28 March 2017

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This article includes the discussions and presentations of participants in this event but does not necessarily reflect the views or policies of the Mental Health Commission of NSW.

Match: Leaders in Child and Youth Mental Health: Systems Issues and Solutions
Hosted by Mental Health Children and Young People, Mental Health Branch, NSW Ministry of Health
Sydney, Australia

Progress in combatting teenage self-harm

By Helen Signy

Schools are being urged to treat students with more compassion and understanding to combat rising levels of psychological distress and an increase in self-harm among young people.

In Australia, as many as one in 10 teenagers – about 186,000 children – have self-harmed at some time in their life, according to the Second Australian Child and Adolescent survey of Mental Health and Well-Being. In girls aged 16 to 17, that figure is as high as 25%.

Suicide rates are also increasing, with about one in 13 teenagers in Australia having seriously contemplated suicide.

Self-harm is one of the biggest risk factors for suicide, but children in psychological distress are not always identified.

Schools and communities are being urged to look beyond children’s behaviour to understand the underlying causes and offer young people a pathway to access help and support, according to international youth mental health leaders from Australia, New Zealand, Ireland and the United Kingdom, who met for two days to discuss systems issues and solutions in the lead up to the International Initiative for Mental Health Leadership (IIMHL) forum in Sydney.

“Teachers see students every day and are aware of the shifts in these children’s behaviour,” says Paul Burstow, Chair of the Tavistock & Portman NHS Foundation Trust and former Minister of State for Care Services in the Cameron government.

“It’s about teachers identifying and noticing the children at risk, being more compassionate and understanding, being aware of resources and supports, and referring on.”

An urgent need for intervention

Surveys with school counsellors and School-Link coordinators, conducted by researchers at the University of Wollongong, have identified self-harm is one of the most significant challenging mental health issues facing schools in NSW.

In the United Kingdom, where there has been a 70% increase in people presenting to emergency departments due to self-harm, Prime Minister Teresa May has announced comprehensive reforms to mental health support, with an emphasis on children and young people.

There is a similar picture in New Zealand, where the Youth 2000 study has shown a steady increase in self-harm in the last five years in both boys and girls, while in Ireland, the State of the Nation's Children Report: Ireland 2016 found the had risen by more than a third since 2009, to 1,246.

The reasons for the rising tide are unclear, though Mr Burstow stress around exams, pressures of school life and increasingly complex digital lives are thought to contribute. One Irish study found girls presenting to hospital emergency departments following self-harm cited “sadness” as their overriding motivation. For some, copying their peers has a role to play.

Some of the self-harming behaviour in teenagers is experimental and irregular. But in some teenagers, self-harm becomes longer term and more persistent. While all self-harm in children should be addressed, in some it may be a red flag for suicidality or a mental illness such as an emerging personality disorder.

“Research in Australia with secondary students identifies that students often they feel a great deal of distress, but lots of young people don’t tell anyone about it,” says Dr Michelle Townsend, a Research Fellow in the School of Psychology at the University of Wollongong, whose team has developed a series of resources on how to work with students with complex mental health needs in schools.

“School surveys show that almost half of young people aged 12-17 who are in psychological distress speak to no-one at all.  One of the solutions is to upskill teachers to be able to identify kids who might be at risk, and to understand and respond compassionately to emerging mental health difficulties, trauma and self-harm.”

The number and rate of suicide of young people is now the highest since 1997, according to the NSW Child Death Review Team’s 2015 report. The rate of young women taking their own lives has doubled over the past decade.

In the United Kingdom, more than half of teenagers and young people with mental health problems do not receive any clinical treatment, and are significantly more likely to be on welfare benefits and to have contact with criminal justice services, according to a recent report by Professor Martin Knapp of London School of Economics, Youth Mental Health: New Economic Evidence.

The UK education sector is bearing 90% of mental health-related costs, with just a fraction being paid by primary care, paediatrics or mental health services. “It means resources are being misdirected because they are not being directed to schools,” says Mr Burstow.

The roles of teachers and schools

Getting young children on track

NSW Health is rolling out an early intervention program for children from Kindergarten to Year 2 in more than 85 NSW schools annually to help parents and teachers deal more effectively with emerging conduct disorders and challenging behaviours.

The Getting on Track in Time (Got It!) program is provided by specialist child and adolescent mental health teams in partnership with schools. It identifies at-risk children through screening and offers a 10-week group intervention for parents and children.

The program teaches parents to recognise and problem-solve their children’s emotions and behavioural problems, and upskills teachers with professional development offered by the child and adolescent mental health team.

During its years of operation, the cost benefit of early intervention and prevention has become clear: it can prevent poor trajectories for children including dropping out of school and involvement with the juvenile justice system.

An evaluation of the program has shown positive outcomes six to eight months later, including that parents were more likely to feel part of the school community and to seek help, that their parenting style had changed, and that siblings were benefiting. The behaviour of children completing the program also improved.

Schools play a major role in supporting young people with emotional and behavioural problems and are often where symptoms of mental disorders are first identified.

Almost all of the 14% of children aged 5 to 17 who suffer a mental health disorder every year will be attending school. According to the Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing, a school staff member was among those suggesting the need for help in approximately 40% of cases, and just over half (53.5%) of 4-17 year-olds using services used both health and school services.

A 2015 survey by beyondblue found that only one in five of the 600 teachers and principals questioned felt confident in addressing the mental health needs of students. Half said they did not have time, and the same number did not think it was easy to find training tools to help them.

“Traditionally we have focused on providing training to school counsellors, but we now also provide support and training to teachers around wellbeing - increasing their mental health literacy,” says Pauline Kotselas, the Education Department’s Leader of Psychology and Wellbeing Services.

“Our schools are wanting to know how to respond to mental health, there is strong interest and commitment by teachers for professional learning in this area.”

Tangi Noomotu, Clinical Coordinator of Aroha Ki Te Tamariki Trust - Mirror Services in Dunedin, New Zealand, believes many schools are struggling to manage young people with mental illness.

Too often, he says, young people who externalise psychological distress through poor behaviour or drug taking are labelled as ‘bad’ and excluded from school or expelled. But research shows that for this group, remaining at school confers greater benefits than it does for children who are doing well.

“Often these kids are excluded because they are difficult to manage in the classroom. You can’t blame the teachers, they are trying to manage 20 or 30 kids on their own all day,” he says.

“But we know these kids do better off in school. It’s where they get positive social interaction and reinforcement, and positive social and community connection. That’s massive in terms of being a protective factor against mental illness and substance abuse, yet we exclude them.”

Dr Townsend agrees. When teachers are shown a film featuring ‘Chloe’, a teenager talking about her self-harm, there is often a lightbulb moment in how to approach young people in psychological distress.

“Teachers see the film and we discuss a discipline issue and how, if they took a traditional approach, did they think she would she respond.

“There was a real shift. They could see that traditional discipline approaches aren’t going to help her because she won’t respond to them – teachers need to try something different. They need to approach her with compassion and understanding, and to think beyond the behaviours,” says Dr Townsend.

A coordinated approach

Project Air: identifying emerging personality disorders

The Project Air Strategy for Personality Disorders is workingin partnership with NSW Health and the Department of Education to upskill teachers across the State in dealing with students with complex mental health concerns and to manage challenging behaviours, including self-harm. 

Currently being rolled out across NSW secondary schools, the project delivers full day professional development sessions to school counsellors, school psychologists and School Link coordinators. They in turn will deliver accredited training to NSW public school staff in distinguishing the difference between normal adolescent behaviour and areas of concern, possible referral pathways, and how to respond to students who may be in crisis, such as those at risk of suicide.

The Project Air team has also developed resources to assist schools to recognise and respond to complex mental health problems, including a film, a set of guidelines and seven fact sheets.

NSW established the School-Link program in 1999 in response to a spike in suicides by young men. Operating in more than 3000 schools and TAFEs in NSW, the program involves the provision of specialist mental health services to young people by the public mental health sector working in partnership with teachers and school counsellors.Historically, government agencies tend to work in silos, and there remains a need for a coordinated, community-wide approach to wellbeing in schools.

The NSW Government has allocated an increased investment of $167.2 million over four years for a comprehensive package to support the wellbeing of students in public schools across New South Wales. This package, Supported Students, Successful Students, includes $80.7 million to employ 236 additional school counselling service positions.

NSW Health is also expanding the School-Link program to forge stronger relationships between schools and local community mental health services.

In 2015 the NSW Department of Education introduced a wellbeing framework for schools that requires all schools to have a planned approach to wellbeing, with an emphasis on training teachers to support the cognitive, emotional, social, physical, and spiritual wellbeing of students.

Internationally, there is a movement towards greater cross-sectoral collaboration between Health and Education so that schools become places where young people can seek help.

In the United Kingdom, where there schools have traditionally been explicitly excluded from addressing students’ wellbeing, the Prime Minister recently announced “mental health first aid training” for every secondary school, and trials to strengthen links between schools and local NHS mental health staff.

The Care Quality Commission will also lead a major thematic review of children and adolescent mental health services across the country, and a new green paper has been commissioned on children and young people’s mental health, which will transform services in schools, universities and for families.

In New Zealand, the Prime Minister’s Youth Mental Health Project is attempting to improve the mental health and wellbeing of young people through programs and activities in schools as well as via health and community services and online.

The country is also overhauling its child care and protection services, with a new focus on trauma-informed practice consistently across all agencies, including education.

“We are now understanding how intergenerational trauma leads to many of our child and youth mental health issues in New Zealand, says Sue Dashfield, General Manager of Werry Workforce Whāraurau.

The Irish Minister for Mental Health is focusing strongly on youth mental health and has established a taskforce to determine how the sector can work together more effectively at community and national service level to support the wellbeing of young people.

A key issue for all countries is bringing an evidence base to practice and ensuring the fidelity of programs as they are rolled out and up-scaled in the face of the everyday constraints and pressures in education, says Mr Carlton Quartly of NSW Health. “It’s about resources, implementation and ensuring it becomes a core part of all school activity, rather than just another competing priority.”

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Last updated: 21 June 2017