Mental health of adolescents on the edge of care

1. Social Work Research & Development Unit Mental health of adolescents on the edge of care Nina Biehal Social Policy Research Unit University of York

2. Outline Research on the mental health of adolescents in the general population Mental health of young people on the edge of care Implications for policy and practice

3. Time trends in adolescent mental health (Collishaw et al. 2004 ) Analysis of UK surveys from 1974, 1986 & 1999 Focused on 15-16 year olds Found: Increase in emotional problems (eg depression, anxiety) since 1980s Continuous rise in conduct problems over 25 years. IoP (London) analysed comparable surveys of adolescent MH (SDQ and earlier versions) Increase for both boys and girls. CONDUCT PROBLEMS � increase is mainly in non-aggressive conduct problems eg lying, stealing, disobedience rather than aggressive problems e.g fighting. USA analysed CBCL scores for hundreds of 7-16 yr olds i.e. not just adolescents Group differences in level � why has rate of MH disorders risen over last few decades? Likely to be due to wider social factors. Models in the media IoP (London) analysed comparable surveys of adolescent MH (SDQ and earlier versions) Increase for both boys and girls. CONDUCT PROBLEMS � increase is mainly in non-aggressive conduct problems eg lying, stealing, disobedience rather than aggressive problems e.g fighting. USA analysed CBCL scores for hundreds of 7-16 yr olds i.e. not just adolescents Group differences in level � why has rate of MH disorders risen over last few decades? Likely to be due to wider social factors. Models in the media

4. Time trends in adolescent mental health (2) Changes not due to: Change in thresholds (what counts as a problem?) Changes in family type Changes in socio-economic indicators Why? Increase in family disruption? Increase in educational expectations? Increase in major decision-making (re: sex and drugs)? Increased availability of drugs? Reduced community cohesion? Rutter et al have suggested possible influences are: But no clear evidence yet�. NOW � move to main focus of this workshop � (1)look at mental health problems in a study of adolescents at imminent risk of placement referred for FPS, and (2)consider what the evidence from this and 2 recent national surveys of adolescent MH can suggest to us about the development of servicesRutter et al have suggested possible influences are: But no clear evidence yet�. NOW � move to main focus of this workshop � (1)look at mental health problems in a study of adolescents at imminent risk of placement referred for FPS, and (2)consider what the evidence from this and 2 recent national surveys of adolescent MH can suggest to us about the development of services

5. Survey of child and adolescent mental health in GB (Meltzer et al 2000) 11-15 year olds scoring over clinical threshold for mental disorder (SDQ) National In care (n=10,500) (n=1,000) Any mental disorder 11% 49% Conduct disorders 6% 40% Hyperkinetic 1% 7% disorders Emotional disorders 6% 12% Self-harm 1% -

6. Working with adolescents study: young people on the edge of care Research design Quasi-experimental study 11-16 year olds at imminent risk of placement (n=209) Youth referred to 6 specialist support teams (experimental) compared to Youth referred to 3 mainstream s/w services (controls) 6 month follow-up Quantitative and qualitative methods 50 case studies

7. Outcome measures Emotional and behavioural difficulties Strengths and Difficulties Questionnaire (SDQ) Family functioning Family Assessment Device (FAD) Parental mental health difficulties General Health Questionnaire (GHQ-12): Child�s subjective sense of well-being Cantril�s Ladder Nature & severity of problems Severity of Difficulties Placement prevention

8. �Major� problems in last 6 monthsParent rating Behaviour at home 85% Parent/child arguments 78% Violence 55% (to parents) 69% (to others) Involvement in crime 22% Drug problems 12% Alcohol problems 10% Truancy 42% School exclusion 35% Self harm 20% At imminent risk of placement � parents refusing to keep them due to extreme behaviour problems. Problems at referral Multiple problems � 51% reported 6-10 problems, 42% reported 11 or more.At imminent risk of placement � parents refusing to keep them due to extreme behaviour problems. Problems at referral Multiple problems � 51% reported 6-10 problems, 42% reported 11 or more.

9. Past and present difficulties Recent abuse and/or neglect (total) 54% Physical/sexual abuse 14% Emotional abuse 34% Neglect 17% Past abuse/neglect 35% Domestic violence (ever) 43% Problems >3yrs duration 33% Ever in care 25% Histories Current abuse & neglect � some overlap � total current concerns about abuse neglect = 54% Past abuse/neglect � for 35% had been past concerns (+ had been past cncern for nearly half of those for whom there were current concerns)Histories Current abuse & neglect � some overlap � total current concerns about abuse neglect = 54% Past abuse/neglect � for 35% had been past concerns (+ had been past cncern for nearly half of those for whom there were current concerns)

10. Number of problems at referral 51% had 6-10 difficulties at referral 42% had 11+ difficulties at referral Risks at the level of the child, family, school and peer group interacted Cumulative interaction between risks thought to be more harmful than isolated risks. Need to consider not risk factors per se, but how they operate to produce harmful effects � in other words we need to look at the mechanisms whereby risk factors may produce their effects. But it is important to bear in mind that risk factors do not necessarily lead to MH difficulties, they just increase the risk that they will occur. So it�s important to understand the mechanisms whereby risk factors produce harmful effects. For example: poverty/unemployment (national study found higher risk for mental disorder) � family stress � increased risk of MH problems. Clearly a high proportion of our sample were experiencing family risk factors which were likely to contribute to MH problems. Complex issues in their lives - likely to be multiple causal processes which interact with one another: Individual liability to develop a mental disorder eg genetic And/or Environmental factors may interact with individual predisposition to a disorder, if any (e.g family conflict, parental MH problems, bullying, negative influence of peer group, school problems) And of course, these environmental factors may also be protective eg the family or school environment, a positive peer group. It is the cumulative interaction between risk factors, rather than isolated risks, which usually has the most harmful effects (Rutter, 1979). We saw earlier that multiple risk factors for emotional and behavioural problems were evident in the lives of all of these young people. Going to return now to considering the yp in my FPS study, many whom, as we�ve seen, had significant MH needs. Would like to end this session by considering The nature of the interventions they were offered The outcomes for these yp at 6 month follow-up AND FINALLY, I�d like us to consider how best to meet the needs of this kind of group. Need to consider not risk factors per se, but how they operate to produce harmful effects � in other words we need to look at the mechanisms whereby risk factors may produce their effects. But it is important to bear in mind that risk factors do not necessarily lead to MH difficulties, they just increase the risk that they will occur. So it�s important to understand the mechanisms whereby risk factors produce harmful effects. For example: poverty/unemployment (national study found higher risk for mental disorder) � family stress � increased risk of MH problems. Clearly a high proportion of our sample were experiencing family risk factors which were likely to contribute to MH problems. Complex issues in their lives - likely to be multiple causal processes which interact with one another: Individual liability to develop a mental disorder eg genetic And/or Environmental factors may interact with individual predisposition to a disorder, if any (e.g family conflict, parental MH problems, bullying, negative influence of peer group, school problems) And of course, these environmental factors may also be protective eg the family or school environment, a positive peer group. It is the cumulative interaction between risk factors, rather than isolated risks, which usually has the most harmful effects (Rutter, 1979). We saw earlier that multiple risk factors for emotional and behavioural problems were evident in the lives of all of these young people. Going to return now to considering the yp in my FPS study, many whom, as we�ve seen, had significant MH needs. Would like to end this session by considering The nature of the interventions they were offered The outcomes for these yp at 6 month follow-up AND FINALLY, I�d like us to consider how best to meet the needs of this kind of group.

11. Emotional and behavioural difficulties: scores above clinical threshold on SDQ Total difficulties 76% Conduct problems 80% Hyperactivity 71% Emotional symptoms 26% Peer problems 31% Pro-social 40% Now going to look specifically at their MH difficulties - SDQ is a screening measure for mental disorder in children up to 16 years. Very high rates of mental disorder among these yp at imminent risk of placement. Going to put this in context in 2 ways Compare this sample to others in the wider population in GB. Look at time trends for adolescent mental health Now going to look specifically at their MH difficulties - SDQ is a screening measure for mental disorder in children up to 16 years. Very high rates of mental disorder among these yp at imminent risk of placement. Going to put this in context in 2 ways Compare this sample to others in the wider population in GB. Look at time trends for adolescent mental health

12. Comparison with 11-15 yr olds in general population and in care Sample National Care (n=209) (n=10,000) (n=1,000) Any disorder 76% 11% 49% Conduct disorders 80% 6% 40% Hyperkinetic 7 1% 1% 7% disorders Emotional disorders 26% 6% 12% Self-harm 20% 1% - Striking differences, even with yp in foster care. Our study used same general screening instrument as the national study (SDQ) � general and care pops s - discuss figures., National study was supplemented by other measures and interviews, so likely to be more accurate � will have reduced the number of false positives showing up on initial screening. Nevertheless, difference is so extreme that it�s unlikely to be fully accounted for by higher proportion of false positives. Important to recognise high levels of MH disorder among adolescents at risk of placement. This is borne out by National study of MH of children in foster care: those on a court order but placed with parents were As likely as those in res. Placements to have a mental disorder (40% of those placed with parents had mental disorder). In particular: >2X as likely to have emotional disorder as those in foster families (33%v.14%). (But conduct disorder more likely among those in res. Care or fostered). Self-harm (in last year) �also much higher among our fps sample than general population 11-15 yr olds without a mental disorder: 20% is close to the rate for prevalence of self-harm among 11-15 yr olds with depression (19%).(Meltzer 2001). Why????? Going to consider: Time trends � hypotheses about social factors Evidence from research about family risk factors Yp in families in crisis DO seem to have particularly high rates of mental disorder, which suggests that situational factors are likely to contribute. Some evidence of this from our study.Striking differences, even with yp in foster care. Our study used same general screening instrument as the national study (SDQ) � general and care pops s - discuss figures., National study was supplemented by other measures and interviews, so likely to be more accurate � will have reduced the number of false positives showing up on initial screening. Nevertheless, difference is so extreme that it�s unlikely to be fully accounted for by higher proportion of false positives. Important to recognise high levels of MH disorder among adolescents at risk of placement. This is borne out by National study of MH of children in foster care: those on a court order but placed with parents were As likely as those in res. Placements to have a mental disorder (40% of those placed with parents had mental disorder). In particular: >2X as likely to have emotional disorder as those in foster families (33%v.14%). (But conduct disorder more likely among those in res. Care or fostered). Self-harm (in last year) �also much higher among our fps sample than general population 11-15 yr olds without a mental disorder: 20% is close to the rate for prevalence of self-harm among 11-15 yr olds with depression (19%).(Meltzer 2001). Why????? Going to consider: Time trends � hypotheses about social factors Evidence from research about family risk factors Yp in families in crisis DO seem to have particularly high rates of mental disorder, which suggests that situational factors are likely to contribute. Some evidence of this from our study.

13. Defining mental health problems �The social worker said he needed to go to my doctor so she could assess whether he was mentally ill or just plain naughty� (parent of boy, age 13). �His parents wonder if he�s schizophrenic whereas other professionals have focused on the behavioural and emotional problems. I have to say I�m a bit at my wits� end about it� (social worker of boy, age 12) ��With her ADHD it�s difficult and she�s very hard to parent�.you don�t know what�s adolescence and what�s ADHD� (parent of girl, age 14).

14. Parents� difficulties Lone parents 46% Domestic violence (ever) 43% Serious health problems 25% Mental health difficulties (GHQ) 72% Financial problems 42% No support network 25% Over threshold score for poor family functioning (on FAD) 80%

15. Family risk factors for mental disorders in children Sample % of children with MH problems with this risk factor (in GB) Family functioning 80% Odds ratio 1.82 Parental MH 72% Odds ratio 2.23 Lone parent 46% Odds ratio 2 Domestic violence 43% - high score for emotional problems (+ high score for conduct problems if witnessed by child). If we compare the circumstances of our sample with national evidence on risk factors for mental disorder in young people (same national study), can see that these yp at risk of placement were at very high risk of experiencing MH problems for a number of reasons. Right hand column (national study) shows the likelihood that children who are above clinical threshold for mental disorder will have this risk factor. Family functioning (measured by FAD). 80% of families in our sample had scores above cut-off for unhealthy functioning on FAD. National statistics show that children with mental disorder nearly 2x as likely to be part of discordant families than children with no disorder (35% cf 19%).. Particular impact on conduct disorder (43% of those with conduct disorder had unhealthy scores for family functioning � national study). Clearly child�s behavioural problems contributed to unhealthy family functioning � a vicious circle of mutually reinforcing difficulties. Parental mental health problems (GHQ measures non-psychotic psychiatric disorders in community settings) � mainly depression: Very high, so increased odds of child mental disorder.(similar effect on all types of disorder). Lone parent � this sample 2x more likely to be living with a lone parent. National MH study found that living with lone parent doubled the risk on mental disorder (family stress/poverty?). Domestic violence �those violent to parents had high scores for emotional symptoms on SDQ. Other UK studies have found increased risk for e&b problems among children who witness domestic violence. Severe behavioural problems 17xhigher for boys who and 10% higher for girls who witness domviol (Wolfe et al 1985). Surprisingly, though, in my study experience of abuse/neglect (35%) had no impact on SDQ scores. Learning difficulties (15%) 22% of those with LDs have mental disorder (cf 10% of all children) If we compare the circumstances of our sample with national evidence on risk factors for mental disorder in young people (same national study), can see that these yp at risk of placement were at very high risk of experiencing MH problems for a number of reasons. Right hand column (national study) shows the likelihood that children who are above clinical threshold for mental disorder will have this risk factor. Family functioning (measured by FAD). 80% of families in our sample had scores above cut-off for unhealthy functioning on FAD. National statistics show that children with mental disorder nearly 2x as likely to be part of discordant families than children with no disorder (35% cf 19%).. Particular impact on conduct disorder (43% of those with conduct disorder had unhealthy scores for family functioning � national study). Clearly child�s behavioural problems contributed to unhealthy family functioning � a vicious circle of mutually reinforcing difficulties. Parental mental health problems (GHQ measures non-psychotic psychiatric disorders in community settings) � mainly depression: Very high, so increased odds of child mental disorder.(similar effect on all types of disorder). Lone parent � this sample 2x more likely to be living with a lone parent. National MH study found that living with lone parent doubled the risk on mental disorder (family stress/poverty?). Domestic violence �those violent to parents had high scores for emotional symptoms on SDQ. Other UK studies have found increased risk for e&b problems among children who witness domestic violence. Severe behavioural problems 17xhigher for boys who and 10% higher for girls who witness domviol (Wolfe et al 1985). Surprisingly, though, in my study experience of abuse/neglect (35%) had no impact on SDQ scores. Learning difficulties (15%) 22% of those with LDs have mental disorder (cf 10% of all children)

16. Focus of family support interventions Main focus Parenting strategies Work on child behaviour Mediation Communication Peer group/positive leisure activities Some work on� School Drug or alcohol problems Social skills Emotional problems

17. Changes in SDQ scores by 6 month follow-up Per cent above clinical threshold for mental disorder At referral 76% At follow-up 55% Those with higher scores for difficulty at referral more likely to show improvement (post-crisis) Improvement less likely for those with ADHD

18. What made a difference? Providing concrete strategies to child and parent Enhancing parents� sense of efficacy Changes in child and parent behaviour were mutually reinforcing � a virtuous circle Parenting style acts as both a moderator and mediator of change more success if parenting was weak than when parenting was harsh Ecological approach Multi-faceted response to multiple risk factors Therapeutic alliance was a key mediator of change Worker skills + child & parent readiness to build relationship

19. References Nina Biehal (2005) Working with adolescents: Supporting families, preventing breakdown. London: BAAF. Nina Biehal (2005) Working with adolescents at risk of out of home care: the effectiveness of specialist teams. Children and Youth Services Review, 27 (9). Nina Biehal (2008) �Preventive services for adolescents: exploring the process of change�, British Journal of Social Work, 38, 3, pp 444-461. Stefan Collishaw et al. (2004) Time trends in adolescent mental health Journal of Child Psychology and Psychiatry 45 (8) Howard Meltzer et al. (2000) Mental health of children and adolescents in Great Britain. London: National Statistics To provide some context to our discussion, will first look at recent time trends in child and adolescent mental health�..To provide some context to our discussion, will first look at recent time trends in child and adolescent mental health�..