post-it stickers to show their parents they are struggling. Others like to use coloured cards that mean they are angry or upset. ➢ Sometimes talking to someone outside the immediate family may be easier than talking to parents. You can encourage a positive relationship with a trusted family member or close friend. Help support young people to keep in contact with friends too. You may need to get professional support if you continue to be worried. ➢ Try to keep the support system around the child going, even if the child isn’t fully engaged. They may need to withdraw a bit, but if the adults around them keep in touch with support systems, they are still there when the child is ready to engage again.

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KEY POINTS

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It is helpful if we can keep trying to make connections with our young people. Our skills in connecting need to keep adapting as children’s needs change as they develop and grow. Showing empathy and working on our communication skills can help us connect.

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Non-verbal communication is very important. It is helpful to be aware of how eye contact, posture and facial expressions affect ­communication. Touch is also a key part of connecting in a physical way, although we need to be aware of the boundaries around safe touch and always touch children and young people with consent.

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To aid verbal communication, show you are available to listen. Adopt an open and positive stance. Be aware of which words you are ­choosing and try to use open questions when possible.

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If young people seem to be struggling to connect, we can reach out to them in different ways, including just spending time together, using written communication or creative methods. Sometimes asking a trusted friend or relation to connect may help. In some cases, however, it may be necessary to seek professional support.

Useful Resources Web-Based Resources ➣ Research in Practice is a website for families involved in fostering and adoption, funded by the UK Department for Education. It has helpful tips on communicating with children and young people. Although it was written for families going through fostering and adoption, its principles are universally relevant. Further information can be found at www.fosteringandadoption.rip.org.uk/topics/communicating-effectively/

9 Supporting Partners and Co-Parents Very few of us would dispute that parenting is one of the most challenging jobs there is. It’s even harder if you are a single parent. Fortunately, many parents do have co-parents or at least close friends or family who can offer support. Sharing the parenting load with supportive others is protective for both parents’ and children’s mental health. In this chapter we think about how you and your co-parent can support one another. If you don’t have a romantic partner, perhaps you have another adult providing significant support with parenting. I know of many single parents whose own parents or close friends provide them with a lot of hands-on parenting support. If this is the case, then investing in your relationship with these people is very important too.

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Why Is Investing in the Relationship with a Co-Parent Helpful (If Possible)? ➢ Being a parent is tough: If you can support each other through the different phases of your children’s development, and share tasks out with a supportive partner, you can often give children a better side of yourself. ➢ It’s often helpful to get another perspective, especially when things are difficult. Sometimes getting stuck when you are in the middle of a difficult situation can make problems seem bigger than they really are. ➢ Different people have strengths in different areas, so you can help to complement each other, and play to each other’s strengths. It’s important to encourage your co-parent to bring out the best in themself, which may be using a totally different approach to your own. ➢ You can give each other backup and show a united front, which stops children trying to pit you against one other. ➢ Your children won’t be home forever … and it’s also not easy adjusting when they leave home. So, if you can work out ways to support each other early on, things will be easier when you deal with transitions of young people leaving home.

What Can You Do to Support Your Partner/ Co-Parent? ➢ Try to be kind and respectful to each other. Check in regularly how the other person feels. Listen to them. Can you carve out time for a daily debrief? ➢ Tell them you appreciate what they do and why. For example, ‘I love it when you take the children on bike rides as they really enjoy being outdoors and burning off the energy.’ ➢ Blaming is never helpful. A good tip is to use ‘I’ statements for things you find difficult about what’s going on around you rather than using ‘you’

Supporting Partners and Co-Parents

statements which blame. Try to concentrate on moving forwards rather than picking apart your co-parent’s difficulties. For example, ‘I struggle to get around safely to put washing away if the floor is covered with your work’ rather than ‘You’re such a slob messing up the room.’ ➢ Give each other time and space to do things for yourselves. What sustains you and your co-parent? It’s likely to be different things for both of you. Can you make an agreement that everyone gets some of their own time in the week? ➢ Invest in some quality time together. Can you book in something special together every month or so? It’s helpful to try to continue to nurture your relationship, even when life is hectic. ➢ Support them if they need extra help, for example for their own health. As parents we often let our own health needs slide, especially for our mental health difficulties.

How Can You Ensure You ‘Sing from the Same Hymn-Sheet’? ➢ Discuss which values you hold in common. How can you carry them through to parenting? What gets in the way of living your values? ➢ Consider which rules are most important for the family. Try discussing what your non-negotiables are, and which battles you will fight. Some families have a regular family meeting to negotiate rules. ➢ If you have a difference of opinion, try to discuss it away from the children. Think about how you may be able to work through it. Listen to the other person’s perspective and try to compromise, a crucial skill for children to see. ➢ Think through solutions rather than problems. Try and discuss how to manage solutions at the end of each day or few days. ➢ Show a united front using ‘we’ rather than ‘I’ statements when you refer to boundaries, rather than blaming the other person for a difficult rule. It’s unfair for someone to always be the ‘bad cop’.

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What If You Have a Difficult Relationship? ➢ You may need time and independent help to work through your relationship difficulties. Mediators and relationship counsellors (e.g., through Relate in the UK: www.relate.org.uk) can be helpful if there’s been a difficult event to work through. ➢ It’s tricky to ‘hold the line’ in parenting, but still possible. It’s often helpful to shift the focus from being a family to putting children first. So, if you have separated, what are your shared aims in parenting and how can you work together on them? ➢ It’s important not to involve children in disputes and talk disrespectfully about an ex-partner. Venting your anger with other adults away from the children will help maintain your co-parent’s relationship with their child. ➢ Try to support your co-parent’s or partner’s relationship with their child if it’s safe to do so. Losing a relationship with a separated parent can often be extremely difficult for the child in the long run, so it’s best to try and support the separated parent to maintain the relationship with their children if it’s safe and possible.

KEY POINTS

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Investing in the relationship with your co-parent or partner is wise. The co-parent could be a close friend or family member if there isn’t a romantic partner. If you can support each other it is likely to be beneficial for the mental health of everyone involved.

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Ways to support one another as parents include adopting a respectful and appreciative stance; avoiding blaming each other; giving each other time and space; booking in time for your relationship; and getting extra help if needed.

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We can sing from the same hymn-sheet by sharing our values; having house rules; discussing differences of opinion away from children;

Supporting Partners and Co-Parents

thinking through solutions; and trying to show a united front using ‘we’ statements.

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If you have a difficult relationship, it’s important to consider how to move forwards rather than keeping alive angry feelings about the past. Shifting the focus to putting the children first is often helpful. You may need professional help to work through difficulties, but it’s often worth trying to help the separated parent maintain a ­relationship with their children.

Useful Resources Web-Based Resources ➢ Relate is a national UK charity which offers relationship counselling and support: www.relate.org.uk. There are lots of useful resources on their website.

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10 Creating a Network of Support Humans are social creatures. We have evolved to support one another in strong communities. However, this tradition has gradually been eroded in the last few generations. It is now common for parents to feel isolated from their wider family networks, and they are often too busy to prioritise building strong local networks. The phrase ‘it takes a village to raise a child’ rings true from a mental health perspective, as children, young people and families gain strength and resilience if they feel embedded in networks of support. In this chapter we discuss how we can re-create strong networks for ourselves and our children.

Why Create a Network of Support? Young people report feeling more isolated than any previous generation. Even though they may have more ‘virtual’ connections, they can feel they have fewer meaningful face-to-face relationships. Here are some reasons why building networks of support is so important:

Creating a Network of Support

➢ Our brains are wired to interact with others, which is reflected in the neurochemicals, including dopamine and serotonin, we produce in our brain when we feel part of a social group. ➢ Being part of a network can help a young person feel secure and loved and provide a sense of belonging. Loneliness is associated with negative outcomes in physical and mental health. This has been studied in animal and human models, and the brain and stress-response hormones are both negatively affected by feelings of isolation (1). ➢ Different people in your network can offer valuable perspectives and ways of helping, which may be useful for different situations. For example, a young person may be more comfortable talking about sensitive relationship issues with people outside the immediate family.

How Can You Build a Support Network Model with Your Child? It is often helpful for young people to draw a visual model of what their own network of support looks like. A method sometimes used in mental health services is a model of concentric circles with the people closest to the child in the innermost circles. It is important for the child or young person to decide for themselves who to put in each of the circles. Here are the steps in helping a child or young person create a visual network: 1. Make a list of all the important people in your life who help support you. 2. Draw yourself a model of concentric circles (see Figure 2) with you in the centre. 3. Position those closest to you in your innermost circle. These are the people who you feel most strongly connected to. 4. Gradually move outwards through the circles until you have included everyone important. Think about how people in your circles connect with each other. 5. Stick your network on the wall or fridge. This can help remind you of who is around to support you.

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Figure 2 gives an example of how to do this. Neighbours

Grandparents

Mum and dad

Youth club friends

Best friend

Me

Aunt

Group of school friends

Sister Me Form tutor

Extended family, friends

Figure 2:  An example of a young person’s network of support

What about Contributing to Others’ Support Networks? ➢ Another exercise is to draw out interconnected webs which show how we interdepend on other people. This shows children and young people how different people’s circles of support impact on each other as we rely on different people to help us.

Creating a Network of Support

➢ Talk about how you contribute to other people’s networks, and about how showing generosity and supporting others has a positive impact on you. Studies show it also affects your mental health and brain activity. The more you consistently link in with other people’s networks, the stronger your real and virtual communities. ➢ It is important to talk about how you need to stay in control of support you give others, to protect your own mental health. Some people will want more of you than you can give, but this could potentially lead to you not being able to look after yourself very well. So, giving and receiving support should be in balance.

Figure 3 shows how networks can join and overlap.

Network 1: Grandma’s network Network 4: Neighbour Arthur’s network

My network

Network 2: Auntie Kim’s network

Network 3: Best friend Joe’s network

Figure 3:  Diagram of overlapping support networks

How Can Support Networks Change with Your Changing Needs? ➢ Support networks change and evolve over time. This is a healthy process which you can welcome: as you grow and develop, the systems around you change. We all need support from different sources at different times of our life. You can talk about this with children and young people

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and draw diagrams to show how children’s and young people’s networks may have changed over time. ➢ As an exercise, children and young people could think about who was important to them when they were very young, for example a nursery teacher or a childminder, and how this has changed over time. Friendship groups also often change as children and young people develop and move schools and homes. ➢ Patterns of how we relate to each other within families will also change, even though family relationships are often our longest-lasting connections.

KEY POINTS

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Humans are dependent upon each other for support, but many of the traditional supportive communities are being replaced by virtual ­networks. This makes it more challenging to forge deep and m ­ eaningful connections. Consider how you can help children and young people understand and build supportive networks around themselves.

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Benefits of a strong network of support include helping to build security and trust; gaining new perspectives; avoiding loneliness; and activating help from others when needed.

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You can help your child or young person draw their own network of support using a concentric circles model, with those closest to the young person in their inner circles.

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You can think with children and young people about how they contribute to other people’s support networks. Being part of other people’s support networks reinforces our sense of self-worth. However, it’s important to teach children and young people to stay in control of the process of offering and accepting support.

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Support networks invariably evolve with time. This is part of healthy development. Children can understand this by considering how their own networks have evolved through time as they have moved through a range of environments.

Creating a Network of Support

References (1) Campagne, D. 2019. Stress and Perceived Social Isolation (Loneliness). Archives of Gerontology and Geriatrics 82, 192–199. https://doi.org/10.1016/ j.archger.2019.02.007.

Useful Resources Web-Based Resources ➢ An Australian Queensland government website has useful information about building a safety and support network, including guidance on how to draw a circles of safety and support tool. Available at https://cspm.csyw.qld.gov.au/practice-kits/ care-arrangements/working-with-young-people-1/responding/ building-a-safety-and-support-network

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11 Positive Parenting Strategies Being a parent is one of our most difficult and important tasks, yet very few of us get any training in it. There is growing evidence that how we parent can have a significant impact on our children’s mental health and their longer-term outcomes. Parenting sensitively and thoughtfully will help children develop positive emotional wellbeing and coping skills. We don’t have to get it all right all the time but doing the best we can and learning from experiences are important principles. It’s often worth investing some time researching parenting strategies that may be helpful for your family. Here are some tips to get you on the right track. If you want to learn more about parenting, there are some useful resources listed at the end of the chapter. Parents and caregivers of younger children may find this section particularly useful.

Positive Parenting Strategies

Is There Such a Thing as Being a Perfect Parent? ➢ There’s no such thing as a perfect parent. If you can show children that you don’t always get everything right but are willing to learn from your mistakes, children will appreciate this. ➢ The concept of the ‘good enough mother’ is a helpful one to use. The psychoanalyst Donald Winnicott (1) first coined this term. It describes the process of parenting where at first the mother or caregiver strives to attend to every need of the baby, but this is impossible to maintain. The mother must then allow the baby to gradually experience more frustrations in a move towards developing independence. Through this process the baby learns to explore the world and that their mother is there for them when they need her, but she isn’t always there or always perfect. This helps the baby develop a healthy understanding of their world. The concept of being a ‘good enough mother’ can expand to include fathers and other key caregivers. ➢ All parents are on a learning journey that will be different for each child–parent relationship. As each child has their own set of needs and behaviours, they will require you to parent them differently. Parents with more than one child will be aware that their parenting will differ between their children. It is important that your parenting is based on each child’s level of need and doesn’t necessarily have to be exactly the same or equal if you have more than one child.

Why Is Staying Calm and in Control so Helpful? How Can You Work towards This? ➢ Staying calm and in control is important because you are using the ‘thinking’ part of your brain, which can only work on solving problems when the reactive primitive part of your brain isn’t activated. The reactive brain makes decisions on impulse without proper consideration and causes you to do things you may later regret. Discipline means teaching, which you are only able to do effectively when you are using your calm and rational ‘thinking’ brain.

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➢ You may need to work on your own ways to stay calm, so that you can activate your ‘thinking’ brain rather than your ‘reactive’ brain. Some of us find it more difficult to switch on our thinking brains when we are annoyed, and it takes practice. Breathing exercises, trying to work out your triggers, listening to music and exercising can all help. ➢ It’s important to take yourself out of a situation when you feel you are losing control and may do something you will regret. If you can model telling your children you need to go off to calm down, they might learn to follow suit. It’s helpful to assign calm-down spaces for everyone in the family.

How Can You Show Your Children That You Are There for Them? ➢ Show love, affection and give time to each child. Children need reminders of how much you love them, especially when the going is tough. Hugs, play and laughter are all important, as is trying to find special time for each child, even if it’s only 5 minutes. ➢ Active listening is one of the most valuable skills a parent can model. This means listening with your full attention and then showing your children you have heard them by making appropriate responses. For example, summarise what they have said using your own words to check you understood them, and reflect back what they may feel, for instance ‘You said someone called you … How did that make you feel?’ We are often so busy we don’t stop to really hear what our children are saying.

What about Praise? How Often and How Should You Praise? ➢ We all respond much better to praise and encouragement than punishments. Think about yourself: if someone criticises you at work or at home, it’s natural to feel hurt and upset, even if it is meant constructively.

Positive Parenting Strategies

A huge body of evidence now shows that we learn better if we are praised rather than criticised. Hence parenting programmes universally emphasise praising as the best way to shape behaviour. ➢ Aim to praise two times more than you criticise. As many of us adults have grown up in critical households ourselves, it is very hard to praise enough. If you do have to be critical try to practise using a positive sandwich, where the criticism is sandwiched between two positive items of praise. ➢ Praise effort rather than results and be specific with praise. For example, ‘I really liked the way you tried hard to make all your writing fit in the lines’ rather than ‘Good boy’.

What about Punishments and Consequences for Difficult Behaviours? ➢ Punishments don’t tend to work as they focus on the negative, often making children angry, upset and resentful. ➢ Consequences can be helpful for learning but should occur as quickly as possible after behaviours. They should be proportionate and fair, and you should use warnings, where possible. For example, if children keep fighting over a computer game despite a warning, a fair consequence may be to take away the game for an hour. ➢ Natural consequences are useful when children get older, so they learn to take responsibility for themselves. For example, if a child in secondary school forgets their money or coat, it may not be helpful to run after them. Most learn in time to remember the things they need. ➢ Stay in control when implementing a consequence. If you’re not in a calm state when implementing a consequence, take a break or ask for support from another adult. It’s important to follow through after you give a warning. It’s all too easy to threaten something you can’t follow through, which then makes setting boundaries in future more difficult.

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Is Having Clear Rules or Boundaries Important? ➢ Use a few clear, reasonable rules for behaviour. Rules can help children feel ‘contained’, which then gives them the space to develop in a supported way. However, too many rules aren’t helpful. ➢ Make house rules together as a family. If children can feel part of the process of drawing up rules and they understand why they are important to the family, they are more likely to buy into them. It’s better to frame the rules in a positive way rather than using lists of don’ts, for example ‘We talk with respect’ rather than ‘We don’t shout’. ➢ Many families find family meetings useful. You can use meetings to discuss a range of topics, including rules. ➢ Boundaries can be negotiated as children gain independence, and they will be pushed in the teenage years, but children often need something to push against. It helps if you have already thought about which consequences may follow rule violations.

What about Routines? Is More Structure Better? ➢ Children and young people generally respond well to routines. Having activities planned around a basic structure of mealtimes and bedtimes helps everyone know where they are. Humans are creatures of habit: consistency grounds and settles us all. It also gives children a sense of familiarity and control. ➢ Sticking to regular bedtimes is very important for sleep quality, which is directly related to how well a child can function. You may think you are giving children a treat by having late bedtimes at weekends, but this can lead to overtiredness, which often has a negative impact on mental wellbeing, especially in children more sensitive to sleep deprivation.

Positive Parenting Strategies

What Is a Helpful Analogy for Thinking about Parenting? ➢ Current thinking around parenting is that the analogy of a parent as a gardener is more helpful than the old-fashioned one of a carpenter. ➢ The gardener tries hard to provide the best conditions for their seeds (children) to grow but tries not to interfere with the child’s developmental outcomes, as each child will develop into their own individual personality. ➢ On the other hand, the old-fashioned analogy of the parent as a carpenter is where the parent moulds their child into someone the parent wants them to be. This often involves pushing the child in a certain direction set by the parent, which can stifle the child’s individuality and developmental trajectory.

What Is Helicopter Parenting? How Can You Help Your Children Develop Independence? ➢ Try to avoid getting too overprotective and too over-involved. This is sometimes known as ‘helicopter parenting’, which comes from the idea that these parents ‘hover’ over their children and rescue them when needed. This is driven by a parent’s worry that their child might come to harm or not do well. ➢ For children to develop independence they need to make mistakes and learn from them. If they are afraid to make mistakes this interferes with developing problem-solving skills. They also need to learn to work things out when they fight among themselves, rather than parents always stepping in to judge who is to blame. ➢ You can help your child by encouraging them to gradually do more for themselves, for example dressing, and preparing and eating food. This can be frustrating at times as children can do things very slowly

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when we are in a hurry to get going! At each stage of their development think about what you can let them do to expand their independence. For example, when can you let them cross a road and venture to the corner shop alone? Resist the urge to constantly check and correct, and instead let them learn.

How Can You Sort out Disagreements and Arguments? Disagreements between parents and children are healthy, and avoiding conflict can make resentments build up in an unhealthy way. Ways to manage disagreements include: ➢ Use a problem-solving approach to manage differences – i.e., for solutions rather than problems. ➢ Use ‘I’ statements to describe how others’ actions make you feel instead of accusing. For example, ‘I feel uncomfortable when there are clothes all over the floor. Could you tidy it up today, please?’ rather than the order ‘Your room’s an absolute tip: clear it up now.’ ➢ Move on swiftly after an argument. Even if someone has done something very hurtful, holding onto grudges isn’t helpful. A new day, a new start is a good way to look at things. If children can go to bed feeling secure and loved they will sleep better.

What If You Do Something You Regret? Should You Apologise? ➢ Certainly: It’s important to show children that you can reflect on your own behaviour and apologise if you do something you regret. Being able to own your mistakes and learn from them is exactly the kind of behaviour you want your children to learn. I noticed my own

Positive Parenting Strategies

children started apologising and reflecting on their own behaviour once I consciously started to do this more myself.

KEY POINTS

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Parenting is one of our most important tasks, but it’s rare to get any training in it. Each child will have their own needs, so how you parent one child will be different from another.

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The concept of ‘good enough’ parenting is helpful for parents. If you actively listen to your children and try to understand them, it signals you are there for them and want to help them develop.

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Staying calm and in control is a key skill in parenting. You may need to work on trying to stay calm using breathing exercises and other methods that help with self-regulation.

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Praise is one of the most important aspects of parenting: it’s best if praise is specific and focuses on effort rather than results. You should aim to praise at least twice as much as you criticise.

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Have clear rules and boundaries and a consistent routine, especially around sleep and mealtimes. Consequences should be quick and fair, and you should aim to follow through on warnings.

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Always consider how you can develop children’s independence: try to let them work things out for themselves, and view mistakes as opportunities to learn.

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Use a problem-solving approach to manage difficulties and use ‘I’ statements when you want behaviours to change and avoid blame. Try not to hold on to grudges.

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If you can show children you can reflect on your own behaviour and apologise, they are more likely to do the same.

References (1) Winnicott, D. 1971. Playing and Reality. New York: Basic Books.

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Useful Resources Web-Based Resources and Podcasts ➢ Family Lives (www.familylives.org.uk) is a UK national charity which offers support to parents and caregivers. It has lots of useful information on its website and offers a confidential helpline, live chat, online parenting programme, a community forum and useful videos. ➢ Family Links (www.familylinks.org.uk) is a national charity and training organisation dedicated to the promotion of emotional health at home, at school and at work. It has several helpful resources on parenting and offers training to professionals based on a nurturing programme. ➢ Dr Maryhan is a UK-based psychologist who has specialised in parenting and I have found her advice and podcasts very useful and up-to-date. She has a podcast entitled ‘How Not to Screw Up Your Kids’ and also includes free resources on her website: https://drmaryhan.com ➢ Good Inside (https://goodinside.com/) is a web resource produced by US-based clinical psychologist Dr Becky Kennedy, who rose to fame for her very helpful advice on parenting during the COVID pandemic. She has produced a number of helpful free podcasts which directly answer questions about parenting dilemmas. There are also a number of subscription-based workshops available.

Books ➢ How to Talk So Kids Will Listen and Listen So Kids Will Talk, written by Adele Faber and Elaine Mazlish, is another easy-to-read parenting book with lots of good tips on how to engage cooperation and support children make good choices. Published by Piccadilly Press in 2012. ➢ The Book You Wish Your Parents Had Read (and Your Children Will Be Glad That You Did) is a very useful book written by UK-based psychotherapist Dr Philippa Perry. It gives parents an understanding of how their own childhood and how they were parented is so important,

Positive Parenting Strategies

and also considers how they can parent in a more effective way. It was published in 2019 by Penguin Life. ➢ The Incredible Years®: Trouble Shooting Guide for Parents of Children Aged 3–8 Years (third edition) by Carolyn Webster-Stratton. The Webster-Stratton parenting method is another well-researched parenting programme developed in America and adopted widely in UK programmes. Published by Incredible Years in 2019. ➢ 1-2-3 Magic: 3-Step Discipline for Calm, Effective, and Happy Parenting is a simple but effective parenting programme, which has helped many families and has been adopted by many UK-based parenting programmes. It was pioneered in America in the 1980s but is now used internationally as it focuses on being very clear and consistent with children. The principles are that children should be given warnings for both ‘start’ and ‘stop’ behaviours and learn clear consequences for their behaviour. The book is written by Thomas Phelan and was produced by Sourcebooks in 2016.

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12 Helping Children and Young People to Manage School Although schools aim to be nurturing and supportive environments, school life is not always plain sailing, especially if a child has additional needs. School difficulties inevitably have an impact on children’s mental health and wellbeing. Most of these difficulties can be managed and worked through with support from families and schools, but sometimes difficulties are more substantial and need professional help. Children and young people with additional needs generally require tailored support. It can be difficult for schools to meet everyone’s needs all the time, especially in a stretched mainstream school environment. We often see the fallout of when schools can’t meet children’s and young people’s individual needs due to the impact on their mental health. In this chapter I discuss how to help children manage school and what to do if extra support is needed.

Helping Children and Young People to Manage School

How Can You Help Your Child Manage School? ➢ The most important thing is to keep home a secure and safe space. If you keep a safe and nurturing environment at home, this will give children more strength to manage school’s challenges. Try to make sure each of your children has their own safe space at home, even if they share a room. ➢ Prepare your child for each new school year before term starts. The hardest time for many children is settling into a new school year after the summer break. It can be helpful to think several weeks ahead and talk about school in a positive way, including the new teacher and how you will manage routines. This is especially important for children on the autism spectrum. Many schools will offer some extra transition planning to those who struggle. You can request this if you know the transition may be difficult. ➢ Keep routines as stable as you can. This includes morning, evening and bedtime routines. You could make a visual routine chart with pictures of tasks that you can tick off. Think about how to prioritise sleep and mealtimes so children have time for a good breakfast before school and a warm meal after school. Getting to bed early with a screen-free winddown is important. ➢ Work on getting the right balance of school and extra-curricular activities. Many parents try to cram too much in and don’t leave enough time for playing and resting. Younger children often find the school-day exhausting enough. Although it can be helpful for children to develop other interests and friendships, you don’t want to overwhelm them with too many extra activities. ➢ Check in with your child at the end of each school-day. Start with the positives. Ask about what went well, what was difficult and what may help them cope better. If you can, speak to or email the teacher before problems escalate.

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How Can You Best Sort Things out with School If There’s a Problem? ➢ Get in touch with the class teacher in the first instance. You could either email them or ask for a telephone call. ➢ Find out who would be the most helpful home–school link person for your child’s issues, and how you can contact them. This may be a member of the support or pastoral staff or the Special Needs Coordinator (SENCo). ➢ Consider using a home–school communication book or email with a link person if issues need ongoing monitoring. This can be a helpful way of ensuring regular communication and you get on top of problems quickly. ➢ There may be a parent network you can tap into. Try to find out from other parents what strategies have worked for them. Nowadays many schools have online parent networks. ➢ Speak to the headteacher. Headteachers often have a good overview of what is going on in the school and tend to prefer to deal with issues at an early rather than an advanced stage. ➢ If the school can’t solve the problem, consider writing to the chair of the governors. All schools have a governing body who should be accessible to consider important school issues. If you need to raise things beyond the school, how you do this will depend on the way the school is run. For many schools, the local education authority is the next port of call if the school cannot resolve the issue. For academies it can be through the academy trust. ➢ Think about asking for support from other organisations involved with the child such as social care services. Special needs support services at the county council or mental health services can help bridge some communication gaps with the school.

What Should You Do if Your Child Has Special Needs? ➢ It depends on the child’s individual needs and to what extent a school can manage them in a mainstream classroom. In the UK, the

Helping Children and Young People to Manage School

first port of call to check this out is usually the class teacher. All schools have a Special Educational Needs Coordinator (SENCo), a teacher in the school who has extra training in managing children with additional needs, who works with class teachers to put a plan in place around a child’s needs. ➢ If your child does need extra help for learning or managing in the classroom or support with physical or personal care difficulties, then you can request the school to write a pupil profile. The school can put together such a document after a meeting with them and you can request regular reviews.

Who Gets an Education, Health and Care Plan (EHCP) in the UK? ➢ An Education, Health and Care Plan (EHCP) is for children and young people aged up to 25 who need more support than a mainstream school, college or nursery could provide through their Special Educational Needs support. These plans are legal documents which name the educational, health and social needs of the child and set out the additional support required to meet those needs. They replace the previous ‘statements’ of needs. ➢ In practice the school SENCo is often the person who puts in EHCP applications. This is because they are aware of the threshold needed to get such a plan, and to what extent a school can meet the child’s needs. ➢ Evidence to support an EHCP can include information from different professionals, including school staff, doctors and other allied health professionals who have been involved. For many children an assessment from an educational psychologist is important evidence. As a psychiatrist I am often asked to supply medical evidence for applications. Although a diagnosis of a mental health disorder isn’t strictly needed, it can often be helpful.

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What If the School Won’t Apply for an EHCP or You Don’t Agree with the Process? ➢ You or the child can also ask your local authority to carry out an assessment if you think an EHCP is needed. ➢ If you don’t agree at any stage of the process of putting together an Education, Health and Care Plan, you can challenge the local authority and appeal. If you can’t resolve the difficulty with the local authority you can appeal to the UK First-tier Tribunal.

What If Your Child Needs a Specialist School Place? It’s a good idea to visit some different types of specialist schools to get a feel for the environments, and it’s also helpful to try and talk to other parents before you make a choice. Here are some potential benefits and drawbacks:

Benefits ➢ They are set up to manage a specific group of children’s needs, which includes specially trained staff and resources. ➢ Class sizes are often much smaller than in mainstream schools and there is often more funding for extra staff and activities. ➢ Socially, children with difficulties may feel more understood and more easily able to find like-minded people. They may be less likely to be bullied for their difference/disability.

Drawbacks ➢ Children may feel more stigmatised if they are not in mainstream school.

Helping Children and Young People to Manage School

➢ Children may have to travel further from home. Many children will travel in taxis, which may also mean parents see the school and teachers in person less often, although many staff are excellent at communicating on the telephone or digitally. ➢ Some parents may be worried about the influences of some children with more severe difficulties and the lack of contact with mainstream peers.

KEY POINTS

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As schools are usually at the centre of a child’s life and their development, it’s helpful to try to make sure children have as much support there as they need.

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Parents can help their children to manage school by creating a secure base at home, getting familiar with school routines and ensuring good communication with schools.

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If you need to sort out a problem with school, consider who to raise the issue with and try to keep communication channels open with the school.

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If your child has special needs the first step is to meet with the Special Educational Needs Coordinator (SENCo), who can help draw up a school-based plan which should be reviewed at regular intervals.

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If the child needs more support than a mainstream school can offer, they may be eligible to apply for an Education, Health and Care Plan (EHCP). Schools often coordinate the application process.

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There are advantages and disadvantages to special schooling. It’s helpful to think through the options carefully and visit each school first. Talking to other parents may be useful.

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Useful Resources Web-Based Resources ➢ SEND: A Guide for Parents and Carers: This document, produced by the UK government, has comprehensive information about UK Education, Health and Care Plans. Available at www.gov.uk/government/publications/ send-guide-for-parents-and-carers

13 Building Resilience and Strength Every child and every young person has their own strengths. It’s important to actively look for and build on each individual’s strengths to develop their self-esteem. All too often we focus on mental health difficulties without first identifying strengths, which may fuel a sense of hopelessness rather than positivity. It’s also crucial to develop strategies to cope with challenges. This chapter looks at building on strengths, resilience and coping skills. Resilience is the ability to bounce back from difficult life events and challenges and to use coping skills effectively. In mental health services, there is now a growing trend towards using a solution-focused and strengths-based rather than a problem-oriented approach. Children and young people tend to respond more positively to building on what they enjoy and are good at rather than concentrating only on their problems. This is an approach parents and caregivers can also take to help develop children’s and young people’s self-worth and mental w ­ ellbeing.

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Why Is It Helpful to Build Resilience Factors? ➢ If you imagine a see-saw with resilience or coping skills on one side and risk factors on the other, the more we strengthen the coping skills (resilience) side, the more able the child is to deal with challenges (risks). So, we need to try and focus on building children’s strengths and coping skills to balance out any of the challenges. This has been illustrated in the Harvard Resilience Series (1) and a simple model has been drawn below (see Figure 4). ➢ If we build up more resilience factors, we can swing the see-saw up towards more coping and move towards more positive outcomes for the child. ➢ If, on the other hand, risk factors build up without coping strategies to buffer them, the see-saw swings up towards negative outcomes. Coping strategies E.g., having a safe, supportive adult; being able to talk about difficulties

Risk factors E.g., trauma; parental mental illness

Figure 4:  See-saw model of risk factors versus coping strategies showing a balanced see-saw

What Can You Do to Help Build Resilience and Strength in the Face of Challenges? ➢ A strength-based approach in mental health involves building positive connections with your children. Connection is built from strong attachment relationships, which provide a secure base for children.

Building Resilience and Strength

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To provide children and young people with a secure base, you first need to look after your own health and mental wellbeing. It’s important to keep working on connecting and reconnecting with your children as it’s so easy to disconnect. Fragile relationships can break down if we don’t figure out how to nurture them. Build strong support networks around your children. You are stronger and better able to manage challenges if you are connected with others and are open to accepting support from others. Think about continuing to build your networks of support through friends, extended families, schools and clubs/hobbies. Help children to express their feelings in words and find effective ways of managing difficult feelings. If children can learn to express their feelings, they are more likely to get appropriate support, and find helpful ways of coping with feelings. Help children develop self-care by showing them ways you care for yourself and encourage them to develop their own self-care strategies. Music, spending time in nature, exercise, creative arts, meditation and relaxation and talking to trusted people are all strategies for self-care. Nurture a growth mindset. A growth mindset is when you believe success depends on putting in time and effort to build understanding and learning from mistakes. You can teach children to welcome challenges, persist through obstacles and seek out inspiration in others’ success. Allow children to work things out independently. How can you help your children develop problem-solving skills? By letting them work things out rather than doing things for them. You need to avoid the trap of getting too over-involved and overprotective. This can be challenging at times as children may resist doing things for themselves. However, it’s important to keep your eye on the long-term goal of supporting children to be independent adults who can do their own problem solving. Work in partnership with schools. Often when young people hit an obstacle at school, it’s easy to get angry with the school and blame them. However, if we can instead try to work together with the school to find solutions, things often work better for children and young people. Look for professional support when needed. Many of us try and sort everything out for ourselves and don’t like asking for help. But asking for

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help when it’s needed is a valuable life skill rather than a weakness, and if we show our children this, they are more likely to follow and be able to access their own help when they need it too.

KEY POINTS

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Resilience is the ability to bounce back from difficult life events and challenges. Resilience factors help us cope better with life’s challenges.

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Focusing on a child’s or young person’s strengths as well as difficulties is a good way of starting to find possible solutions and coping strategies.

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The see-saw model can help us visualise how to balance risk versus coping skills in mental health. The aim is to tip the see-saw towards resilience factors and coping skills and try to reduce risk factors.

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There are several things we can do to help young people build resilience, including: connecting with children; building strong networks; helping young people express their difficult feelings; having a growth mindset; allowing children to work things out independently; working together with schools; and seeking out support if we need it. Prioritising self-care is also very important.

References (1) In Brief: Resilience Series. Harvard University. Center on the Developing Child. Available at https://developingchild.harvard.edu/resources/ inbrief-resilience-series/

Part 3 What Are the Common Mental Health Difficulties in Children and Young People and How Are They Managed? What Can You Do to Help? In Part 3 of this book, I describe a range of common mental health difficulties and disorders. The first chapter introduces concepts of assessment, diagnosis and consent. Each of the subsequent chapters takes a different area of mental health difficulty and then explains how children and young people tend to struggle with the difficulty; how common it is; the point at which a difficulty may become a mental health disorder, and support and treatment approaches. The final two chapters give an overview of mental

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health first aid and mental health teams and support. The chapters are as follows: ➢ Introduction to Part 3 ➢ Chapter 14: Difficulties with mood: depression, mood swings and emotional dysregulation, and bipolar disorder ➢ Chapter 15: Difficulties with worries and anxiety ➢ Chapter 16: Difficulties with self-harm and suicidal thoughts ➢ Chapter 17: Difficulties with trauma and PTSD ➢ Chapter 18: Difficulties with anger and behaviour ➢ Chapter 19: Difficulties with attachment ➢ Chapter 20: Difficulties with autism and neurodevelopmental conditions, including tics ➢ Chapter 21: Difficulties with attention and activity levels ➢ Chapter 22: Difficulties with alcohol and drugs ➢ Chapter 23: Difficulties with eating ➢ Chapter 24: Difficulties with body image and body dysmorphic disorder ➢ Chapter 25: Difficulties with perfectionism, obsessions and OCD ➢ Chapter 26: Difficulties with losing touch with reality (psychosis) ➢ Chapter 27: First aid for mental health ➢ Chapter 28: Mental health teams: who works in them and what are the different specialist teams?

Introduction to Part 3 It wasn’t so long ago that most people thought mental health disorders could be classified in ‘boxes’ and either someone could be labelled as either having a mental health disorder or being well. We now know that almost all mental health difficulties and disorders are actually on a sliding scale from having no symptoms to severe symptoms. In this section we consider both mental health difficulties and more severe mental health disorders and look at the tipping point at which a mental health difficulty may become a disorder. The see-saw model shows that if risk factors build up without coping strategies to buffer them, the see-saw swings up towards negative outcomes and the risk of developing a mental health disorder is significantly greater. We also consider how mental health professionals assess and diagnose mental health conditions, the pros and cons of using the psychiatric model, and the concepts of capacity, confidentiality and consent. If your child has been experiencing mental health difficulties and may need support or a diagnosis, you are likely to be understandably concerned and may be anxious to learn more about what is happening to them and what you can do to support them. It can be an incredibly frightening and overwhelming experience to watch a young person go through mental health distress. I hope this book will be a useful starting point for you to understand more and seek support. Please do turn to the chapters which may be relevant to you. If you are in such a situation, it may also be helpful for you to go back to Part 2, which has lots of information about how to look after yourself and strengthen your relationships.

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What Causes Children and Young People to Struggle with Mental Health Difficulties? Mental health difficulties become more likely when risk factors start to outweigh our coping abilities (resilience factors): ➢ Returning to the see-saw model of risk factors versus coping strategies from the last chapter (see Part 2, Chapter 13), if a child stacks up a lot of risk factors (such as abuse, neglect, poverty, lack of support) without enough coping abilities (supportive adults, strong attachments), their chances of experiencing mental health difficulties will be greater. ➢ Those young people who have had adverse childhood experiences (ACEs) are at greater risk of developing mental health difficulties (see Part 1, Chapter 4, which explains ACEs in more detail). For example, if a young person experiences parental separation and bullying despite having some support, their chances of struggling with mood are higher, as in the see-saw model in Figure 5.

Risk factors E.g., history of trauma, parental Coping strategies E.g., reduced availability of supportive adult and child using maladaptive strategies, such as selfharm or alcohol

mental illness with bullying and school difficulties

Figure 5:  See-saw model showing that if there are not enough coping abilities to buffer a build-up of risk factors, there is an increased chance of mental health difficulties

Introduction to Part 3

➢ There are often common trigger points when mental health difficulties become more likely. In the UK at transition between primary and secondary school, or in high-stakes exam years, even the most resilient young people may find things tricky.

When Does a Mental Health Difficulty Tip into Becoming a Disorder? What Causes Mental Health Disorders to Arise? ➢ Mental health difficulties can usually be managed by supportive adults around the child without the need for specialist help. If mental health difficulties become more persistent and start to affect everyday functioning, they can become disorders. For example, low mood can gradually increase and turn into a depressive illness if it persists beyond a few weeks and affects functioning. ➢ Disorders are caused by a combination of inherited and environmental factors. ➢ To understand why a condition may arise in a particular individual, it’s helpful to consider possible contributory factors. These may include a relationship break-up; underlying factors, for example an inherited risk of mood disorders; and maintaining factors, which keep the problem going. It’s helpful to take a positive approach and highlight strengths and protective factors. ➢ We use what is known as a bio-psycho-social model in mental health to work out contributing risk factors to becoming mental unwell. This means we can identify a range of biological, psychological and social factors which may cause a young person to become unwell at a certain time. For example, for a young person with depression: biological factors may include their increased inherited risk due to having two close family members with depression; psychological factors include perfectionist traits which make them self-critical; and social factors could include lack of close friendships.

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How Are Mental Health Disorders Diagnosed? ➢ Psychiatrists are trained to assess mental state and make diagnoses according to the number and type of symptoms they see or have reported to them. ➢ We use international classification systems, such as the International Classification of Diseases (ICD, currently version 11), in the UK (1), and the Diagnostic and Statistical Manual of Mental Disorders (DSM, currently version 5), the American Classification System (2). ➢ There is also a classification system for under 5s called the DC 0–5 (3). However, we use this less often in Child and Adolescent Mental Health Services, as we have historically managed children from around 5 years, and colleagues in community paediatrics and health visiting teams tend to deal with pre-schoolers. This may vary according to the geographical area and may well change in the future, as there is increasing interest and investment in infant mental health.

What Are the Pros and Cons of Assigning a Diagnosis to Children and Young People? Pros ➢ A diagnosis can often be helpful for families and schools to understand symptoms better, and to get access to useful sources of information around conditions. ➢ A diagnosis can help guide professionals in the use of evidencebased treatments and resources to support a child with a particular group of difficulties. ➢ A diagnosis is also a helpful tool to aid research. It enables mental health professionals to understand more about disorders and how to treat them.

Introduction to Part 3

Cons ➢ There are still many developmental changes happening, which means diagnoses may not be clear-cut in children. Symptoms change over time and children may not fit neatly into diagnostic boxes. ➢ Assigning a label may cause us to overlook the family and social context around the child, which may be the root cause of the mental health difficulties. Sometimes making changes to the system is a more acceptable approach, rather than labelling a child with a disorder. ➢ It’s also important not to use a diagnosis as an excuse for a child not to learn to take responsibility for behaviour, for example saying it’s OK for a child to misbehave because they have ADHD.

Is There Always a Big Difference between Having a Diagnosis of a Mental Health Disorder and Not Having a Diagnosis? ➢ There isn’t necessarily a big difference between having a diagnosis of a mental health disorder and not having one: most mental health disorders are on a spectrum from not having symptoms to having severe symptoms. ➢ Many of us in the general population may also have traits of different mental health disorders which cause some difficulties with functioning but not enough symptoms to have the full disorder. ➢ Sometimes the difference between having traits or symptoms and having a disorder is small, especially when we are counting symptoms. That is why it is important to describe the impact of symptoms on functioning, and to look at a child in their context as well as counting the number of symptoms they have.

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Mild symptoms

Child has symptoms that may cause a few difficulties

No symptoms

Child unaffected

Child is very unwell with several symptoms and severe difficulties with functioning Child has significant symptoms with a moderate impact on functioning

Child has enough symptoms for a diagnosis, although the impact on functioning is mild

Child has some symptoms, causing difficulties, but below the cut-off for a diagnosis

Cut-off point for having a diagnosis

Severe disorder

Moderate disorder

Mild disorder

Moderate symptoms or traits

Introduction to Part 3

Do Mental Health Professionals Always Keep Children’s and Young People’s Difficulties Confidential? ➢ Professionals who work with young people’s mental health are bound by ethical standards to keep their difficulties confidential. ➢ However, if a professional finds out a young person or someone else is at risk of serious harm or death, they may need to break confidentiality. Confidentiality may also be broken if a court orders it or in other exceptional circumstances. In cases where we may have to break confidentiality, professionals try their best to let children and young people know this as soon as they can.

How Do You Judge Whether a Young Person Can Make Their Own Decisions about Their Health Capacity is covered in UK law for over 16s by the Mental Capacity Act: we are generally considered able to make our own decisions unless there is evidence of incapacity. A young person’s capacity to make decisions can also vary according to the specific decision in question: they may be able to make basic decisions themselves but may well need help understanding more complex decisions. Capacity is assessed by considering the following questions for each individual decision, and going to lengths to make sure that a young person is supported in each step to try to maximise their decision making: ➢ Does the young person have the ability to understand the relevant information? ➢ Can the young person retain the information? ➢ Can the young person weigh information in the balance as part of decision making? ➢ Can the young person communicate their decision?

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Professionals are encouraged as much as possible to involve children under 16 in their decision making, together with those with parental responsibility, as they are usually considered to be under the scope of parental responsibility. There are three key questions to help identify whether a decision falls within this scope: 1. What is the nature of the decision? What type of treatment/intervention is proposed? Is the child resisting? What are the age and maturity of the child? 2. Are there any indications that the parent may not act in the best interest of the child? 3. Does the parent have the capacity to make the decision?

Children under 16 can consent to medical treatment without parental influence if they are competent to make a decision, which involves understanding what the treatment is and weighing up the pros and cons. This is known as Gillick Competence, named after a landmark case in UK law.

Can Children and Young People Who Are Mentally Unwell Be Treated in Hospital If They Refuse Treatment? ➢ Yes: most countries have laws which allow the detention of people who are mentally unwell in hospitals for treatment without their consent. The Mental Health Act is the UK legal framework used when patients are admitted to and detained in hospital without their consent. ➢ A person can be detained under a Section of the Mental Health Act if ‘they are suffering from a mental disorder of a nature or degree which warrants their detention in hospital for assessment or treatment AND the person ought to be so detained in the interests of their own health or safety or with a view to the protection of others’ (4). ➢ However, for detention there also needs to be a suitable hospital available to receive the young person for assessment and treatment.

Introduction to Part 3

Examples of when children and young people may be detained under a Section are: ➢ Young people with severe eating disorders who are convinced they are well and are refusing treatment despite losing weight rapidly. ➢ Young people with severe psychotic illnesses (e.g., schizophrenia), requiring antipsychotic treatment and nursing care in hospital. ➢ Young people with severe depression who are at high risk of suicide and require 24-hour monitoring and treatment in hospital.

KEY POINTS

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Mental health difficulties often arise when there are not enough coping abilities to buffer a build-up of risk factors.

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Mental health difficulties can turn into mental disorders if the symptoms significantly affect functioning and require treatment.

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Mental health disorders and conditions are caused by a combination of inherited and environmental factors. We use a bio-psycho-social model to understand an individual’s risk of becoming unwell. We also try to understand underlying, trigger and maintaining factors to explain how mental health disorders arise.

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We use international classification systems to classify disorders based on the number of symptoms. In general terms, the more symptoms and the greater the impact on everyday functioning, the more severe the condition.

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Most mental health disorders and conditions are on a spectrum. Sometimes the difference between getting a diagnosis or not is small. There are pros and cons to assigning diagnoses. We are generally more cautious in giving diagnoses in children and young people than adults.

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Children and young people under 16 together with those holding their parental responsibility are usually both consulted around their

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treatment. Young people may be able to agree to some types of medical treatment themselves if they are competent to do so. The Mental Capacity Act covers young people over 16. Young people are presumed to have capacity for a specific decision, unless there is evidence to the contrary.

•

The Mental Health Act is the UK legal framework used when patients are admitted to and detained in hospital without their consent. It is needed if young people have a severe mental disorder that requires treatment in hospital for their own health, safety or for the protection of others, and they are unwilling to be admitted.

References (1) World Health Organization. ICD-11. Updated 2022. International Classification of Diseases 11th Revision. The Global Standard for Diagnostic Health Information. Available at www.icd.who.int/en (2) American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association. (3) Zero to Three. 2016. DC:0–5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Washington, DC. (4) UK government, Department of Health. 2015. The Mental Health Act Code of Practice. P113. Available at https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/435512/ MHA_Code_of_Practice.PDF

14 Difficulties with Mood: Depression; Mood Swings and Emotional Dysregulation; Bipolar Disorder Children and young people can experience a range of mood-related difficulties, from feeling low in mood, to having disorders including depression or bipolar disorder. Severe difficulties with emotion regulation (or emotional dysregulation) describes severe mood instability, which is not uncommon in adolescence, and in some cases can lead to personality difficulties and disorders. Mood-related difficulties may present with different presentations in children and young people to adults. In this chapter I will try to explain how to detect mood difficulties and disorders and how to offer support.

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Difficulties with Low Mood and Depression Mood is an emotional state that tends to be longer-lasting but less intense than an emotion. Mood disorders, like depression and bipolar disorder, are longer-term disturbances in mood. Most of us have experienced low mood at some point, and depression is one of the most common illnesses worldwide. In fact, 24% of women and 13% of men in England are diagnosed with depression in their lifetime (1). It’s likely that you will have personal experience of depression, either in yourself or someone close to you. Children and young adults with low mood and depression can present differently to adults. I discuss here how to detect difficulties in children and young people and what you can do to help. I also describe the current recommended treatment approaches.

How Much Is Being Sad Normal in Young People? ➢ Being sad at times is healthy and part of the range of emotions we all feel. We vary as to how naturally optimistic we are. ➢ However, sadness that persists and gets in the way of us doing things is not normal. Children with persistent sadness may need extra help as they may be becoming depressed.

How Can You Help Your Children Manage Low Moods? You can help your children become aware of their emotions, so they can learn to communicate and manage them. This process is as follows: ➢ Recognising emotions: This involves learning to put words to feelings, or, if this is too difficult, using labels or cards with different emotional faces

Difficulties with Mood

(like happy/sad/angry). To start with you could give children some options before they learn to name their feelings. For example, ‘How did not getting invited make you feel?’ ‘Did it make you feel sad or angry inside?’ ➢ Processing emotions: Talking through feelings with a trusted adult or writing or drawing them on paper helps children process and understand emotions. This processing is a step to realising that the emotions will pass, and don’t define them as people. ➢ Finding ways to manage difficult emotions: This will be different for each child. I often encourage young people to make a personal list for their bedroom wall of things that can lift their mood. The more specific the list is to the individual the better: writing the name of a song is better than just writing ‘music’.

What Is the Difference between Having Depression and Just Being Sad? ➢ Depression is more serious than just being sad. ➢ It is where feeling sad, low in energy and/or unable to enjoy things becomes overwhelming for at least 2 weeks and starts to interfere with one’s ability to function.

How Common Is Depression in Young People? ➢ Depression is one of the most common mental health conditions. According to the last UK national survey, around 2 in 100 young people are depressed at any one time (2). Rates increase sharply with age, especially after puberty. Very few younger children (less than 1%) have a diagnosis, but this rises to around 5% of 17- to 19-yearolds. ➢ Depression is more common in girls than boys, although there is some evidence that girls are also more likely to come forward for help.

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How Is a Diagnosis of Depression Made? Doctors make a diagnosis of depression based on assessing someone’s mental state (which includes observing how a young person looks and talks or plays), hearing their story and getting information from others, for example close family members. How much history we get from the child or young person themselves depends on their age, developmental level and how unwell they are. We find out whether they have core and additional symptoms of depression. Core symptoms of depression are low mood, low energy or tiredness and lack of pleasure in activities. Additional symptoms of depression are as follows (3): ➢ Sleep problems, which can include problems falling asleep, waking up many times in the night, sleeping in the daytime and being overtired. ➢ Difficulty concentrating even for reading/watching TV and for school-work. ➢ Becoming more withdrawn. Young people often retreat to their room and stop spending time with family and friends. ➢ Reduced self-esteem, including feelings of inadequacy and having insecurities about their appearance. ➢ Physical symptoms. Appetite and weight changes are common. Headaches and stomach aches are common in children and young people with depression. ➢ Feeling empty or numb, which can be more difficult to manage than low mood. ➢ Thoughts of self-harm or suicide. Feeling worthless and that life isn’t worth living is often part of depression. (See Chapter 16 on self-harm and suicidal thoughts for more detail.) ➢ Behaviour changes such as increased aggression, clinginess or engaging in risky behaviour. Sometimes young people express frustrations by becoming aggressive to others. Adolescents may try to escape the pain of depression with drug or alcohol use. ➢ There may be loss of touch with reality, known as psychosis in severe depression. (See Chapter 26 on psychosis for more information.)

Difficulties with Mood

Note: The number of additional symptoms affects whether a diagnosis of mild, moderate or severe depression is made.

What Causes Depression? ➢ Depression is caused by a mixture of inherited and environmental factors. In some young people there is an obvious trigger, such as a relationship break-up or bullying. In others, there may be no obvious trigger. ➢ Young people who have experienced several adverse childhood experiences (ACEs), such as trauma, are at much higher risk of depression (see Part 1, Chapter 4 for a more detailed explanation of ACEs). ➢ Certain risk factors in a young person’s background can also increase risk such as if there is a family history of depression or drug or alcohol misuse. Poverty is a significant risk factor.

What Can You Do to Support a Child Who May Be Depressed? It is usually helpful to talk with your child about how they are feeling in a non-judgemental way, check how they are regularly and show them you are there for them whatever their mood. How you next support them will depend on the severity of symptoms as follows: ➢ For milder symptoms, where a child is struggling with negative mood but is still functioning reasonably well, supporting them at home can usually be enough to help them cope. This can include listening to what has been useful in the past, building in activities they can manage and previously enjoyed, making use of their support network to help, and if needed getting some school-based support. However, if symptoms continue beyond around 2 weeks or they would like to access treatment, you can ask for a referral to the local Child and Adolescent Mental Health Services.

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➢ If symptoms are moderate or severe and you are worried about the child’s ability to manage without extra help, you can request a referral from your family doctor or school nurse to the local Child and Adolescent Mental Health Service, who can assess further.

Which Treatments Are Recommended for Depression in Young People? According to the UK national guidance (known as NICE guidance) (4): ➢ Mild symptoms: Supporting children at home with watchful waiting to start with. Then if symptoms persist for more than 2 weeks treatments may be offered: digital therapy or group therapy if available. If these do not meet the child’s needs, then we consider using family therapy or individual therapy. ➢ Moderate to severe symptoms: Psychological treatments, for example Cognitive Behavioural Therapy (CBT), family therapy or psychodynamic therapy are first-line treatments. What is offered may depend on the individual child’s difficulties as well as what is available in the local mental health services. Combined psychological treatment and antidepressant medication may be offered if needed. ➢ Depression unresponsive to above treatments: A different type of psychological treatment should be made available, and an alternative antidepressant medication can be tried.

How Do Antidepressants Work? ➢ The antidepressants licensed in children are part of a group of medicines called ‘Selective Serotonin Reuptake Inhibitors’ (SSRIs), for example fluoxetine. They work by increasing the amount of serotonin available in the nerve endings in the brain. We know that the amount of serotonin and similar brain chemicals used for nerve cells to connect with each other is reduced in depression.

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How Helpful Is Antidepressant Treatment for Children with Depression? Are There Risks to Taking Them? ➢ Antidepressants are far from the ‘magic bullet’ we would hope them to be. They are less effective in treating depression in children and young people than adults, and there is less long-term data to back up their use. However, studies show they can be helpful as an additional treatment to psychological therapy in children with moderate–severe depression: studies show that about 2 in 3 under 18s in this group will see some benefit. ➢ Although most people tolerate medications well, they have potential side effects like tummy aches, headaches, dizziness and an impact on sleep. These effects are more common in the first week or so of taking medication and happen before positive effects of medication kick in. It generally takes 2–3 weeks before antidepressants start to have a noticeable effect on mood, and the dose may need adjusting. Side effects can be more troublesome for some young people, and in some cases can prevent use of certain medications. ➢ Antidepressants also come with a warning because in rare cases thoughts of self-harm or suicide can become stronger after starting treatment, and the risk is often highest in the early stages of treatment. It is important that a responsible adult manages medication and checks on the child closely.

What about Lifestyle Changes? ➢ There is now increasing research that improving diet and exercise can also help people with depression recover. Although most of the data so far are in adults, children and young people are also likely to benefit from positive lifestyle choices, and it’s unlikely that they would cause harm. ➢ There is evidence from adults that exercise has an impact on mood. A large trial of CBT (psychology) versus exercise-based treatment in

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adults with depression showed that both groups displayed equally good improvement in depressive symptoms after 12 months (5). Similar trials are following. So, encouraging children to keep as active as they can even when they have low mood could help them get better more quickly. ➢ There is increasing evidence that a healthy diet has a positive impact on mood. The SMILES Trial, an Australian trial that looked at adults with depression, showed that offering individual dietary advice to change diet towards a healthy modified Mediterranean diet improved depressive rating scales (6). This study came from the Food and Mood Centre in Australia (https://foodandmoodcentre.com.au), which is doing interesting research in this area.

How Long Does It Take Children with Depression to Get Better? ➢ It is highly variable, and depends on many factors, for example severity of symptoms; quality of support; response to treatment. ➢ Most people respond to treatment over a period of weeks to months. Usually, it is a matter of weeks for milder forms of depression and up to several months for more severe forms to improve.

Which Other Diagnoses Are Related to Depression? ➢ Dysthymia (also known as subthreshold depressive symptoms) consists of depressive symptoms that are milder in severity than depression but last for longer (i.e., at least a year). Children may seem unhappy for longer periods. Dysthymia is important as it can tip into a depressive illness. ➢ Disruptive mood dysregulation disorder (DMDD) is a new diagnosis in the DSM-5 American classification system. It consists of severe and recurrent temper outbursts that are grossly out of

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proportion in intensity or duration to the situation. These occur, on average, three or more times each week for one year or more. Between outbursts, children display a persistently irritable or angry mood, most of the day and nearly every day, which is observable by parents, teachers or peers. A diagnosis requires difficulties in two settings for at least a year, and symptoms must be severe in at least one of these settings. The onset of symptoms is between ages 6 and 10. Children with DMDD are more likely to go on to suffer from depression than other mood disorders.

Case Example Layla is 15. She used to be bubbly and outgoing and enjoyed school, but in the last few months has gradually become more withdrawn, spending most of her time in her room, with minimal contact with friends. She is irritable at home, seems low in mood and is often tearful over slight disappointments. She has missed school several times in the last month as she has felt ‘unwell’. She often tells her mum she isn’t hungry at mealtimes and seems to be losing weight. She seems very tired and said she doesn’t have the energy to go dancing, so stopped classes. She’s struggling to get to sleep. Her teachers are concerned her grades have started to slip. When mum notices cut marks on Layla’s arms, and Layla admitted to self-­ harming, mum books an appointment with the GP to ask for help. Mum herself has suffered with depression on and off for several years. The GP refers Layla to the local Child and Adolescent Mental Health Service where Layla admits she has felt low for three to four months after her best friend moved away and stopped replying to her messages. Layla also misses her grandpa, who died a year ago. Layla has 16 sessions of therapy (CBT) with a psychologist. She improves a little, but she is not back to her usual functioning, so she also sees a psychiatrist in the team, who prescribes her an antidepressant called fluoxetine. Layla improves with the combination of therapy and medication and starts to gradually feel better over the next few months, although not quite back to how she was

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before she was depressed. She continues to require extra support from school and also considers getting grief counselling.

Notes on the Case Example ➢ Layla has moderate depression: her mood is low, she is irritable, tearful and has lost enjoyment, and her functioning is quite impaired. She also has several other symptoms, including poor sleep, stopping activities she used to enjoy and self-harming. ➢ The fact that Layla’s mum has a history of depression is a risk factor for Layla. The trigger to Layla becoming unwell was probably Layla’s friend moving away and the death of her grandpa. Layla’s reaction to her grandpa’s death is not just a normal grief reaction, however, as her difficulties are more severe and impact on her mood. ➢ In many young people, psychological therapy is enough for them to improve. In some young people like Layla, the addition of an antidepressant can be helpful. However, it is important to note that depression takes many forms and has many pathways. The treatment approach will depend on the individual patient and their circumstances. Not all young people will self-harm when depressed and for many young people there may be no obvious trigger. It is helpful when contributory factors are found though, as this can be useful in directing treatment approaches.

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It is normal for children and young people to experience a low mood from time to time. If sadness persists and starts to impact on their ability to function at home or school, we may need to be alert to the possibility of depression developing. We can support children and young people manage and understand their moods by (a) helping them identify their emotions; (b) helping

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them process emotions by talking or writing and drawing them; and (c) finding ways to manage emotions, for example making a personal list of specific things that help them lift their mood. Depression is a serious mental health disorder. Psychiatrists can make a diagnosis from conducting a mental state examination and taking a detailed history of symptoms. Depression can be mild, moderate or severe depending on the number of symptoms and level of difficulty in functioning. Depression is treatable but generally takes weeks to months to recover. We can use different treatments depending on how severe difficulties are and the young person’s preference. For moderate–severe depression, psychological therapies, including CBT, have a good evidence base. Antidepressants can sometimes also be useful as an added treatment. It’s worth considering how to improve lifestyle factors like sleep and exercise, which can have a positive impact on mood. There’s emerging evidence in adults that depression can be improved with lifestyle modifications, and it’s unlikely to be harmful to use similar principles with young people.

References (1) Craig, R., Fuller, E. and Mindell J (eds.). 2015. Health Survey for England 2014: Health, Social Care and Lifestyles. Available at https://webarchive .nationalarchives.gov.uk/20180328135732/http://digital.nhs.uk/catalogue/ PUB19295 (2) World Health Organization. Updated 2022. ICD-11. International Classification of Diseases 11th Revision. The Global Standard for Diagnostic Health Information. Available at www.icd.who.int/en (3) NHS Digital. 2018. Mental Health of Children and Young People in England, 2017: Emotional Disorders. Available at https://files.digital.nhs .uk/14/0E2282/MHCYP%202017%20Emotional%20Disorders.pdf (4) National Institute for Health and Care Excellence (NICE). 25 June 2019. Depression in Children and Young People: Identification and Management. NICE guideline [NG134]. Available at www.nice.org.uk/guidance/ng134

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A Guide to the Mental Health of Children and Young People (5) Hallgren, M., Helgadóttir, B., Herring, M., et al. 2016. Exercise and Internet-Based Cognitive Behavioural Therapy for Depression (Regassa): A Multicenter Randomised Controlled Trial with 12-Month Follow-Up. British Journal of Psychiatry 209(5), 414–420. (6) Jacka, F. , O’Neil, A., Opie, R., et al. 2017. A Randomised Controlled Trial of Dietary Improvement for Adults with Major Depression (the ‘SMILES’ Trial). BMC Medicine 15(23). https://doi.org/10.1186/s12916-017-0791-y.

Useful Resources Web-Based Resources ➢ The Royal College of Psychiatrists has some useful online information for families about depression in young people at www .rcpsych.ac.uk. Including a helpful leaflet entitled ‘Depression in Children and Young People’. Available at www.rcpsych .ac.uk/mental-health/parents-and-young-people/young-people/ depression-in-children-and-young-people-for-young-people

Books ➢ So Young, So Sad, So Listen: A Parents’ Guide to Depression in Children and Young People is a readable guide on supporting children and young people with depression, written by Philip Graham, a UK psychiatrist, and Nick Midgley, a UK psychologist, produced by Cambridge University Press in association with the Royal College of Psychiatrists. The third edition came out in 2020.

Difficulties with Mood Swings and Emotion Regulation Mood swings are so common we often see them as a rite of passage in teenagers. For a variety of reasons, some young people struggle a lot more than others. There is also a group of higher-risk young people who struggle

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with more serious and long-standing poorly regulated mood patterns, also known as emotional dysregulation, often in conjunction with patterns of destructive behaviour such as self-harming, aggression and risk-taking. We can use approaches with these young people to help them to self-­ regulate and gain more control over their emotions. However, a small proportion of these higher-risk young people struggle to such a large extent with an unstable mood and sense of self that they are at risk of developing personality difficulties and disorders. Many of these young people have had difficulties with early attachment and previous trauma or abuse, and they may find specialist support useful in helping them gain a sense of control and establish effective coping skills.

How Normal Is It for Teenagers to Have Mood Swings? ➢ It is normal and expected for most teenagers to have mood swings, especially considering the range of body and brain changes they are experiencing. ➢ However, mood swings should not normally significantly affect the young people’s ability to function at home, school and socially. If the impact is significant, it may be helpful to seek professional help.

Which Factors Can Affect Mood Swings? ➢ Puberty and physical health issues: Swinging hormone levels can be a lot for young bodies to process. Many girls find their mood changes with their menstrual cycles. Young people can also be affected by a range of other physical health issues as they grow and develop. ➢ Food, drugs and stimulants, including sugar, caffeine and alcohol, can have a big impact on mood, as can certain medications. ➢ Sleep: Many young people don’t get enough sleep and are chronically tired, especially with their natural rhythms of sleep disturbed by technology and the early waking needed for school.

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➢ Brain changes: The brain is a hotbed of changes in adolescence. As young people’s brains mature their ability to self-regulate and manage their moods generally improves, but this can be a lengthy process. (See Part 1, Chapter 1 section on the developing brain for further details.) ➢ Personality factors: Some young people have a lower frustration tolerance than others; others are particularly impulsive or perfectionist. ➢ Social factors: Peer relationships are hugely important to young people and difficulties can cause significant emotional upsets.

How Can You Help Children and Young People Manage Mood Swings? ➢ Try to get them to understand their triggers. For some people keeping a mood diary can be helpful, to understand triggers such as amount of sleep, food intake, menstrual patterns and impact of stressful events. ➢ Encourage healthy sleeping and eating habits. Establish consistent bedtimes and switch off technology before bed. Encourage regular healthy meals rather than sugary snacks, which can cause sugar rushes and dips, resulting in mood swings. ➢ Encourage maintenance of interests and activities, even if they don’t always feel in the mood. Adolescents can go through a phase of giving up hobbies without much reason and then may fill the void with social media. Following active interests like sports and music that give a sense of achievement can be helpful for stabilising mood. ➢ Find coping strategies that help to shift mood, like taking a walk or listening to a favourite song. Being out in nature is a great way to reset moods. Keeping a personal diary can also help to process their moods. ➢ Let young people know you are there for them, but also give them some space. Teenagers need their parents to be there for them, but they are also going through a process of becoming independent. ➢ Be a sounding board. Young people need time to work through their emotions and having a supportive adult listen to them can help to regulate their moods. Try not to rush to offer solutions but allow them to work through their problems.

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What Is Meant by the Term ‘Emotional Regulation’? ➢ Emotional regulation is the way a person understands and acts on their emotional experiences. ➢ A young person with positive emotional regulation skills can use strategies to manage difficult emotions and learn to gain control over their responses. ➢ On the other hand, people with severe emotion regulation difficulties (emotional dysregulation) struggle to understand their emotions and to control the urge to act impulsively. They may develop unhelpful coping strategies by self-harming, being reckless or aggressive when under stress. Young people with emotional regulation difficulties have often had difficulties in their attachment relationships and may have been subject to severe stress or trauma.

Which Symptoms Do People with Severe Emotion Regulation Difficulties Typically Have? ➢ Intense and frequent mood swings with difficulty expressing emotions. This often leads to difficulty managing relationships. ➢ Feeling numb or ‘empty’, which leads to feeling lonely and engaging in harmful behaviours in order to feel something. ➢ Difficulty with relationships, often leading to unstable or intense relationships. ➢ Having an unstable sense of self, which can lead to self-destructive behaviours. ➢ Difficulty managing anger, which can lead to violence and destructive behaviours. ➢ Fear of abandonment, which can lead to intense relationships, which are at higher risk of breakdown. The root cause of this fear is usually early trauma or attachment difficulties. ➢ Paranoia and sense of feeling cut off from the body or self. ➢ Self-damaging behaviours, for example risky sex, drug use, self-harming or unhelpful patterns of eating.

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Which Coping Skills May Help with Emotional Regulation? Although many of the strategies which help with mood swings are also likely to be useful for those with severe emotion regulation difficulties, there are some additional strategies for the latter, which are outlined below: ➢ Lifestyle strategies including taking part in regular exercise and getting into a good sleep routine, limiting alcohol and eating healthily. ➢ Developing emotional awareness. Young people need to learn to understand their emotions including what causes them to change. Encourage them to talk and keep records of how they feel. ➢ Grounding exercises. This involves trying to zoom in on all the layers of a sense in the body (including touch, hearing, sight, smell) to return to the present moment. Examples include listening to nature sounds; using a water mister to spray the face; snapping a rubber band. ➢ Distraction by doing another active behaviour like going for a walk. The act of doing something else distracts from inner turmoil. ➢ Speak to a trusted person or call or text a helpline (e.g., Samaritans or Childline). Although talking things through can be supportive and helps slow down thinking, many young people prefer to text a 24/7 mental health helpline such as SHOUT on 85258. ➢ Mindfulness, breathing and relaxation. Young people may find learning mindfulness and breathing techniques useful. A good relaxation technique is to deliberately tense and then relax each muscle group from the toes up to the forehead. ➢ Music and exercise can give peace and can also help alter emotions. ➢ Getting professional help if needed. Therapeutic support can be very beneficial, especially if young people get stuck into unhelpful coping styles. ➢ There is a well-researched freely available self-harm guide for parents and carers produced by a group based at Oxford University in association with the Charlie Waller Trust which includes strategies on distress tolerance (1).

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Which Therapeutic Approaches May Help with Severe Emotion Regulation Difficulties? ➢ Cognitive behavioural therapies (with cognitive analytic therapy (CAT) also being available in some centres): These treatments all try to help young people see how their thinking patterns affect their behaviour and relationships. ➢ Dialectical behaviour therapy (DBT) is a type of therapy increasingly offered to those with emotion regulation difficulties and those with emerging or diagnosed personality disorders. It fosters acceptance and change at the same time. It teaches skills including mindfulness, interpersonal effectiveness, managing emotion regulation and distress tolerance. Many UK mental health teams offer to support young people using DBT strategies. Increasing numbers of youth mental health teams also offer a more intensive DBT programme for young people with more severe difficulties, for example who have experienced several severe selfharm or suicide attempts. This often involves a combination of group and individual work and can last for several months. ➢ Mentalisation-based treatments: These therapies aim to improve the ability of people to understand their mental states in relation to other people’s. These treatments are only available in some UK mental health teams. ➢ There is some evidence for the use of some medications to treat symptoms of these difficulties, for example we often use antidepressant medication to treat depressive symptoms.

When Can Emotionally Unstable (Borderline) Personality Disorder Be Diagnosed? ➢ If the above pattern of mood swings and associated behaviours is severe, persists for a long period and has a significant impact on functioning, it may emerge into an emotionally unstable or borderline personality disorder. We are very careful at assigning this diagnosis to young people,

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but in some cases it can be helpful and informative in terms of support and treatment access. Emotional dysregulation is one of the core symptoms found in emotionally unstable (or borderline) personality disorder. Mental health professionals have traditionally been cautious about assigning a label of a personality disorder to a young person, partly due to the stigma, partly because the brain and personality are still developing into our mid-twenties, and partly because once someone is given this label it is difficult to undo. Hence, there is a trend to describe symptoms of emotional dysregulation or traits of personality difficulties in teenagers rather than to assign the label of a personality disorder or difficulty. However, this is an area of much contention. Many young people and their families strongly identify with the label of ‘emerging emotionally unstable personality disorder’ or traits. They believe it allows them to access the correct treatment pathways and that it most accurately describes their distress. A growing number of professionals also take this view and if the young person’s difficulties are severe and impairing, an increasing number of young people over 16 receive this diagnosis. The updated international ICD-11 classification system (2022) (2) has reframed the section on personality disorders and difficulties, taking a more dimensional approach and reflecting that all the difficulties tend to be on a sliding scale. This moves away from the traditional black box of assigning a personality disorder label, and instead sees all difficulties on a spectrum based on how adaptively the person can function.

Is There Also a Specific Mood Disorder Where People Have Regular Mood Swings? ➢ Cyclothymia is a mental disorder where there is persistent instability of mood involving several periods of mild depression and mild elation, none of which is severe or long enough for a diagnosis of bipolar disorder or depression.

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➢ Cyclothymia often follows a prolonged course and is hard to pick up without a longer period of mood tracking. It is more commonly diagnosed in adults rather than young people. ➢ Cyclothymia is in both major international classification systems: In the American classification system children should have experienced at least a year of symptoms to qualify for a diagnosis.

Case Example Sara is 16. She experienced attachment difficulties in early life as her mother had severe drug and alcohol problems. She has lived with several different relatives through her childhood and has a troubled relationship with her mum. Sara reports her moods have felt out of control for the last few years and swing several times per day. When she’s very happy she’s often texting friends, posting on social media or out and about. When she gets very low, she zones out of her body and can’t cope. She manages by cutting herself or taking small overdoses of tablets. She sometimes finds her mum’s alcohol and drinks it. After another visit to Accident and Emergency after cutting herself, she is referred to the mental health team and DBT skills work is offered. Her aunt takes her along to the sessions and Sara learns some skills to take control of her mood, including mindfulness and relaxation. She uses a diary to keep a record of her feelings for a few weeks. She then makes a list of strategies that are helpful for her, which includes drawing, talking to her best friend, doing a dance workout or watching her favourite TV series. After a few months Sara’s moods start to feel more stable.

Notes on the Case Example ➢ Sara’s functioning is quite seriously impaired by her difficulties. She is on the more severe end of a spectrum of young people with emotion regulation difficulties.

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➢ As in Sara’s case, attachment difficulties and parental mental health difficulties are common in young people who struggle with emotional regulation. ➢ Sara feels a loss of control of her moods. This can be a difficult experience for young people, and they may cope with it in ways that are unhelpful. ➢ Self-harming and engaging in other destructive behaviours (such as drug use) are common ways that young people with emotional instability try to manage their mood. ➢ There are a range of useful tools to help young people manage their moods and emotions more effectively. Dialectical behaviour therapy (DBT) has a number of these strategies embedded within it and many young people find it very helpful.

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It is normal for young people to have some degree of mood swings. However, if mood swings start affecting everyday functioning, extra support may be needed. There are different factors which can influence mood swings, including hormones, sleep, food and stimulants, technology and social pressures, and brain changes. We can help young people with mood swings in different ways, including helping them find triggers; looking at making lifestyle changes; encouraging fun activities; listening to them and offering support. Emotional regulation is a key life skill, but some people struggle much more significantly than others, often due to underlying biological factors as well as difficulties with attachments or early trauma. Young people with emotional dysregulation often have a range of common symptoms and develop maladaptive coping strategies. Many young people who have got stuck into poor coping skills may need professional therapeutic help. Dialectical behavioural therapy (DBT) is a useful therapeutic approach with a growing evidence base. There are other therapeutic approaches which may be helpful, depending on individual circumstances.

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References (1) Centre for Suicide Research, University of Oxford. 2016. Coping with Self-Harm: A Guide for Parents and Carers. Printed in association with Charlie Waller Trust. Available at www.oxfordhealth.nhs.uk/news/ coping-with-self-harm-a-guide-for-parents-and-carers-highly-commended/ (2) World Health Organization. Updated 2022. ICD-11. International Classification of Diseases 11th Revision. The global standard for diagnostic health information. Available at www.icd.who.int/en

Useful Resources Web-Based Resources ➢ The Mental Health Foundation has produced some helpful information, including a page entitled ‘Living with Emotional Dysregulation’. Available at www.mentalhealth.org.uk/stories/ living-emotional-dysregulation-what-it-is-and-how-i-cope

DBT Resources There is a useful YouTube channel produced by Rutgers University in the US explaining dialectical behavioural therapy principles in several short clips. Available at www.youtube.com/channel/UC7lKAPBLp ZzXk3AZbG_BAQQ

Books For Families ➢ Marsha Linehan, the creator of dialectical behavioural therapy, has written a number of books over the years about the therapy and its principles. A recent and accessible workbook is her DBT Skills Training Manual (second edition, published by Guilford Press in 2015).

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For Young People ➢ Sheri van Dijk has written some very helpful books aimed at adolescents on DBT strategies, including Don’t Let Your Emotions Run Your Life for Teens, Second Edition: Dialectical Behavior Therapy Skills for Helping You Manage Mood Swings, Control Angry Outbursts, and Get along with Others. The paperback edition was published in 2021 by New Harbinger Press.

Bipolar Affective Disorder The term ‘bi-polar’ refers to the two opposite poles of mood, i.e., ‘highs’ and ‘lows’, and is different from mood swings. The mood disturbances of depression, mania and hypomania are severe and enduring and can last for weeks to months rather than minutes to hours. Although bipolar disorder is rarely diagnosed in children and young people, as it often takes some years to recognise and track the pattern of the illness, if it recognised and treated in good time it can make an enormous difference to those affected.

What Is Bipolar Affective Disorder? Bipolar disorder consists of episodes of both depression (lows) and mania or hypomania (highs): ➢ High mood (also known as mania or hypomania, with mania being more severe than hypomania) consists of periods of intensely elated or irritable mood with extreme behaviour and energy that lasts for at least a week. ➢ Low mood (also known as depression) is where mood is depressed with low energy and/or lack of enjoyment for at least two weeks. (See first section in this chapter on depression for a fuller description of what constitutes a depressive episode.)

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Is Bipolar Affective Disorder Common in Children and Young People? ➢ It is unusual for a young person under 18 in the UK to be diagnosed with bipolar affective disorder, as most people who develop bipolar disorder will not yet have built up enough evidence for both the manic and depressive episodes in their teenage years. However, it’s important to consider the possibility of bipolar disorder in young people with depression. A clue that a young person may be at risk of bipolar disorder is if they switch to a high mood after being prescribed antidepressant medication. ➢ According to the last UK Adult Psychiatric Morbidity Survey in 2014 (1) 3.4% of 16- to 24-year-olds screen positive for bipolar disorder. Rates are higher in the over 18s.

What Possible Behaviour Might You See in Someone Who Is Experiencing a High Mood? Symptoms of a high mood (mania or hypomania) can include: Elevated mood, feeling on top of the world, elated (or very irritable) mood. Increased activity levels, which can sometimes lead to aggression. Reduced need for sleep. Talking very fast, technically described as ‘pressured’ speech. Having an elevated sense of self or having grand plans, for example someone thinking they are Jesus or that they have superpowers and are able to do remarkable things, like solve world poverty. ➢ Struggling to concentrate on one thing for long and jumping between topics. ➢ Loss of inhibitions, which can lead to doing risky or embarrassing things, such as taking drugs, having unprotected sex or spending money excessively. ➢ Neglecting to eat, drink and take care of themselves. Young people may need prompting for their basic self-care.

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➢ In some cases, there is a loss of touch with reality (psychosis). (Chapter 26 explains psychosis in more detail.) ➢ Mania is more extreme and longer-lasting than hypomania. Mania, in contrast with hypomania, may also include losing touch with reality (psychosis).

How Long Can a Bipolar Episode Last? Hypomanic episodes can last for several days. Manic episodes can last from a few weeks to four to five months. Depressive episodes can last from weeks to several months. The pattern of illness is very variable: some people have long gaps between episodes; others have shorter gaps. This may depend on the compliance of the young person in taking mood stabilising medication. ➢ There is usually good recovery between episodes. ➢ Rapid cycling disorders are when a person experiences four or more episodes of mania and depression in a one-year period. Some people have very rapid switches, which in the most extreme form can occur within a day. About 10–20% of people with bipolar disorder have a rapid cycling pattern.

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How Is Bipolar Affective Disorder Treated? Although bipolar affective disorder is a serious condition which has a significant impact on functioning, generally treatment is effective and can help people to manage their lives. Current UK recommended treatments are (2): ➢ A combination of psychological treatments together with medication. ➢ Talking therapy (psychological treatment) is very important in helping young people understand and manage their illness and in

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preventing relapse. In children and young people, individual and familybased treatments are both helpful. ➢ Medications: Mood stabilisers and antipsychotics can treat illness as well as preventing relapse. Mood stabilisers include medications like lithium and carbamazepine as well as antipsychotic medications like quetiapine (which are often the treatment of choice in children and young people due to their relatively less severe side effects). ➢ Antidepressants can play a useful role in treating depression but need to be closely monitored as they can sometimes trigger a switch from a low to a high mood. It can be a trial-and-error process finding the right groups or combinations of medications for each young person. ➢ Although it used to be routine to treat people with bipolar disorder in hospital, nowadays most people can receive treatment at home. However, sometimes admission to hospital may be needed if families struggle to manage risk, the person is very unwell or it’s difficult to find effective treatments.

How Can You Support a Young Person with Bipolar Disorder? ➢ Support the young person to get professional help. It’s best to ask for a GP referral to a mental health team. Unfortunately, we often come across unhelpful stories in the media about people who manage bipolar without support or treatment: this may prevent young people from accessing help when they need it. ➢ Try to understand the condition together. Get inspired by talented people with bipolar disorder. Receiving a diagnosis can be difficult for young people to get their heads around, but there are many inspirational and creative people who have had or have bipolar disorder, including Mariah Carey, Stephen Fry, Kanye West and Russell Brand. ➢ Build a support network of family and friends. It is common for friends and family to spot a young person’s early warning signs of illness before they themselves are aware they are becoming unwell. So, alerting others to signs to look out for can be helpful. It’s not usually beneficial to

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keep the diagnosis secret. Schools and colleges could also be made aware and provide support to the young person when they are unwell. Set up positive and fun activities, including exercising and spending time outdoors. Neglecting personal needs and getting out of helpful routines can happen quickly when young people become unwell and can lead to further deterioration. Support positive sleep hygiene. Setting up regular night-time routines to maximise sleep is very important in staying well. (See Part 1, Chapter 2 for further information on sleep hygiene.) Access support from bipolar charities and communities. Young people can draw strength and support from other people with the same condition. Moderated forums, for example Bipolar UK’s e-community (see Useful Resources below), can be a helpful way to tap into a network. However, it’s important for adults to check the content of any web-based forums with young people first, as misinformation can also spread easily, including about treatments without a scientific evidence base. Support the young person to make a risk plan. If people get unwell rapidly, they can be very vulnerable: it’s common for people to do things like use their savings quickly and engage in unprotected sex and drug use when they are manic. Think of ways to protect them in advance, for example putting safeguards on bank accounts to avoid withdrawing too much cash and talking to close friends about supporting young people to be safe, including contacting supportive adults when needed. Draw up a plan to spot triggers and think of ways to tackle them to prevent relapse. Stress is one of the most common triggers, so supporting young people in managing stress is helpful.

Case Example Jade is 17 and has an outgoing personality and a keen interest in drama. She is involved in a school play. Recently, she has started to act in an over-excitable way, talking ten to the dozen and trying to take over the rehearsals, announcing she is also going to direct as well as act. Her friends have noticed she is very overbearing and talks over them most of the time. Teachers have also noticed she is constantly talking and isn’t getting her work done.

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In the last week Jade has started to stay up all night learning all the lines of every part: she told her parents that sleep is a waste of time. She thinks she can play the main part in the play and has told everyone she will be the next West End star. She uses her savings to buy expensive costumes. She has been going out late socialising and in the last few weeks has been out with several different boys and got drunk. Jade’s parents consult the GP as they are worried about her: she appears irritable and agitated and seems to be neglecting herself. Jade had been depressed a year ago, which improved with counselling and family support. The GP refers Jade to the mental health team. She is assessed promptly and gets a care coordinator, Sarah, an experienced community nurse, who supports her and her family. The team psychiatrist prescribes medication (quetiapine) to stabilise Jade’s mood and the home treatment team help her family keep things calm at home. The mental health team support Jade at home, and then after a few weeks she starts psychological treatment to help her understand her condition and prevent relapse. She continues to take medication and the mental health team monitor her for several months. She builds a good relationship with Sarah and they meet weekly.

Notes on the Case Example ➢ Jade is starting to develop hypomanic symptoms: she has increased energy; talkativeness; reduced need for sleep; has an inflated sense of what she can achieve; has started doing risky things like going out with lots of different boys, getting drunk and using her savings. ➢ Jade is vulnerable to exploitation and risk: this is a big factor for families to consider for young people with bipolar disorder. She needs support to keep herself safe. ➢ As Jade is usually outgoing, some of her behaviour may not appear out of character if people didn’t know her well. Bipolar disorder may not be recognised if those around Jade are not aware it may be a possibility. It’s important to note that bipolar must always be considered a potential diagnosis in those with a history of depression, like Jade.

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➢ Jade has had a rapid referral to a mental health team, who treat her with the support of her family in the community. This rapid response pathway is important in preventing many hospital admissions, as symptoms can be treated before they escalate.

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Bipolar disorder consists of episodes of both depression and mania or hypomania. It is more extreme and longer lasting than adolescent mood swings.

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Although bipolar disorder is a relatively uncommon diagnosis in children and young people, it is important to be aware of it as it is a serious condition which requires treatment. Consider bipolar disorder as a possibility in each child or young person who has previously been depressed.

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You can support children and young people with bipolar disorder by guiding them to get professional help; understanding their condition and the pattern of their illness; spotting common triggers; learning to take care of themselves and manage stress; and finding ways to reduce their risk.

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Bipolar disorder is treated with a combination of psychological treatment, medication and specialist mental health support. While in the past young people were almost always hospitalised when they were unwell, nowadays the aim is to treat people at home with extra mental health support for periods of acute illness, for example from crisis teams. However, sometimes hospital admission is needed if the young person is very unwell or at increased risk to themselves or others at home.

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References (1) Marwaha, S., Sal, N. and Bebbington, P. 2016. Chapter 9: Bipolar Disorder. In S. McManus et al. (eds.) Mental Health and Wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Available at https:// files.digital.nhs.uk/pdf/2/k/adult_psychiatric_study_ch9_web.pdf (2) National Institute for Health and Care Excellence (NICE). 24 September 2014. Bipolar Disorder: Assessment and Management. Clinical Guideline [CG185]. Last updated 11 February 2020. Available at www.nice.org.uk/ guidance/cg185

Useful Resources ➢ Bipolar UK (www.bipolaruk.org/) is a UK national charity which supports people with a diagnosis of bipolar disorder. The website contains useful information, community forums as well as details about how to access their peer support line. ➢ Young Minds, the UK youth mental health charity, has produced a useful information leaflet on bipolar disorder on its website: https://youngminds .org.uk/find-help/conditions/bipolar-disorder/

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15 Difficulties with Worries and Anxiety Worrying is a natural and universal emotion. We have evolved to worry about risk to keep ourselves safe, but the difficulty is that if we worry too much it can get in the way of managing and enjoying life. It’s especially hard for children and young people developing and adapting to the world around them to get the balance of how much to worry right. In this chapter we consider how much worrying is too much and what can help restore a healthy balance. We also consider what happens when worries become anxiety disorders and how we can help children and young people with these.

Worrying How Much Worrying Is Normal? Does This Vary by a Child’s Age? ➢ Some worrying is protective and keeps us safe from danger. The fight or flight response helped our ancestors quickly get into gear and escape from threats in order to survive. We make decisions to assess risk all the

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time. For example, if we need to cross a road or escape from a threat a healthy amount of worry helps keep us safe. We can teach children how to judge risk and what may be an appropriate amount of anxiety, so they can begin to learn how to make risk assessments for themselves. It is often helpful to have some anxiety about performing well, for example before tests and performing in front of others, as the extra adrenaline can help us do our best. We can then relax afterwards until the next event we have to prepare for. However, sometimes children can worry too much, which can stop them managing normal activities, including at home or school. How much worrying is normal for an individual child or young person varies according to their age and stage of development. Babies and children are typically anxious if separated from their caregivers, while preschool aged children tend to be more worried about animals and the dark. Teenagers, on the other hand, are much more worried about social rejection.

What Happens If We Worry too Much? ➢ If we get trapped into cycles of worrying, we start avoiding things. As we avoid more things, it becomes increasingly difficult to do normal activities and confidence can reduce. ➢ Our brains have different systems: the higher ‘thinking’ system, which can help us problem solve, and the primitive ‘reactive’ system. If the ‘reactive’ part of our brain becomes trapped into the worry loop and starts going into a stress overdrive, it gets harder to think clearly. This is especially the case as our thinking brain system tends to go offline when we are in reactive mode. ➢ Our bodies start producing stress hormones, which can drive it into a stressed state, leading to the physical and behavioural signs of worry. This would be useful if we had to run away from a wild animal, as our ancestors did. However, if we don’t have to run away from anything, the stress hormones build up and have a negative impact on the mind and body. It becomes difficult to switch off from a state of tension, sleep is affected and we end up worrying about getting anxious. This becomes a vicious cycle which is difficult to switch off.

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How Can You Tell If Someone Is Struggling with Their Worries? Worrying can show itself in both behavioural and emotional symptoms as well as physical symptoms. Young children are more likely to complain about physical symptoms of worry (like tummy aches and headaches) as they can find it hard to express their worries in words. Sometimes families think their children have a real physical illness but they are misinterpreting symptoms of anxiety. This is because symptoms of anxiety can be indistinguishable from those with a physical cause. It is important that these children do get an initial medical assessment to rule out a physical cause, but then after this they do not need to get over-investigated even if they continue complaining of physical symptoms, and asking for more physical health investigations. We try to help these families understand that physical symptoms can be caused by anxiety and can be addressed by treatments for anxiety. Here are some typical physical symptoms of worry: ➢ Feeling sweaty and shaky ➢ Heart racing ➢ Tense muscles ➢ Chest pains ➢ Butterflies in the tummy ➢ Feeling sick and vomiting ➢ Dryness of mouth ➢ Dizziness ➢ Feeling short of breath

Behavioural and emotional symptoms of worry are: ➢ ➢ ➢ ➢ ➢ ➢

Acting jumpy and irritable Finding it hard to concentrate Feeling overtired and sleeping badly Feeling low Avoiding or stopping doing things Asking for reassurance

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How Can You Support a Child or Young Person with Their Worries? You can help a child and young person understand and process their worries in the following ways: ➢ Listen to their worries and help them to process them. Putting worries to bed by writing them down and putting them in a ‘worry box’ can be helpful. ➢ Tell children and young people they are not alone and worrying is common. ➢ Talk to children and young people about what happens to their body and their brain when they worry. It can be scary for children to get physical symptoms without understanding that they are linked to worry. ➢ Help children and young people to recognise triggers to worries. You can help younger children learn to spot their own triggers like a detective and make a note of them, which will help with managing them. ➢ Explain that if you give your worries lots of air by focusing energy on them, they get bigger. You can demonstrate this by drawing a picture representing scary worries on a balloon using a permanent marker. You can then blow up the balloon (giving the scary picture lots of air) and show how much bigger the scary picture or worries get. If you then let the air out of the balloon the scary picture of worries gets very small again. You can help children practise not giving too much air to their worries by focusing on other things as much as possible. ➢ Talk about the role of avoidance in keeping worries going. Avoidance brings down anxiety quickly initially but then tends to make it worse as it becomes ever harder to face the situation. ➢ Explain that anxiety always reduces with time. The worry wave is a good visual aid to help explain this: worrying initially peaks but then inevitably gets weaker with time following a wave pattern (see Figure 6). Help children think of examples of when they had a strong worry which then improved over the following hour or so.

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Level of anxiety

Time

Figure 6:  The worry wave

Try out Strategies to Help Manage Worries: ➢ Relaxation and mindfulness exercises can help children and young people feel less stressed. There are some very helpful resources on YouTube, for example progressive relaxation in the Go Zen online channel (www .youtube.com/c/gozenonline), and the Cosmic Kids Zen Den (https:// cosmickids.com/?video_series=zen-den) has mindfulness and yoga for kids. ➢ Distraction from worries can help bring down stress. Doing something active together like walking outside, listening to music or having a hug may be helpful. ➢ Help children and young people face the things they are anxious about with support. Avoidance maintains anxiety, so it’s important that children and young people are helped in trying to stop getting into cycles of avoidance. ➢ Just being there for the child or young person is important. Being around someone supportive can be helpful, especially if you ask the young person what you can do to help them. ➢ Avoid giving too much reassurance, as children and young people can start to rely on it, which can keep worries going.

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➢ Link in with school if worrying is affecting school and suggest setting up a support plan. School pastoral staff and counsellors are generally experienced at dealing with anxiety.

When Should You Seek Professional Help? ➢ If anxiety happens more often or intensely than expected for the child’s age and gets in the way of doing everyday things, for example managing school or meeting friends, it may be time to seek professional help.

Anxiety Disorders Anxiety can become a disorder in children and young people if worrying starts to have a significant impact on functioning. There are different types of anxiety disorder, which will be explained further below.

How Common Are Anxiety Disorders in Young People? ➢ Anxiety disorders are the most common disorders in children and young people. Around 7 in 100 young people suffer from an anxiety disorder (1). ➢ The rates of anxiety disorder increase with age: In 17- to 19-yearolds 1 in 8 young people suffer with an anxiety disorder. Anxiety is much more common in children with other mental health conditions, especially depression and autism.

What Increases the Risk of a Child Getting an Anxiety Disorder? A combination of factors increases the risk of getting an anxiety disorder. Common factors include:

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➢ Inherited factors: Family studies show that anxiety runs in families. ➢ Certain personality traits, including perfectionism and being shy, increase the risk of anxiety. ➢ Major life stressors, such as bullying or trauma. ➢ Exposure to parent or caregiver anxiety: Anxiety can become internalised by the child if it’s been a core feature of their environment. This has been seen in pregnant mothers too: prenatal stress predicts fearfulness in children. Hence, engaging with therapy for your own anxiety as a parent can reduce the risk of it being passed on to children.

What Is a Panic Attack? ➢ A panic attack happens when physical symptoms of worry come on suddenly and intensively out of the blue. Panic attacks can be very scary. It is common to be gripped by the fear you are dying or are having a heart attack or can’t escape from a situation. Physical symptoms can include heart racing, over-breathing and feeling dizzy, getting shaky and sweaty.

How Can You Help If Your Child Is Having a Panic Attack? ➢ The most important thing is to be calm and patient, and to try and talk gently to your child in a calm space. ➢ The UK Charity No Panic (https://nopanic.org.uk/) has produced some helpful resources around managing panic attacks. ➢ You can help someone with a panic attack using the following steps (2): 1. FOCUS: Feel your feet flat on the floor. Recognise and name three things you see around you. 2. BREATHE: Check you are breathing through your nose, slowly in and out. ACCEPT: You are doing fine; panic feelings are caused by adrenaline, which will soon start to decrease. 3. RELAX: Concentrate on dropping your shoulders as you breathe out.

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➢ Breathing slowly can help with hyperventilating. You can teach your child deep breathing by breathing in for a count of four through the nose, and then out for a count of four through the mouth. ➢ Let the child know they can cope, and the attack will end quickly, usually within a few minutes. You don’t want them to start avoiding situations because they have had one attack, as this can lead to more anxiety.

What Are the Different Types of Anxiety Disorder? There are several different types of anxiety disorder, some of which are more common in different age ranges, but many of which can happen in children and young people as well as across the lifespan. Here are some of the more common anxiety disorders: ➢ Phobias are worries triggered by certain situations or objects (like spiders, dogs or lifts), which are then avoided as they can lead to feeling anxious and losing confidence. ➢ Agoraphobia is fear of open spaces and crowded places from which there is lack of an immediately available exit, including shops, crowds, public spaces or public transport. ➢ Social phobia is fear of other people’s reaction in social situations, which may be worse in small groups. This leads to avoidance of social situations as those affected are worried about others judging them. Some people worry they will do something embarrassing in front of others. ➢ Social anxiety disorder of childhood is when there is significant social anxiety, generally in younger children. ➢ Panic disorder is when panic attacks start to get more regular. For a diagnosis several attacks should have happened in one month. A panic attack is often followed by ongoing fear of having another attack, which leads to avoidance. ➢ Separation anxiety is when children and young people get unusually distressed for a long time after separation from a parent or main caregiver. Although it is normal for very young children to get upset when they are separated from caregivers, this generally settles as children

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mature. If high levels of anxiety persist through school years, it can become a problem. ➢ Selective mutism is an anxiety disorder in which a person normally capable of speech cannot speak in specific situations or to specific people. Children may stop speaking in school when anxiety becomes overwhelming. Selective mutism is common in children with social anxiety and in autism. ➢ Post-traumatic stress disorder, obsessive compulsive disorder (OCD) and body dysmorphic disorders are also types of anxiety disorder, but they will be dealt with in separate chapters. ➢ Generalised anxiety disorder is when someone has multiple and persistent worries in different situations most of the time, for more than six months. It is more common in older teenagers and adults.

What Should You Do If You Think Your Child Needs More Help? It may be helpful to keep a record of triggers and patterns. Find out how much worrying is also affecting school by asking staff. If anxieties are significantly affecting the child, you can request a referral to a Child and Adolescent Mental Health Service from your GP or school.

How Can Anxiety Disorders Be Treated? ➢ The most helpful treatments for anxiety are psychological treatments. ➢ Cognitive behavioural therapy (CBT) is one of the most common and effective psychological treatments and is recommended for most anxiety disorders. The next section explains how it works. ➢ For more severe cases, a combination of psychology (talking therapy) and medication may be helpful. Antidepressant medication, despite its name, can be helpful for both anxiety and depression.

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What Is CBT? Why Is It Such an Important Part of Treating Anxiety? ➢ Cognitive behavioural therapy (CBT) is a structured talking (psychological) therapy based on understanding the links between thoughts, feelings and behaviours and physical state and learning how to break vicious cycles. An anxious child will be encouraged to explore what maintains their anxiety and to experiment with different ways of managing it. ➢ A key concept of CBT is to learn to start facing anxiety-provoking situations by breaking up a difficult experience into smaller tasks, and then building up exposure in small steps. The idea is to learn to manage anxiety for gradually longer until it reduces. For example, if a child is worried about going to the dentist, they may break the task down as follows: The child may first practise visiting the dentist’s building. Once they manage this step, they may next practise sitting in the waiting area. Next, they may practice sitting in the dental chair without opening their mouth. They may be ready on a third or fourth visit to have their teeth looked at. ➢ The difficulty is CBT only works well if the child or young person is motivated to change and actively works hard on the tasks given. Younger children and those with intellectual disabilities may need the CBT modified to a more basic level or to have sessions together with parents.

What Are the Outcomes for Children with Anxiety? ➢ Most children with anxiety do recover. ➢ Longer-term outcomes depend on a variety of factors, including the type of anxiety disorder, whether there are other mental health problems, the age of onset and severity of difficulties. ➢ Some people with a tendency to struggle with anxiety will go on and develop other anxiety disorders as they get older.

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Case Example Noel is 16. His parents say he has always been a worrier. He started getting panic attacks at school since being bullied there in the last few months. He has become increasingly worried about going into school because his big fear is having another panic attack, losing control and other pupils laughing at him. Now in the spring term he is missing two to four school-days a week. He often says he feels too sick in the morning to go in, and his parents report he seems so anxious and shaky they don’t push him to go. School have sometimes sent work home. The school attendance officer is worried about Noel’s wellbeing and attendance, so she sets up a meeting with Noel’s parents. The school make a referral to the local Child and Adolescent Mental Health team. Noel has a psychology assessment over two sessions as Noel is so anxious that he struggles to focus on the psychologist’s questions. However, Noel manages to talk about his difficulties and is keen to access support. The team psychologist offers Noel CBT, where Noel learns to manage his anxiety. His parents have some sessions too to learn to support him at home, without feeding into his worry cycles. The psychologist sorts out a part-time timetable with school where Noel starts going into school every day for a short time, building up to a few hours every day. The aim is by the end of term to build up to full days. Noel gets lots of support from the school pastoral staff and his family, and learns to manage his anxiety, and after a few months is back to school full-time.

Notes on the Case Example ➢ Noel has a background of being anxious and then develops panic attacks. The panic attacks cause him to develop high levels of generalised anxiety and school avoidance. ➢ It is concerning that he becomes increasingly anxious about school, which feeds into worry loops of avoiding school, and hence his

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school attendance drops off. If school non-attendance in the context of anxiety is not tackled quickly, then a pattern of avoidance can turn into school refusal and children can struggle to get back into mainstream school. It is common to start back with a part-time timetable and require a lot of support around a phased return to school. ➢ Noel finds it difficult to express his anxiety in words and gets physical symptoms of anxiety, including tummy aches. Noel responds well to CBT to help him manage his anxiety. It’s also helpful that his parents are involved in treatment to help him break the worry cycles, rather than feeding into them.

KEY POINTS

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Worrying is a normal human emotion. It is a helpful evolutionary response designed to keep us safe, but if worrying starts to get in the way of being able to manage doing what we need to do, we may need strategies to manage it. It’s hard to get the right balance of worrying enough but not too much.

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We can get trapped into ‘worry loops’ where we worry, then avoid our worries and then we worry more about them. If we don’t break these loops, we can increase the risk of developing an anxiety disorder.

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Tips to help children and young people with worries include talking through their worries and explaining how worrying affects the body and brain. Ways to help manage worries include using strategies like mindfulness, yoga and distraction and linking in with school to ensure there is enough support in place.

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Anxiety disorders are the most common type of mental disorder in children and young people. There are a range of anxiety disorders which can affect children and young people, including: separation anxiety; generalised anxiety disorder; specific phobia; social phobia; agoraphobia; panic disorder; and selective mutism.

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Most anxiety disorders improve with psychological treatment. Cognitive behavioural therapy (CBT) has the best evidence base. Sometimes medication is also used to help young people manage talking therapies. Antidepressants (SSRIs) are the most common types of medication used as they work for both anxiety and depression.

References (1) NHS Digital. 2018. Mental Health of Children and Young People in England in 2017. Summary of Key Findings. Available at https:// digital.nhs.uk/data-and-information/publications/statistical/ mental-health-of-children-and-young-people-in-england/2017/2017 (2) No Panic. 2021. End a Panic Attack in Three Minutes [free downloadable leaflet]. Available at https://nopanic.org.uk/wp-content/uploads/2021/07/ End-a-panic-attack.pdf

Useful Resources Web-Based Resources ➢ The Royal College of Psychiatrists has some very useful information and resources around dealing with anxiety. This includes the information sheet: ‘Worries and Anxieties – Helping Children to Cope: For Parents and Carers’. Available at www.rcpsych.ac.uk/mental-health/ parents-and-young-people/information-for-parents-and-carers/ worries-and-anxieties–helping-children-to-cope-for-parents-and-carers ➢ Young Minds, one of the leading UK charities on youth mental health, has an excellent website with a help sheet on anxiety in children and young people. Available at https://youngminds.org.uk/find-help/conditions/ anxiety/ ➢ The National Institute for Health and Care Excellence (NICE) offers guidance on managing anxiety. There is a section on treatment in children: Social Anxiety Disorder: Recognition, Assessment and

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Treatment. Clinical guideline [CG159], 2013. Available at www.nice.org.uk/ guidance/cg159/ifp/chapter/treatment-for-children-and-young-people ➢ Nip in the Bud (https://nipinthebud.org/information-for-parents-andchildren/) is an organisation that produces films on mental health topics in young people. It has various resources on anxiety including short films for young people and for professionals as well as a fact sheet. ➢ Anxiety UK is a national UK charity focused on helping people with anxiety. The website also includes resources for parents: www.anxietyuk .org.uk/ ➢ The UK charity No Panic has a website (https://nopanic.org.uk/) for people with panic and other anxiety disorders as well as for carers. There is a helpline for young people, a general helpline as well as a crisis number with breathing techniques for people having a panic attack.

Books ➢ Helping Your Child with Fears and Worries by Cathy Cresswell and Lucy Willetts (second edition, Robinson, London, 2019). This is a very helpful and practical book by Dr Lucy Willetts, an experienced clinical psychologist and Prof. Cresswell, a professor of psychology at the University of Oxford, who has also carried out a lot of research on anxiety in children. ➢ Coping with an Anxious or Depressed Child: A Guide for Parents and Carers by Sam Cartwright-Hatton (Oneworld Publications, Oxford, 2007) is another succinct and useful book for parents. ➢ The Huge Bag of Worries by Virginia Ironside (Hodder Children’s Books, London, 2011): This is a helpful book for younger children about dealing with worries.

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16 Difficulties with Self-Harm and Suicidal Thoughts Self-harm is defined as an intentional act of self-poisoning or self-injury, irrespective of the type of motive or the extent of the suicidal intent and is an expression of emotional distress (1). Self-harm is relatively common in young people, especially in those with other mental health difficulties and disorders but is relatively rare in healthy young children. Many young people may also experience thoughts of not wanting to be alive sometimes, although fortunately most young people don’t act on their thoughts. Seeing that a young person has self-harmed or is expressing suicidal thoughts can be shocking and emotionally very difficult to get your head around. It is important to learn to manage your own strong emotional reactions so that you can support the young person in distress. This chapter covers the different types of self-harm and how to support young people who have thoughts of hurting themselves and ending their lives.

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Self-Harm How Common Is Self-Harm? ➢ Data from the Health Behaviour in School Aged Children 2014 survey (1) showed 1 in 5 (22%) 15-year-olds reported they had ever self-harmed. ➢ Self-harm is around two to four times more common in girls than boys (1). ➢ According to NHS Digital (2) in 2017, a quarter of 11- to 16-year-olds with a mental disorder had self-harmed or attempted suicide at some point, compared to 3% of those who were not diagnosed as having a mental disorder.

How Can You Tell Someone Is Self-Harming? It is not always obvious that young people are self-harming. Here are some signs to look for: ➢ A young person may be keen to cover up arms and legs and is wary of getting changed in front of others. ➢ There may be visible scars, cuts, burns or bruises. Forearms and thighs are common places. ➢ Sharp objects may have gone missing. ➢ The young person’s mood may be irritable or depressed. ➢ Social media: Young people may have joined social media forums about self-harming or have looked up methods to hurt themselves online. It is important to be clear with young people that you will monitor their browser history to help keep them safe.

What Are Different Ways Young People Can Self-Harm? There are many methods of self-harming. Here are some common examples:

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➢ Self-cutting with any sharp objects, including knives, razor blades or pencil sharpeners. ➢ Overdosing on medications, which could either be prescribed medicines or over-the-counter pills, most commonly paracetamol. ➢ Burning or picking at skin or putting objects into body parts. ➢ Swallowing or chewing objects: Some objects, like batteries and glass, can potentially cause internal injuries and are cause for greater concern than many small objects, like buttons, which children mostly excrete out. ➢ Tying objects around the neck, known as using ‘ligatures’ and, more rarely, attempts at hanging. ➢ Using weapons, including knives, although almost any object can also be used as a weapon. ➢ Hitting or punching self or banging head or body against objects. ➢ Jumping from heights or from vehicles.

Why Do Young People Hurt Themselves? There is no one simple reason why young people self-harm as it has different functions for different people. Hence, in mental health services we try to explore with every individual what drives their self-harm. Here are some of the reasons young people may give for self-harming: ➢ To express feelings like sadness or guilt that are difficult to articulate. ➢ To feel something if they are feeling empty or numb. ➢ To show others how upset they are. Although many adults call this ‘attention seeking’, it is often much more complex than this. ➢ To punish themselves or to feel pain. ➢ To give a sense of release of built-up feelings like anger. ➢ To manage stress, which may become habitual. ➢ To feel connected to others who are self-harming; hence the importance of understanding the young person’s peer group culture and social media use. ➢ It is important to note that in rare instances, self-harming can also sometimes be a suicide attempt.

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Who Is More at Risk of Self-Harm? Risk factors for self-harming are as follows: There is a peak in young females aged between 16 and 24. Coming from a deprived background strongly increases risk. Feeling socially isolated or bullied. Stressful life events, for example relationship difficulties and domestic violence. ➢ Mental health or chronic physical health problems. ➢ Alcohol and/or drug misuse and ➢ Involvement with the police (3).

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How Can You Help Someone Who Is Self-Harming? ➢ First aid – safety comes first: – For suspected overdoses: Go to the hospital emergency department as soon as possible. Try and find out the quantity and medication used and take it with you. Sometimes antidotes can counteract the drug taken, but they often need to be given quickly to be most effective. – For cuts: Clean with disinfectant (if dirty) and apply pressure to the wound. If it is deep or bleeding it may need medical attention, for example stitches or SteriStrips. – For burns: Put under cold running water for 30 minutes. – For all methods: Remove and lock away medication and objects used to self-harm. ➢ Listen, try to stay calm and suspend judgement, and instead show compassion and support. ➢ Consider getting professional help if self-harm is frequent or severe or if the young person has an underlying mental health problem such as depression. In such cases, aim to discuss support with your GP and consider requesting a referral to mental health services. Getting help from the school counsellor or nurse may also be helpful.

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➢ Discuss alternative ways to deal with urges to self-harm. Mental health services may support young people by recommending some of the following strategies: – Distraction strategies and mindfulness: Doing exercise, going out into nature, listening to music or watching a favourite TV programme, phoning or texting someone who cares and listening to mindfulness podcasts may also be useful. – The ice-dive: The idea is to plunge the face into ice when the urge to self-harm comes. The shock of the change in temperature will stimulate the dive reflex and switch off non-essential processes like anxiety. – Pinging elastic bands around wrists is an alternative way to manage urges to cut which may be helpful when a young person is at school. – Releasing energy quickly by doing intense exercise or using a punchbag. This can release some of the destructive urges safely. – Using a self-harm app or online tool. There are now apps and websites available which use some of the above principles to help offer alternatives to self-harm.

Suicidal Thoughts and Acts It can be very distressing to hear about children and young people experiencing suicidal thoughts or thoughts of life not being worth living, but it’s important for supportive adults to not rush into a panicked response around this. Experiencing some suicidal thoughts is common across all age ranges and can vary hugely in their frequency, intensity and severity, and don’t necessarily indicate an active suicide plan. However, expressing such thoughts does need to be taken seriously and generally indicates that further mental health support is likely to be needed to assess and attempt to reduce the level of risk.

Difficulties with Self-Harm and Suicidal Thoughts

What Should You Do If a Young Person Reports Suicidal Thoughts? ➢ Listen, show support and talk to them about it. Asking about suicide does not increase risk. By asking, you are giving young people a space to talk through difficult thoughts they may have. ➢ Even though hearing a young person talk about suicide may feel alarming, it is important not to lose your cool. Although most people who express suicidal thoughts will not take their life, you should always take young people expressing these thoughts seriously. ➢ You need to be clear at the outset that if someone is at risk of death or serious harm, you may need to override confidentiality and get professional help. ➢ It is usually helpful to consult with a mental health professional. There may well be an underlying mental disorder which needs treating. Help with accurate risk assessments is also important. ➢ Encourage online safety and make sure the young person is aware of telephone and text helplines for people in distress: these can often be lifesaving and are available 24/7 in the UK from the Samaritans (samaritans. org); Papyrus (papyrus-uk.org); Childline (childline.org.uk); Shout (giveusashout. org). You can offer to put these key numbers on the young person’s phone.

How Common Is Reporting Thoughts That Life Is Not Worth Living? ➢ Around 1 in 5 adolescents report suicidal thoughts at some point, although most young people will not act on these thoughts (4).

Which Young People Are at Greater Risk of Carrying Out a Serious Suicide Attempt? ➢ Young people who have experienced several adverse childhood experiences, including family difficulties (e.g., parental mental illness, physical

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illness or substance misuse); childhood abuse; bullying; problems with their physical health; social isolation; mental ill health and alcohol or drug misuse. ➢ Special groups of young people at greater risk of completed suicide include those bereaved by suicide; looked after children; vulnerable groups such as LGBT young people.

How and When May Having Suicidal Thoughts Lead to Suicidal Acts? There is often a gradual progression from the passive feeling that life isn’t worth living to carrying out an actual suicide attempt. To work out their level of risk, it may be helpful to consider the stage the young person is closest to: 1. A young person who feels that life isn’t worth living intermittently but without concrete suicidal plans or urges is at a lower relative risk of suicide. Having fleeting thoughts of not wanting to be here but not acting on these often goes together with low mood. These young people generally benefit from mental health support, although it is less urgent. 2. If the thoughts of life not being worth living become a sustained wish to die, the young person is at moderate risk of serious selfharm or suicide. It is likely the young person is also suffering from a mental disorder that requires professional support. Although the young person may not intend to actively end their life, they may be less careful about looking after themselves, for example not paying due attention to road safety, so they may require extra supervision. These young people will need a higher level of support at school and home. 3. A young person who has active suicidal thoughts and plans is at highest risk of suicide. The presence of added risk factors such as having had a previous suicide attempt or active drug and alcohol use will also increase risk. It’s important to note that the leap from having suicidal thoughts to acting upon them is generally significant and fortunately rare. However, many young people at high risk of suicide are also struggling with a serious mental health disorder which requires more urgent support. These young people often need a high level of more intensive support from mental health home treatment teams, and in some cases hospital admission is needed.

Difficulties with Self-Harm and Suicidal Thoughts

Red Flag Warnings That a Young Person May Have a Higher Suicidal Intent Include: ➢ Having made previous serious suicide attempts. ➢ Making careful plans of how to carry out the attempt, including researching suicide methods. ➢ Planning last acts, including saying goodbye and making notes. ➢ Working hard to avoid detection, for example ensuring they are home alone. ➢ Being disappointed when an attempt is intercepted.

Is the Level of Suicide Risk Usually Predictable? ➢ Although it may be possible to identify some vulnerable young people who are clearly at higher risk of suicide, some young people are notoriously unpredictable in their behaviour, especially those with high levels of impulsivity, and will not follow the standard pattern of increasing risk. Young people with very intense emotional swings and emotional regulation difficulties fit into this category. ➢ These young people may be at risk of what is known as ‘death by misadventure’ because their spur of the moment actions can be very difficult to predict.

How Common Is Completed Suicide in Young People in the UK? ➢ Suicide is the most common cause of death for people aged 10–19 in the UK (both boys and girls), accounting for 14% of deaths in that age group. However, it’s important to note that the suicide risk is much higher in older than younger teens and is very small in children under 10. ➢ In 2019 there were 11 deaths attributed to suicide in the 10–14 age group (0.3 per 100,000) and 185 deaths attributable to suicide among 15- to 19-year-olds (5.7 per 100,000), according to the UK Office of National Statistics (5).

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How Can You Help Young People Who Have Frequent Suicidal Thoughts? The following approaches may help with young people who have frequent suicidal thoughts: ➢ Show young people compassion and support and try to keep calm. ➢ Ensure the safety of the young person and minimise access to any object that can cause harm: Ensure close supervision and regular checking in with the young person, up to a few times a day. You should lock away blades and medication. Make sure there are no accessible ligature points (for strangulation) and ropes/scarves are put away, as hanging is the commonest cause of suicide in young people. ➢ There are some therapies and ways of helping these young people gain control of their emotions, including principles from dialectical behaviour therapy. Consider researching DBT strategies together. (See the Other Resources section at the end of this chapter for further information.) ➢ Refer to the local mental health team to help with risk management and treatment. Support will depend on severity of symptoms and whether there is an underlying mental disorder. ➢ Monitor unhelpful access to social media and refer on to specialist support if needed.

How Can Mental Health Services Support Those at Increased Risk of Suicide? ➢ Treat any underlying mental health conditions, most commonly depression. Young people with severe depression expressing suicidal ideation should ideally see a child and adolescent health team within 24 hours of referral (6).

Difficulties with Self-Harm and Suicidal Thoughts

➢ It is important for mental health teams to work in partnership with families to draw up a safety plan, which should go into the young person’s care plan. ➢ Mental health services may activate extra support for short periods of suicidality to regularly check on families and offer intensive input. This may involve crisis mental health teams. If a young person’s risk cannot be managed safely in the community, hospital admission may be needed. ➢ Other agencies may be involved in care planning and can play a key role in offering support including social care services or schools.

What Support Is Helpful for Young People Who Experience Someone Close to Them Engage in Suicidal Acts? Many young people have experienced someone close to them engage in self-harm or suicidal acts. Support may come through several sources, including the following: ➢ Counselling is often helpful, but some people who are vulnerable may need to access specialist mental health services. There are also several third sector or community organisations that can help with bereavement support, such as Survivors of Bereavement by Suicide in the UK (https://uksobs.org). ➢ In the UK and some other countries, mental health services are often alerted if a young person in a school or college takes their life, so a school support strategy can be worked out for other pupils who may be affected by the event. ➢ It is important to be aware of the issue of contagion. This is where other vulnerable young people who knew the person who killed themselves may be induced to copy suicidal actions.

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Case Example Jenny is 14. Her parents separated two years ago, and she doesn’t have a good relationship with either of them. She recently had to move to a new house and school after her parents broke up. She doesn’t feel she has any deep friendships or people who can listen to her. She has linked up with an online forum of young people who cut themselves as a coping strategy for managing difficult emotions. Jenny started cutting herself with a razor blade in the shower after an argument with her mum and found when she felt upset it helped her release some of her anger and frustration. She got used to doing this on her thighs and forearms and it became a pattern over several months. At school she sometimes used a pencil sharpener blade until her form tutor found her doing it and referred her to the school counsellor for some support. Jenny felt listened to by the school counsellor, who had previously worked with other young people who had engaged in self-harming. The counsellor also linked Jenny in with a school-based mental health worker. The counsellor and primary mental health worker helped her with DBT skills, teaching her mindfulness and distraction. She practised using the ice-dive rather than self-harming. After several months Jenny’s cutting and mental health improved. The mental health worker also spoke to Jenny’s mum with Jenny’s permission, and they talked about how to reduce arguments at home and plan in some positive times together. They also talked about developing her artistic hobby and linking into a local art group instead of the young people who were encouraging self-harm. This helped Jenny be part of a more positive peer group where she could also develop her creative expression as a way to cope with difficult feelings, rather than focus on self-harm. Jenny’s social relationships also improved.

Notes on the Case Example ➢ Jenny has experienced several recent difficulties, including her parents separating and moving school. These difficulties built up and

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together led to Jenny not feeling able to cope and developing less helpful coping strategies. ➢ The fact that Jenny has found some so-called ‘friends’ online who self-harm to regulate feelings may have encouraged her to use this method too. It is generally important to investigate young people’s social media use when trying to support them in moving forwards. ➢ As with many young people, Jenny’s self-cutting has started to become a regular but unhelpful way of dealing with her difficult feelings. ➢ It was helpful that Jenny’s form tutor was alert to the fact she was struggling and quickly referred her to the school mental health team and counsellor, who suggested strategies to manage Jenny’s selfharm and to support the situation at home. Support in schools is very important at picking up and working with mental health difficulties before they develop into serious disorders.

KEY POINTS

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Self-harm is any attempt to deliberately harm yourself. It can include a range of methods, such as cutting, burning, overdosing, tying ligatures, banging.

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Self-harm can have a range of different functions for young people. It is helpful to explore what drives the young person you know to self-harm, as reasons can vary.

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You can support someone who has self-harmed by being kind and compassionate and helping to manage their safety. There are some useful techniques a young person could try to deal with self-harm urges, including distraction, drawing on themselves with red pen, pinging elastic bands on wrists and doing ice-dives.

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•

It’s worth noting that a young person with thoughts that life is not worth living may well be depressed. These thoughts need to be taken seriously, and professional help should be sought. Although completing suicide is rare in young people it is still the most common cause of death in 10- to 19-year-olds.

•

There are often a few mental steps young people go through from having fleeting thoughts to taking their life. Young people with more frequent suicidal thoughts and concrete plans are at higher risk and will need a higher level of support.

•

Certain mental health teams can offer crisis support by drawing up crisis plans with young people and their families and treating underlying conditions. Sometimes support from additional services like crisis teams or inpatient admission may be needed to maintain safety.

References (1) Public Health England. 2017. Intentional Self-Harm in Adolescence. An Analysis of Data from the Health Behaviour in School-Aged Children (HBSC) Survey for England, 2014. Public Health England. (2) NHS Digital. November 2018. Mental Health of Children and Young People in England, 2017. Available at https://digital.nhs.uk/data-and-information/ publications/statistical/mental-health-of-children-and-young-peoplein-england/2017/2017 (3) National Institute for Health and Care Excellence (NICE). Clinical Knowledge Summaries. Self-Harm. Last revised 2020. Available at https:// cks.nice.org.uk/topics/self-harm/ (4) Hawton, K., Saunders, K. and O’Connor, R. 2012. Self-Harm and Suicide in Adolescents. The Lancet 379(9834), 2373–2382. https://doi.org/10.1016/ S0140-6736(12)60322-5. (5) Office for National Statistics (ONS). September 2020. Suicides in England and Wales: 2019 Registrations. Available at www.ons.gov.uk/ peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/ bulletins/suicidesintheunitedkingdom/2019registrations

Difficulties with Self-Harm and Suicidal Thoughts (6) National Institute for Health and Care Excellence (NICE). 30 September 2013. Depression in Children and Young People. Quality statement 3: Suspected Severe Depression and at High Risk of Suicide [QS3]. Available at https://www.nice.org.uk/guidance/qs48/chapter/Quality-statement-3Suspected-severe-depression-and-at-high-risk-of-suicide

Useful Resources Web-Based Resources ➢ There is a very helpful free information leaflet produced by mental health staff and researchers at the University of Oxford aimed at parents and carers entitled ‘Coping with Self-Harm: A Guide for Parents and Carers’ (Centre for Suicide Research, University of Oxford, printed in association with Charlie Waller Trust, 2016). Available at www.oxfordhealth.nhs.uk/news/ coping-with-self-harm-a-guide-for-parents-and-carers-highly-commended/ ➢ The American-based National Child Traumatic Stress Network provides links to many useful resources and has produced a helpful free downloadable leaflet entitled ‘Words to Use When Talking about Suicide’. Available at www.nctsn.org/resources/ words-to-use-when-talking-about-suicide

Books ➢ The Parent’s Guide to Self-Harm by Jane Smith (Lion Hudson, Oxford, 2012) could be a source of useful information for parents and caregivers.

Other Resources ➢ Dialectical behaviour therapy (DBT) strategies can be extremely helpful in managing self-harm and suicidal thoughts. (Please refer to the Resources section at the end of Chapter 14: emotional dysegulation section for further resources on DBT.)

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17 Difficulties with Trauma and Post-Traumatic Stress Disorder Children can show a range of different symptoms and difficulties following trauma, not just in the form of the classical post-traumatic stress disorder (PTSD), which may also have a different presentation in children. Research shows that childhood trauma is a strong risk factor for a range of adult mental health conditions, including depression, personality disorders and drug and alcohol disorders, to name but a few. Chapter 4 in Part 1 of this book considered trauma as a stress factor affecting children’s and young people’s mental health. This chapter, on the other hand, looks at children and young people who have experienced trauma and discusses how to support them with these difficulties.

Difficulties with Trauma and PTSD

What Affects How Children Respond to Trauma? How a child or young person responds to trauma depends on a range of factors, including the balance of risk and protective factors, as well as their personality and stage of development. Children are more likely to struggle to process trauma if they have the following risk factors: ➢ ➢ ➢ ➢

History of attachment difficulties. Past exposure to trauma and other adverse childhood experiences (ACEs). Trauma that is severe, life-threatening or repeated. Poor coping skills, for example due to learning difficulties or lack of support.

Children are more likely to have the ability to manage trauma if they have the following protective factors, including: ➢ ➢ ➢ ➢

Supportive attachment relationship with caregivers. Strong networks of support, including with school and extended family. If the traumatic event was a one off. Effective coping skills for processing difficult feelings.

Which Symptoms Can Result from Trauma? Children may struggle with a range of symptoms, some of which overlap with symptoms of post-traumatic stress disorder, including: ➢ ➢ ➢ ➢ ➢ ➢

Changes in mood, including sadness or mood swings. Anger and behaviour difficulties. Sleep difficulties: bad dreams and nightmares. Separation difficulties and clinginess to parents. High levels of stress, often being in a state of hyper-alertness. Avoidance of reminders of the trauma.

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What Is Post-Traumatic Stress Disorder (PTSD)? Post-traumatic stress disorder (PTSD) may happen after experiencing or witnessing an extremely frightening event, like a severe accident or rape, which then impacts on the child’s or young person’s daily life after the traumatic event. The child or young person is unable to bounce back after the trauma and experiences difficulties for longer than a month. Symptoms include: ➢ Re-experiencing trauma in some way, including flashbacks, scary dreams or nightmares, distressing images, and seeing, hearing or sensing something linked to the trauma. Younger children may re-enact the trauma in their play. Traumatic memories and experiences can feel so real it is like the trauma is happening again. ➢ Avoiding triggers relating to the trauma. ➢ Emotional numbing. ➢ Feeling moody, tense and irritable, with lack of interest in activities. ➢ Difficulty sleeping and concentrating often due to increased stress. ➢ Seeming to go backwards in skills, for example going back to bedwetting. ➢ Behaviour changes, including aggression or behaving in risky ways, for example self-harming or drug and alcohol use. ➢ Physical symptoms, like muscle aches and pains.

Are There Different Levels of Severity of PTSD? ➢ Yes: PTSD can be classified as uncomplicated or complex PTSD. Uncomplicated PTSD is the most common type, and is generally linked to one major traumatic event. ➢ Complex PTSD is a more serious reaction to a long-lasting traumatic experience, of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible, for example repeated sexual or physical abuse or

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torture. As well as having the symptoms of uncomplicated PTSD, people with complex PTSD also have difficulties with regulating emotions; beliefs about feeling defeated accompanied with shame or guilt; and difficulties sustaining relationships. This often has a significant impact on a person’s ability to function and is likely to require more specialist treatment, including psychotherapy (see Chapter 14 for more information on this).

What Can You Do to Help a Child or Young Person Who Has Experienced Trauma? ➢ Allow children and young people a space to talk, but don’t force them to talk until they feel ready. Acting as though the trauma didn’t happen doesn’t allow processing of their feelings. Be guided by the child or young person as to what they want to discuss and when. ➢ Encourage children to engage in play and creative arts. Depending on the child and their interests, you may be able to help them access crafts, music, drama, literature and poetry. These can all be therapeutic and give young people a creative space away from the trauma. ➢ Create plenty of opportunities for movement and exercise. Being outdoors in nature and keeping active can be restorative. ➢ Respect a child’s or young person’s desire to avoid difficult triggers of the trauma until they are ready. If triggers do need to be faced, for example crossing a busy road, give lots of support around this, and seek professional advice if needed. ➢ Support the child/young person when they do need to face reminders of the trauma. ➢ Help children and young people learn to be self-compassionate. Self-blame and criticism are sadly common in children and young people who have been exposed to trauma. It’s important for children and young people to learn that the trauma was not their fault and giving them permission to exercise self-care and prioritise their need to rest and recover can be helpful.

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➢ Get specialist help. It may be easier for the child or young person to talk to a professional than a family member, so asking for a referral to a mental health service is often a useful first step. In more complex cases, and if the courts/law are involved in a case (e.g., due to rape or child protection) multi-agency support may be needed. It’s then helpful to have a lead professional who the child or young person trusts and who can link in with the family and coordinate services. You can ask school staff to help accommodate children’s and young people’s difficulties. ➢ If the adults are struggling too, they can also consider getting help for themselves. Parents and caregivers will be in a better position to help children and young people if they are first managing their own difficulties. Seeking help for these difficulties is a sign of strength and sends out a positive signal to the child or young person.

What Are Effective Treatments for PTSD and Other Trauma-Related Difficulties? The most effective treatments for PTSD in children and young people are psychological (1). However, it’s important to do a careful assessment before starting therapy to check the child is able, ready and properly supported in accessing therapy. Here are some important psychological treatments: ➢ Trauma-focused cognitive behavioural therapy (CBT): This is a form of psychological therapy in which the therapist helps the child to set up a neutral memory of the trauma rather than emotionally laden fragments of memory which can contribute to nightmares and flashbacks. The child learns to cope with distress about the trauma at the same time as identifying negative thoughts or misrepresentations of what happened. ➢ Eye movement desensitisation and reprocessing (EMDR): This is a technique carried out by trained therapists that uses rapid eye movements to reduce distress from bad memories. In the UK it is the second-line treatment if children and young people can’t manage trauma-focused CBT.

Difficulties with Trauma and PTSD

➢ There aren’t currently specific UK guidelines around management of trauma symptoms that don’t follow a classical PTSD pattern. However, in practice, mental health services tend to follow a similar model of treating trauma-based difficulties using psychological support in the first instance, and treating associated symptoms as needed according to the clinical presentation. ➢ Although medications are not specifically recommended by UK guidelines to treat PTSD per se, sometimes medications may be used in conjunction with psychological treatment to treat severe symptoms, including depression, which can emerge from the trauma.

Are There Longer-Term Risks if PTSD Is Not Treated? ➢ Yes. Although many children and young people manage to improve without treatment, there is an increased risk of drug and alcohol use, as well as several other health conditions due to ongoing high levels of stress and difficulties with relationships. ➢ However, most children and young people do recover, especially if they are well supported and not too overwhelmed by their experiences.

Case Example Ajay is 13. He was in a severe car crash over the summer holiday when his family were visiting relatives in India. The accident left his mum wheelchair-bound and killed his aunt. Ajay managed to escape with minor injuries and tried to settle back into school to take the pressure off his family, who were trying to sort out his mum’s care. Ajay found school hard to manage as he was struggling with sleep and to concentrate and seemed on hyper-alert the whole time. His friends described him as jumpy, and he kept getting flashbacks of the car crash. He admitted to

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his dad he was getting nightmares and he seemed to be very low and tearful. He would walk a very long and quiet route to school to avoid contact with as much traffic on major roads as he could. After several months of trying to cope, he broke down on the phone to his best friend and told him he wasn’t coping and couldn’t get past the accident. He felt guilty because his mum was so injured and trying to adjust to life with a severe disability. His friend spoke to his dad; he took him to his family doctor, who referred him to the Child and Adolescent Mental Health Service. Ajay agreed to engage in trauma-focused CBT. After around 24 sessions, Ajay was less affected by flashbacks, nightmares and other symptoms and had developed coping strategies. His psychologist also linked in with his family and school to try and help them understand what he had been through and reduce his workload while he adjusted to his trauma.

Notes on the Case Example ➢ Ajay has suffered from typical symptoms of post-traumatic stress disorder, including re-experiencing the trauma with flashbacks and nightmares, and avoidance of main roads, which he links to the accident. His mood has dropped, and he is struggling to concentrate. ➢ It takes several months for Ajay to admit to his difficulties as he feels guilty about taking attention away from his mum, who was more severely injured by the accident than him. This delay in help seeking often happens in young people, especially younger children, who may struggle to express how they feel. ➢ Ajay responded well to trauma-focused cognitive behavioural therapy and was able to gradually get back to his normal life after support from his school and family.

Difficulties with Trauma and PTSD

KEY POINTS

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Childhood trauma is a major risk factor for many different mental health conditions. How children respond to trauma depends on a range of factors, notably the balance between risk and protective factors.

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Protective factors for children to manage trauma include good support available, positive early attachment experiences and effective coping skills. Children are at higher risk if the trauma was sudden, severe or life-threatening.

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Children may respond to trauma with a range of different symptoms, some of which overlap with PTSD, including difficulties with mood, sleep and nightmares and showing a range of behaviours, like clinginess.

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Children and young people may or may not experience the classically described PTSD. Key features of PTSD include re-experiencing the traumatic event through nightmares and flashbacks, avoiding triggers and emotional symptoms, such as feeling numb and low in mood.

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Supportive adults can help children and young people who have experienced trauma by offering a safe space to talk; creating opportunities for creativity and activity; encouraging self-compassion rather than blame; and accessing professional support for themselves if needed.

•

Psychological treatments have the best evidence base for trauma. However, children need to be properly assessed first to check their ability to access therapy and make sure they have enough support to do so. Psychological treatments include trauma-focused cognitive behaviour therapy (CBT) and eye movement sensitisation and reprocessing (EMDR). Sometimes medications can be useful, usually in addition to psychology.

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References (1) National Institute for Health and Care Excellence (NICE). 5 December 2018. Post-traumatic Stress Disorder. NICE guideline [NG116]. Available at www .nice.org.uk/guidance/ng116/chapter/Recommendations#management-ofptsd-in-children-young-people-and-adults

Useful Resources Web-Based Resources ➢ The Royal College of Psychiatrists’ website includes a useful section on ‘Traumatic Stress in Children: For Parents and Carers’. Available at www.rcpsych.ac.uk/mental-health/ parents-and-young-people/information-for-parents-and-carers/ traumatic-stress-in-children-for-parents-and-carers ➢ Young Minds, a UK youth mental health charity, has a useful information section on trauma in its ‘Parent Information’ section. Available at www .youngminds.org.uk/parent/parents-a-z-mental-health-guide/trauma/ ➢ Nip in the Bud is a UK charity which produces films on mental health in children and young people. It has useful films on childhood PTSD, resources and a fact sheet for teachers. Available at https://nipinthebud .org/ptsd-in-children/ ➢ The North American Council on Adoptable Children has produced several useful articles and webinars on childhood trauma. Available at www.nacac.org/help/parenting/childhood-trauma/ ➢ The National Child Traumatic Stress Network (www.nctsn.org) is a USbased network which has useful online information about child trauma.

Books (for Parents and Professionals) ➢ The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk is an informative and classic book by an

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American pioneering trauma researcher and psychiatrist explaining the impact of childhood trauma on longer-term functioning of the mind and body (Penguin, New York, 2015). ➢ The Boy Who Was Raised as a Dog, 3rd Edition: And Other Stories from a Child Psychiatrist’s Notebook – What Traumatized Children Can Teach Us about Loss, Love, and Healing by Bruce D. Perry and Maia Szalavitz is a thought-provoking book which uses a number of case studies to explain the impact of childhood trauma and how support can be transformative afterwards (Basic Books, New York, 2017).

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18 Difficulties with Anger and Behaviour Anger and aggression are powerful instincts, which have served an important evolutionary purpose for humans. However, these instincts can make life very difficult for children, young people and their families if unchannelled. In this chapter we discuss why some children and young people may struggle more than others with their anger and antisocial behaviour. We also discuss which strategies may be most effective in managing such behaviours. We then consider the two recognised behaviour disorders (oppositional defiant disorder and conduct-dissocial disorder) and how best to support children and young people with these conditions.

Anger and Behaviour Difficulties Why Do Some Children and Young People Have Difficulties with Managing Their Anger? There are several complex reasons for anger and behaviour difficulties: both genes and environment play a role. Here are some common factors

Difficulties with Anger and Behaviour

to consider when assessing why a child or young person may struggle with anger: ➢ Children who have difficulties in their early development, such as attachment problems and abuse and having been the victim of anger themselves, may find it much harder to regulate their emotions than those who have had secure, calm developmental experiences. ➢ Some inherited conditions like ADHD and autism can make it more difficult to stay calm. This may be due to increased impulsivity in ADHD and emotion regulation difficulties in autism. Young people with depression and anxiety can experience high levels of irritability which can tip into anger. ➢ Problems with drugs and alcohol can increase risk of difficulties with anger and emotion regulation. Substance use by family members may expose children and young people to dysregulated environments where explosive outbursts become normalised.

Which Parenting Techniques Can Help Children and Young People with Anger and Behaviour Difficulties? ➢ Focus on giving lots of positive attention: Children who struggle with their anger often have low self-esteem as they are trapped in cycles of blame and punishment. Reward and praise are the most powerful motivators. ➢ Help children withdraw to a calm-down space when they feel anger coming on. It’s important children and young people are guided to a calm-down space when they are getting out of control to help to contain aggressive urges: this needs to be a safe place for both the child and the rest of the family. ➢ Talk about the child learning to make good choices rather than giving the child a negative label. Many of us will remember what it’s like to have had a ‘naughty’ label as children, which is unhelpful: we need to emphasise to children they are in control of their behaviour and they can make good choices rather than saying they are inherently bad. ➢ Be very specific about what behaviours you would like to see rather than what you don’t want to see: this helps the child know what to aim

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for. You may need to build up slowly rather than expect huge changes straight away and build in rewards. When the child is calm you could talk about how destructive behaviours can add fuel to the angry flames. ➢ Consider whether there may be an underlying problem driving anger. It could be a mental disorder or could be an unprocessed loss. Can you help the child identify the problem and get appropriate help? They may need support in processing difficult feelings.

Which Strategies May Help Children and Young People Learn to Manage Their Angry Feelings? ➢ Try using traffic light coloured cards to name and share angry feelings (green = calm, amber = getting irritated, red = angry). After some practice, jumping from green to red should happen less often, as most of the time anger goes through an amber ‘build-up’ stage, which is the stage to work on with anger-management strategies. ➢ Help young people see patterns in what triggers their anger: Using charts can be beneficial as it helps understand the detail of what happens during and after anger outbursts. Once you find a pattern, you can then try and work out alternatives to behaviours. For example, you could draw what is known as an ABC behavioural chart with the following headings: A (antecedents)

B (behaviours)

C (consequences)

What happens before I get angry? What am I feeling? Who is around?

What do I do when I’m angry? What do I do? What do I feel?

What happens after I’m angry? What do I feel? Who is around?

E.g., My brother hits me or says something irritating.

I feel rage and start hitting him and pulling his hair.

I feel upset that I acted without thinking it through. Mum asks me to go to my room to calm down.

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➢ Go through some relaxation exercises together. It’s important to help children learn the difference between feeling tense and relaxed inside their body. One popular exercise called progressive relaxation is learning to tense and relax all the muscle groups in your body, one by one, from your toes up to your eye muscles. Once you practise this a few times you will be able to consciously relax when you feel tense. Learning to breathe deeply is also important. ➢ Consider high-energy outlets for anger, for example a punchbag, a trampoline, kicking a football or squeezing a pillow. Many young people report martial arts training is very helpful. Having supervised ‘rough play’ can be a good outlet for physical kids, for example for those with ADHD. ➢ Look for creative channels for anger, such as writing, drawing, music or playing (in younger children). Diary writing or recording voice reflections in a journal can be very helpful for young people in expressing their emotions. ➢ Identify factors which make behaviour worse. For example, if the young person is using drugs or alcohol or gets ‘sugar rushes’ from food or sugary drinks, you could help them identify these triggers. ➢ Encourage young people to learn to choose their battles. Teaching children that walking away from a battle is often the stronger choice but takes some work. You could practise with role-play and discuss how to respond to someone trying to trigger your anger.

Behaviour Disorders When anger and behaviour disorders start to significantly impact on a child or young person and their family’s functioning and ability to cope, they may be developing a diagnosable behaviour disorder (conduct or oppositional defiant disorder). These are discussed further below.

Are Behaviour Disorders Classified as Mental Health Disorders? ➢ There have been many debates over the years about whether behaviour disorders should be grouped together with other serious

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mental health conditions. However, antisocial behaviour difficulties do have a clear impact on functioning as well as mental health. Therefore, behaviour disorders are classified as mental health disorders. ➢ There are two recognised behaviour disorders in children and young people in both the international and UK classification systems: oppositional defiant disorder and conduct-dissocial disorder (often both confusingly lumped together as ‘conduct disorders’). These disorders describe persistent maladaptive patterns of behaviour where the child or young person violates the basic rights of others or ageappropriate social norms.

What Increases the Risk of Getting ConductDissocial or Oppositional Defiant Disorder? ➢ An interplay of inherited and environmental factors causes conduct disorders. There are real differences in brain functioning in young people with these conditions. ➢ Boys are more than twice as likely as girls to have a diagnosis. ➢ Learning difficulties increase risk. ➢ Some mental health conditions, like ADHD and autism, increase risk. ➢ Family circumstances, including attachment difficulties, abuse, parental drug and alcohol use, poverty and parent mental health problems all increase risk.

What Is Oppositional Defiant Disorder (ODD)? ➢ ODD is when a child has high-level behaviour problems, with defiant, disobedient and disruptive behaviour. ➢ Often children with ODD argue with adults, disobey rules and set out to annoy others and have frequent temper tantrums. Children seem angry and resentful and blame others.

Difficulties with Anger and Behaviour

What Is Conduct-Dissocial Disorder? Conduct disorder is known in the latest international classification system as conduct-dissocial disorder in order to include the antisocial as well as the behavioural aspects of the disorder. It is a condition characterised by a repetitive and persistent pattern of aggressive, antisocial or defiant behaviour that is more severe than what you would expect for a child of that age. The child or young person breaks age-appropriate rules and violates the basic rights of others. They also deliberately hurt other people. Examples of such behaviours include: ➢ Aggression: fighting or bullying, often with weapons. ➢ Stealing. ➢ Repeated lying. ➢ Severe destructiveness to property. ➢ Truancy from school and running away from home. ➢ Temper tantrums that are frequent and severe. ➢ Cruelty to people/animals. ➢ Fire-setting.

There are two main sub-classifications of conduct-dissocial disorder: childhood onset and adolescent onset. Both can be listed with either limited or typical pro-social emotions to indicate whether or not they lack empathy and feeling for others’ distress.

How Common Are Conduct-Dissocial Disorders and ODD? ➢ They are one of the most common types of disorders, found in about 5 in 100 young people. ODD is more common in primary school age children and conduct disorder is more common in young people of secondary school age.

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Are Children and Young People with ConductDissocial Disorder at Risk of Having Other Mental Health Disorders? ➢ Conduct-dissocial disorders commonly co-occur with other mental health disorders. ADHD is the most common. Children and young people with conduct-dissocial disorders are at higher risk of depression and anxiety. ➢ Underlying conditions are often missed, as negative behaviours can become the focus of management strategies.

What Can You Do to Support Young People at Risk of Developing Conduct-Dissocial Disorders? ➢ Help build children’s and young people’s self-esteem. Encourage the child or young person to pursue something they enjoy and can achieve at so they can learn to gain a sense of mastery of a skill, which will improve their self-worth. ➢ Focus on positive rather than negative behaviours. Often young people get stuck in cycles of getting attention for negative behaviour and are very angry at people in authority. Steady, consistent and positive support that focuses on the positives for children and young people can really help turn their lives around. ➢ Think about whether school can offer extra support. Does the child need a learning needs assessment? Are they in the right type of school for their needs? ➢ Consider whether changes can be made to the family environment. Giving parents support and parenting advice is often a powerful way to help the whole family change behavioural cycles. Social care services or other more specialist support may be helpful with boundary-setting if this is becoming too difficult for families to manage alone. ➢ Can the young person readily access social skills training or support? Could they benefit from a mentor? Positive role modelling is often very important.

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➢ Can you link the young person with community or youth groups or programmes in third sector organisations? Often young people who are less academic need to find an opportunity to shine at a more vocational, sports-based or creative skills. ➢ Always consider the possibility of child abuse in children with behaviour problems, especially when there has been a change in behaviour.

When Can a Child with Behaviour Problems Be Referred on for Extra Help? You should refer a child or young person on for specialist support if their behaviour is affecting their everyday ability to manage at home or school. UK guidance is as follows (1): ➢ If the child does not have an associated mental health condition, refer on for a behaviour intervention (either parent and/or child training or multimodal intervention). You can make the referral via the local authority or the county council, safeguarding services or family and children information services. ➢ If the child does have an associated mental health condition (including depression, PTSD, ADHD, autism or drug and alcohol misuse) refer on to the local Child and Adolescent Mental Health Service.

Which Interventions Can Help with Behaviour Disorders? According to UK national guidance (1) the first-line management for behavioural disorders is behaviour and social interventions as follows: ➢ Parenting training groups for parents and caregivers of younger children aged 3–11 years, with special programmes for those with complex needs. ➢ Child social and problem-solving programmes to children and young people aged 9–14 years. In practice these programmes may not always be easy to access.

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➢ Multimodal interventions are recommended for young people aged 11–17, with a ‘family and supportive’ focus. ‘Multimodal’ means looking at all the different aspects of a young person’s life and facilitating the use of a range of approaches. There is increasing evidence for psychological treatments, like dialectical behaviour therapy (explained further in Chapter 14: emotional regulation section). ➢ It’s important to treat underlying mental health and learning disabilities. For example, if the young person has ADHD, we first treat their ADHD symptoms. ➢ Sometimes we may use medication as a last resort to treat shortterm severe behaviour disturbance in conduct disorder. For example, if the child or young person is extremely physically aggressive to others, a short-term dose of medication may be helpful if behaviour options have been exhausted.

Which Other Types of Services May Get Involved in Supporting Young People with Behaviour Disorders? ➢ Forensic mental health services may get involved if young people have been in trouble with the law or exhibit behaviours that are risky to others and there are concerns regarding mental health or neurodevelopmental conditions. ➢ Some mental health and social care services have specialist teams which deal with harmful behaviour; these may help schools and families draw up behaviour support plans. ➢ Youth offending teams have input from different agencies, including health, and who seek to address offending behaviour and identify any specific needs in the young people with whom they work. They manage young people who, wherever possible, are diverted from the youth justice system, those on community court orders and maintain contact with young people who receive a custodial sentence for a serious crime in a secure setting (a young offender institution (YOI), a secure training centre (STC) or a secure children’s home (SCH)).

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What Is Antisocial Personality Disorder? ➢ Antisocial personality disorder (ASPD) is characterised by impulsive, irresponsible and often criminal behaviour. People with this disorder will typically be manipulative, deceitful and reckless and do not care for other people’s feelings. We rarely diagnose personality disorders before the age of 16, as personality is still evolving, and may be influenced by early developmental difficulties. Personality difficulties and disorders are on a spectrum, and in this case can range from occasional antisocial behaviour to repeatedly breaking the law and committing serious crimes. Psychopaths are adults who have a severe form of antisocial personality disorder (2). ➢ Many people with ASPD struggle to empathise with others and their brains are wired up differently from those without these difficulties. ➢ 90% of adults with ASPD have had conduct disorder in childhood or adolescence. ➢ 40% of young people with conduct disorder progress to antisocial personality disorder. ➢ On the positive side, there’s increasing evidence that early intervention can steer people away from negative pathways of crime and delinquency. Investment in early intervention is so important.

Case Example Larry is 15. He lives with his mum, who works long hours as a carer. Larry has no contact with his dad, who is in prison and was violent towards his mum. Larry has been excluded from several schools for aggression, bullying and swearing at teachers and now attends a specialist small Pupil Referral Unit (PRU) for young people with severe behaviour problems. His teacher at the specialist unit has identified learning difficulties, including poor short-term memory. Larry’s mum explains that he has struggled with behaviour difficulties from a young age, and used to have frequent temper tantrums, in which he has been

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verbally and physically aggressive to several family members and has been cruel to pets. Larry always found school hard, struggled to make friends and was frequently in trouble. After a stable period, he has now got involved with a local gang and has been stealing, getting into fights and, more recently, has dabbled in drug use. Larry is assessed by the local mental health team, who screen for other mental health problems, which are not identified. Larry’s mum is seen by social care services. The youth offending team offer a multimodal intervention to Larry and his mum which consists of an intensive programme of several meetings a week over a four-month period delivered by a case manager. After the intervention, Larry manages his anger and aggression better. He reduces offending and does a mechanics entry-level course together with maths and English with a local youth scheme. Larry’s youth offending team worker, college tutor and social worker stay involved in Larry’s case for several months to offer support to Larry and his mum, as Larry is at high risk of further conduct difficulties.

Notes on the Case Example ➢ Larry is on a worrying pathway towards developing conduct disorder and would likely end up in prison or caught up in drugs networks if intervention is not swift, positive and multimodal. ➢ The early exposure to domestic violence and the fact that dad is in prison are risk factors. ➢ The pattern of several school exclusions and learning problems is typical of children with conduct disorder. ➢ Larry is lucky he has been supported in this way, so that his path can be changed, and he can be helped in moving forwards positively, rather than falling into a life of drugs, gangs and crime. Unfortunately, many people don’t get picked up as early as Larry. There are many young people with similar difficulties to Larry in prisons and young offender institutes who do not have access to early intervention.

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➢ Following the UK national NICE guidance (1), which recommends behaviour interventions for these cases, many local authorities are now working with social care and mental health teams to provide specialist interventions for families and young people at risk.

KEY POINTS

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There are many reasons why children and young people may struggle with anger and behaviour problems, including both inherited and environmental factors. Conditions like ADHD and drug and alcohol use can often make it more difficult for children and young people to stay calm.

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We can help children with behaviour difficulties in different ways, including developing self-esteem by finding activities they enjoy, giving lots of praise and tracking and charting patterns of difficulties.

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Diagnosable behaviour disorders include oppositional defiant disorder and conduct disorders.

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We generally treat behaviour disorders with parenting programmes and positive behaviour programmes.

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A child with a behaviour disorder will generally only get referred to specialist mental health services if they also have another mental health condition that requires treatment. Parent training and multimodal support are very important.

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Forensic mental health services together with other specialist agencies may become involved if young people are a high risk to others or commit crimes. A child who commits a severe crime may be sent to a young offender institute. The emphasis is gradually shifting towards offering supportive and restorative work with young people rather than criminalising them. In this way, we can often turn around the life chances of troubled young people.

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References (1) National Institute for Health and Care Excellence Guidance (NICE). 27 March 2013. Antisocial Behaviour and Conduct Disorders in Children and Young People: Recognition and Management. Clinical guideline [CG158]. Last updated 19 April 2017. Available at www.nice.org.uk/guidance/CG158/ chapter/1-Recommendations#pharmacological-interventions–2 (2) NHS website. Mental Health: Antisocial Personality Disorder. Available at www.nhs.uk/mental-health/conditions/antisocial-personality-disorder/

Useful Resources Web-Based Resources ➢ Young Minds, the UK youth mental health charity, has good information for both parents and young people on helping managing anger and behaviour, including the following leaflet: www.youngminds.org.uk/ media/jvxpsv0s/young-minds-anger-issues.pdf ➢ The Royal College of Psychiatrists’ website has a useful information page entitled ’Behavioural Problems and Conduct Disorder: For Parents, Carers and Anyone Working with Young People’. Available at www.rcpsych.ac.uk/mental-health/parents-and-young-people/ information-for-parents-and-carers/behavioural-problems-and-conductdisorder-for-parents-carers-and-anyone-who-works-with-young-people ➢ Nip in the Bud is a charitable organisation with online mental health information and short film clips. It provides helpful information and a short film on conduct disorder. Available at https://nipinthebud.org/ child-mental-health-conditions/recognising-conduct-disorders/

Books ➢ Presley the Pug Relaxation Activity Book: A Therapeutic Story with Creative Activities to Help Children to Regulate Their Emotions and

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to Find Calm is a helpful book by Dr Karen Treisman, published by Jessica Kingsley Publishers in 2019; it is aimed at children aged 5–10. ➢ I Am Stronger Than Anger is a picture book aimed at young children about dealing with anger written by Elizabeth Cole and independently published in America in 2020. ➢ The Anger Workbook for Teens: Activities to Help You Deal with Anger and Frustration by Raychelle Cassada Lohmann is an example of a youthfriendly workbook on anger management for teenagers. There are several similar workbooks on anger management which follow the same basic principles available online (published by ReadHowYouWant, 2020).

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19 Difficulties with Attachment As explained in detail in Part 1, Chapter 1 of this book, a child’s secure attachment to their parents or caregivers is generally the most important protective factor underpinning positive mental health development. Indeed, a lack of early secure attachment increases the risk of children and young people developing mental health difficulties and disorders. Unfortunately, not all children experience secure attachment in their early life. In this chapter we explore attachment difficulties and disorders, and how to support children with these difficulties. This information may be particularly helpful for parents and caregivers who foster or have adopted children, as well as professionals working with these groups.

Which Children Tend to Have Attachment Difficulties? The biggest predictor of attachment difficulties is if a child has not experienced a secure connection with a parent or caregiver in the first

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few years of life, due to neglect, abuse, institutionalisation or disruption of care. Common reasons why parents may be unable to provide a secure connection with their child are: ➢ Parents have had significant mental health difficulties, including antenatal or postnatal depression. ➢ Parents with substance misuse problems. ➢ Parents who had difficulties with their own attachments, for example if they have been in care themselves. There is evidence of intergenerational patterns of attachment difficulties. ➢ Parents with very little support, for example many teenage mothers or parents in hostile environments of domestic abuse. ➢ Parents with minimal resources and who live in high levels of poverty or unstable environments.

How Can We Reduce the Risk of Children Developing Attachment Difficulties? ➢ There is now increasing evidence that providing support to mothers with children at risk of attachment difficulties from pregnancy through to the first three years of a child’s life can reduce the risk of attachment difficulties (1). ➢ Numerous programmes have been set up around the world to support attachment in at-risk communities. Sure Start, an early years UK government initiative supporting families, launched in 1998, was a positive example of this, although most of the funding for this initiative has been withdrawn in recent years. In Singapore the GUSTO project is collecting evidence about the impact of a range of factors on early development and attachment (2). ➢ It is important to signpost vulnerable families to support, for example to health visitors. A supportive approach is better than criticising parents, which can be harmful and restrict access to services.

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Attachment Disorders What Are Attachment Disorders? How Common Are They? ➢ Attachment disorders consist of patterns of behaviour which are the result of a lack of development of normal secure bonds with a primary caregiver in early childhood (i.e., in the first five years). These disorders are most frequently seen in children in care, who have often experienced very unregulated and insecure attachments. ➢ Fewer than 1 in 100 children have attachment disorders in non-deprived populations, but the rates are slightly higher in deprived populations (3).

How Are Attachment Disorders Classified? The international classification system (ICD-11) recognises two sub-types of attachment disorder, both of which develop within the first five years of life: ➢ Reactive attachment disorder: This is a disorder characterised by a lack of attachment behaviour towards caregivers following a history of highly inadequate childcare: children tend not to seek comfort when distressed and do not respond when they are comforted by their caregivers. Children struggle with abnormal social relationships and have emotional disturbances. Children may show fear towards others and have poor social skills, and may be aggressive towards themselves and others, and sometimes show growth failure. ➢ Disinhibited social engagement disorder: This is a disorder where children may show extremely abnormal social behaviour, including attention-seeking and indiscriminately friendly behaviour in the context of highly inadequate childcare. Children don’t have strong attachments to their caregivers and tend to struggle with peer interactions and social boundaries.

Difficulties with Attachment

Which Strategies Can Help Support Children with Attachment Difficulties and Disorders? ➢ Work with the support network around the child to find ways to help the child and caregiver. For example, school may be able to set up nurture groups, mentors or play therapy; social care services may offer parenting support; attachment teams may offer parent–child therapy. ➢ Alter age-related expectations. Children with attachment difficulties may seem much less emotionally mature and have fewer self-regulation skills then their peers and will often need more patience and support. ➢ Take time to listen to children and play with them. Children with insecure attachments may struggle to communicate verbally, but it is important to think about what they may be trying to tell you through their actions and play as well as through words. ➢ Keep routines and expectations clear and consistent as this will help children feel contained. Predictability is often something children with attachment difficulties have lacked, so adding it in brings some security. ➢ Build in calming-down time after conflict and apologise for your own mistakes. Often children with insecure attachments have deep feelings of abandonment, and conflict can be difficult to manage, as it can bring these feelings back. If you can remain calm and supportive, even when things get tough, you can help children feel contained. If you can also say sorry when you get things wrong that also helps children learn to reflect on their own behaviour. ➢ Make a list of things that help children feel better. It is good to use sensory objects like stress balls and soft blankets, and items that help remind them of positive attachments to soothe them when needed.

The above tips are adapted from Norfolk Educational Psychology and Specialist Support, UK (4).

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Are There Guidelines around How to Support Children with Attachment Disorders? ➢ Yes: There is UK national guidance (5) on assessing and treating children with attachment disorders who are on the edge of going into care. ➢ Often children with attachment disorders will find therapeutic input useful to help them learn to manage relationships.

Case Example Mini is 5 and in her first year of primary school. She lives with her mum, who has struggled with drug and alcohol problems for several years, including when she was pregnant with Mini. Mum separated from Mini’s dad in early pregnancy and it’s likely that dad is unaware of Mini’s existence. Social care professionals have been involved in the past and her maternal grandma offers some support, although she is still working. School is concerned because in her first term Mini seems very emotionally unstable: she can sometimes be over-friendly, wanting close physical contact, and sometimes she hits other children and shouts and swears at them. She has also shown her underwear inappropriately on a few occasions. She often needs the teaching assistant to support her to manage in the classroom as she can quickly get into arguments with children around her and often talks over the teacher. Children avoid her as they don’t know how she will be with them. She doesn’t seek comfort when she’s upset, tending to retreat to the toilets, and her relationship with mum appears distant, not greeting her mum when she sees her. When school attempt to telephone Mini’s mum she often has her phone switched off and her maternal grandma sometimes picks Mini up from school without warning. The school safeguarding lead sets up a meeting with mum and grandma and asks social care services to offer further input.

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Mini receives weekly play therapy for her Reception year at school and goes to a small nurture group in school. Social care services also offer some parenting support to Mini’s mum and grandma. There are ‘Team around the Family’ meetings. Mini gets referred to a children’s mental health service, where she is assessed and diagnosed with a reactive attachment disorder. After a year of parenting support and play therapy, where Mini has built a stable relationship with her therapist, she starts to cope better, her behaviour is more settled, and she forms better relationships at school. She continues to need extra input from professionals at school, including teaching assistants and a nurture group. The mental health team also offer consultation to school staff around behaviour management. The team around Mini are aware that she will need longer-term support, so they continue to have a plan in place for her for the duration of her first few years at primary school, where she has termly progress reviews. Mini also sees the community paediatrics team for developmental checks and to review whether Mini’s mum’s drug and alcohol use may have affected Mini’s health.

Notes on the Case Example ➢ Mini has a reactive attachment disorder: there is a lack of secure attachment towards her caregivers and she doesn’t seek comfort when distressed, presumably due to her early disruptions in attachment relationships. Mini is struggling with regulating her emotions and behaviour and doesn’t know how to have healthy peer relationships. ➢ Mini’s mum’s difficulties with drug and alcohol problems meant she was not available to provide Mini with ‘good enough’ responsive parenting and the support she needed in her early life, which disrupted the attachment relationship. ➢ Mum’s drug and alcohol use in pregnancy may have also had an impact on Mini’s physical health, for example due to a lack of adequate nutrition. She was also at risk of foetal alcohol spectrum disorders from alcohol exposure in the womb, which cause a range of

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physical, behavioural and learning problems. This may require further investigation by the paediatrics team. ➢ Parenting support that works directly with families to improve the parent–child relationship is very important in restorative work. This parenting work was very helpful in Mini’s case in rebuilding Mini’s relationship with her mum and ensuring her mum was able to be appropriately sensitive and supportive. ➢ Play therapy or psychotherapy for a young child can also be very helpful for children with attachment disorders. Children often work through their difficulties during play and a consistent secure relationship with a therapist can help the child form a positive internal model of an attachment relationship, which is protective for mental health.

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Children who have not had a secure attachment with a primary caregiver often go on to develop attachment difficulties. Issues which may interfere with the attachment process include parental illness, substance misuse and parent’s own attachment difficulties.

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Initiatives which give extra support for at-risk pregnant mums and their young children in their first three years of life have a good evidence base in reducing attachment difficulties. There is increasing global investment in infant mental health which focuses on the mother–child relationship, for example through community support and therapy.

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The two main attachment disorders recognised by the international classification systems are reactive attachment disorder and disinhibited social engagement disorder.

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There are some strategies we can use to help children with attachment difficulties, such as adjusting age-related expectations; using support from the network around the child; and taking time to listen to and play with the child.

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References (1) Moore, T., Aref Adib, N., Deery, A., Keyes, M. and West, S. 2017. The First Thousand Days: An Evidence Paper – Summary. Parkville, Victoria: Centre for Community Child Health, Murdoch Children’s Research Institute, Melbourne. (2) GUSTO. 2021. Growing up in Singapore towards Healthy Outcomes. Available at www.gusto.sg (3) Minnis, H., Macmillan, S., Pritchett, R., et al. 2013. Prevalence of Reactive Attachment Disorder in a Deprived Population. British Journal of Psychiatry 202(5), 342–346. doi: 10.1192/bjp.bp.112.114074. (4) Norfolk County Council. Educational Psychology and Specialist Support. Norfolk. Updated June 2017. Available at www.norfolkepss.org.uk/ supporting-children-with-attachment-difficulties-information-forparentscarers/ (5) National Institute for Health and Care Excellence (NICE). 25 November 2015. Children’s Attachment: Attachment in Children and Young People Who Are Adopted from Care, in Care or at High Risk of Going into Care. NICE guideline [NG26]. Available at www.nice.org.uk/guidance/ng26/

Useful Resources Web-Based Resources ➢ National Institute for Health and Care Excellence. Attachment Problems in Children and Young People. Information for the Public: This guideline is written for older children and young people who are at risk of going into care and their caregivers and describes the level of support they should receive during this process. Published 25 November 2015. Available at www.nice.org.uk/guidance/ng26/resources/ attachment-problems-in-children-and-young-people-2825525572549 ➢ Help Guide. Childhood Issues. Attachment Disorders in Children: Causes, Symptoms, and Treatment. This is a useful guide to attachment disorders in children. Available at www.helpguide.org/articles/parentingfamily/attachment-issues-and-reactive-attachment-disorders.htm

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20 Difficulties with Autism and Neurodevelopmental Difficulties including Tics Autism is a neurodevelopmental condition, which means the brain is wired up differently and follows a different pathway of maturation than what is considered typical. Other neurodevelopmental conditions include ADHD, intellectual disability, specific learning disorders and motor coordination disorders like dyspraxia. I discuss ADHD separately in the next chapter. People on the autism spectrum experience and interact with the world in a different way from what is typical. This is often most visible as social and communication difficulties, but the whole internal world of people with autism is different, including how they experience their senses and emotions, their strong need for sameness and predictability and their hyper-focus on certain interests. There are often positive aspects to having neurodevelopmental conditions, as well as impairments. Hence, people in the neurodevelopmental community generally prefer the term ‘condition’ to disorder and may use the term ‘neurodiverse’ to explain their differences from what is considered usual or ‘neurotypical’.

Autism and Neurodevelopmental Conditions

Schools and families are increasingly recognising the wider spectrum of autism-related difficulties in children and young people, partly due to public education and celebrities talking about their experiences of the condition. This wider recognition is generally positive as there is now a broader understanding of how to support children and young people with neurodiverse needs. However, increased awareness has also meant that in many areas services are struggling to meet increased demand for assessments and there are often long waiting times.

What Are Neurodevelopmental Conditions? Autism is in a family of conditions termed ‘neurodevelopmental conditions’. These are conditions which affect the growth and development of the brain and central nervous system. Other neurodevelopmental conditions include: ADHD (see the next chapter for further information on ADHD). Communication and speech and language disorders. Learning (intellectual) disabilities. Motor disorders, including motor coordination disorders and tic disorders. (See below for a short section on tics.) ➢ Neurogenetic disorders, including Downs syndrome and Fragile X syndrome. ➢ Specific learning disorders, for example dyslexia. ➢ Traumatic brain injuries and disorders due to toxic chemicals affecting the developing brain, for example foetal alcohol syndrome.

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Autism and ADHD are the most common neurodevelopmental conditions. Autism is discussed in detail in this chapter and ADHD will be dealt with separately in Chapter 21.

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Tics What Are Tics and What Is Tourette’s Syndrome? ➢ Tics are fast, repetitive muscle movements that result in sudden and difficult to control body jolts (motor tics) or sounds (vocal tics). ➢ Tics are quite common, not usually serious and generally improve with time. They can become frustrating if they interfere with children’s functioning. ➢ Tics often co-occur with other neurodevelopmental conditions, including ADHD and autism. There is also an overlap with OCD. ➢ Tics tend to be worst in middle childhood and then improve after puberty. ➢ Stress and tiredness can worsen tics, as can focusing on them. Most children feel an ‘urge’ in anticipation of the tic. ➢ Tourette’s syndrome is a condition where both motor and vocal tics have been present for over one year.

Do Tics Need to Be Treated? If So, What Can Help Them? ➢ Tics don’t necessarily need treatment. They are often mild and disappear on their own. However, if tics are very regular, interfere with functioning, cause embarrassment or bullying or even pain or discomfort, it may be helpful to go to the GP and ask for help with treatment. ➢ To help your child manage tics, reassure them they are common and not their fault. Try not to respond to them when they happen as this can worsen them. Talk to others who regularly spend time with your child and ask them to try not to react to them too. The teacher may give them a pass to leave the classroom if tics are more severe. To try to reduce tics at home ensure the child gets enough sleep and look into improving stress-management strategies. ➢ Neurology or psychiatry multi-disciplinary teams tend to manage tics in tics clinics.

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➢ The main treatments for tics are behavioural interventions. Key interventions include: - Habit reversal therapy, where the child learns to spot when their tic is going to happen and then learns to do other actions when they feel the urge to tic. - Comprehensive behavioural intervention, where the child learns a set of behavioural techniques to help reduce the tics. - Exposure and response prevention, where the child learns to suppress the feeling of needing to tic until this feeling reduces. ➢ Medications can sometimes also be helpful as a second-line treatment, for example if behavioural treatments alone weren’t effective enough.

Autism Autism is a lifelong developmental condition that affects a child’s or young person’s communication and social relationships and the need for sameness, often resulting in repetitive or rigid thoughts and behaviours. There are a range of different forms and severities of autism spectrum conditions, depending on the combination of difficulties and strengths a person has. As families and schools are increasingly becoming aware of the autism spectrum, it is more commonly diagnosed and understood in children and young people. This is generally a good thing as autism is losing its stigma and families and schools are becoming more autism-friendly.

How Common Is Autism in the UK? Who Is More Likely to Have Autism? ➢ According to the 2017 NHS Digital Survey in the UK autism is present in just over 1 in 100 children aged 5–19 (1), although UK and international surveys now estimate the number of people with autism is closer to 1 in 50. ➢ Autism traits are common in the population and may in fact have an evolutionary advantage for some tasks and in certain environments.

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➢ Autism is currently around five times more commonly diagnosed in boys than girls. This appears to be due to a combination of reasons, including the way girls tend to be socialised in many communities, which causes them to mask their autistic traits to ‘fit in’; as a result their difficulties tend to be overlooked. The pattern of early brain development may also be different in many girls which can have an impact on how autistic behaviours are manifested. ➢ Autism is also more common in children with special needs, and in those from deprived backgrounds.

What Symptoms Are Needed to Make a Diagnosis of Autism? Both major classification systems have now moved to using the term ‘autism spectrum disorder’. In the last few years we have been using the diagnostic criteria from the DSM-5 American classification system more commonly than the international classification system as it contains helpful updated clinical descriptors that reflect the spectrum nature of autism. DSM-5 states a diagnosis should include all of the following symptoms of persistent difficulties in social communication/interaction across contexts (so for children this means you see difficulties both at home and school). There are: ➢ Problems with social or emotional interaction: Children typically don’t chat or smile socially. They may not show emotions or pick up on others’ emotions easily, and often have a literal interpretation of language. ➢ Severe problems maintaining relationships: Children find it difficult to know how to maintain relationships. They often struggle with pretend play. ➢ Non-verbal communication problems: Children often find eye contact uncomfortable, they have reduced facial expressions and hand gestures and their voice may be monotonous or unusual.

Two of the four symptoms related to restricted and repetitive behaviour need to be present: ➢ Unusual or repetitive speech, movements or use of objects: There is often speech delay, and speech problems are common. Speech may also be very precise and professor-like.

Autism and Neurodevelopmental Conditions

➢ Excessive sticking to routines, ritualised patterns of verbal or non-verbal behaviour, or excessive resistance to change: Change needs advanced warning and there is a strong need to keep sameness and routine. ➢ Highly restricted interests that are abnormal in intensity or focus: Children may have an encyclopaedic knowledge of a certain topic and only want to talk about this. ➢ Sensory sensitivities including to noises/sounds, textures, tastes, light and pain/temperature: This may mean that for some children, noisy environments such as classrooms and shops can be overwhelming, while others insist on eating alone as they can’t stand the sound of others’ eating. Many children only wear certain textures, prefer to be naked or only tolerate certain foods.

How Do We Classify the Severity of Autism? As autism sits on a wide spectrum at one end of which people experience severe difficulties with a significant impact on their functioning, while at the other end some experience milder difficulties, it’s important to note the severity of impairment. There are three levels of severity in DSM-5, which focus on the amount of support required: 1. Requiring some support: The child will need extra support from family and school to function successfully. Many children who were previously diagnosed with Asperger syndrome or high-functioning autism would fit into this category, as their relative intelligence and language ability generally predicts better outcomes. Please note that clinicians tend not to use sub-categories such as Asperger syndrome any more due to the preference for terminology which emphasises the spectrum of autism. However, some families do continue to identify with such terms. 2. Requiring substantial support: It is likely that an Education, Health and Care Plan with added resources is needed for the child to manage in a school setting. A specialist school setting may be necessary. 3. Requiring very substantial support: The child is likely to be severely impaired, often with language difficulties and learning disabilities, and may

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well need very specialised individual input in a specialist school setting as well as substantial parental adjustment and support.

How Is Autism Assessed? There is no one specific autism test: it is a clinical diagnosis made by trained professionals who may use the following information to make a diagnosis: ➢ Detailed information from parents/caregivers about the child’s development. It is important to take a careful history of the child’s developmental pathway, from the mother’s pregnancy until the current day. No two children with autism will be the same, so it’s necessary to map out the child’s individual profile. ➢ Information from family and schools about current and past behaviour, including how children relate to their peers; how they manage change; how they manage school and tolerate noise. A school observation can be useful in some cases. ➢ Observation of the child or young person, noting their mental state and interactive play and looking at their verbal and non-verbal communication and emotional literacy is important. ➢ There are some structured clinical tools that may help, especially with judging the severity of symptoms: for example, structured clinical interviews, like an Autism Diagnostic Interview (ADI), and structured play assessments, like the Autism Diagnostic Observation Schedule (ADOS). ➢ Sometimes investigations such as blood tests are needed, if there are medical concerns, to exclude genetic disorders or to see whether physical health concerns contribute to behaviour.

How Is Autism Managed? We talk about management of autism rather than treatment: it is a condition not an illness, so there is no cure. UK national guidance outlines the following principles of management (2):

Autism and Neurodevelopmental Conditions

➢ One of the most important principles is understanding what autism is, how it affects the individual and which strategies can help to manage it. Supporting children and young people, their families and teachers to understand the condition and how it affects them, and to learn strategies to manage in different situations, can make an enormous difference in navigating life ‘on the spectrum’ and feeling in control. Many areas offer post-diagnostic parent programmes. Helpful information is available through local and national autism charities and support networks, the most well-known one is the UK National Autistic Society (www.autism.org.uk). ➢ Psychological approaches with the young person and family (see below for further information). ➢ Sometimes medication is used to treat symptoms, including very severe behavioural disturbances or another coexistent mental health condition. ➢ Specific treatments within mental health services are available for those with mental health disorders in addition to autism or where there are severe behavioural disorders.

How Can You Help Support Children and Young People on the Autism Spectrum? ➢ The key is to help the network around the child or young person understand as much as possible about their form of autism and how to manage it. Contrary to certain traditional views, knowledge tends to help rather than hinder a child’s development, as the child’s experience of the world makes much better sense when they understand how their brain functions. There are now local and national support organisations and books which provide helpful information. ➢ Think carefully about what may be helpful for the child or young person in the school environment. Schools vary tremendously in support for children with autism, and it’s important to try to optimise the environment as early as possible by having close dialogue with teachers and special needs support teams. While many children with autism can function well in a mainstream school with support, others struggle without a lot

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of extra adaptations, and a specialist school may be more appropriate. An Education, Health and Care Plan (EHCP) is often an important part of getting appropriate support in place. (Chapter 12 ‘Helping Children and Young People Manage School’ in Part 2 of this book gives some helpful information about EHCPs.) A major sticking point even in children who manage primary school is the transition to secondary school, as that environment is often much more difficult to control and manage for people on the autism spectrum. ➢ Get support for parents and siblings. Families who are supporting young people with autism may also benefit from extra help. Local groups and national forums can be helpful. However, try to be cautious when taking advice from other parents on forums: each child’s experience will be different, so while some advice may be useful, it’s also important to find out what works out for each child.

Which Support Strategies Will Help a Child with Autism to Cope Better? Many children with autism struggle with a range of social and communication and sensory difficulties. Helping them cope with these can make an enormous difference to their wellbeing. Common support strategies can include the following: ➢ Support with expressing and communicating emotions: This often needs a lot of practice. Using pictures of people showing a range of facial expressions as a discussion point can be helpful. ➢ Support with managing relationships with others: Some children need lots of extra help with verbal and non-verbal communication, including with greeting others, smiling and giving eye contact, giving space and considering the feelings of others. Sometimes adults need to encourage and supervise play. Try to be wary of young people just retreating into the online world rather than face-to-face relationships: a mixture is important. ➢ Support with speech and language: Children and young people may need extra help from speech and language therapists if there are specific speech difficulties or delays.

Autism and Neurodevelopmental Conditions

➢ Working out a child’s sensory sensitivities and interests: Many children can’t manage noisy environments (like classrooms and shops) without ear defenders; for others, lights are too bright or textures on certain clothes may be so uncomfortable they can’t wear them. Occupational therapy support may be helpful in identifying a child’s sensory profile. ➢ Help with managing change and transitions: Giving lots of warnings for change and using charts or pictures of timetables can help children cope. ➢ Managing worries: Anxiety is often a core part of autism, so working through worries is helpful. ➢ Helping children with their understanding of the difference between reality and fantasy: People with autism often have a different experience of what feels real and what is imagined. Sometimes their imaginations can appear so vivid it feels real. Films and stories can appear so real they may trigger nightmares. Hearing voices which feel like real voices can also be a common experience in autism. Helping children manage these can help them cope. ➢ Looking out for other mental health difficulties: People with autism are at risk of also having another mental health disorder. Other neurodevelopmental conditions like ADHD, tics and dyspraxia are common. Treating these conditions is an important part of helping support the person with autism.

Is There Evidence for Any Autism-Specific Treatment Programmes? To date the best evidence base for management of autism is for treatments that focus on parent–child interactions. Recent European ­guidelines on autism have looked carefully at the evidence base for management of autism. They have concluded that despite limited overall ­evidence for the management of autism due to lack of good-quality trials, there is some evidence for the following interventions (3):

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➢ Developmentally based social communication therapies: There is strong evidence for therapies including Joint Attention Symbolic Play Engagement and Regulation programme (JASPER) and the Preschool Autism Communication Trial (PACT). The focus is on parents learning to respond to their child’s cues to develop their communication skills, joint attention and imaginative play. ➢ Applied Behavioural Analysis (ABA) and other interventions based on behavioural strategies: There is weaker evidence for behavioural interventions, although ABA has been widely used in many settings since its introduction. ➢ Parent and caregiver behavioural management programmes: There is some evidence that increasing parents’ behaviour-management skills helps improve children’s adaptive behaviours. ➢ Social skills programmes: There is weak evidence of effectiveness of different programmes designed to enhance social skills, including social groups and computer programmes, and it is unclear which children would benefit the most from these programmes in real-life settings. ➢ Other therapies: Speech therapy focusing on increasing comprehension and communication can include specific programmes (including TEACCH, a strengths-based approach using visual methods to help children learn) which, to date, although extensively used, has a limited evidence base. Occupational therapy to help minimise motor and sensory functioning also still has a limited evidence base. ➢ Interventions for challenging behaviour: UK national guidance (2) recommends psychosocial interventions to assess and change environmental factors, and some recent research has focused on positive behavioural support, for example targeted individual support in schools. ➢ Treatment for co-occurring conditions: There is increasing evidence this is helpful. ➢ Medication: There is no specific medication for autism, and there is some evidence that people with autism are often more sensitive to medication and may not respond as well to it. However, there are some circumstances in which medication may be helpful, especially to treat co-occurring disorders, and for extremely challenging behaviour.

Autism and Neurodevelopmental Conditions

Case Example Zac is 7. His mum said he never wanted to cuddle and frequently played alone, often ordering or spinning wheels on cars for hours, and collecting shiny things. His room has to be arranged in a specific way, and he gets upset if anything is moved. He hates anything new or unexpected and can shout and scream and throw things if he feels he can’t manage. Zac has quite a restricted diet as he can’t stand a lot of textures of foods. He always takes his clothes off at home and cuts out labels. Zac hates going out shopping or to restaurants, so the family don’t take him on outings. Zac’s dad has some similar difficulties: he often prefers to be alone, is quite fixated on trainspotting, but doesn’t have a diagnosis of autism. Zac’s younger sister, Sian, is 5 and has no health or school difficulties. Sian complains Zac is aggressive if she goes near him or into his room and says Zac never plays with her or shares with her. Zac was slow to talk and had speech therapy at nursery. He finds the mainstream classroom environment too noisy, so he uses noise-cancelling earphones in class and works better in a small group outside the classroom. He cries if there are changes to routines or staff and can’t manage assemblies or trips. He is good at maths and seems to have a great memory for numbers, but struggles with literacy and can’t yet read or write. He doesn’t have friends and is often alone in the playground. Zac is assessed for autism. Information requested from school supports a diagnosis of autism. Zac’s parents are asked for a developmental history and Zac is assessed by a psychologist using play. Zac’s eye contact is poor, and he gives one-word answers. He can talk about Pokémon in long monologues but doesn’t realise when the other person loses interest. Zac struggles to express emotions or understand others’ emotions. Clear difficulties are evident in both his verbal and non-verbal communication. Zac is given a diagnosis of autism spectrum disorder. Zac and his parents are given information about autism, and his parents attend the next available

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a­ utism parents’ education group sessions and are linked in with the local autism parent and young people network. Zac is discharged from children’s mental health services. School arranges an educational psychology assessment, which shows Zac has an uneven learning profile. Hence an Education, Health and Care Plan is applied which includes specialist help at school. Zac is invited into a school nurture group for children who struggle with friendships and is also assigned a mentor. Over several months of parents and teachers using autism-friendly strategies, Zac’s behaviour markedly improves.

Notes on the Case Example ➢ Zac has several social and communication difficulties which were clear from a young age, including delayed speech, problems with social interactions, difficulties with relationships and the need for sameness. He struggles to relate to others and avoids eye contact but can talk for a long time about his special area of interest, Pokémon. ➢ It is common for children with autism to have what is known as ‘meltdowns’ or explosive episodes of challenging behaviour when things don’t go as predicted, especially if there are changes to routines. In many cases it is this challenging behaviour which may trigger a mental health assessment. ➢ Like many children with autism, Zac has a range of sensory sensitivities: he prefers not to wear clothes and hates the feel of certain textures and labels. ➢ A careful diagnosis is made using information from different sources including interviewing Zac’s parents, getting school information and an individual assessment with Zac. ➢ Parent and school support are very important in helping Zac and the system around him learn to manage autism. As Zac’s dad may also be on the autism spectrum, the information will need to be tailored around his own ability to understand and manage his condition. ➢ As there is no specific cure for autism or funding for ongoing mental health services (unless the child has a coexisting mental health or

Autism and Neurodevelopmental Conditions

behaviour problem), ongoing management and support will occur through school, self-help groups and in the community. ➢ Children with autism may be re-referred to mental health services after diagnosis if they go on to develop another mental health disorder, such as anxiety or depression. Zac does not access mental health services after diagnosis, but his parents do access support and autism education from local third sector organisations.

KEY POINTS

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Neurodevelopmental conditions include a range of different conditions which affect the growth and development of the brain. Examples are autism, tics and ADHD (see next chapter).

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Tics are fast repetitive muscle movements that result in sudden and difficult to control body jolts or sounds. Although they are often not serious, they can be troublesome, and some children and young people may request treatment. Behavioural treatments are first line, but sometimes adding in medication can also be helpful.

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Autism is a neurodevelopmental condition where the brain is wired up and matures differently from what is typical. We now understand autism is on a spectrum and having autistic traits is reasonably common in the population. We are getting better at recognising different forms of autism; hence it is increasingly diagnosed.

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People with autism often have a combination of social and communication difficulties together with the need for sameness, which means rigid patterns of behaviour and interests. There are also commonly sensory sensitivities.

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There is no cure for autism. Instead, it is managed by helping the child, family, school and network to understand strategies to support people with their difficulties and differences. Mental health services will continue to be involved if there are co-occurring mental health disorders or challenging behaviour.

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You can help children and young people with autism by supporting parents; optimising the school environment; increasing understanding in the family and wider networks; and helping the child develop different skills, including emotion regulation, relationships and managing change.

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There is evidence for specific intervention programmes for people on the autism spectrum, for example social communication therapies, but more research is needed.

References (1) NHS Digital. 2017. Mental Health of Children and Young People in England, Autism Spectrum, Eating and Other Less Common Disorders. Available at https://files.digital.nhs.uk/FB/8EA993/MHCYP%202017%20Less%20 Common%20Disorders.pdf (2) National Institute for Health and Care Excellence (NICE). 28 September 2011. Guidance on Autism: Autism Spectrum Disorder in under 19s: Recognition, Referral and Diagnosis. Last updated 20 December 2017. Clinical guideline [CG128]. Available at www.nice.org.uk/guidance/cg128 (3) Fuentes, J., Hervás, A. and Howlin, P. July 2020. European Guidance on Autism: ESCAP Practice Guidance for Autism: A Summary of Evidence‑Based Recommendations for Diagnosis and Treatment. European Child & Adolescent Psychiatry. https://doi.org/10.1007/s00787-020-01587-4.

Useful Resources Web-Based Resources ➢ The UK National Autistic Society is a leading UK-based charity with information and support for those on the autism spectrum. Its website has a wealth of very useful information and resources, including short films and leaflets for parents, families and young people on autism. It also has a range of different helplines for different scenarios, a national services directory, as well as an online community. Available at www.autism.org.uk/

Autism and Neurodevelopmental Conditions

➢ Ambitious about Autism is a UK-based charity that grew out of an educational trust which provides information and support for children and young people on the autism spectrum. It has lots of information about education and employability, influences national policy and offers training: www.ambitiousaboutautism.org.uk/ ➢ The Royal College of Psychiatrists’ website has useful information on autism for young people and families. Available at www.rcpsych.ac.uk/ mental-health/parents-and-young-people/information-for-parents-andcarers/autism-and-asperger’s-syndrome-information-for-parents-carersand-anyone-who-works-with-young-people ➢ Young Minds, a UK youth mental health charity, has lots of useful information and articles about supporting children and young people with autism. Available at https://youngminds.org.uk/find-help/conditions/ autism-and-mental-health/ ➢ Spectrum Gaming, a moderated online gaming community for young people on the autistic spectrum. Available at www.spectrumgaming.net

Review Article For parents who want to view the current European guidance on evidence-based diagnosis and treatment, it may be helpful to look at the following review: J. Fuentes, A. Hervás and P. Howlin, ‘European Guidance on Autism: ESCAP Practice Guidance for Autism: A Summary of Evidence‑Based Recommendations for Diagnosis and Treatment’. European Child & Adolescent Psychiatry. https://doi.org/10.1007/ s00787-020-01587-4.

Books For Parents ➢ It Can Get Better … Dealing with Common Behaviour Problems in Young Autistic Children by Paul Dickins and Liz Hannah. This book was published by the National Autistic Society in 2014, the largest UK-based charity for autism. It is very practically focused.

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➢ Asperger’s Syndrome: A Guide for Parents and Professionals (Jessica Kingsley Publishers, London, 1997) and The Complete Guide to Asperger’s Syndrome (Jessica Kingsley Publishers, London, 2008) both by Tony Attwood are excellent introductory guides to people with high-functioning autism. Tony Attwood is a leading educator and communicator in the autism spectrum world. ➢ Parenting a Child with Asperger Syndrome: 200 Tips and Strategies by Brenda Boyd is aimed at parenting adolescents with Asperger syndrome (Jessica Kingsley Publishers, London, 2003).

For Children ➢ I Am Special: Introducing Children and Young People to Their Autistic Spectrum Disorder by Peter Vermeulen: an engaging book aimed at children to help them understand the strengths as well as challenges of autism (Jessica Kingsley Publishers, London, 2018). ➢ All Cats Are on the Autism Spectrum by Kathy Hoopmann: a very accessible picture book for children to understand the main features of high-functioning Asperger syndrome (Jessica Kingsley Publishers, London, 2020).

For Adolescents with ASD (and Parents) ➢ Freaks, Geeks and Asperger Syndrome by Luke Jackson: an adolescentfriendly book which explains the main features of high-functioning autism (Jessica Kingsley Publishers, London, 2002). ➢ Pretending to Be Normal: Living with Asperger’s Syndrome by Liane Holliday Willey and Tony Attwood. Another helpful book aimed at those with high-functioning autism written by Tony Attwood, a gifted educator and communicator about autism (expanded edition, Jessica Kingsley Publishers, London, 2014).

21 Difficulties with Attention and Activity Levels Most of us know how hard it is to concentrate on something when we are under stress. Our ability to focus also varies depending on several factors, including our tiredness, hunger, motivation and whether there are other distractions around. Some of us are naturally much more active than others, which is the same for children and young people. It’s important for supportive adults to know about what can help children and young people with their ability to manage their attention and activity levels. For some people, concentrating without getting distracted, staying still and thinking things through before acting is a constant challenge. Those with the most difficulties have what is known as ADHD (attention deficit and hyperactivity disorder). We now know people with ADHD have real differences in the ways their brains process and respond to information. We also know people with ADHD are at risk of longer-term problems if they aren’t properly supported and managed. So, it’s important to find strategies to support people with these difficulties.

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Why Is the Ability to Concentrate So Variable in Children? ➢ We all vary as to how well we can focus. Even as adults, some of us struggle more than others. Factors including our gender, early development and access to good nutrition can all influence our ability to concentrate. ➢ Children’s brains develop at different speeds and in different areas throughout childhood. Some children acquire speech very early, while others favour physical activity. Children with less mature front parts of their brains will struggle more with concentration because the more mature front areas of the brain may not yet be fully developed. ➢ All our brains function differently. In the past ADHD was often thought to be due to bad parenting. But in fact, there are brain differences in people with ADHD: some of the brain areas which help us to process and respond to information may work less efficiently in people with ADHD.

How Can You Help a Child Who Is Struggling with Concentration? For a child who is struggling to concentrate, it may be helpful to consider the following: ➢ Our emotional and mental state can affect our ability to concentrate, especially being low in mood or worried. So, it’s first worth checking what else may be affecting the child’s ability to focus. Do they need help with managing worries first? ➢ Consider how to improve physical health, including sleep and nutrition. Is the child too tired to focus or is their nutrition poor? Skipping breakfast or lunch can significantly affect a child’s ability to concentrate at school. Could there be another physical reason for poor concentration, such as a chronic illness or using drugs/alcohol?

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➢ Think about what could help motivate the child and how they learn. What are the child’s interests? Can they be engaged in a way that helps them? ➢ Is the work the right level for the child? If the child has a learning difficulty, they will not be able to focus. If you are worried about a specific learning difficulty, it’s worth asking the school for an educational psychology assessment. ➢ Give short tasks with simple short instructions. How short each task will be will depend on the child’s age and ability. Many children need breaks between activities. ➢ Use visual reminders and timers to help structure activities. Picture cards of timetables and tasks may help younger children. ➢ Think about the best place for a child to sit in class. This may be near the teacher and away from known distractors.

How Can You Help a Child Who Seems to Be Constantly on the Go? ➢ Children need to move about: Some will need more movement opportunities than others. Crowded classrooms are artificially constraining for many kids. The Daily Mile initiative in the UK or starting the day with any exercise routine is fantastic to get young bodies moving. Regular movement breaks can also be helpful for those with ants in their pants! ➢ Give a child a fidget bag of sensory or textured items/toys. It can help children who naturally need to keep moving with focus.

How Can You Help an Impulsive Child (Who Does Things Too Quickly without Thinking Them Through)? ➢ Go over techniques to help them slow down, including slow belly breathing and counting to 5 in their head before speaking or acting.

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➢ Teach relaxation, mindfulness and calming-down exercises. Listening to meditation or mindfulness tracks on YouTube can be helpful, as can spoken instructions for progressive relaxation (which is tensing and relaxing each set of muscles in the body, from the toes upwards to the face). Try to help them to signal ‘time out’ if they start to feel they are moving too quickly. ➢ Instil in them the rule that hurting others is always unacceptable. It may take extra time to help children learn to use words to express feelings rather than fists. It’s helpful to think about physically separating out children who may spark off one another.

Attention Deficit Hyperactivity Disorder (ADHD) What Is ADHD? What about ADD? ADHD stands for Attention Deficit Hyperactivity Disorder. It describes a condition with a persistent pattern of the following three key features: 1. Severe and sustained difficulties with concentrating. 2. Impulsiveness (i.e., acting too quickly without thinking through). 3. Hyperactivity. ➢ For a diagnosis, these symptoms must have a direct impact on functioning (educational and social) and will be present in more than one setting (i.e., at home and school) middle childhood (by age 7 in DSM-5 and by age 12 in ICD-11). ➢ ADHD predominantly inattentive type (often known as ADD) refers to primarily inattentive difficulties with less of a clinically significant hyperactivity/impulsivity component. It tends to be more common in girls and more easily missed as it’s less obvious.

Difficulties with Attention and Activity Levels

What Are the Main Difficulties Seen in ADHD? Poor Concentration ➢ ➢ ➢ ➢ ➢ ➢

Flitting between activities every few minutes and getting bored easily. Carelessness with details. Starting things but not finishing them. Constantly losing things; poor self-organisation. Appearing not to listen. Forgetting things easily.

Impulsiveness ➢ Doing things without thinking them through. ➢ Shouting out and interrupting in class. ➢ Getting into fights due to being ‘hot-headed’ and reacting easily to triggers. ➢ Making careless mistakes. ➢ Poor risk awareness and poor road safety are a major red flag concern.

Hyperactivity ➢ ➢ ➢ ➢ ➢

Often described ‘as if driven by a motor’ with lots of energy. Engages in lots of physical play and struggles to play quietly. Talks and shouts too much. Fidgety and constantly moving. Can’t sit still and leaves their seat in classroom.

How Is a Diagnosis Made? Psychiatrists can make a diagnosis of ADHD if they methodically gather together evidence from school, families and the child or young person:

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➢ There is a typical history from parents or caregivers of sustained difficulties in all three key areas, with at least 12 symptoms from the above lists which impair functioning and are present in more than one type of situation and setting (i.e., home and school). Symptoms have been present from below the age of 7 and aren’t due to another condition. ➢ School information: There are various ADHD questionnaires that parents and teachers can fill in. ➢ Assessment of the child’s or young person’s mental state, including concentration and activity levels. Nowadays we can also use computer programs which assess distractibility, for example the QB (quantified behavioural) test, which can contribute to information towards a diagnosis. Observing the child is important.

What Happens to the Brain in ADHD? ➢ There is immaturity and under-connectivity of brain circuits responsible for regulating behaviour and concentration, especially in the frontal lobe of the brain, which helps to regulate behaviour and focus on tasks. These brain areas can mature over time. ➢ The filter in the brain that normally helps children focus is less effective, so they are overstimulated and distractible and can’t focus on tasks; they struggle to stop and think before acting and to keep their activity at a normal level.

Figure 7 shows a diagram of the brain filter, which may be helpful to show children.

How Common Is ADHD? Who Is More at Risk? ➢ Around 2 in 100 children between ages 5 and 15 have ADHD. ➢ ADHD is more common in boys, children with learning disabilities and children with autism (about 1 in 3 children with autism also have ADHD). This is because there is overlap between ADHD and other disorders affecting the brain’s development and wiring.

Difficulties with Attention and Activity Levels (a)

(b)

Brain filter working normally The brain can filter out lots of stimuli coming through (e.g., parents arguing, baby crying and TV on)

A working filter adds some thinking time before acting and makes it easier to concentrate and to be calm

Brain filter in ADHD Lots of stimuli bombard the child’s brain

The filter which helps process all the stimuli isn’t working, so the child is very distractible and often acts without thinking

Figure 7:  Brain filter working normally (a) and brain filter in a child with ADHD (b)

➢ ADHD runs strongly in families. It is very rare to find a case where there isn’t an affected family member, even if they don’t have a formal diagnosis. ➢ Certain factors associated with pregnancy and birth can increase risk. Birth trauma or birth-related complications, very low birth weight, and use of drugs and alcohol and smoking during pregnancy all increase risk. ➢ Factors affecting the brain can also increase risk, for example learning disabilities or certain medical conditions.

Why Is ADHD More Commonly Diagnosed in Boys? ADHD is much more commonly diagnosed in boys: the male to female ratio is around 10:1. ➢ There is some evidence that, on average, girls’ brains mature more quickly at a younger age. How much of this is due to nature or nurture is difficult to work out, as there is also a cultural socialisation process at play where girls learn to internalise their difficulties.

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➢ It is likely many girls have undiagnosed attentional difficulties, but are perhaps less behaviourally challenging in the classroom, so are not noticed as often.

Are Children and Young People with ADHD More at Risk of Developing Other Problems? Yes: ADHD makes children more vulnerable to some of the following problems: ➢ Low self-esteem and risk of poor peer relationships, often due to impulsiveness and quick temper. ➢ Anxiety and depression. ➢ School underachievement. ➢ Behaviour problems: Children are often labelled as ‘naughty’ at school and are more likely to get excluded. ➢ There is an increased risk of drug and alcohol problems and antisocial behaviour and criminal activity.

But the good news is … if ADHD is treated and managed successfully, outcomes can be positive and children and young people can be supported to reach their potential. ADHD is a condition that is very responsive to treatment.

What Should You Do if You Think a Child Has ADHD? ➢ If ADHD symptoms are affecting the child’s school or social functioning, ask either the GP or the special needs coordinator at school for a referral to the local child health clinic that deals with ADHD: in some areas this will be the child and adolescent mental health team, in others the paediatrics team. ➢ Children need extra supervision and reminders to stay safe, especially with road safety.

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➢ Consider use of parenting strategies focused on the following areas: – Give lots of praise and reinforce positive behaviours, perhaps linked with rewards. Children with ADHD tend to have low self-esteem. – Build in plenty of opportunities for physical activity. – Keep instructions short and clear. – Use a simple and consistent parenting approach, for example 123 Magic (www.123magic.com). – Use visual charts to help children remember routines. – Try to plan ahead and think about which activities a child can manage. A sit-down restaurant meal is likely to be unrealistic for a young child with ADHD. – Keep play-dates short and supervised and try to build them around an activity. ➢ Implementing a school action plan will be helpful in many cases. It’s beneficial for teachers to try out strategies to help the child manage in the classroom, for example regular movement breaks. Those with more severe difficulties may require more specialist support through an EHCP application. (See Chapter 12 in Part 2 ‘Helping Children and Young People to Manage School’.) ➢ Use strategies to help children to slow down and pause before acting or speaking. For older children this also applies to responding on social media, phone or email. The online world can be fast-moving, and you need to monitor use carefully. Techniques such as sending messages to oneself first and then waiting at least an hour, counting or visualising a calm setting can help. ➢ Alert extra-curricular teaching staff about children’s difficulties with concentrating and impulsiveness, so children can still take part with extra support and understanding. Exercise is especially helpful, and it is important not to exclude children unnecessarily.

Which ADHD Treatments Can Be Helpful? ➢ Psychoeducation: The first step for young people, families and schools to understand what ADHD is and how to manage it.

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➢ Classroom-management strategies at school are important to implement before medication should be considered and can often reduce the dose of medication needed. ➢ Parenting support and programmes using behavioural methods. ➢ Medication has a very good evidence base for treating moderate– severe ADHD. However, as with all medication approaches in children, it’s good practice to try behaviour and parenting strategies first.

What Types of ADHD Medication Are There? How Do They Work? ➢ There are different types of medications for ADHD which can improve symptoms, including stimulants (e.g., methylphenidate, commonly known as ‘Ritalin’), available in short- and longer-acting forms, and non-stimulant medication (including atomoxetine and guanfacine). ➢ ADHD medication helps improve concentration and reduce activity levels by stimulating parts of the brain that are important for planning and carrying out tasks. However, medication does not make children and young people more hyperactive.

Are There Side Effects of Medication? What Monitoring Is Needed? ➢ As with all medication, ADHD medication can have side effects, and different medications vary according to their side effect profiles. The most common side effects are sleep and appetite disturbances. ➢ Stimulants can also impact blood pressure, pulse, weight and growth, so it’s important to check measurements regularly (by plotting height and weight according to age) and blood pressure and heart rate. For some children it is important to do extra checks before starting treatment, especially if there is a family history of certain conditions, for example affecting the heart. ➢ Children’s need for medication changes as they grow and develop. ADHD clinics often ask for teacher rating scales so we can judge how well medications are working.

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Can a Child Grow out of ADHD? This varies a lot but it’s helpful to know … ➢ There are three predictors of ADHD persistence: family history, having other mental health disorders and being exposed to other social difficulties. The more predictors there are, the more likely a person will continue to experience ADHD. Impulsivity is one of the most significant predictors of poor outcomes in ADHD. ➢ Roughly a third of children get significantly better in adulthood. Around half of children with ADHD will show some improvement, but with some ongoing symptoms, although how much the symptoms impact on day-to-day functioning will vary as children get older. ➢ Many children who do improve somewhat choose not to continue medication in adulthood. However, treating ADHD into adulthood can help with many longer-term outcomes for those with ongoing symptoms, including with education and work, the ability to develop lasting relationships, the number of accidents (especially road accidents) and drug and alcohol use.

Case Example Charlie is 7. His mum says compared to her other two children he has always been the ‘live wire’, just like her brother Joe. Even as a toddler Charlie was always on the go and wouldn’t sit still to listen to a story or even watch a TV programme. Mum said she always had to take him outside to burn off energy every day, and on rainy days he was often bouncing off the walls. Since starting primary school, Charlie has really struggled with school-work and behaviour. He won’t sit still in the classroom and distracts other children. He can only get something done in class if the teaching assistant takes him to the back corner to work. Charlie’s teacher said the main problem is he doesn’t listen properly, and he can’t remember tasks he’s given. He also is often in trouble with other children as he has a short fuse and reacts impulsively. Other children say they don’t want to play with him and talk about him as the ‘naughty’

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boy. Charlie isn’t invited to parties and often gets upset about this and has low self-esteem. Charlie’s teacher thinks he is bright, but he is falling behind his peers with school-work due to his distractibility and restlessness, so she advises Charlie’s mum to request a GP referral to the children’s mental health service. Charlie is assessed by the ADHD team: school fills in questionnaires, the mental health nurse observes Charlie in class, and then the nurse and doctor see Charlie in clinic and talk in detail to his parents about his development following the assessment process. Charlie is given a diagnosis of moderate–severe ADHD. The first step after diagnosis is for Charlie and his family to understand what ADHD means and how to manage it. Charlie’s parents attend an ADHD parenting group. The ADHD nurse contacts the school and asks the special needs coordinator to help implement classroom-management strategies to help support Charlie. These strategies include having clear instructions written down, sitting at the front of the class and having regular movement breaks. After 12 weeks, the ADHD nurse reviews progress. Unfortunately, despite implementation of classroom strategies, Charlie is still struggling at school, so the psychiatrist prescribes stimulant medication for school-days, which helps him to concentrate in class. Charlie, his parents and teacher are all very happy with the impact of the medication as Charlie is much calmer and more focused in class and gets on better with his peers. Medication is monitored carefully in clinic and adjusted according to response.

Notes on the Case Example ➢ As in Charlie’s case, it is often helpful when parents can make a comparison with siblings about activity and concentration levels, with the caveat that siblings are also at an increased risk of ADHD symptoms. In Charlie’s case there was a definite difference between him and his siblings. ➢ ADHD is a strongly inherited condition, and it is rare for young people not to have a family member without similar difficulties. If not a

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parent, an uncle, cousin or grandparent often has ADHD but may not have a formal diagnosis. Charlie’s uncle Joe also has ADHD. Charlie has all three of the major symptoms of ADHD: difficulties sustaining attention, hyperactivity and impulsiveness. He had symptoms from a very young age and they are present at home and school. Charlie’s difficulties are starting to cause problems with both schoolwork and social development (e.g., finding playmates), which is having a negative impact on his self-esteem. This is very common in children and young people with ADHD. It is important for Charlie and his family to understand the nature of ADHD as a brain condition and not his or his parents’ fault. Parenting support is important as it is challenging to parent children with ADHD, and it is easy to get into negative cycles of punishment. Classroom-management strategies at school are important and can make a big difference to how children function in the classroom and potentially reduce the need for and dose of medication. Medication is often an important treatment approach for moderate– severe ADHD and can improve a young person’s life chances in terms of their educational, social and relationship functioning. However, medication needs to be monitored, and adjusted at regular intervals as children grow.

KEY POINTS

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Attention and activity levels vary in children due to several factors, including genes and the environment. The child’s level of brain development is important.

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ADHD stands for Attention Deficit and Hyperactivity Disorder. It describes a strongly inherited condition where there are difficulties in three key areas: sustaining attention, hyperactivity and impulsiveness. Some

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c­ hildren struggle to concentrate but are less hyperactive (ADD): these children are more likely to be missed as they are less disruptive in class.

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In ADHD the filter in the brain that normally helps children focus and think before acting is faulty. Brain scan studies of people with ADHD show there are also functional changes in parts of the brain.

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Children with ADHD can be supported in various ways both at home and school. Understanding what ADHD means as well as its impact on the child’s functioning is important for children and their parents. Parents often benefit from extra parenting support. Classroommanagement strategies can also help young people cope in school and can reduce the need for medication.

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Once behavioural strategies have been tried, medications can also be helpful for those with moderate–severe ADHD. Stimulants are the most commonly prescribed medications and are available in both short- and longer-acting preparations. Medication needs to be closely monitored at regular intervals for side effects and to check the dosage is right for the child as they develop and grow.

Useful Resources Web-Based Resources ➢ The Royal College of Psychiatrists’ website has useful information on ADHD. There is a resource page on ADHD for parents and carers available at www.rcpsych.ac.uk/mental-health/parents-and-young-people/ information-for-parents-and-carers/attention-deficit-hyperactivitydisorder-and-hyperkinetic-disorder-information-for-parents-carers-andanyone-working-with-young-people ➢ The National Institute for Health and Care Excellence: Guidance on Attention Deficit Hyperactivity Disorder: Diagnosis and Management. NICE guideline [NG87]. Published date 14 March 2018. Last updated 13 September 2019. This UK-based national guidance covers how a diagnosis

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of ADHD should be made and gives more specific advice around ADHD management, including how medication should be prescribed and monitored. This may be a useful reference guide for families. Available at www.nice.org.uk/guidance/ng87 ➢ The ADHD Foundation is a national UK-based ‘neurodiversity’ charity which aims to help people with ADHD and associated disorders access help with health and education. The website has useful resources. Available at www.adhdfoundation.org.uk/ ➢ ADHD UK is a relatively new charity formed by people with ADHD. It has useful information and resources, including videos and guides for parents. Available at https://adhduk.co.uk/

Books ➢ All Dogs Have ADHD by Kathy Hoopmann: a very child-friendly book with lots of pictures of different dogs with characteristics of ADHD that follows the same format as All Cats Are on the Autism Spectrum. Published by Jessica Kingsley in 2008. ➢ The Survival Guide for Kids with ADHD by John F. Taylor: a child-friendly book written by an American author aimed at around ages 7–12 which explains to children the ins and outs of ADHD and how to manage it. It has fun quizzes and illustrations. Published by Free Spirit Publishing in 2013.

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22 Alcohol- and Drug-Related Difficulties and Disorders In Part 1, Chapter 2 of this book, I looked at drugs and alcohol as a lifestyle factor which has a significant impact on mental health. This chapter, on the other hand, focuses on drug and alcohol difficulties and disorders in young people. It also considers the two-way relationship between mental health and drug and alcohol problems. Young people with both mental health and drug and alcohol difficulties are a particularly vulnerable group in terms of their mental health as they also often fall between services.

How Common Is Alcohol and Drug Use in Young People in the UK? According to the NHS Digital UK national survey of 2018 (1): ➢ 7 out of every 10 15-year-olds have drunk alcohol previously. ➢ More than 1 in 8 15-year-olds said they drink alcohol at least once a week. ➢ Around 1 in 10 15-year-olds said that they had been drunk in the last four weeks.

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➢ One-quarter of school pupils aged 11–15 said they had taken illegal drugs. ➢ Around 1 in 5 15-year-olds said they had taken drugs in the last month, mostly cannabis and volatile substances. ➢ The pattern of drug use changes with age. Volatile substances are more common in early teenage years, while cannabis use peaks in late teenage years.

What Are the Different Types of Illegal Drugs? The main types of drugs are classified as: ➢ Stimulants make you feel alert and excited. Examples are cocaine, amphetamines, ecstasy and synthetic stimulants. ➢ Sedatives make you feel calm and sedated. Examples are cannabis, opiates like heroin and morphine, and benzodiazepines like diazepam and GHB. ➢ Hallucinogens distort how you see and hear things. Examples are LSD and mushrooms. ➢ Dissociatives change your sense of self and how you feel in your body. Examples are ketamine and nitrous oxide. ➢ Some modern drugs are ‘synthetics’ and can be designed to be like any of the other drugs in the classes above, including synthetic marijuana, LSD and stimulants. They often fly under the radar of regulators, as they aren’t yet in the formal illegal classification systems. They tend to be stronger than the drugs they are designed to mimic.

How Are Drugs Classified by UK Law? ➢ Class A drugs: Crack cocaine, cocaine, ecstasy (MDMA), heroin, LSD, magic mushrooms, methadone, methamphetamine (crystal meth). These carry the harshest punishment for possession and life imprisonment for dealing. ➢ Class B drugs: Amphetamines, barbiturates, cannabis, codeine, ketamine, methylphenidate (Ritalin), synthetic cannabinoids, synthetic cathinones.

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➢ Class C drugs: Anabolic steroids, benzodiazepines (e.g., diazepam), GHB and GBL, piperazines (BZP) and khat. ➢ Temporary class drugs: 3,4-DCMP, HDMP-28, IPP or IPPD and their simple derivatives (2). ➢ You should tell young people that they may be charged with possessing an illegal substance if caught with drugs, whether they belong to them or not. If the young person is under 18, the police can tell their parent, guardian or caregiver that they have been caught with drugs.

How Do Drugs Affect the Brain? ➢ Drugs disrupt brain signalling pathways, which has an impact on thinking, mood and behaviour. Some drugs, like cocaine, overstimulate pathways, other drugs, like cannabis, cause understimulation of pathways. ➢ Several drugs overstimulate the reward pathways of the brain, which causes a ‘high’. However, after a high there’s always a crash. Regular disruption of the reward pathways causes changes to the brain and makes it less receptive over time to rewards. This causes tolerance, which means you need more and more stimulation for the same reward. It also hijacks the normal ability to feel pleasure because nothing else can cause the same high as drugs. ➢ The adolescent brain is very vulnerable to the harmful effects of drugs as there are so many developmental brain changes going on. ➢ The effects of drugs and the brain vary according to the individual: Some people are more vulnerable than others, perhaps because of genes they inherited or because of other health issues. ➢ If certain drugs are taken to overdose, this can cause loss of consciousness and in some cases even death if the brainstem is starved of oxygen. Long-term brain damage can also result from drug overdoses, particularly in terms of memory, planning and emotion regulation.

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What Are Different Patterns of Drug Use in Young People? ➢ Recreational use: This is when young people experiment with taking drugs and use drugs occasionally, but don’t come to longer-term harm. It is the most common type of drug use. ➢ Harmful use: This type of use causes damage to health and is when young people use drugs more regularly, and the effects can start to impact body and brain functioning. ➢ Dependence syndrome (addiction): This is when you are hooked on a drug to the extent that you no longer feel in control of your use. You crave the drug and need increasing amounts of it to get the same effect. You also experience withdrawal symptoms if you don’t take the drug.

What Are Signs That a Young Person May Be Having Difficulties with Drugs or Alcohol? Some signs to look out for in young people whom you suspect may be having difficulties with drugs and alcohol are:

Appearance and Physical State ➢ Are there any changes in how they look? For example, neglecting self-care or losing weight? ➢ Are there any new injuries, including unexplained bruises or track-marks? ➢ Have they lost clothes or money without a reliable explanation? ➢ Are there any changes to their eyes? For example, red eyes in cannabis or small pupils in opiates? ➢ Have they had nosebleeds or fits? Are their sores around their mouths?

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➢ Have you noticed unusual smells or drug-related items, like silver foil, in their rooms?

Behaviour and Mental State ➢ ➢ ➢ ➢ ➢ ➢

Have they started staying out later? Have they been lying or stealing? Are they skipping school or stopping other interests? Have you noticed any mood changes or new-onset tiredness? Do they have excess energy or are they struggling to focus? Have they ever responded to things that aren’t there? Examples include experiencing voices or seeing things that others can’t see.

Social Group Changes ➢ Have their friendship groups changed? ➢ Have they lost interest in their school or friends? ➢ Are you worried about where they are going or what they are doing?

What Types of Harm Are Associated with Drug Use? ➢ Physical harm: Different drugs will have a range of physical health problems associated with them. Well-known effects include liver damage with alcohol, bladder problems with ketamine, and heart problems with cocaine. ➢ Psychological harm: This can include immediate, short-term and longerterm effects. Common effects include depression and anxiety. ➢ Social harm: Drug and alcohol use will invariably impact on social functioning, including relationships with others and the ability to manage school or work.

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What Increases the Risk of Young People Getting into Problems with Drugs and Alcohol? ➢ Some personality traits are more strongly linked to drug use, for example impulsiveness, so often those with ADHD tendencies are more at risk. ➢ Some people have inherited a greater vulnerability to drug and alcohol use: Addictions run in families. ➢ Young people who have had adverse childhood experiences (ACEs) have a much greater risk of problematic drug and alcohol use. People exposed to five or more ACEs are seven to ten times more likely to use illegal drugs, to report addiction and to inject illegal drugs (3).

Why Are the Risks of Addiction and Harmful Use Higher in Those Who Have Had Difficult Early Life Experiences? ➢ It is becoming increasingly publicised that those with addictions often have had early traumatic experiences. According to the leading addiction specialist, Dr Gabor Maté, addiction arises because of a failure of brain circuits to develop properly in response to our basic needs not having been met by a nurturing supportive environment (4). So, people seek out harmful behaviours either to soothe an inner deep pain or to distract from it.

What Can You Do to Support Young People with Drug and Alcohol Difficulties? ➢ Keep calm and don’t panic. It’s a good idea to plan how you will approach the young person carefully, perhaps by talking through things with another adult first.

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➢ Do some research yourself first. There’s lots of useful updated information on the Talk to Frank website: www.talktofrank.com/. The book The Drug Conversation by Owen Bowden-Jones (see Useful Resources at the end of the chapter) is a good starting point. ➢ Stay open and honest. If you can show you are open and truthful about what has shaped your own views, young people may be more likely to understand your position. ➢ Tell them you understand there are advantages as well as disadvantages to using drugs. This will help the young person see you are trying to understand their perspective. If you only talk about the harmful effects of drugs and alcohol without recognising their positives they are more likely to clam up. ➢ See if you can get to any underlying issues which may be driving the drug use. Is there bullying or an underlying mental health condition that requires support or is anyone putting pressure on the young person to use the drugs? Perhaps the young person has suffered abuse or trauma and is trying to numb the pain. ➢ Try to understand what’s going on in the young person’s social network. Is there a culture of drug use you or the school should be aware of? Can you help to nudge the young person towards other influences? ➢ Is there drug or alcohol use in the family home or extended family? If so, this increases the risk of use in young people. It is important that adults in the family are encouraged to get support for their own use and the needs of the young people are investigated carefully in the context of their family. ➢ It is often helpful to seek out professional help from specialist addiction services. It may be useful to book an appointment with the GP to check on physical health and ask about how to access other services. You can search for local addiction services in the UK on the NHS website at www.nhs.uk/service-search/other-services/. It is worth noting that third sector organisations rather than the NHS tend to run addiction services. Services available will depend on age and the young person’s difficulties. ➢ People often go through cycles of use, and addiction is a hugely powerful drive, so expecting an instant cure is often unrealistic. The young person needs to accept they have a problem first in order to move forwards.

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What about Support for Families? ➢ Remember to look after yourself and your family at this stressful time. The strain on families can be tough, so it’s helpful to get your own support and look for support groups through local and national organisations. DrugFAM (www.drugfam.co.uk), for example, is a UK charity that offers support for families. You can also ask social care teams for a carer’s assessment.

Are Drug and Alcohol and Mental Health Difficulties Linked? ➢ Yes. There is a strong two-way relationship: Drug and alcohol use increase the risk of many mental disorders (e.g., depression and anxiety) and many mental health conditions increase the risk of drug and alcohol use (e.g., untreated ADHD). ➢ If someone has both substance misuse difficulties and a mental health condition it is called dual diagnosis.

Does Having Both Substance (Drug/Alcohol) Use and Mental Health Conditions Make Treatment Trickier? Yes: people with drug and alcohol use in combination with mental health problems are among the most difficult group to support and treat. There are several possible reasons for this, including: ➢ Drug and alcohol misuse can make mental health problems worse and harder to manage. For example, alcohol and other depressants can worsen the effects of a clinical depression and can make it harder to treat.

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➢ Treatments for mental health conditions are less likely to work because engagement with psychological treatments may be poor; medication is less effective and in some cases the combination of substances with prescribed medication can be dangerous. ➢ Substance misuse and mental health services are often separate. Mental health services often say they can’t treat the young person unless their drug and alcohol use is first managed, so the young person falls between the services. In many areas, different types of organisations run drug and alcohol services and mental health services, so joined-up support can require careful planning.

How Can People with Drug and Alcohol Difficulties Be Helped? ➢ It is important for the young person to first have a full assessment of their needs and treatment goals: for example, do they want to stop using or cut down? A good assessment will involve an integrated approach that looks at how drugs and alcohol affect all aspects of a young person’s life. ➢ Many substance misuse services offer an ‘outreach’ approach of getting alongside the young person in the community. This can work well as young people are less likely to respond positively to the traditional clinic model. ➢ It is important for professionals to look at immediate support as well as longer-term rehabilitation as drug and alcohol problems are often longer-term conditions.

There are different types of treatment which can involve one or more of the following approaches: ➢ Psychological: – Motivational interviewing aims to increase a person’s motivation to change, checks where the young person is on the cycle of change and uses a nudging questioning approach.

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Cognitive behavioural therapy can also be helpful by focusing on rectifying maladaptive thought patterns and behaviours linked with drug use to promote positive change. – Contingency management focuses on promoting positive behaviour change, by introducing rewards when you meet your goals in treatment (such as abstinence from drugs) and withholding rewards or giving sanctions if goals are not met. ➢ Social and family: This can involve supporting the young person with school or college; setting up family work or support; looking at peer relationships; helping with housing and other benefits; and working with youth offending services if needed. ➢ Medical: This will involve monitoring and treating physical conditions, checking investigations like blood tests and infections like hepatitis or HIV. Some young people with more severe problems may need support from addiction specialists around detoxification or replacement treatments.

What May Affect How a Young Person Manages Treatment? There are several factors involved which affect how a young person manages treatment, including: ➢ How motivated they are to change: I cannot overstate the importance of this! A young person needs to want to change for change to happen. ➢ How severely affected they are: Those that are dependent and are using more addictive drugs tend to do worse. ➢ The availability of support: Those with more support around them at home and school/college will tend to do better. ➢ How quickly the young person gets treatment: Treatment delays can make it more difficult to change.

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What Are County Lines and How Do Young People Get Involved? ➢ County lines are the networks across the country that drug gangs use to distribute drugs. ➢ These gangs recruit a mix of vulnerable children and young people, often through social media, to distribute drugs. Sometimes gangs target young people just because their profile is less likely to be picked up by the police and other services (e.g., white, middle-class young people). ➢ Often drug gangs give young people mobile phones with location software to control and threaten them. Coercive sex may also be involved. ➢ In order to help disentangle young people from these networks and offer support, often complex multi-agency work with the criminal justice system, social care and mental health is needed.

Case Example Cemi is 15 and is from a single parent family, with no contact with his dad. His mum works shifts in a warehouse so doesn’t always see him when he gets in from school. Mum has started to notice her money going missing from her purse and Cemi is out increasingly often. Cemi’s moods seem very up and down and at times he seems quite suspicious about people around him. Sometimes he is very talkative and other times he is starting to look vacant. School have said his attendance has dropped off and he has stopped doing his homework. Cemi says he hates school and doesn’t care about it anyway. Cemi started smoking and drinking at 12, then progressed onto cannabis and a range of other drugs, including cocaine and hallucinogens. He is spending more time with a gang who are into drugs and crime. Mum is upset Cemi won’t talk to her and asks Cemi’s uncle to chat to Cemi and find out what’s going on. Cemi’s uncle used to belong to a local gang, and he spent some time in prison

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due to gang-related activities, but he has now put that life behind him and has a regular job and partner. Cemi initially doesn’t talk but after spending some time together he opens up and tells him he’s using different drugs, including cannabis and stimulants regularly, and is now having to do jobs for a gang he feels he can’t get out of. Eventually Cemi agrees to see a nurse from the local substance misuse team. Cemi gets on well with the nurse, who uses motivational interviewing techniques and works on reducing his drug use, which helps him become less paranoid. With the help of a community mentor, he manages to distance himself from the gang and joins a local youth group instead. His moods start to stabilise, and he starts attending school more regularly. He makes plans with the careers adviser regarding an apprenticeship in carpentry after his GCSEs as he enjoys working with his hands.

Notes on the Case Example ➢ Cemi is a vulnerable young man who falls into a pattern of increasing drug use, which quickly worsens with his association with a gang. This is a common story in many deprived communities. ➢ Regular cannabis use contributes to Cemi’s paranoia and mood swings. It is very common for drugs and alcohol to affect mental health, which will then also impact on school, social and family functioning. ➢ Cemi is able to talk to a trusted adult – his uncle – who had previous difficult experiences with substance misuse and crime; talking to him encourages Cemi to accept help from the substance misuse team. ➢ It is also useful to get community support and link Cemi into a youth group to help shift his social network. ➢ It is good that Cemi has an apprenticeship to aim for. Many young people feel unmotivated in middle adolescence at school because academic subjects don’t feel relevant to them.

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KEY POINTS

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While recreational alcohol and drug use is common among young people, a sub-group of vulnerable young people misuse drugs and alcohol in a harmful way from a young age.

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There are several signs to look out for if you suspect a young person may be using drugs or alcohol. You may find clues in their appearance, behaviour, mental state and social changes, as well as concerns raised by other people/agencies.

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It is worth being aware of the mental health impact of the most common types of drugs, as well as their physical health impact. Drugs are broadly classed as stimulants, depressants, hallucinogens and those with mixed properties.

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Many young people with addictions often have had very difficult early experiences and may well be misusing drugs and alcohol to try to treat their own inner pain or trauma. It’s therefore important to treat these young people with compassion rather than blame.

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We can support young people with substance misuse difficulties by listening, being open, treating them with empathy and trying to get them specialist help. Psychological, social and family, and medical approaches can all be helpful.

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People with mental health and substance misuse problems are often much more difficult to treat. However, it is important these young people don’t fall in the cracks between services, and supportive adults can help them navigate health and community teams in order to find their way ahead.

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County lines is an emerging issue of concern, where gangs use vulnerable children and young people to distribute drugs across the country. Tackling county lines requires multi-agency input to try to stop children and young people getting trapped into criminal networks.

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References (1) NHS Digital. 2019. Smoking, Drinking and Drug Use among Young People in England 2018 [NS]. Available at https://digital.nhs.uk/ data-and-information/publications/statistical/smoking-drinkingand-drug-use-among-young-people-in-england/2018/part-5-alcoholdrinking-prevalence-and-consumption#pupils-who-have-ever-had-analcoholic-drink (2) UK government website. Drugs Penalties. Available at www.gov.uk/ penalties-drug-possession-dealing (3) Felitti, V., Anda, R., Nordenberg, D., et al. 1998. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine 14(4), 245–258. doi:10.1016/ s0749-3797(98)00017-8. (4) Maté, G. 2018. In the Realm of Hungry Ghosts: Close Encounters with Addiction. London: Vermilion Ebury.

Useful Resources Web-Based Resources ➢ Talk to Frank (www.talktofrank.com/) is a useful and youth-accessible UK website with encyclopaedic information on drug and alcohol use. ➢ Young Minds is a UK-based website on youth mental health which has useful information on drug and alcohol use: https://youngminds.org.uk/ find-help/looking-after-yourself/drugs-and-alcohol/. It also has a PDF information sheet for parents: https://youngminds.org.uk/media/3827/ drugs-and-alcohol-updated-feb-2020.pdf ➢ DrugFAM is a UK support organisation for families with members affected by drug, alcohol or gambling difficulties. Available at www .drugfam.co.uk

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Books ➢ The Drug Conversation by Owen Bowden-Jones. Published by the Royal College of Psychiatrists in association with Cambridge University Press, 2016. This is a very useful book written by an experienced psychiatrist who works with drug and alcohol problems about how to talk to children and young people about drugs. It is packed with factual information on the topic.

23 Difficulties with Eating Many children and young people struggle with their eating at some stage. There are different reasons for this, but a major common factor is gaining back control through eating where a child or young person may feel they have lost control in other areas of their life. It is therefore not surprising that eating problems have increased significantly in the last few years in the wake of COVID. In fact, according to NHS Digital, which collects UK nationwide data, the proportion of children and young people with possible eating problems increased between 2017 and 2021, from 6.7% to 13.0% among 11- to 16-year-olds and from 44.6% to 58.2% among 17- to 19-year-olds (1). Difficulties with eating can range from picky eating in children to the serious mental disorders of anorexia nervosa and bulimia nervosa more common in teenagers. Although eating difficulties are almost all worrying, some difficulties and disorders are more severe than others. Some eating disorders are so severe they require hospital treatment. This chapter discusses the range of eating difficulties found in children and young people and how to offer and find appropriate support.

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How Common Is Fussy Eating in Younger Children? ➢ Fussy eating is very common in younger children and is one of the ways children learn to exert some control in their lives. It generally improves if parents persist in offering a range of foods, repeatedly offering healthy choices and avoiding getting too emotional at mealtimes. ➢ Some young children need encouragement to try a food over a hundred times before they start to accept it in their diet! The strategy of encouraging youngsters to try a bit of different foods is generally better than trying to force them to finish their meals. ➢ Eating generally improves in most children when they adjust to primary school. The peer pressure of seeing other children eat is often helpful. ➢ Selective eating, however, can become extreme in some children, especially those on the autistic spectrum. If a primary school aged child only accepts a very limited diet, then it may be helpful to seek professional help. The GP can refer to dieticians or community paediatricians.

Why Are So Many Young People Preoccupied with Weight Loss and Dieting? While most young people’s worries about their weight don’t become extreme or persistent enough to meet the criteria for an eating disorder, many young people do have eating difficulties. There is a complex interplay of reasons why young people, particularly girls, worry about their weight and shape, including: ➢ Peers can have a strong influence on eating behaviours, particularly in certain environments, such as all-girls high-achieving schools. Comments made by peers around body shape are often highly significant.

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➢ Social media and celebrity culture: In youth culture there is a strong tendency to over-value outward appearance. Young people may feel peer pressure to post photos of themselves on social media to fit a certain ideal: girls tend to aspire to be thin and boys often aspire to be strong. ➢ The need to have control in at least one area of their life: Many young people feel they have lost control of many aspects of their life. Those who have struggled with adverse experiences may feel an extra loss of control. ➢ Physical reasons: Some people struggle a lot more than others with putting on weight, due to slower metabolism. Our bodies change during adolescence too: we naturally ‘fill out’, making it a vulnerable time for worries about body shape. ➢ Our sedentary, fast food culture: Sitting down has become the ‘default’ mode, with many young people struggling to fit in enough exercise. Fast food is also available everywhere and is convenient for young people on the go, even though it’s just empty calories.

Can You Do Anything to Help Young People with Concerns about Eating? ➢ Carefully consider the family environment. Be aware of how food is talked about at home and be careful of judging others on their body shape or appearance. Sometimes a throwaway comment that someone is chubby can be enough to trigger eating difficulties. ➢ Consider peer group influences. It’s worth finding out what the culture around eating is in a school class or friendship group, and whether school can encourage more healthy behaviours. ➢ Help young people to develop a sense of self-worth unconnected with their body image. Working on developing self-compassion and kindness to others can help shift the focus towards a sense of inner rather than outer self-worth.

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➢ Discuss how media influences can present a false image of bodies. Discourage the constant checking of social media photographs and comparison by people’s outward appearance. ➢ Help young people work out how to achieve a healthy food intake, and how to balance this with regular exercise. Young people may need support around food and exercise as they often find it hard to manage the balance of energy intake versus output. You can help by discussing food shopping and meals together and encouraging healthy snacks.

Eating Disorders An eating disorder is when a young person has an unhealthy relationship with food which can take over their life and make them ill. It might involve eating too much or too little or becoming obsessed with weight control.

How Common Are Eating Disorders? ➢ Clinical experience indicates that eating disorders are becoming increasingly common, but it can be difficult to find truly representative data, as many children and young people with eating disorders don’t present to mental health services until very late, and many with eating disorders don’t fit all the strict classification criteria, so may not be counted. ➢ In an English 2017 national mental health survey (1), eating disorders were identified in 0.4% of 5–19-year-olds. They were more common in girls (0.7%) than boys (0.1%); and in older age groups than younger ones (0.1% of 5- to 10-year-olds; 0.8% of 17- to 19-year-olds). ➢ A large US national study of 10,000 US adolescents aged 13 to 18 years (3) published in 2011, found the lifetime prevalence of eating disorders was 2.7%. Eating disorders were more than twice as prevalent among females than males. Anorexia nervosa was found among 0.3% of young people, 0.9% had bulimia nervosa and 1.6% had binge eating disorders.

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➢ Other studies have found the prevalence of the full range of eating disorders to be around 5% (4).

Which Disorders and Conditions Will Be Covered in This Chapter? ➢ ARFID: avoidant-restrictive food intake disorder. ➢ Pica: persistent eating of non-food items. ➢ Obesity: although not strictly a mental disorder, it can increase the risk of mental health problems. ➢ Anorexia nervosa. ➢ Bulimia nervosa. ➢ Binge eating disorder. ➢ OSFED: other specified eating and feeding disorders.

ARFID What Is ARFID? ➢ Avoidant-restrictive food intake disorder (ARFID) is a pattern of restricted eating that is not motivated by a fear of fatness. It is a new diagnosis classified in ICD-11. ➢ There is a pattern of rigidity around eating and avoiding certain foods, resulting in a deficient energy intake, lasting for at least one month. There may be refusal to eat foods based on smell, taste, texture or appearance. ➢ It may be caused by a fear of choking or vomiting, sensory sensitivities to food (common in autism) or lack of interest in food. ➢ ARFID is often found in children and young people with other mental and physical health conditions, including autism, anxiety disorder, OCD or a medical disorder.

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How Is ARFID Treated? There are as yet no UK national guidelines on ARFID. However, there is an increasing evidence base for a multi-professional and multimodal care pathway, as expressed in a 2021 review by Rachel Bryant-Waugh, one of the UK’s leading experts in this condition (5). Treatment can involve: ➢ Psycho-behavioural approaches such as cognitive behavioural therapy to help people face their avoided foods and expand the range of foods eaten. Family-based psychological work and parent-led interventions and group work may also be helpful. ➢ Medical management will involve weight and physical health monitoring and medication may be used as added treatment. ➢ Dietary management is often important, including calculating micro- and macro-nutrients present in the diet and supporting weight restoration, and education sessions about the nutritional content of food. ➢ Other management may include management of sensory sensitivities and liaison with other agencies, including school.

Pica What Is Pica? ➢ Pica is a condition in which children persistently eat non-food items (e.g., soil, paint chippings). ➢ Eating non-food items is common in very young children exploring different textures, but if this habit persists into children of pre-school age it can become pica. ➢ Children with certain brain and developmental difficulties, including autism and intellectual impairments, are more likely to have pica.

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How Is Pica Treated? There are currently no evidence-based treatments for pica and research is inconclusive. We generally use a combination of approaches to manage it. The UK National Autistic Society (6) has put together a useful list of possible suggestions that may help, including: ➢ ➢ ➢ ➢ ➢ ➢

Nutritional supplementation. Redirecting: encouraging the person to throw the item away instead. Restricting access to harmful pica items. Promoting self-soothing behaviour. Making the environment ‘pica-safe’. Replacing pica items with similar, safe alternatives, for example chew toys and necklaces.

Obesity Although obesity is not classified as a mental health disorder in the major mental health classification systems, the drivers of many types of obesity have a strong psychological element and it has a significant impact on both mental and physical health. Self-esteem in people who are obese is notoriously poor, which can increase the risk of other conditions, including depression and anxiety. In children and young people, adjusted weight for height calculations are needed to work out if they are clinically obese, rather than the body mass index used in adults. Physical health problems, including difficulties with mobility, diabetes and circulation problems, impact on mental health.

How Common Is Obesity? What Causes It? ➢ Obesity often starts early in life. The National Child Measurement Programme for England (NCMP), undertaken by the UK government and recorded on the NHS Digital website (7), includes nearly all children in

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Reception Year (aged 4–5) and Year 6 (aged 10–11) in English schools. It showed that in 2020/21 1 in 4 children in Year 6 were obese. The NHS Digital website holds updated data on child measurements (7). ➢ Obesity is caused by a complex interplay of factors, including social and biological factors. It is strongly linked to deprivation, although inherited factors are also important. Those in the most deprived areas in the UK have double the rates of obesity than less deprived areas. This link with deprivation is due to many reasons, including poor access to education and reduced availability of healthy food options and activities in poor areas.

How Can Obesity Be Treated? ➢ Tackling the causes of obesity is one of the most difficult public health problems. This is because it is caused by a complex interplay of factors, including social and biological factors. ➢ It is important to take a stance of understanding rather than blame, encouraging families to make small steps towards eating in a healthier pattern. Eating patterns are intergenerational, so work with parents is crucial. ➢ There are UK national guidelines on supporting children and young people with obesity (8). These programmes include a multipronged approach and include working on diet, physical activity, monitoring time spent sitting still and developing strategies for behaviour change.

Anorexia Nervosa What Is Anorexia Nervosa? Anorexia nervosa is a serious mental health disorder where there is: ➢ Deliberate weight loss induced by the child or young person. Weight loss may be caused by restricted eating, excessive exercise or

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vomiting. Body weight is at least 15% below expected or there is a failure to gain weight at a time of a normal growth spurt. ➢ The child or young person has a dread of fatness and has a false perception that they are fat. The brain gets into a cycle of convincing itself the body is too fat; this worsens the thinner someone gets, becoming a serious thought distortion. Hence, if you ask a young person with anorexia to draw themselves, they will often draw an enormously fat body when they are extremely thin. ➢ Physical symptoms which can often stop or pause puberty and fertility as the body is just preserving energy for its essential functions instead.

What Are the Physical Symptoms and Signs of Anorexia Nervosa? There are many physical complications related to being underweight, including: ➢ Hormones: Young people’s puberty may be delayed or put on hold and many girls’ periods stop or become irregular. ➢ Blood salt and chemical imbalances worsened by vomiting: These imbalances can be dangerous for body organs like the heart and kidneys, so we often need to do regular blood tests to check levels. ➢ Gut: Constipation is common and delayed emptying of the stomach can cause bloating and tummy pain. ➢ Skin, hair and nails become dry and thin and prone to infection. ➢ Bones and muscles become thinned so there is an increased risk of bone breakages and muscle weakness. ➢ Blood pressure and heart rate can be very low, which can cause fainting and dizziness. ➢ The immune system works less well so infections are more common. ➢ Brain: Brain-fog, tiredness and inability to concentrate are common due to lack of energy going to the brain. ➢ Temperature can drop below the normal range, so feeling cold is common.

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How Is Anorexia Nervosa Treated? ➢ We treat anorexia nervosa with a combination of behaviour and psychological treatments. This follows UK national NICE guidance (9). ➢ Most children and young people with anorexia nervosa are treated at home by community mental health teams rather than in hospital settings. However, hospital admission may be needed if a child or young person becomes seriously or suddenly unwell and cannot be safely managed at home. Sometimes admitting a child or young person to a general hospital can help stabilise their physical health if it requires urgent support, for example due to dehydration. Young people may be admitted to mental health units if longer-term treatments are needed because community treatment hasn’t worked. ➢ Family-based treatment is the most effective community-based treatment for anorexia nervosa. Mental health teams help parents and caregivers to take charge of meals at home to support the young person to eat, before handing back responsibility to the young person again. It is a challenging treatment but works well if the family is in a position to manage it. ➢ If family-based treatment is ineffective, an individual psychological approach such as CBT-E (cognitive behavioural therapy for eating disorders) may be offered. This is an individual therapy in which the young person has a key role in developing a healthy eating pattern and tackling concerns about weight and shape and other psychological issues. ➢ It is important to monitor physical health. Children and young people are often cared for jointly by physical health and mental health teams. If a young person is physically unwell it is important for medical teams to step in to treat physical health problems. In severe cases where young people stop eating completely, they may need to be fed through a tube in hospital. Generally, the child or young person would need to be admitted under a Section of the Mental Health Act (UK) if they are resisting treatment. In less severe cases, children and young people may be managed in the community, where they can have frequent physical health check-ups. Bone scans may also be useful to show bone health.

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➢ We also need to ensure we attend to any underlying mental health problems. For example, treating depression and anxiety with psychological work and adding in medication if needed.

Why Is It Important to Restore Weight Gradually? What Is Re-feeding Syndrome? ➢ In young people with anorexia nervosa who are very low weight, weight needs to be gradually restored (e.g., 0.5–1 kg/week) as there is a danger of the body decompensating and body systems not working properly if done too quickly. Chemical imbalances take some time to restore and resolve. This is known as re-feeding syndrome.

Bulimia Nervosa What Is Bulimia Nervosa? Bulimia nervosa consists of repeated bouts of over-eating and an extreme preoccupation with control of body weight leading to using extreme measures to counteract the fattening effects of food. There is: ➢ Bingeing: There are periods of over-eating large amounts of food in short bursts of time. ➢ Strong preoccupation with eating and irresistible food cravings. ➢ The young person tries to counteract the fattening effects of food by making themselves vomit, restricting food intake or using laxatives or appetite suppressants, which can be dangerous. ➢ There is an over-evaluation of weight and shape. Both anorexia nervosa and bulimia nervosa have this feature in common. It’s helpful to note there is a significant overlap between the two conditions, and young people may be susceptible to both.

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What Are Common Physical Complications of Bulimia Nervosa? ➢ Disturbances of blood chemicals due to vomiting (notably the level of potassium in the blood), which can lead to seizures/fits; heart rhythm problems, including irregular heartbeats; dehydration and muscle weakness. Low potassium levels in the body are particularly dangerous if a young person is also over-exercising. ➢ Hormones: Irregular or absent periods. ➢ Gut: There can be major damage to the oesophagus due to vomiting, including bleeding. Constipation, diarrhoea and indigestion are common. ➢ Teeth and mouth: Vomiting can cause sore throat, erosion of enamel and tooth decay due to stomach acid coming back up into the mouth. The salivary ducts can get enlarged so cheeks may look puffy.

How Is Bulimia Nervosa Treated? ➢ The first-line treatment is family-based therapy (9). Family therapy should usually last for six months and include between 18 and 20 sessions. This involves: (a) helping families work together to get into regular eating habits, and to change any behaviours the young person uses to try to control their weight; (b) showing parents and caregivers how to support the young person; and (c) helping the young person stick to new eating habits, known as relapse prevention. ➢ The second-line treatment is CBT for bulimia nervosa (CBT-BN). This psychological treatment typically involves 18 sessions over a period of six months. CBT-BN helps young people think about how bulimia affects their life and motivates them to change their eating habits by learning how to deal with difficult thoughts and feelings around food. They also learn strategies to avoid getting into unhelpful eating patterns in the future.

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Binge Eating Disorder What Is Binge Eating Disorder? ➢ Binge eating disorder is regularly eating large portions of food all at once, often in secret, until the young person feels uncomfortably full, and then is often upset or guilty. ➢ Common symptoms include eating very fast, eating when not hungry, eating alone and feeling disgusted afterwards.

How Is Binge Eating Disorder Treated? ➢ The first-line treatment is guided self-help. This means working through a programme about binge eating and having short sessions with a practitioner to check progress. This could be a book or online method. A helpful book that is currently recommended is Professor Christopher Fairburn’s Overcoming Binge Eating: The Proven Program to Learn Why You Binge and How You Can Stop (second edition, Guilford Press, New York, 2013). ➢ The second-line treatment is cognitive behavioural therapy (CBT) if guided self-help is ineffective. This can be group or individual CBT and should generally be roughly 16 sessions. It should cover: – Showing young people how to plan food intake. – Working out the triggers for bingeing. – Helping the young person change negative beliefs about their body. – Helping young people stick to their new eating habits.

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Other Specified Feeding or Eating Disorder (OSFED) What Is OSFED? ➢ The American classification system (DSM-5) has coined the term ‘OSFED’, which stands for Other Specified Feeding or Eating Disorder. This encompasses most common eating disorders which don’t strictly fit into a neat category but where eating patterns are abnormal and have a significant impact on someone’s ability to function. ➢ OSFED can include different patterns of symptoms, such as atypical anorexia nervosa, bulimia nervosa or binge eating disorder of lower frequency or duration, purging disorder or night eating syndrome. ➢ OSFED is a serious mental disorder that concerns not only the way the person treats food but also underlying thoughts and feelings. ➢ OSFED now replaces the term ‘EDNOS’ (Eating Disorders Not Otherwise Specified) due to the updated classification of eating disorders in DSM-5. However, parents may still come across the term EDNOS if researching the eating disorders literature.

How Is OSFED Treated? ➢ There is no set treatment plan for OSFED, as cases vary widely based on the pattern of symptoms. The treatments offered will tend to follow the pattern of symptoms the young person struggles with the most. For example, the bulimia treatment pathway may be the most helpful if the young person has this group of symptoms. ➢ In general, psychological treatments that use a family-based model in conjunction with physical health monitoring are most often used.

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How Can You Help People with Eating Disorders? ➢ Support the young person get professional help as quickly as possible. Treatment is usually more straightforward if accessed more quickly. ➢ Find out as much as possible about eating disorders and look for support for yourself too. Eating disorders are quite challenging to understand, as much of the current advice around supporting young people goes against what most of us may have been taught when we were growing up. Be aware of what lengths a young person may go to in order to lose weight (e.g., secret exercise and buying unregulated diet products online). Trying to find support through local networks and national organisations can be very helpful. The national eating disorders charity Beat has helpful resources as well as online support (www .beateatingdisorders.org.uk). ➢ Take part in family-based treatments and work closely with mental health professionals. Successful family therapy is often a key part of recovery. It’s often very hard for families to get the balance right in putting down boundaries and not giving into the distorted thinking of eating disorders and being supportive. Seek guidance from the team and ask for help too. ➢ Link in with schools, family and friends. Giving information rather than pretending everything is OK is important. It’s useful to be able to draw from a helpful network of support and understanding around the young person. Maintaining friendships, interests and school links is very important when functioning is difficult. ➢ Try to stay hopeful but realistic. Eating disorders tend to be tricky and chronic and relapses are common. ➢ Help young people make positive connections. Sometimes young people gravitate to those with similar difficulties, and some social media sites known as ‘pro-ana’ can exacerbate difficulties, encouraging anorexic behaviours. It’s important for adults to try and work out which connections are helpful, and which are less helpful on the road to recovery.

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What Are the Outcomes for Eating Disorders? How Can We Hold out Hope? ➢ Eating disorders can be treated and do significantly improve in many cases. Around half of young people significantly improve with treatment within one year, and 75–80% improve to some degree. ➢ A key message is that young people have better outcomes if the eating disorder is treated early and the whole family engages with treatment. Once the young person has had the disorder for more than three years, it becomes much more difficult to treat. ➢ Eating disorders are often long-term conditions. In adolescence, eating disorders teams work towards recovery rather than cure. ➢ It’s important to understand eating disorders are serious conditions which can be life-threatening, largely because of their impact on physical health and increased suicide risk, and they carry the highest death rate among all mental disorders. ➢ There are many positive examples of people who have done very well and achieved amazing things despite having had an eating disorder. There are several examples on the Beat Eating Disorders charity website (www.beateatingdisorders.org.uk/).

Case Example Safia is 14. Her parents have become concerned as she has lost 5 kg over the last few months. Her periods have now stopped. Her weight loss was triggered by a boy calling her ‘chubby’ at school, although she has always been anxious about her appearance. She picks at her food, has switched to being vegan and often retreats to the toilet after meals. Safia’s parents are worried that Safia is looking very thin but has started to say she thinks she is fat and has begun counting calories in every food item she eats. Her brother has caught her doing 100 star-jumps in secret. She doesn’t want to go out to meet friends as she is worried people will comment on her

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eating. Instead, she spends time preparing family meals, which she doesn’t eat. Her parents have gone out of their way to buy foods she will accept but she is still eating very little. Mum takes Safia to the GP as she is worried about Safia’s health and doesn’t know how to help her. Mum gets a rapid referral to the local eating disorders team in the young people’s mental health service. Safia is assessed quickly and seen by a nurse and psychologist in the team who discuss a treatment plan with Safia’s family. A meal plan is set up which adds in extra calories each day. Safia’s GP is asked to carry out a number of blood tests and a physical health check. Safia and her family are seen by both the eating disorders nurse and psychologist weekly for around ten weeks, along with regular medical checks, and then she is seen fortnightly. Safia’s family also take part in family therapy. Safia improves over six to eight months with support from family and school around supervised eating. Safia does very well with psychology sessions, which also help her with underlying anxiety. After she has regained weight, Safia returns for check-ups for the following months to consolidate her recovery and ensure she has strategies to prevent relapse.

Notes on the Case Example ➢ Safia’s pattern of restricting food, losing weight and secret exercise together with a strong fear of being fat are typical of adolescent girls with anorexia nervosa. ➢ The trigger here was a peer who called Safia ‘chubby’. This type of trigger is unfortunately common as adolescents are often very sensitive about comments relating to their physical appearance. ➢ Many young people with eating disorders adopt special diets like veganism and vegetarianism as this often allows them to restrict their diets more and gain more control. ➢ It is also common for people with anorexia to spend lots of time preparing food for others, which they themselves don’t eat.

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➢ It is a worrying sign that Safia’s periods have stopped, and it would be important for her doctor to do a thorough physical examination and blood tests to check the rest of her physical health. ➢ It is helpful that the eating disorders team were able to see Safia quickly and she was able to engage with them effectively. Familybased treatments are an important part of recovery. Young people who struggle to engage in treatment often have worse outcomes. In severe cases they may require involuntary treatment under the Mental Health Act.

KEY POINTS

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It is relatively common for children and young people to develop some difficulties with eating at some stage in their development. Eating difficulties are frequently linked to feeling a lack of control and it’s noteworthy that they have increased in the last few years in the wake of the COVID pandemic.

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Fussy eating is common in young children, but most grow out of it. Some youngsters also eat non-food items, which is known as ‘pica’. Certain groups, such as children and young people on the autistic spectrum, are more susceptible to eating difficulties, including restricted eating due to their sensory sensitivities.

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Obesity is a major public health problem that is difficult to tackle as causes are complex and linked to deprivation and ingrained eating patterns. Although it is not a mental disorder it does have significant mental health implications.

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Eating disorders include a range of mental health disorders where there are abnormal or disturbed eating habits that affect a young person’s ability to function. Anorexia nervosa and bulimia nervosa are the most well known, but there are other eating disorders which can also significantly impact upon young people’s functioning.

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It is very important to treat and monitor physical health associated with eating disorders as there can be serious short- and long-term physical complications. Often medical staff need to work together with mental health professionals to treat young people holistically.

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There is a growing evidence base for treatment of eating disorders that includes psychological therapies, behaviour treatments and family work. Most UK mental health services have specialist professionals who work with young people with eating disorders, and many have specialist eating disorders teams.

References (1) NHS Digital. 30 September 2021. Mental Health of Children and Young People in England 2021 – Wave 2 Follow Up to the 2017 Survey. Available at https://digital.nhs.uk/data-and-information/publications/statistical/ mental-health-of-children-and-young-people-in-england/2021-follow-upto-the-2017-survey#data-sets (2) NHS Digital. 22 November 2018. Mental Health of Children and Young People in England, 2017: Autism Spectrum, Eating and Other Less Common Disorders. Available at https://files.digital.nhs.uk/FB/8EA993/MHCYP%20 2017%20Less%20Common%20Disorders.pdf (3) Swanson, S., Crow, S., Le Grange, D., et al. 2011. Prevalence and Correlates of Eating Disorders in Adolescents. Results from the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry 68(7), 714–723. (4) Le Grange, D., Swanson, S., Crow, S. and Merikangas, K. 2012. Eating Disorder Not Otherwise Specified Presentation in the US Population. International Journal of Eating Disorders 45(5), 711–718. (5) Bryant-Waugh, R., Loomes, R., Munuve, A. and Rhind, C. 2021. Towards an Evidence-Based Out-Patient Care Pathway for Children and Young People with Avoidant Restrictive Food Intake Disorder. Journal of Behavioral and Cognitive Therapy 31(1), 15–26. (6) Shea, L., Frankish, M. and Frankish, S. 2019. Understanding and Managing Pica. The National Autistic Society. Available at www.autism.org.uk/ advice-and-guidance/professional-practice/managing-pica

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Useful Resources Web-Based Resources ➢ Beat is one of the UK’s leading eating disorders charities. Its website, www.beateatingdisorders.org.uk/, has lots of useful information for young people and their families about managing eating disorders. ➢ Young Minds, a UK mental health charity, has some useful information about eating disorders on its website. Available at https://youngminds.org .uk/find-help/feelings-and-symptoms/eating-problems/

Books For Caregivers ➢ Skills-Based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method (2nd edition, Routledge, Abingdon, 2016) by Janet Treasure, Gráinne Smith and Anna Crane is co-written by Janet Treasure, one of the pioneers of UK eating disorders. It helps caregivers learn practical strategies for supporting those with eating disorders.

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➢ Anorexia and Other Eating Disorders: How to Help Your Child Eat Well and Be Well: Practical Solutions, Compassionate Communication Tools and Emotional Support for Parents of Children and Teenagers by Eva Musby (Aprica UK, 2014 and updated in 2022) is written by a parent of a young person with anorexia nervosa and offers practical advice on how to get alongside your child and offer support. Some of the chapters and other helpful resources can also be found online at anorexiafamily. com. ➢ ARFID Avoidant Restrictive Food Intake Disorder: A Guide for Parents and Carers by Rachel Bryant-Waugh (Routledge, Abingdon, 2019): Dr Bryant-Waugh is a world leader in the emerging field of ARFID, and her book is a clearly written guide to parents on how to support young people with this condition.

For Young People ➢ Overcoming Anorexia Nervosa, 2nd Edition: A Self-Help Guide Using Cognitive Behavioural Techniques by Patricia Graham and Christopher Freeman (Robinson, London, 2019) is a useful book which offers young people cognitive behavioural techniques to help them tackle anorexia nervosa. ➢ Getting Better Bite by Bite: A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorders by Ulrike Schmidt, Janet Treasure and June Alexander (Routledge, Abingdon, 2015) is a well-regarded book by highly experienced and authoritative pioneers in the field. It gives young people evidence-based tools to help themselves with bulimia nervosa and binge eating disorder.

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24 Difficulties with Body Image and Body Dysmorphic Disorder Physical appearance is often of central importance to young people and can cause much stress, which may be heightened by social media and peers. A large 2017 survey carried out by the ‘Be Real’ Body Image Campaign found that over half of 11- to 16-year-olds regularly worry about how they look (1). A quarter of young people in a 2019 Mental Health Foundation survey (2) said celebrities caused them to worry about body image and 40% said peers and friends caused them to worry about their body image. To counteract this pressure, it’s important that we continue to give the message to children and young people that we value them and others for who they are on the inside rather than how they look. We don’t have much control over how we look but we can control our actions and behaviour. Unfortunately, for some young people, worrying about an aspect of their appearance can become such a strong fixation that it can stop them functioning in other areas of their life. This can in severe cases lead to a condition known as body dysmorphic disorder (BDD). We will look at what may lead to such concerns and how to support young people if they do have BDD.

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How Can Thoughts about Body Image Impact on Mental Health? ➢ Anxiety is very common: About a third of young people said their body image caused them anxiety (1 and 2). ➢ Depression is more common in those with worries about body image. ➢ Risky behaviours may increase, including self-harming, taking pills or considering surgery to fix their perceived problems. In the Be Real 2017 survey about a third of 11- to 16-year-olds said they would do ‘whatever it takes’ to look good, including considering cosmetic surgery (1). A significant proportion of boys in some surveys consider taking steroids to look better. ➢ Withdrawal from healthy activities like exercise: Around a third of girls and a quarter of boys avoid physical activity due to concerns about how they look. (Refer to Part 1, Chapter 2 to understand how important exercise is for maintaining mental health.)

What Can You Do to Help? ➢ Talk positively and confidently about your body. If we can show young people that we treat our own bodies with kindness and respect, they are more likely to follow us. It is common to focus on the negative parts of our bodies, rather than talking about how amazing our bodies are, and how it’s important to look after them, whatever our natural size and shape. ➢ Discuss the way real bodies look: i.e., they are very different from airbrushed media images. Discuss how people on social media often post only the best images of themselves. ➢ Emphasise the most important part of a person is how they choose to behave not how they look. We need to consciously think about how we talk about others, so rather than admiring how someone looks, try to point out something special they do as a person. It’s important for young people to get the constant message from supportive adults that we value others for who they are on the inside, not how we look on the outside. Films and books like Wonder by R. J. Palacio can be helpful (3).

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➢ Schools can use helpful resources from campaign groups and charities like Be Real (www.berealcampaign.co.uk) as an educational tool, for example their Body Confidence Campaign toolkit for schools.

What Is Body Dysmorphic Disorder (BDD)? Body dysmorphic disorder is a mental health condition where there is a disabling preoccupation with perceived flaws in one’s own appearance (e.g., skin, hair and nose). This makes the young person very self-conscious although flaws are often unnoticeable to others. Symptoms include: Worrying a lot about a specific area of the body. Spending a lot of time comparing looks with those of others. Excessively checking in the mirror. Going to a lot of effort to camouflage flaws – for example by spending a long time combing hair, applying make-up or choosing clothes. ➢ Avoiding certain places or activities because of concerns about appearance. ➢ Picking at skin to make it ‘smooth’ or combing or cutting hair.

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What Causes BDD? ➢ Inherited factors are important, including a family history of body dysmorphic disorder, OCD or depression. ➢ Environmental factors are important. There may be significant difficulties in the home environment as well as attachment difficulties, trauma or abuse, which can cause high levels of stress and increase risk.

How Common Is Body Dysmorphic Disorder? When Does It Start? ➢ Community surveys show about 2% of both the adult and adolescent population have BDD (4).

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➢ Although it commonly starts in adolescence, many people don’t seek help for several years.

What Are Some Effects of BDD? ➢ Emotional distress, which can lead to depression and anxiety. ➢ Avoiding school, social and family activities. Some people can end up housebound because of their difficulties.

What Can You Do to Support Someone with BDD? ➢ Help the young person get support and treatment from mental health teams as early as possible. Try to dissuade the young person from seeing cosmetic surgeons: there are some unscrupulous practitioners who may go ahead and treat people without seeking a mental health opinion first. This is a significant issue because the rate of BDD in cosmetic surgery and dentistry populations is around 13–20% (4). ➢ Encourage the young person to try to keep doing as many normal activities as they can despite their difficulties. Support them to continue with their hobbies and friendships and try to distract them from their perceived flaw. ➢ Don’t get into arguments about the young person’s beliefs about their perceived flaw in appearance. Their thoughts around their appearance are often so distorted and fixed that you can’t use logic to persuade them they look fine.

How Can BDD Be Treated? The current UK national guidance (5) recommends the following treatments:

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➢ Psychological therapy in the form of cognitive behavioural therapy (CBT), which is specific for BDD, when the problem causes mild or moderate functional impairment. This is usually the mainstay of treatment, as it gets to the root of challenging the underlying thoughts that cause the difficulties. ➢ A combination of CBT and antidepressant medication (fluoxetine is recommended as first line) when the problem causes moderate or severe impairment. We may use a different antidepressant medication if there is a poor response to the first medication. ➢ For very severe cases, we may consider referring the young person to a national or regional specialist service.

Case Example Jenna is 15 and lives with her mum, who works long shifts as a carer. Jenna has hated her nose since she was around 8, when she heard a peer make a comment about her having a ‘snub-nose’, although no one else ever commented on her nose being different. Her hatred of her nose worsened in puberty when she also started to get acne on her face. She is up at 5 o’clock every morning looking in the mirror for over two hours, checking her nose and applying lots of different make-up and creams to her face and blow-drying her hair so it covers most of her face. Jenna has spent all her birthday and paper-round money on cosmetics. Jenna’s friends are worried about her as she has started making excuses not to go out and at school her hair covers most of her face. She has started looking at plastic surgery websites. She spends most of her time at home in her bedroom in front of her mirror. Jenna’s tutor at school also contacts her mum and tells her she is worried Jenna is spending a lot of lesson times in the toilets, and in the classroom she is often distracted and falling behind with work. Mum talks to Jenna and Jenna explains she really hates her nose and her appearance and tries to persuade mum to use her savings to see a private plastic

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surgeon. Mum is worried and takes her to see the GP. The GP refers Jenna to the Child and Adolescent Mental Health Service. Jenna reluctantly attends an appointment and says she doesn’t need any help from mental health services, she just needs her nose fixed. Luckily, the mental health nurse sensitively tries to engage Jenna to work on stress. The mental health nurse is a trained CBT therapist and sets up several sessions for Jenna. She also arranges an appointment with the psychiatrist, who discusses the option of medication. Jenna agrees to take it and attends psychology sessions, and after a few months her mental health improves. Over time, Jenna gradually becomes more accepting of her appearance and reduces the time spent checking herself in the mirror.

Notes on the Case Example ➢ Jenna’s story of hating one body part is typical of body dysmorphic disorder (BDD). The obsessive mirror checking can get into cycles that go on for hours and can significantly impact on a young person’s ability to engage in any other activities. ➢ The impact of Jenna’s preoccupation with her nose on her life is significant: it is taking a lot of her time, her grades are slipping and she is isolating herself from friends. ➢ Jenna has also started looking up cosmetic surgeons, which is a worrying sign, but a common one. People with BDD are more likely to present themselves to a cosmetic surgeon rather than a psychiatrist. Luckily, nowadays most surgeons have undergone training to be alert to BDD and refer on to mental health. ➢ As in Jenna’s case, there is often a delay in getting support due to a reluctance to seek help. Fortunately, many professionals working in young people’s mental health services are sensitive to this, as is the mental health nurse, who finds ways to engage Jenna in treatment. ➢ As with Jenna, where things have got very stuck, medication can be a helpful added treatment to psychology when someone’s functioning is so disrupted.

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KEY POINTS

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Difficulties with body image are common and are influenced by factors including families, peers and social media.

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Body image problems can cause mental health problems, including anxiety, depression and risky behaviours, for example buying diet pills online.

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We can help young people learn to develop a healthier view of body image by talking positively about bodies, discussing how real bodies look and work and focusing on inner qualities we have control of rather than outward appearance.

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Body dysmorphic disorder is a disabling preoccupation with perceived flaws in appearance (e.g., facial skin, hair or the nose). We can support sufferers by getting professional help early, trying to maximise their functioning and not unnecessarily challenging beliefs.

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The main treatments are psychological but sometimes adding ­medication can be helpful.

References (1) The Be Real Campaign. 2017. Somebody Like Me: A Report Investigating the Impact of Body Image Anxiety on Young People in the UK. Available at www .berealcampaign.co.uk/research/somebody-like-me (2) The Mental Health Foundation. 2019. Body Image: How We Think and Feel about Our Bodies. Available at www.mentalhealth.org.uk/publications/ body-image-report (3) Palacio, R. J. 2014. Wonder. London: Corgi Children’s Books. (4) Veale, D., Gledhill, L. J., Christodoulou, P. and Hodsoll, J. 2016. Body Dysmorphic Disorder in Different Settings: A Systematic Review and Estimated Weighted Prevalence. Body Image 18, 168–186. (5) National Institute for Health and Care Excellence (NICE). November 2005. Guidance: Treating Obsessive-Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) in Adults, Children and Young People. Clinical guideline [CG31]. Available at www.nice.org.uk/Guidance/CG31

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Useful Resources Web-Based Resources ➢ The Body Dysmorphic Disorder Foundation (https://bddfoundation .org/) is a UK national charity aimed at supporting people with body dysmorphic disorder and their families. ➢ Be Real Campaign (www.berealcampaign.co.uk/) is a UK campaign founded by YMCA and Dove to investigate and tackle the difficulties young people have with their body image. ➢ The Mental Health Foundation, a UK mental health charity, has produced some very useful resources around body image in childhood, via a campaign that was set up in 2018. Available at www.mentalhealth.org .uk/get-involved/campaigns/body-image

Books ➢ The ‘Wonder Collection’ by R. J. Palacio is a group of books featuring a boy with a congenital disfigurement. It helps emphasise the importance of judging people from their inner qualities rather than outward appearance (https://wonderthebook.com).

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25 Difficulties with Perfectionism, Obsessions and OCD As with many other characteristics, some people naturally have more ­perfectionist traits than others. Perfectionism can both be a strength and make life more difficult. Some people, for example those with high levels of anxiety and those with autistic traits, may be comforted by consistency and sameness. I explore perfectionist traits in the first part of the chapter. Obsessive compulsive disorder (OCD) is a serious and not uncommon mental health condition. Some of the most mentally distressed young people I have seen have this condition. I discuss in detail what OCD is, how to support children and young people with it and how it is treated.

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Should You Be Worried about a Young Person with Perfectionist Traits? ➢ It depends, as we all vary as to how perfectionist we are. Some people are naturally very exacting about getting things just right, and others less so. ➢ It is common to hear that a person is ‘a bit OCD’, describing someone who is very neat and organised and likes things to be ‘just so’. However, this is incorrect. OCD is, in fact, a serious mental disorder and is not synonymous with perfectionism. ➢ Having perfectionist traits can have its advantages. For example, many jobs in science and technology rely on 100% precision, so employees with perfectionist traits may be highly valued in these areas. ➢ On the other hand, being too worried about getting things exactly right can be a mental struggle for many people with perfectionist traits. They may beat themselves up if they don’t get things ‘just right’ and they may not attempt things unless they think they will do something perfectly.

What May Help Young People with Perfectionist Traits? Children and young people with perfectionist traits struggle with allor-nothing thinking: they would rather avoid doing something than not doing it to an extremely high standard. When perfectionism causes distress and starts affecting functioning, then the person may find a psychological approach helpful. This may include: ➢ Learning to wait gradually longer periods before double-checking things helps children and young people learn to tolerate the feeling of anxiety until the anxiety starts to reduce. ➢ Learning to accept that things don’t always have to be done perfectly by developing compassionate self-acceptance together with self-care strategies.

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What about People Who Like to Follow Rituals and Routines and Those with Overwhelming Interests? ➢ Rituals or routines can be soothing for many children, for example having a certain bedtime routine helps many children settle at night, but the reliance on these routines generally reduces as children mature. ➢ Some children will struggle if we change routines, particularly children and young people with autism or autistic traits. ➢ People with autism also often have intense and overwhelming interests which can become obsessional. This can become a problem if this affects day-to-day functioning.

OCD What Is OCD? OCD stands for Obsessive Compulsive Disorder. It is a disorder where a child can have either repeated obsessional thoughts or feel a drive to act out certain behaviours or both. For a diagnosis, these difficulties should have been there for at least two weeks, and difficulties should cause worries and distress and prevent a child from managing their usual activities. Obsessions are uncontrollable thoughts, images or impulses which repeatedly pop into the person’s head. They are always intrusive and disturbing and significantly interfere with the person’s ability to function because they are so difficult to ignore. The individual will go to great lengths to resist the thoughts, but they become overwhelmed by their distress. Examples of common obsessions in children and young people are: ➢ Contamination: This includes fear of harm from dirt, germs or viruses. The number of young people with these fears increased after the start of the COVID pandemic. ➢ Checking: For example, fear of something bad happening if locks are not shut properly.

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➢ Superstitious ideas or religious/spiritual beliefs, for example fixation with having to count lucky/unlucky numbers or objects to prevent danger. ➢ Intrusive thoughts that may be sexual or violent: These can be particularly difficult for children to own up to. ➢ Worries about themselves or a loved one coming to harm: This is common in children and young people and can result in high levels of safety behaviours to try to prevent harm.

Compulsions are behaviours or mental acts repeated again and again to reduce or take away the anxiety caused by the obsessive thoughts. The behaviour is not rational and isn’t enjoyed. The child often tries to resist the compulsions but feels they can’t stop them. Examples of common compulsions in children and young people are: ➢ Washing and cleaning, commonly washing hands excessively or cleaning repeatedly. ➢ Checking, for example, checking switches and taps are off or doors are locked, or checking other people are safe. ➢ Counting, ordering or arranging things to a certain ‘right’ sequence or number and avoiding wrong or unlucky numbers. ➢ Thinking or saying ‘neutralising’ thoughts/words to counter obsessive thoughts.

Who Gets OCD? We know that for OCD: ➢ There is a strong inherited link. ➢ There may be an external trigger, like a house move or parental separation, which makes OCD more likely. ➢ Note: There is also a rare type of sudden onset OCD called PANS or PANDAS, which can happen after children get a type of bacterial infection called streptococcus. In these cases, it is important the infection is medically treated, and caregivers seek advice from children’s medical doctors prior to going down the mental health route.

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What Should You Do If You Think a Child or Young Person May Have OCD? ➢ Keep a record of symptoms, for example in a diary, which can help to understand whether behaviours are increasing. Sometimes obsessions will disappear after some weeks. ➢ Listen to the child’s or young person’s struggles and show support. It is distressing and often scary to have OCD. Letting the child or young person know you are there for them however overwhelming or frightening the thoughts are can be very helpful. Explain it is not the child’s fault and you will try and support them to find help. ➢ Try to find out what helps the child with their thoughts. Distraction with music or podcasts, being active or talking to others can be helpful. ➢ Try not to get drawn into offering constant reassurance, as you can end up strengthening the child’s or young person’s OCD loops, and they may then start to depend on your ongoing reassurance, which can restrict them moving forwards. ➢ Look online for support organisations. At the end of this chapter, you will find a list of OCD organisations online, which may offer further information and support and some of which have forums and information lines for parents. ➢ Seek professional help. It is good to first see the GP and ask for a referral to the local mental health service for support. However, if the OCD is of sudden onset and follows a viral illness, you should ask for a referral to the paediatrics service for medical treatment to exclude PANS.

How Can Children and Young People with OCD Be Helped? There are UK national guidelines around OCD treatment (1). The main treatment for OCD is psychological and is follows: ➢ The best evidence-based intervention includes cognitive behavioural therapy (CBT), which means understanding the thoughts,

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feelings and behaviours underlying OCD, the way they link into cycles, and how to manage worries. CBT will also involve exposure and response prevention, which involves learning to gradually sit with anxiety for longer periods without acting on the compulsions. The child or young person will learn to see that anxieties invariably reduce with time. This technique works best with compulsions. ➢ For children, involving parents in the therapy is crucial. Parents learn how to respond to OCD situations, and how to support their child without giving in to rituals. They learn not to get drawn into cycles of false reassurance, which can feed OCD. ➢ If symptoms are severe, a combination of psychological treatment and medication may be offered. Antidepressants, for example, sertraline, are the medications with the best evidence base for OCD and anxiety as well as depression and can work well in many cases.

What Are the Longer-Term Outcomes of OCD? ➢ OCD can be a long-lasting condition and can persist into adulthood in about half of cases.

Case Example Jane is 12. Since going to a restaurant with her family several months ago and getting food poisoning, she has been worried about picking up germs and has been washing her hands hundreds of times a day. Jane’s hands have become all cracked and raw, and her GP prescribes her special creams for them. She feels she needs to repeat ‘I am clean’ 20 times in her head and if she gets interrupted, she must start again. She will only eat certain foods she has inspected and washed. She showers for at least an hour in the mornings, and each time she leaves her house too, and after showering she still doesn’t feel completely clean. At school she washes her hands between every lesson in case she touches something she thinks is contaminated.

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Jane’s parents are worried she has started to lose weight as she is worrying so much. Jane is also falling behind and isn’t concentrating on her work and her teachers are getting concerned. She has told her mum this is because she is worried about getting dirty all the time. She has also stopped meeting with friends. Jane goes to her family doctor, who refers her to the children’s mental health team for an assessment. She does three months of CBT with a psychologist and her OCD improves somewhat but she also requests some medication and sees the psychiatrist, who prescribes her sertraline. The combination of psychological support augmented with medication helps Jane’s functioning gradually improve over the next year. She learns to manage her anxiety and gradually increase the time before she must wash her hands until she only washes them when necessary.

Notes on the Case Example ➢ Jane has OCD. She is really struggling with her obsessions and compulsions around cleanliness. Her functioning has deteriorated because of her rituals. She has started to lose weight, isn’t contacting friends and is falling behind with school-work. ➢ Fears of contamination are a common obsession in young people, and for many this worsened with the COVID-19 pandemic. ➢ It often takes quite a long time before young people speak up and then can access help, but psychology can often be very helpful. As in Jane’s case, medication can sometimes be useful to add in to help a child or young person recover and access psychological treatments more effectively.

KEY POINTS

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Some people have perfectionist traits. This doesn’t mean they have OCD. Perfectionism can be a strength but can also become a problem if it gets in the way of a person managing their day-to-day life.

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It is often comforting for young children to follow routines and rituals, especially for those with high levels of anxiety and/or autistic traits, but if these get excessive, this can become a problem. Young people on the autistic spectrum are also more vulnerable to obsessive difficulties.

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OCD is a serious mental health condition where people get unwanted thoughts, feeling or fears (obsessions) which can make them anxious. They may have to then do behaviours (compulsions) to get rid of or neutralise the obsessions.

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OCD is treatable. The treatments with the best evidence base include cognitive behaviour therapy, which includes exposure and response prevention. In more severe cases, antidepressant medication may be helpful in combination with psychology.

References (1) National Institute for Health and Care Excellence (NICE). 29 November 2005. Obsessive-Compulsive Disorder and Body Dysmorphic Disorder: Treatment. Clinical guideline [CG31]. Available at www.nice.org.uk/ guidance/cg31/evidence

Useful Resources Web-Based Resources ➢ The Royal College of Psychiatrists have useful information on OCD in general and have an information page on OCD in young people. Available at www.rcpsych.ac.uk/mental-health/parents-and-young-people/ young-people/ocd-young-people ➢ OCD Youth (https://ocdyouth.org) is a UK charity website written and run by young people with OCD and has lots of useful information and resources.

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➢ OCD UK (www.ocduk.org) and OCD Action (www.ocdaction.org.uk) are both large UK OCD charities with lots of information on OCD for all ages. ➢ The International OCD Foundation is a US-based website with useful information on OCD in children and adolescents. Available at https://kids .iocdf.org ➢ The Child Mind Institute (www.childmind.org) is a US-based website which has a useful information page on PANS or PANDAS (the acute onset OCD which follows a strep bacterial infection). Available at https:// childmind.org/guide/parents-guide-to-pans-and-pandas/

Books ➢ Breaking Free from OCD: A CBT Guide for Young People and Their Families is a useful book, based on CBT principles written especially for young people by four experts: Jo Derisley, Isobel Heyman, Sarah Robinson and Cynthia Turner (Jessica Kingsley, London, 2008). ➢ Talking Back to OCD: The Program That Helps Kids and Teens Say No Way – and Parents Say Way to Go is an accessible American book published by Guilford Press in 2007 based on sound psychological principles. The first section of each chapter teaches children skills they can use to take charge of the illness, showing them how to ‘boss back’ when OCD butts in. Instructions that follow show their parents how to provide encouragement and support.

26 Difficulties with Losing Touch with Reality (Psychosis) Although psychosis, or the state of losing touch with reality, is relatively rare in children and young people, it is an important condition to recognise. Psychosis can be distressing and frightening and may increase the child’s or young person’s risks and vulnerabilities. In this chapter I explain what is meant by psychosis, what may cause it and who is most at risk. We discuss that the term ‘psychosis’ encompasses a range of conditions, not just paranoid schizophrenia, which is the most wellknown type of psychosis. I also look at treatment options for psychosis, following UK guidelines.

What Is Psychosis? What Conditions Can Cause It? ➢ Psychosis is an experience where someone loses touch with reality, such as hearing voices or believing things that don’t have a basis in reality, including paranoid ideas.

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➢ We see psychosis in a number of different conditions, including schizophrenia, bipolar disorder and severe stress/depression; it can also be triggered by different drugs (e.g., cocaine, skunk cannabis, LSD) as well as some medications, like steroids.

How Common Is Psychosis? Who Is Most at Risk? ➢ About 3 in 100 people will experience psychosis at some point in their lives, but it is much less common in children than adults. ➢ Rates of psychosis start to go up much more quickly in late adolescence, especially as conditions like schizophrenia become more common. ➢ People with a family history of a psychotic illness like schizophrenia or bipolar disorder are more at risk. ➢ People who misuse drugs or alcohol are at increased risk.

What Are the Symptoms of Psychosis? ➢ Hallucinations: This describes a state where someone hears, sees or otherwise senses things that do not have a basis in reality. Hearing voices when no one is around is the most common. You may see children or young people responding to voices, as if they are talking to someone they think is there when they are alone. ➢ Delusions: This is where a person has strong beliefs that are not shared by others. For example, someone believing there’s a conspiracy to harm them. Young people may start acting in odd ways and appear paranoid or suspicious of others. They may neglect their health and selfcare as they become convinced by certain beliefs. ➢ Disorganised thinking or speech: There may be interference or muddling of thoughts making it hard to think clearly. Young people may appear confused, blank and to not really hear what you are saying, and frequently switch topic.

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These symptoms can cause severe distress and changes in behaviour in children and young people.

If Someone Is Hearing Voices Does It Mean That They Are Psychotic? ➢ No: hearing voices on its own is surprisingly common and doesn’t mean a person is unwell or psychotic. Hearing voices may occur in a number of situations and conditions, including severe stress, trauma, illness, personality difficulties, as well as autism. ➢ It is important to find out what other symptoms the young person has, and the type of voices heard. For example, hearing voices that come from inside the person’s head are more likely to relate to underlying stress and are less likely to be psychotic. ➢ An analysis of several studies showed that around 1 in 8 children and young people report hearing voices when there is no one else around, and about three-quarters of young people have heard a voice at least once (1).

Is It Helpful to Label the Condition Causing Psychosis in Children and Young People? ➢ No: In young people it is not always possible or even helpful to diagnose a serious mental disorder like schizophrenia at the onset of psychosis. We don’t always yet know how the difficulties will evolve over time: things can change a lot in developing brains. ➢ Once a young person has received the label of a diagnosis like schizophrenia it’s very difficult to undo, even if it’s not accurate, so it’s important to first treat symptoms and collect evidence before we assign a diagnosis.

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How Can You Get Help for Someone with Psychosis? What If They Refuse to See a Doctor? ➢ Support them to get help from a doctor. The first port of call is a GP or psychiatrist. Many areas of the UK now have an Early Intervention in Psychosis team. Rather than telling the young person they need help because they seem paranoid or are seeing things that aren’t real, which may make them suspicious of you, you can say they seem to be under stress, and you are concerned about their health, as someone with psychosis will often find it difficult to look after themselves properly. ➢ If the young person refuses to go to see a doctor, a close family member can discuss with the GP how to move forwards, while trying to keep the young person on side if possible. There may be different ways for healthcare professionals to assess the situation – for example through a home visit or a telephone assessment. Mental health services are usually very experienced at finding ways to assess people who are reluctant to be seen. ➢ If all other methods to assess the situation fail, a last resort is to ask the GP or duty social worker to arrange a Mental Health Act assessment. A Mental Health Act assessment is the mechanism for detaining someone with a disorder of the mind to hospital for assessment or treatment if their health or safety or the safety of others are at risk. Psychosis is a common reason for detention under the Mental Health Act, especially if the person’s insight into their difficulties is poor.

Is There Anything Else You Can Do? ➢ Give reassurance and support basic care needs. Often young people with psychosis can be frightened because they feel persecuted. They may think they are being followed or targeted, and it’s helpful for them to know they are not alone. Young people may need extra support with looking after themselves, such as with food preparation, personal care, transport and relationships with others.

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➢ Keep in touch with schools/colleges and other important support systems. Not everyone needs to know the full details of the young person’s condition; however, it’s often helpful to keep key support people in the loop. You may need to ask school or college to send work home. Sometimes children or young people may need to repeat their year if they are unwell for a few months or more. ➢ Help young people keep healthy and active. Young people may need extra encouragement to eat well and exercise, especially if they are on antipsychotic medication, which can often cause increased appetite and weight gain. Distraction with music and doing activities they enjoy can be helpful. ➢ Aid young people in managing their health. Young people will need extra blood tests, investigations and appointments when on antipsychotic medication. It’s beneficial for young people to have some support through these tests, which can feel intrusive, helping them to build some sense of control and choice. ➢ Be very careful with your use of language. Labels can still be stigmatising, and many people do not want to be defined by their illness. Rather than calling someone ‘schizophrenic’, it’s generally preferable to use the term ‘a young person with schizophrenia’.

How Can Psychosis Be Treated? There is the following UK national guidance (2) on treatment of psychosis: ➢ Antipsychotic medication is used to treat psychosis. Medication generally works very well at decreasing hallucinations and delusions. However, side effects can be troublesome and may need monitoring. Common side effects include weight gain, blood pressure changes, dry mouth and stiffness. ➢ Psychological interventions may be helpful, including family interventions, individual cognitive behavioural therapy and arts-based therapies if available (e.g., dance, music, drama or art therapy) for children and young people with psychosis or schizophrenia.

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➢ Although most young people can be supported with treatment at home, for more severe cases hospital admission or intensive home support may be needed.

Case Example George is 17, and lives with his parents and younger brother and attends his local sixth form college. His grandfather had paranoid schizophrenia and his mother suffered from depression. He was previously an able student in school and college and has no history of alcohol or drug use. His parents and his college tutor have been getting concerned about his behaviour over the last few months: he has been increasingly withdrawn and irritable. His college attendance is now very irregular as most days he says it is not safe enough to leave the home. He also hasn’t handed in any work for several weeks because he complains he can’t concentrate. George refuses to go on the bus as he says there are people on the bus who are following him. He unplugged the TV in his room because he complained he was being spied upon. His mum sometimes hears him talking to himself in his room and he seems to be up all hours. George has lost weight and is refusing most foods unless he can open them from packages himself because he thinks the ‘spies’ are poisoning his food. His friends have told his mum they are concerned because he has sent odd texts saying secret police are after them and they should watch their backs. George’s parents ask him to go to the family doctor but he refuses, so they ask the doctor to visit at home. George is suspicious of the family doctor and says he thinks he may be working for ‘them’. The doctor is concerned so he contacts an Early Intervention in Psychosis team for support. The Early Intervention in Psychosis team come over to assess George at home and manage to convince him to have some basic investigations for his health and start an antipsychotic medication. George responds well to medication; he

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becomes less paranoid and starts to recover his eating pattern and sleep and to trust the nurse who visits him weekly and supports his parents. They agree to start a course of family therapy. After a few weeks George starts therapy with the team psychologist. After a few months of treatment George eases back into college work, starting part-time and concentrating on a few of his favourite subjects, then gradually manages to increase his workload and functioning. He considers repeating the academic year to reduce the pressure of college-work and allow for recovery and rest.

Notes on the Case Example ➢ George’s history of gradual withdrawal and developing suspiciousness is typical of a young person with psychosis. Young people may feel worried that they are being watched and hear voices that appear to be talking to them. Sometimes young people also feel others are communicating with them through devices like TVs or computers. ➢ Although it is likely from the history that George may be developing a schizophrenic illness, it is often preferable to record the episode of illness as ‘first episode psychosis’ in a young person rather than give a diagnostic label that will be difficult to undo if it is not correct. ➢ As in George’s case, it can be difficult to engage with young people who are paranoid. The GP was right to refer George urgently for treatment. Mental health teams can be skilled at engaging with young people and getting them treatment. If this is not possible and the young person is posing a risk to themselves, others or their own health, a Mental Health Act assessment may be needed. ➢ In the UK and other countries, as well as Child and Adolescent Mental Health teams, Early Intervention in Psychosis teams offer specialist input to young people experiencing psychosis. They tend to provide intensive support in the community, focusing on recovery and positive functioning as well as treatment.

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KEY POINTS

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Psychosis describes a condition where someone loses touch with reality. The core symptoms of psychosis are hallucinations (most commonly hearing voices); delusions (having ideas which are out of step with reality) and disorganised thinking.

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Psychosis can occur in a number of different conditions, including schizophrenia, bipolar disorder and severe depression and can also be brought on by different drugs.

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Psychosis is treated with antipsychotic medication together with psychological treatments which can be individual or family based. Arts-based therapies may also be helpful.

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It is important for young people with psychosis to get professional help, which is often through the GP in the first instance. Early Intervention in Psychosis teams, as well as other mental health services, can offer specialist help.

References (1) Maijer, K., Begemann, M., Palmen, S., et al. 2018. Auditory Hallucinations across the Lifespan: A Systematic Review and Meta-Analysis. Psychological Medicine 48(6), 879–888. (2) National Institute for Health and Care Excellence (NICE). 23 January 2013. Psychosis and Schizophrenia in Children and Young People: Recognition and Management. Clinical guideline [CG155]. Last updated 26 October 2016. Available at www.nice.org.uk/guidance/cg155/

Useful Resources Web-Based Resources ➢ The Royal College of Psychiatrists have a lot of information on psychotic illness and have produced a leaflet for

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young people with psychosis and their parents and carers. Available at www.rcpsych.ac.uk/mental-health/parentsand-young-people/information-for-parents-and-carers/ psychosis-information-for-parents-and-carers ➢ Young Minds has useful information about psychosis on its website. Available at https://youngminds.org.uk/find-help/conditions/psychosis/ ➢ Health Talk is a website where people with health conditions can share their own experiences of them through video clips. The section on psychosis can be found at https://healthtalk.org/experiences-psychosis/ hearing-voices-seeing-things-and-unusual-beliefs

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27 First Aid for Mental Health This chapter is for those of you who want some practical tips on how to support someone developing a mental health problem or crisis. There is now a growing awareness that mental health first aid is a crucial part of first aid, and training across organisations is spreading. If you learn some strategies which can help you to stay calm and cope rather than panic if someone is in a mental health crisis, it can make a powerful difference to the outcomes of the person you are helping.

What Is Mental Health First Aid? ➢ Mental health first aid is coming to the aid of someone having a mental health crisis or emergency. A key part of this is assessing what is wrong and supporting the person until an appropriately trained professional can offer more specialist help or the crisis subsides. ➢ Australia developed the concept first, and it was then adopted by the UK government in 2007 as part of a national approach to improving public mental health.

First Aid for Mental Health

Is There a Difference between a Mental Health Crisis and a Mental Health Emergency? A mental health emergency is a life-threatening situation where someone is imminently threatening harm to themselves or others, severely disorientated or out of touch with reality, has a severe inability to function or is otherwise distraught and out of control (1). Examples in children and young people include the following: ➢ Acting on a suicide plan. ➢ Severe self-harm needing medical attention. ➢ Homicidal or threatening behaviour to others: this is an immediate police issue. ➢ Erratic or unusual behaviour that shows an inability to control oneself (e.g., responding to hallucinations and putting oneself in danger).

A mental health crisis is a non-life-threatening situation where someone shows extreme emotional disturbance or behavioural distress. The child or young person may be considering harm to themselves or others, or they may be out of touch with reality, have a reduced ability to function or are very agitated. Examples in children and young people include the following: ➢ ➢ ➢ ➢ ➢ ➢

Talking about suicide. Self-harm not needing immediate medical attention. Erratic or unusual behaviour. Drug or alcohol use with an impact on mental state. An eating disorder that has become stuck. Emotionally very depressed or anxious.

How Do You Manage a Mental Health Emergency or Crisis? ➢ Keep everyone safe, including yourself and the young person. This is the most crucial step in a potentially life-threatening emergency. It is most common for the child or young person to present the greatest risk to

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themselves, but they may also present a risk to others. Consider what you need to do to ensure everyone’s immediate safety? If you are worried about any person’s immediate safety call for help, then call 999 (in the UK). If it’s less urgent but still serious call 111 (UK) or the GP. Try to get the person in a safe place or position. Attend to physical first aid. Get help from a physical first aider to reduce risk. Put pressure and a tourniquet on bleeding wounds, remove sharps and call for support if urgent medical care is needed. Look for the 4 Ws – Who, What, When and Where to describe the situation – so you can give clear information when asked by medical or emergency staff. For example, if someone has taken an overdose, find out when, where and how much was taken. Keep calm, focus on breathing and try not to panic. A good way to stay calm is to focus on breathing, and you can help the young person in crisis breathe together with you. People often over-breathe quickly and shallowly when they are very anxious, which leads to more panic, so the key is to try to breathe deeply. Placing hands on your tummy helps you realise how deeply you can breathe. The 4 by 4 breathing technique is a simple one to try and goes as follows: inhale deeply through the nose for a count of 4; hold the breath for a count of 4; exhale for a count of 4. Repeat several times until you start to feel calmer. Try to listen first without being judgemental. If the young person wants to talk, let them talk without too many interruptions. Think about what may be helpful to the person in front of you. If you know them, are there any strategies that have helped them before? Is there anyone you can call for them? Stay with the young person until things calm down or professional help arrives. You may need to do shifts with another responsible adult if it’s a longer wait. Remember to rest and recover after you have helped in a difficult situation with whatever helps you. Mental health situations can be very draining, and you may need to debrief afterwards. Debriefing helps you reflect on the situation and decompress by stepping outside it in a supported way, which can help you move forwards.

First Aid for Mental Health

How Is a Mental Health Problem Assessed for Urgency? ➢ Referrals to mental health services can arrive via a variety of routes. Different areas and regions have confusingly different systems. In the UK GPs refer to mental health services giving an indication of the level of the problem and its urgency. Schools and other professionals can also refer children and young people in need of support. In many modern services, young people can also ask directly for support. ➢ If a child has been through a crisis or emergency, it is likely they will have first been assessed in a general hospital to stabilise their physical health. For example, following an episode of serious self-harm or a suicide attempt, a child or young person will first be treated in hospital and then declared ‘medically fit’ before they see the mental health team. ➢ Mental health triage is the process of first assessment that occurs at point of entry to the mental health service. Specialist professionals triage referrals by going through all the information they have about cases and then they prioritise access to the most appropriate service. ➢ All referrals are screened using brief psychiatric assessment tools to decide whether the child or young person has a mental health-related problem, the urgency of the problem and which service will best meet their needs. ➢ Most services use a sliding scale to try to work out how quickly a response needs to be implemented depending on the young person’s mental state, their risk to self and others and their available supports. Critical cases are prioritised often through duty systems, so a timely response can be provided. Less critical cases will be prioritised following standard criteria. ➢ Most community mental health teams don’t function as emergency teams; instead they work in conjunction with crisis teams and hospital liaison teams to ensure that there is a system through which young people can access mental health support after their emergency.

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What about Training for Mental Health First Aid? ➢ The Department of Health encouraged all employers in England to provide mental health first aid training in its 2012 ‘No Health Without Mental Health: Implementation Framework’ (2). Several organisations now offer youth mental health first aid training courses (3). ➢ Mental health support teams form part of a developing programme in English schools and colleges. These teams can offer support and training around mental health first aid. NHS England and NHS Improvement are leading this programme (4).

KEY POINTS

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Mental health first aid is an important skill that most responsible adults can learn. It involves supporting someone developing a mental health problem or crisis.

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Workplaces and schools should all aim to have mental health first aiders, and there are increasing training opportunities. The new mental health support teams in schools can also offer guidance and training in mental health first aid.

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There are some important steps to take in managing mental health emergencies, including keeping everyone calm and safe, focusing on breathing, helping young people open up and calling for professional help and emergency services support when needed.

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Mental health triage is the process of assessing the urgency of mental health calls for services. Children and young people are assessed according to standardised criteria, including mental state, safety of self and others and what support they have available.

First Aid for Mental Health

References (1) University of Hawai‘i, Honolulu Community College, Wellness Center. What Is the Difference between a Mental Health Emergency and a Mental Health Crisis? Available at www.honolulu.hawaii.edu/sites/www.honolulu.hawaii .edu/files/wellness-difference-emergency-crisis.pdf (2) UK government report. February 2011. No Health without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages – a Call to Action. Available at www.gov.uk/government/publications/ no-health-without-mental-health-a-cross-government-mental-healthoutcomes-strategy-for-people-of-all-ages-a-call-to-action (3) Mental Health First Aid England. Available at https://mhfaengland.org/ (4) NHS England. Mental Health. Children and Young People. New Mental Health Support in Schools and Colleges and Faster Access to NHS Care. Available at www.england.nhs.uk/mental-health/cyp/trailblazers/

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28 Mental Health Teams: Who Works in Them and What Are the Types of Specialist Teams? Who Works in Specialist Mental Health Teams? Teams often include a range of professionals who can help diagnose and treat more serious mental disorders. UK teams may include the following people: ➢ Team managers handle the smooth running of their team, including sorting out referrals, workloads and support of staff. They will often have to manage budgets and interface with other services. They are the person to speak to on the phone if as a parent you are unhappy with the wait or the service. ➢ Service managers have overall responsibility for managing community mental health services, including working strategically within and between organisations and commissioners (who fund services). ➢ Child and adolescent psychiatrists are specialist doctors trained to diagnose and treat young people’s mental health problems. They can

Mental Health Teams: Who Works in Them?

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prescribe medication if needed. Consultant psychiatrists have undergone at least eight years of postgraduate foundation and specialist training after medical school and often hold a leadership role within services. Clinical psychologists have had specialist training to deliver psychological therapies to young people, the most common being CBT (cognitive behavioural therapy), but many are also trained in a range of evidence-based therapies. Psychologists have undergone at least three years of doctoral training in clinical psychology after their first degree, so are highly skilled professionals. Social workers commonly work in mental health teams as professionals who are particularly skilled at supporting families and understanding issues around safeguarding and family support. They have undertaken social work degrees. In mental health teams they often work as specialist mental health practitioners, supporting children and families. Mental health nurses provide much of the specialist clinical care and support of children and young people. Many have also been trained to deliver specialist treatments. They have undertaken mental health nursing training, to degree level, and have a high level of clinical skills in managing young people’s health needs. Occupational therapists are experts in identifying and eliminating barriers to functioning in children and young people who may be impaired in some way to participate in activities of daily living. For example, where there are young people with autism and sensory needs, they may do a sensory assessment and look at ways to help to manage these needs. They have degrees in occupational therapy and often also act as specialist mental health practitioners in mental health teams. Nurse prescribers are specialist nurses who can prescribe a limited range of psychiatric medication, and are often employed in ADHD services, working under supervision of prescribing doctors. Family therapists are specially trained professionals who deliver family therapy. They have undergone postgraduate training in family therapy. This is an important role in CAMHS as families are key to supporting the child or young person and helping them to recover. Family therapists work with the whole family system including siblings.

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➢ Psychotherapists may become involved in longer-term work with children and young people with complex mental health problems which are often rooted in difficulties with attachment and relationships. Access is limited in the NHS as it is expensive. It involves a longer-term, often weekly, commitment on the part of the family and child or young person. Psychotherapists have undergone up to three years of postgraduate training, a prerequisite of which is to undergo their own therapy.

What Are the Different Youth Mental Health Services in the UK? Teams Working with a Range of Conditions ➢ Specialist mental health teams are usually made up of a group of the above professionals who either work with a broad range of mental health disorders in children’s and young people’s mental health services, or they may have specialised into smaller sub-teams to work with different sub-groups of families. In the UK these teams are collectively known as CAMHS, which stands for Child and Adolescent Mental Health Services. It is important to note that as well as carrying out direct interventions, CAMHS teams play an important role in inter-agency working and planning. ➢ Crisis teams can provide more intensive home-based support to a child or young person who is experiencing a mental health crisis for a short period of time. Crisis teams may work from hospitals with young people who have attempted suicide or serious self-harm, or young people involved with community mental health teams who need more intensive treatment. This could involve several contacts a week, including home visits, and is often a more acceptable alternative to hospital admission. These teams are not yet available in all areas. ➢ Outreach teams provide a service to children and young people who have high levels of mental health need but who find it difficult to engage with outpatient services. These services often include a small team of skilled professionals who can meet young people in the community and

Mental Health Teams: Who Works in Them?

provide high levels of input to help prevent inpatient admissions for those most at risk and difficult to engage. This type of service is not yet available in all areas. ➢ Inpatient mental health services look after children and young people admitted to a specialist child or adolescent mental health hospital. They can provide a high level of nursing care and other specialist treatments. Units are now nationally commissioned and cover large geographical areas. Many of the secure adolescent units (for young people who are at higher risk) are also in the private sector. The emphasis is on admissions being as short as possible. Inpatient teams work closely with local community teams to ensure care can be transferred to the community as soon as possible.

Teams Working with Specific Mental Health Disorders ➢ Eating disorders teams offer community care to those with eating disorders. In the last few years there has been a huge expansion of specialist eating disorders teams nationally, so that there are now local specialist teams in most areas which offer timely service and specialist care. Eating disorders teams often work together with crisis and other community teams to provide meal support in the community and may work with general hospitals around admission of unwell patients. ➢ Neurodevelopmental services are involved in the diagnosis and treatment of autism and ADHD. Sometimes these services will sit within paediatrics services, other times in mental health, and sometimes straddle the two services. ➢ Intellectual (learning) disability teams provide support to children and young people with intellectual disabilities. These teams often work in conjunction with families as well as specialist schools and institutions. ➢ Early Intervention in Psychosis services help support young people who are undergoing a first episode of a psychotic illness (such as in schizophrenia or bipolar disorder). They often work in conjunction with CAMHS teams to provide specialist support for young people under 18 and frequently follow a community-based model of treatment.

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➢ Forensic mental health teams are usually regional services and serve the mental health needs of young people who have committed crimes or are at high risk to others (e.g., in young offender institutes or secure hospital placements). They often provide a consultation role to specialist CAMHS teams. ➢ Gender identity services are nationally commissioned services. They provide support for young people with gender identity difficulties. As the referral rate has increased exponentially in the last few years the wait time to access specialist support is often very long. The specialist teams are now working to offer more consultation to local teams. ➢ Other regional and national specialist teams cover most of the major mental disorders, as well as mental health for people with other disabilities, such as Deaf CAMHS. The Institute of Psychiatry, King’s College London, is a hub for many UK highly specialist teams, each with local CAMHS teams, providing advice and second opinions for complex cases.

Concluding Remarks You, as parents, caregivers and teachers, as well as other important adults around children and young people, play a crucial role in both the support and promotion of positive mental health. Understanding important factors that have a key impact on mental health can empower you to help children and young people to improve their mental health and life chances. In Part 1 I discussed these factors, including biological factors, lifestyle factors, relationships, stressors as well as vulnerable groups. Although the amount of information available on mental health topics can appear overwhelming at times, it can be helpful to remember that you don’t have to know everything to offer effective support. Instead, what is most important is for you to maintain an open and listening stance with children and young people as you walk alongside them through their development. You are their strongest advocates and often their greatest supports. It’s beneficial to find out how to get effective help and information and to prioritise your family’s mental health and wellbeing in the same way you prioritise their physical health. Although the stigma of mental health conditions is reducing, it has not yet disappeared, and we can all do our bit to continue to fight it. Part 2 of this book outlined basic principles around strengthening the relationship with children and young people and giving support. Positive relationships underpin so much in mental health and wellbeing. I explained the importance of sticking to basic principles, including connecting with children and young people and helping them build supportive relationships. I outlined how to prioritise getting support for yourself and loved ones, so you have the energy to look after your children.

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Part 3 of this book gave an overview of most of the common mental health difficulties and disorders we come across in mental health services. Whether you read each chapter in Part 3 individually or consult them as needed, a key message to take away is that it is helpful to identify any mental health problems early on, seek support from others and consult with or refer to mental health services if problems persist. School support staff are increasingly aware of mental health issues and often know how to link in with local support networks. You, as parents, caregivers and teachers, are the experts on your children and if you feel that something is wrong, you should feel justified in persisting in seeking help for them. Children and young people learn the most from those they are closest to, so if you take a positive attitude to mental health and look after your own, you are setting an important example. Good luck!

Index abuse and neglect, 96–103 adult abused as a young person, 98 bullying, 98 caring for young people who have been abused, 101–102 child sexual exploitation, 98 child trafficking, 98 definition of, 96 domestic abuse, 98 effects of early support, 99 effects on brain and mental health, 97 effects on developing brains, 99 emotional (or psychological) abuse, 97 female genital mutilation, 98 forms of child abuse, 96 forms of neglect, 97 grooming, 98 Key Points, 102–103 longer-term effects, 99–100 modern slavery, 98 non-recent abuse, 98 online abuse, 98 physical abuse, 97 prevalence of, 96–97 sexual abuse, 97, 98 types of child abuse, 97–98 what to do if you suspect a young person is being abused or neglected, 100, 101 witnessing domestic abuse, 98 academic pressures, 60–63 factors that may make young people feel overwhelmed, 61 Key Points, 63 numbers of young people affected by, 61 signs that a young person is struggling, 61–62 what you can do to help, 62 when to step in, 61–62

addiction (dependence syndrome), 341, 343 adverse childhood experiences (ACEs), 104–106 coping strategies for children, 105–106 definition of, 104 effects on brain and body, 105 helping to build resilience, 105–106 how to reduce the impact of, 105–106 impact on mental health outcomes, 105 Key Points, 106 relationship with negative life outcomes, 104 research that discovered their life effects, 104 types of, 104 agoraphobia, 253 Ainsworth, Mary, 11–12 alcohol, 64–66 educating your child about safe and legal use, 65–66 effects of drinking at a young age, 64 guidance on use by young people, 64 helping young people understand the impact of, 68 Key Points, 68–69 mental health difficulties related to, 338–350 providing young people with accurate information about, 68 risks of drinking at a young age, 65 Alter, Adam, 49 anger and behaviour difficulties, 284–295 Case Example (Larry), 293–295 anorexia nervosa, 360–363 antisocial behaviour, 284–295 antisocial personality disorder (ASPD), 293

414

Index anxiety, 246–258 Case Example (Noel), 256–257 anxiety disorders, 251–258 attachment anxious (or ambivalent) attachment style, 11 attachment styles, 11–12 avoidant attachment style, 11 definition of, 9–10 disorganised attachment style, 12 how attachment behaviours change with age, 12–13 importance of, 10 influence on mental health, 9–14 insecure attachment styles, 11–12 Key Points, 14 nurturing healthy attachment with your child, 13–14 oxytocin bonding hormone in new parents, 11 parental responsiveness and, 12 role in emotional development, 10 secure attachment style, 11, 12 what happens if it is not secure, 12 attachment difficulties, 298–304 attachment disorders, 300–304 Case Example (Mini), 302–304 disinhibited attachment disorder, 300 reactive attachment disorder, 300 attention deficit disorder (ADD), 326 attention deficit hyperactivity disorder (ADHD), 323–336 Case Example (Charlie), 333–335 effects of foods with colours and additives, 39 neurodevelopmental services, 409 autism, 151–152, 306–320 Case Example (Zac), 317–319 neurodevelopmental services, 409 avoidant-restrictive food intake disorder (ARFID), 357–358 behaviour disorders, 287–295 bereavement, 112–117 children experience death differently from adults, 113–114 children’s understanding of death at different ages, 114

factors affecting how a child or young person responds, 113 helping children through grief, 115 how it may be experienced by children and young people, 112 Key Points, 120 risk of becoming stuck in grief, 117 stages of grief, 114–115 strategies to help children cope with grief, 116 what to do if a child seems to be stuck in grief or loss, 117 binge eating disorder, 202 biological processes attachment, 9–14 brain development, 17–21 genetic inheritance, 14–17 influence on mental health, 9–25 puberty, 22–25 bio-psycho-social model risk factors for mental disorders, 209 bipolar disorder, 238–244 Case Example (Jade), 242–244 body dysmorphic disorder (BDD), 374–380 Case Example (Jenna), 378–379 body image concerns, 374–380 bonding role of oxytocin, 11 borderline personality disorder, 232, 233–234 Bowlby, John, 10, 11 brain development, 17–21 ability of the brain to change in response to stimulation, 20 age when the brain is fully mature, 18 differences between the brains of children and adults, 18–19 factors after birth, 20 factors before birth, 19–20 growth mindset and learning, 20–21 influence of external factors, 19–20 Key Points, 21 plasticity of the brain, 20 process of, 19 stages of, 18 breasts changes in boys, 23 development in girls, 22

Index bulimia nervosa, 363–364 bullying, 56–60, 98 definition of, 56 effects of, 57 emotional support for someone who is being bullied, 59 experienced by LGBTQ+ young people, 138 Key Points, 60 practical support for someone who is being bullied, 59 reporting criminal behaviour to the police, 59 reporting bullying to the school, 59 responsibility of the school, 59 school failing to deal with the problem helpfully, 60 signs that a child or young person may be being bullied, 56–57 vulnerabilities for bullying, 57 what to do if you think a child or young person is being bullied, 58–59 what to do if your child is bullying others, 58 who will get bullied, 57 why some children bully others, 58 burnout, 161 caffeine, 38 capacity decision-making capacity of a young person, 213–214 caregivers attachment relationship with the child, 9–14 carers looking after yourself, 161–164 See also young carers Case Examples Ajay (childhood trauma/PTSD), 279–280 Cemi (drug problems), 348–349 Charlie (ADHD), 333–335 George (psychosis), 396–397 Jade (bipolar disorder), 242–244 Jane (OCD), 387–388 Jenna (body dysmorphic disorder), 378–379

Jenny (self-harm), 270–271 Larry (anger and behaviour difficulties), 293–295 Layla (depression), 225–226 Mini (attachment disorder), 302–304 Noel (panic attacks), 256–257 Safia (eating disorder), 368–370 Sara (emotion dysregulation), 235–236 Zac (autism), 317–319 child abuse. See abuse and neglect Child and Adolescent Mental Health Services (CAMHS), 408 child and adolescent psychiatrists, 406–407 child trafficking, 98 childhood trauma, 107–110, 274–281 Case Example (Ajay), 279–280 classification of trauma, 107–108 definition of trauma, 107 effects of severe trauma on the developing brain, 108 helping young people who have been exposed to trauma, 109 Key Points, 110 longer-term mental health impacts, 108–109 post-traumatic growth, 110 clinical psychologists, 407 cognitive behavioural therapy (CBT), 233, 254–255 trauma focused CBT, 278 communication, 166–172 children who don’t seem to want to communicate with you, 171 eye contact, 168 how to connect with children and young people, 166–167 improving your verbal communication, 170 Key Points, 172 non-verbal communication, 167–168 role of empathy, 167 through play and creative arts, 169–170 touch, 168–169 computer games, 49–50 conduct disorder, 287–295 confidentiality issues mental health professionals, 213

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Index connecting with children and young people, 166–172 children who don’t seem to want to communicate with you, 171 eye contact, 168 how to connect, 166–167 improving your verbal communication, 170 Key Points, 172 non-verbal communication, 167–168 play and creative arts, 169–170 role of empathy, 167 touch, 168–169 Cosmic Yoga, 44 county lines, 348 COVID-19 pandemic, 121–127 additional mental health support, 126 groups whose mental health was particularly affected, 124 helping children to understand without unduly worrying, 124–125 impact on the mental health of children and young people, 122–124, 388 Key Points, 127 longer-term impacts, 126–127 supporting mental health during lockdown, 125–126 unequal impacts across society, 122–124 use of technology to connect with people, 48–49 wide-ranging impacts of, 121–122 creative arts connecting with children and young people, 169–170 crisis mental health teams, 268–269 cyber-bullying, 50, 98 cyclothymia, 234–235 decision-making capacity competence of a young person, 213–214 delusions, 391–398 depression, 217–227 Case Example (Layla), 225–226 diagnosis difference between having some symptoms and having a disorder, 211–212

pros and cons of having a diagnosis, 210–211 spectrum of mental health disorders, 211–212 Diagnostic and Statistical Manual of Mental Disorders (DSM), 210 dialectical behaviour therapy (DBT), 233, 268 diet. See food and nutrition discrimination vulnerability of those affected by, 151 disruptive mood dysregulation disorder (DMDD), 224–225 divorce. See parental separation dog walking, 44 domestic abuse, 98 Down’s syndrome, 307 drugs, 64, 66–69 Case Example (Cemi), 348–349 county lines, 348 dependence syndrome (addiction), 341, 343 drugs that are linked to mental health symptoms, 67 helping young people understand the impact of, 68 how they affect the brain, 340 how they affect the brain in young people, 66 Key Points, 68–69 legal classification, 339–340 link between cannabis and mental health problems, 67 links between recreational drug use and mental health, 67 mental health difficulties related to, 338–350 patterns of drug use in young people, 341 providing young people with accurate information about, 68 types of illegal drugs, 339 Dweck, Carol, 20–21 dysthymia, 224 Early Intervention in Psychosis services, 409 eating difficulties related to, 353–371 eating disorders, 353–371 anorexia nervosa, 360–363

Index avoidant-restrictive food intake disorder (ARFID), 357–358 binge eating disorder, 365 bulimia nervosa, 363–364 Case Example (Safia), 368–370 definition of, 356 impact of the COVID-19 pandemic, 124 obesity, 359–360 other specified feeding or eating disorder (OSFED), 366–367 outcomes, 368 pica, 358–359 prevalence of, 356–357 types of, 357 eating disorders teams, 409 Education, Health and Care Plan (EHCP), 197–198 emotion dysregulation, 228–236 Case Example (Sara), 235–236 emotional development role of the early attachment relationship, 10 emotionally unstable personality disorder, 232, 233–234 empathy, 167 environment epigenetic changes caused by, 16 importance of a positive nurturing environment, 16 interaction with genes, 14–15 epigenetics, 16 erections, 23 exercise and movement, 41–46 dangers of over-exercising, 45 dog walking, 44 encouraging exercise in children and young people, 43–44 finding which activity suits your child, 45 fitness apps and gadgets, 44 importance for mental health, 41–42 Key Points, 45–46 mental health benefits, 42–43 mental health support in sports clubs, 45 recommendations for different age groups, 42 tips for getting started, 44 eye movement desensitisation and reprocessing (EMDR), 278

family relationships, 72–75 adult models of positive relationships, 74 benefits of positive family relationships, 72–73 building in more positive family time, 73 forms of modern families, 72 importance to our mental health, 72 Key Points, 74–75 nurturing family connections, 73 role of parents and caregivers, 72 family therapists, 407 female genital mutilation, 98 first aid for mental health. See mental health first aid fitness apps and gadgets, 44 fixed mindset, 21 food and nutrition, 34–40 effects of deficiencies, 37–38 effects of food colours and additives, 39 foods that can have a negative effect on mental health, 38–39 guidance on a balanced diet for adults, 35 guidance on a balanced diet for children, 35–36 gut health, 36–37 impact on mental health, 34 important components of food, 37–38 Key Points, 40 Mediterranean diet, 37 minerals in the diet, 37–38 nutritional needs of children, 35–36 omega 3 and omega 6 fats, 38 principles for mental health, 36–37 promoting healthy eating patterns, 39 vitamin deficiency effects, 37, 38 vitamin supplements, 36 forensic mental health services, 292 forensic mental health teams, 410 Fragile X syndrome, 307 gaming addiction, 49–50, 52 gender identity difficulties, 135–140 defining sexual orientation, 136 distinction between sex and gender, 136–137 gender diversity, 136 gender dysphoria, 136–137 gender identity during development, 137 Key Points, 140

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418

Index gender identity difficulties (cont.) meaning of LGBTQ+, 136 reasons for mental health challenges, 138 risk of mental health difficulties, 135 special mental health concerns of LGBTQ+ young people, 137–138 specialist services and support, 139–140 terms associated with gender identity and dysphoria, 136–137 what parents can do to help, 138–139 gender identity services, 120 generalised anxiety disorder, 254 genetic inheritance contribution of nature and nurture to mental health, 15–16 description of genes, 15 epigenetic changes caused by the environment, 16 genes and mental health disorders, 15–16 influence on mental health, 14–17 interaction between genes and the environment, 14–15 Key Points, 17 Gillick Competence, 214 global health issues. See COVID-19 pandemic grief helping children through, 115 Key Points, 120 risk of becoming stuck in grief, 117 stages of, 114–115 strategies to help children cope with, 116 what to do if a child seems to be stuck in grief or loss, 117 grooming, 98 growth mindset learning and, 20–21 nurturing in children, 203 gut health, 36–37 gut microbiome, 36 hallucinations, 391–398 helicopter parenting, 189–190 helplines for people in distress, 265 household challenges. See adverse childhood experiences (ACEs) Human Genome Project, 15

impulsiveness. See attention deficit hyperactivity disorder (ADHD) inheritance. See genetic inheritance inpatient mental health services, 409 intellectual disability, 130–134 access to additional help or support, 133–134 causes of, 131 classification systems, 131 definition of, 130 difference between disability and impairment, 131 difficulty of recognising mental health problems, 132 factors affecting presentation of mental health problems, 132 how you can help with mental health, 133 Key Points, 134 risk of mental health and neurological problems, 130 sources of support and information, 130 intellectual (learning) disability teams, 409 International Classification of Diseases (ICD), 210 Internet. See technology Kubler-Ross, Elisabeth, 114 languishing definition of, 3 learning growth mindset and, 20–21 learning disability, 130–134 access to additional help or support, 133–134 causes of, 131 classification systems, 131 definition of, 130 difference between disability and impairment, 131 difficulty of recognising mental health problems, 132 factors affecting presentation of mental health problems, 132 how you can help with mental health, 133 intellectual (learning) disability teams, 409 Key Points, 134

Index risk of mental health and neurological problems, 130 sources of support and information, 130 LGBTQ+ young people, 135–140 defining sexual orientation, 136 defining sexuality, 136 gender identity during development, 137 Key Points, 140 meaning of LGBTQ+, 136 reasons for mental health challenges, 138 risk of mental health difficulties, 135 special mental health concerns, 137–138 specialist services and support, 139–140 what parents can do to help, 138–139 lifestyle factors academic pressures, 60–63 alcohol, 64–66 bullying, 56–60 drugs, 64, 66–69 exercise and movement, 41–46 food and nutrition, 34–40 sleep, 26–33 technology, 47–54 loneliness health impacts of, 71 impact on young people, 77 looked-after children, 150–151 looking after yourself, 161–164 avoiding burnout, 161 getting support for your own needs, 163–164 Key Points, 164 things you can do, 162–163 why looking after your own needs is important, 161–162 Maslow’s pyramid of needs, 7 Mediterranean diet, 37 melatonin, 32 mental fitness definition of, 3 mental flourishing definition of, 3 mental health assessment by mental health professionals, 6 definition of, 3 factors affecting, 4–5

link with mental wellbeing, 4 summary of factors affecting, 153–157 Mental Health Act, 214 mental health condition definition of, 5 mental health crisis, 401 crisis teams, 408 See also mental health first aid mental health difficulties, 207 alcohol-related difficulties, 338–350 anger and behaviour difficulties, 284–295 anxiety, 246–258 assessing the decision-making capacity of a young person, 213–214 attachment difficulties, 298–304 attention and activity difficulties, 323–336 attention deficit disorder (ADD), 326 attention deficit hyperactivity disorder (ADHD), 323–336 autism, 306–320 behaviour disorders, 287–295 bio-psycho-social model of risk factors, 209 bipolar disorder, 238–244 body dysmorphic disorder (BDD), 374–380 body image concerns, 374–380 childhood trauma, 274–281 confidentiality issues for mental health professionals, 213 depression, 217–227 diagnosis of mental health disorders, 210 difference between having some symptoms and having a disorder, 211–212 drug-related difficulties, 338–350 eating difficulties/disorders, 353–371 emotion dysregulation, 228–236 Key Points, 215–216 losing touch with reality, 391–398 mood disorders, 217–227 mood swings, 228–236 neurodevelopmental conditions, 306–320 obsessions, 382–389 obsessive compulsive disorder (OCD), 382–389 panic attacks, 252–258

419

420

Index mental health difficulties (cont.) perfectionism, 382–389 post-traumatic stress disorder (PTSD), 274–281 pros and cons of having a diagnosis, 210–211 psychosis, 391–398 risk factors versus coping strategies, 208 see-saw model, 208 self-harm, 260–264, 270–272 spectrum of mental health disorders, 211–212 substance misuse and, 338–350 suicidal thoughts and acts, 264–269, 271–272 support for young people close to someone who engaged in self-harm or suicidal acts, 269 treatment refusal, 214–215 treatment without consent, 214–215 what causes difficulties to arise, 209 when difficulties become a disorder, 209 worry, 246–258 mental health disorders age of onset, 6 classification systems, 210 contribution of genetic and environmental influences, 15–16 definition of a mental health disorder, 5 proportion of young people with, 6 pros and cons of having a diagnosis, 210–211 mental health emergency definition of, 401 See also mental health first aid mental health first aid, 400–404 assessment of the urgency of a mental health problem, 403 definition of, 400 definition of a mental health crisis, 401 definition of a mental health emergency, 401 Key Points, 404 managing a mental health emergency or crisis, 401–402 training for, 404 mental health nurses, 407 mental health problems combination of inherited and environmental causes, 4–5

mental health professionals confidentiality issues, 213 mental health assessment, 6 mental health promotion summary of factors, 153–157 mental health services assessment of the urgency of a mental health problem, 403 inpatient mental health services, 409 management of mental health teams, 406 range of health professionals in mental health teams, 406–408 range of youth services in the UK, 408–410 support for those at risk of suicide, 268–269 teams working with a range of conditions, 408–409 teams working with specific mental health disorders, 409–410 mental health teams Child and Adolescent Mental Health Services (CAMHS), 408 child and adolescent psychiatrists, 406–407 clinical psychologists, 407 crisis teams, 408 Early Intervention in Psychosis services, 409 eating disorders teams, 409 family therapists, 407 forensic mental health teams, 410 gender identity services, 410 inpatient mental health services, 409 intellectual (learning) disability teams, 409 management of, 406 mental health nurses, 407 neurodevelopmental services, 409 nurse prescribers, 407 occupational therapists, 407 outreach teams, 408–409 psychotherapists, 408 range of health professionals in teams, 406–408 range of youth services in the UK, 408–410 social workers, 407 specialist mental health teams, 408

Index teams working with a range of conditions, 408–409 teams working with specific mental health disorders, 409–410 mental illness predictors of, 5 mental wellbeing definition of, 3 factors affecting, 4–5 link with mental health, 4 positive mental wellbeing, 4 predictors of mental illness, 5 supporting children’s mental wellbeing, 6–7 mentalisation, 79 mentalisation-based treatments, 233 mindset fixed mindset, 21 growth mindset, 20–21 minerals in the diet, 37–38 misinformation online, 50 modern slavery, 98 mood disorders, 217–227 Case Example (Layla), 225–226 mood swings, 228–236 Case Example (Sara), 235–236 motor disorders, 307 needs Maslow’s pyramid of needs, 7 meeting children’s basic needs, 7 psychological needs of children, 7 neglect. See abuse and neglect neurodevelopmental conditions, 151–152, 306–320 neurodevelopmental services, 409 neurodiversity, 306 neurogenetic disorders, 307 non-verbal communication, 167–168 nurse prescribers, 407 nutrition. See food and nutrition obesity, 359–360 obsessions, 382–389 obsessive compulsive disorder (OCD), 382–389 Case Example (Jane), 387–388 impact of the COVID-19 pandemic, 124 occupational therapists, 407 omega 3 and omega 6 fats, 38 online abuse, 98

online safety. See technology oppositional defiant disorder (ODD), 287–295 OSFED (other specified feeding or eating disorder), 366–367 oxytocin role as a bonding hormone, 11 panic attacks, 252–258 Case Example (Noel), 256–257 panic disorder, 253 PANS/PANDAS, 385 parental separation, 117–120 impacts on children’s mental health, 118–119 key points, 120 supporting children if you decide to separate, 119 worries of children of separated parents, 118 parenting agreeing common parental values and approaches, 175 coping with relationship difficulties, 176 positive parenting strategies, 184–191 supporting partners and co-parents, 173–177 why co-parenting is helpful, 174 parents attachment relationship with the child, 9–14 looking after yourself, 161–164 partners supporting partners and co-parents, 173–177 peer relationships, 75–81 benefits for children and young people, 76 coping with peer pressure, 79–80 encourage children to think for themselves, 79–80 encouraging the development of positive relationships, 77–78 groups who tend to struggle more with, 78 helping young people develop positive social skills, 78 impact of loneliness on young people, 77 importance of social contact, 75–76 Key Points, 80–81 online friends, 77

421

422

Index peer relationships (cont.) use of mentalisation, 79 when young people fall out, 80 perfectionism, 382–389 periods, 23 phobias, 253 physical activity. See exercise and movement physical health difficulties, 142–146 financial help, 144 help from supportive adults and parents, 144 Key Points, 145–146 range of conditions that children can experience, 142 reasons for increased risk to mental health, 143 risk of mental health difficulties, 142 sources of support, 145 support that schools can provide, 144 pica, 358–359 play connecting with children and young people, 169–170 pornography, 86 positive mental wellbeing, 4 positive parenting strategies, 184–191 analogies for parenting, 189 apologising, 190–191 concept of the ’good enough mother’, 185 disagreements and arguments, 190 helicopter parenting, 189–190 helping children to develop independence, 189–190 Key Points, 191 myth of the perfect parent, 185 praise and encouragement, 186–187 punishments and consequences for difficult behaviours, 187 routines, 188 rules and boundaries, 188 showing your children that you are there for them, 186 staying calm and in control, 185–186 post-traumatic growth, 110 post-traumatic stress disorder (PTSD), 274–281 Case Example (Ajay), 279–280 definition of, 276

levels of severity, 276–277 symptoms of, 276 pre-biotics, 37 premenstrual syndrome, 23 psychiatrists child and adolescent psychiatrists, 406–407 psychologists, 407 psychosis, 391–398 Case Example (George), 396–397 Early Intervention in Psychosis services, 409 psychotherapists, 408 puberty, 22–25 breast changes in boys, 23 breast development in girls, 22 common anxieties for boys, 23 common anxieties for girls, 22–23 definition of, 22 effects on children’s mental health, 23–24 emotion regulation challenges, 24 erections, 23 Key Points, 25 periods, 23 premenstrual syndrome, 23 risk of developing mental health disorders during, 23–24 sleep disruptions, 24 supporting young people during, 24 voice changes in boys, 23 wet dreams, 23 racism vulnerability of those affected by, 151 relationships communication, 166–172 connecting with children and young people, 166–172 creating a network of support, 178–182 family relationships, 72–75 health impacts of loneliness, 71 helping to build resilience and strengths, 201–204 peer relationships, 75–81 positive parenting strategies, 184–191 romantic relationships and sex, 81–87 social relationships, 75–81 supporting partners and co-parents, 173–177

Index resilience and strengths benefits of building, 202 helping children to build, 201–204 Key Points, 204 strength-based approach in mental health, 202–204 ways to help children build, 202–204 resources, 7 romantic relationships and sex, 81–87 benefits of romantic relationships, 82–83 coercive relationships, 84–85 developmental patterns as young people mature, 82 difficulties of early romantic relationships, 83 effects of difficult sexual experiences on mental health, 86 effects of exposure to pornography, 86 helping a young person in a controlling or unhealthy relationship, 84–85 important features of healthy relationships, 83–84 Key Points, 87 potential issues between parents and young people, 81–82 signs that a relationship is harmful to a young person, 84 talking about safe sex with young people, 85 school, 194–199 academic pressures, 60–63 bullying, 56–60 children with special needs, 196–199 Education, Health and Care Plan (EHCP), 197–198 helping your child to manage school, 195 how to sort out problems with the school, 196 Key Points, 199 specialist schools, 198–199 selective mutism, 254 self-care, 161–164 avoiding burnout, 161 getting support for your own needs, 163–164 helping children to develop, 203 Key Points, 164 things you can do, 162–163

why looking after your own needs is important, 161–162 self-harm, 232, 260–264, 271–272 Case Example (Jenny), 270–271 Case Example (Sara), 235–236 separation anxiety, 253 sertraline, 388 sex. See romantic relationships and sex sexual abuse. See abuse and neglect sexual orientation definition of, 136 vulnerable groups, 135–140 sexuality definition of, 136 sleep, 26–33 amount needed by children and young people, 29–30 body clocks of teenagers, 30 factors that can counter sleep, 30 health impacts of, 27 health impacts of lack of sleep, 28–29 helping young people to improve their sleep, 30–32 importance of, 27 individual differences in amount needed, 29 influence on mental health, 26 Key Points, 32–33 mental health issues related to sleep duration, 28–29 natural preferences for when we sleep, 30 ‘night owls’ and ‘early morning larks’, 30 physical health issues related to sleep duration, 29 sleep disorder assessment, 32 sleep hygiene tips, 30–32 sleeping tablets, 32 stages of the sleep cycle, 27–28 what happens when we sleep, 27–28 why teenagers struggle to wake for school, 30 social anxiety disorder of childhood, 253 social media. See technology social phobia, 253 social relationships, 75–81 benefits for children and young people, 76 coping with peer pressure, 79–80 encourage children to think for themselves, 79–80

423

424

Index social relationships (cont.) encouraging the development of positive relationships, 77–78 groups who tend to struggle more with peer relationships, 78 helping young people develop positive social skills, 78–79 impact of loneliness on young people, 77 importance of social contact, 75–76 Key Points, 80–81 online friends, 77 use of mentalisation, 79 when young people fall out, 80 social workers, 407 special educational needs, children with managing school, 196–199 specific learning disorders, 307 sports. See exercise and movement Strava, 44 strength-based approach in mental health, 202–204 stress chronic stress, 91 degrees of, 90–91 harmful effects on body systems, 92 if it is getting out of control, 95 if it is too much to manage at home, 95 Key Points, 95 lasting health impact of prolonged stress, 90 manageable stress, 90 signs that it is becoming a problem for a child, 92 ‘stress bucket’ coping strategy, 93 stress-management strategies, 94–95 stress response, 90 tolerable stress, 90 triggers for, 91 what happens to the body, 91 why too much stress is bad, 92 stressors affecting mental health, 89 abuse and neglect, 96–103 adverse childhood experiences (ACEs), 104–106 bereavement, 112–117, 120 childhood trauma, 107–110 impact of COVID-19 and other global health issues, 121–127 parental separation, 117–120

substance misuse, 338–350 suicidal thoughts and acts, 264–269, 271–272 support networks, 178–182 changing and evolving over time, 181–182 creating a visual model with your child, 179–180 Key Points, 182 overlapping networks of support, 180–181 reasons for building, 178–179 technology, 47–54 advice from mental health professionals, 51–52 balanced approach towards, 47 computer games, 49–50 cyber-bullying, 50 digital natives, 47 exposing children to inappropriate content, 50 gaming addiction, 49–50, 52 internet predators, 50 keeping safe online, 52–54 Key Points, 54 mental health tools, 49 misinformation and harmful advice, 50 parental controls, 51 potential negatives for mental health, 49–50 potential positives for mental health, 48–49 professional help for mental health concerns, 52 research on mental health impacts, 48 social media comparisons and selfesteem, 50 what to do if a young person seems to have lost control over screen use, 52 tics, 308–309 touch role in communication, 168–169 Tourette’s syndrome, 308–309 trauma. See childhood trauma; posttraumatic stress disorder (PTSD) traumatic brain injury, 307 treatment refusal by a young person, 214–215 without consent, 214–215

Index vitamin D, 36 vitamin deficiency effects, 37, 38 vitamin supplements, 36 voice changes in boys, 23 vulnerable groups, 129 autism, 151–152 different sexual orientations, 135–140 gender identity difficulties, 135–140 intellectual disability, 130–134 learning disability, 130–134 LGBTQ+ young people, 135–140 looked- after children, 150–151 neurodevelopmental conditions, 151–152 physical health difficulties, 142–146 those who experience racism and discrimination, 151 young carers, 146–149 Walker, Matthew, 27, 28 wet dreams, 23

Wicks, Joe, 44 Winnicott, Donald, 185 World Health Organization (WHO) definition of mental health, 3 worry, 246–258 worry wave, 249 young carers, 146–149 challenges faced by, 146–147 definition of, 146–147 effects of being a young carer, 148 Key Points, 149 mental and physical health risks, 146–147 numbers in the UK, 147 support available for, 148–149 types of problems supported by, 147 vulnerability to difficulties, 148 youth offending teams, 292

425