NURS 6541 – Primary Care of Adolescents and Children Essay

Adolescence is the transition stage between childhood and adulthood. It is also referred to as teenage years and puberty. During puberty,both boys and girls experience hormonal changes that occur in their early youth. The period of adolescence can extend well beyond the teenage years which can be between 10 – 24 years. The development characteristics of an adolescent include physical,cognitive and social emotional development. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

They are further divided into three different stages: The first stage being the early adolescence (11 – 13 years of age). This is where both sexes grow body hair, increased perspiration and oil production in hair and skin, they grow capacity for abstract thought, struggles with sense of identity, feel awkward about one’s self and one’s body and worry about being normal. In girls, breasts and hip develop on set of menstruation, mostly interested in the present with limited thought to the future and increased influence of peer group. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

The boys develop growth in testicles and penis, they experience wet dreams, deepening of voice, physical growth as they gain height and weight, intellectual interests expand and become more important, deeper moral thinking, desire for independence, tendency to return to “childish” behavior particularly when stressed up and growing sexual interests. The second stage is the middle adolescence(14 -18 years)where puberty is completed and physical growth for girls slows down while for boys continues. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

In cognitive development there is continued growth of capacity for abstract thought,greater capacity for setting goals,thinking about the meaning of life and in social emotional development. There is intensive self-involvement changing between high expectations and poor self concept,worries about being normal, tendency to distance themselves from parents,increased sexual interest with feelings of love and passion,driven to make friends and greater reliance on them. Late adolescence is between 19 – 24 years of age where young women are typically physically developed.

The young men continue to gain height, weight and body hair. In the cognitive development, the girls have the ability to think ideas through from the beginning to the end while the boys have ability to delay gratification. In social-emotional development there is increased concern for others,increased independence and self reliance,peer relationship remain important and increase of more serious relationships besides traditions and culture regain some of their importance. EXPLAIN ATLEAST FIVE PSYCHOSOCIAL CHALLENGES IN ADOLESCENT AND HOW YOU WOULD HELP ADOLESCENTS COPE WITH THEM. . SEXUAL ACTIVITY With reference to some stage about adolescence,the teenage boys and girls experience an increased sexual urge for the opposite sex without knowing the consequences of early boy – girl relationships. The girls may end up pregnant causing the girl to withdraw from the society or to abort and discard the shame. Arbotion is an act of killing which is not allowed within the society. In sexual activity,both the boy and the girl may be infected with sexually transmitted diseases like syphilis which may affect their childbearing in adulthood. 2. ANOREXIA NERVOSA. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

A problem peculiar to adolescents and the number has recently grown especially in girls. They tremendously loose weight and has a multi-organ dysfunction in the period of most rapid growth and can lead to serious developmental disorders both psychological and physical. The ex-anorexia nervosa patients tend to have problems during pregnancy,childbirth and child rearing. They may suffer from a child rearing disorder and find it difficult to take good care of their child or even unable to feed the child with baby food. It is a physical sign that starts to develop a psychological problem affecting the social nature of the teenager. . DRUG ABUSE At some stages in adolescents, there is increase of peer relationships and also a tendency to distance themselves from parents. These areas lead the adolescents to smoking, drinking alcohol, excess dieting due to peer pressure and influence. The behavior results to poor health, seclusion from home, school avoidance. This may result into a social problem. 4. CHILD SUICIDE This factor would arise when the person does not communicate the value of life, decides that life is valueless and does not provide for solutions . NURS 6541 – Primary Care of Adolescents and Children Essay Paper

In this case the person had only the passion of love indicating a problem in the social environment as to be less valued. 5. VIOLENCE When teenagers are driven to make friends and have greater reliance on them, they are denied chances to seek advice from elders and as a result, violence occurs due to misunderstanding and bad groupings which becomes a threat to the society. Violence also occurs when the child is nurtured in a cruel environment thus the child grows into adulthood not knowing the co-existence of love especially within the family members. HOW TO HELP ADOLESCENTS COPE WITH THE ABOVE CHALLENGES. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

This can be achieved by creating awareness raising activities and consultants in cooperation with families and schools so as to create understanding of the adolescents’ childhood anxieties or misgivings respect their dignity as people who have partially acquired competencies such as those of an adult. Parents should be made aware that for good health, good diet contributes a lot to the development of a person both physically, mentally and psychologically. Such a child may not develop health disorders in the future or even have an adverse effect on the next generation.

There is therefore need for supplementary guidance and outdoor activities with the help of specialists. Besides, there should be creation of organizations like community health care in line with medical services and child welfare for an interactive activity which will be responsible for the primary care for the psychological and health care problems of the adolescent. With regard to health issues during adolescence, the public relations (PR) need to be strengthened through television, radio, magazines, pamphlets and posters. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Particular emphasis should be placed on contraception and the prevention of sexually transmitted diseases, drug abuse and early pregnancies. In school, teachers should work as a team to give guidance on adolescent health care in collaboration with school nurse or school pharmacists. The gymnastics and physical health education (PE) should be reinforced and encouraged in schools and the midwives, police personnel, ex-drug regulatory officials and doctors should be invited to hold talks with adolescents on prevention of drug abuse and sex. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

With relation to ministry of education and science it is necessary to urge adolescents to recognize the value of life and to be aware that they will be responsible for rearing their own children in future by encouraging the development of teaching materials, tools and methods which can convey clear messages. REFERENCES. Kaplan P. S. (2004). Adolescence. Boston: Houghton Milffin Company. Lawrence. W. Green, Marshall. W. Kreuter. (1991) Health Promotion Planning: An Educational and Environmental Approach, second edition. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Suicide is the fourth leading cause of death in children between the ages 10 -14years (DeMaso, 2011). Horowitz, Ballard & Pao (2010) noted that every year, suicide claims the lives of tens of thousands of young children worldwide. Despite its high prevalence and known risk factors, suicidality is often undetected by health care professionals (Horowitz, Ballard and Pao, 2010).

Most primary care clinicians (PCCs) and emergency department (ED) clinicians do not routinely screen for suicide risk in children. Studies have revealed that as many as 83% of suicide attempters are not identified as a danger to themselves by healthcare providers, even when examined by PCCs in the months before their attempt(Horowitz,Ballard &Pao,2010).

Undetected and untreated mental health problems in children and adolescents can lead to problems in school, the family and peer and intimate relationships, adult psychopathology and a poor quality of life for the child (Horowitz, Ballard & Pao,2010).Therefore, it is important that children be screened so that early detection of those at risk can be identified. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

The most popular screening tool that is used in school settings and primary care settings, is the Columbia Suicide Screen (CSS). The CSS was developed to detect children and adolescents who are at risk for suicide, so that brief interventions can be implemented and a life can be prolonged or saved. The CSS is an 11-item self-report measure embedded in a general health questionnaire that investigates lifetime suicide attempts, suicidal ideation, negative mood and substance abuse issues (Horowitz, Ballard & Pao, 2010). It is an easy to score and an easy to administer screening tool.

Children and parents can self-administer the tool and report the results to their PCCs. Research using the CSS suggested that screening can identify suicide risk in children whose thoughts and behaviors may have gone otherwise undetected (Horowitz, Ballard & Pao, 2010). NURS 6541 – Primary Care of Adolescents and Children Essay Paper

The CSS is a widely used tool that was validated using the National Institute of Mental Health Diagnostic Interview Schedule for Children, IV (NIMH DISC-IV) with a sensitivity of 0.75, a specificity of 0.83(Horowitz,Ballard & Pao,2010). It was proven to be a valid and reliable screening tool after several test-retest trials in a variety of school research studies (Shaffer et al. 2004). This further demonstrates the utility and validity of the screening tool for use in primary care settings.

The CSS tool can be used in primary care settings by Behavioral health consultants (BHC) for children and adolescents who may present with symptoms related to depression, anger or bullying (Horowitz, Ballard & Pao, 2010). The CSS can also be used as a routine measure for children who visit the ED or the primary care clinics. The CSS can be self-administered and it is quick to score, which makes it an appropriate tool for use in a fast paced primary care setting or ED.

A positive screen or score on the CSS, would indicate that a child is at risk for suicide and immediate interventions can then be implemented for the child and the family. Any indication of a child at risk can be quickly addressed and managed before the child experiences further psychopathology or death. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Suicide among children has become an epidemic. It is important that health care professionals engage in screening so that early detection of children at risk for suicide can be identified and brief interventions can be implemented.

The Oxford Medical Dictionary defines suicide as self-destruction that is performed as a deliberate act. Although it is strongly linked to self-harm, it is noteworthy that self-harm is often not a suicide attempt, but actually a parasuicide -when self-harm is carried out for other reasons other than killing oneself. Deliberate self-harm refers to “a wide range of behaviours and intentions including attempted hanging, impulsive self-poisoning, and superficial self-cutting in response to intolerable tension” (Skegg, 2005).

According to The National Institute of Clinical Excellence (NICE), self-harm is an expression of personal distress, and is not in itself, and illness. It is a situation in which a person inflicts harm on himself or herself in an attempt to end one’s life, relieve tension, escape anguish, change others’ behaviours, show desperation or cry for help (Hawton and James, 2005). Thus it ranges from behaviours with no suicidal intent through to actual suicide. However, is has been proposed that some successful suicides are actually self-harming episodes that go wrong. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Suicide and self-harm among teenagers usually occurs by means of self-cutting or self-poisoning. Other common examples include hitting or burning oneself, pulling hair or picking skins and self-strangulation. Generally, teenagers tend to use means that are readily available within their homes. Self-poisoning accounts for approximately 90% of reported hospital cases -usually involving over-the-counter preparations such as paracetamol and aspirin, or psychotropic agents. Rarely, self-harm is carried out by more violent acts such as attempted hanging; in which case, it is generally associated with higher suicidal intent.

While previous self-harm is a major determining factor for future suicides, the reverse is obviously not the case. Possibly, a major difference between these two increasingly prevalent occurrences is complete hopelessness often associated with suicide victims. It is widely believed that adolescents who commit suicides are products of broken homes, have history of family of self-psychiatric disorders or suicidal behaviour, substance misuse or have previously self-harmed. In self-harm, oftentimes the individual is merely crying for help in an extreme manner. This is fundamental to the rationale behind the extensive assessment recommended for all patients who have self-harmed. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Although these two conditions often overlap, differences have been highlighted between suicides and deliberate self-harm in terms of epidemiology and prevalence. While suicide rates increase with age, the majority of deliberate self-harm occur in people under 35 years of age. Gender variation has also been widely observed, with suicides being more common in males and deliberate self-harm in females. Also, differences arise in the psychiatric status of the patients. Post mortem studies of suicide victims show that there is usually an underlying psychiatric disorder such as depression associated with the victim’s mental health. This is not always the case with self-harm patients. Although there could be a history of depressive illness, self-harm is frequently an impulsive act, probably enhanced by alcohol or drug consumption (Hawton and James, 2005). NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Self-harm is a serious public health problem and young people are particularly affected by it (Mental Health Foundation, 2006). A case of a patient who has self-harmed is a chance for the health services to effectively evaluate and address any relevant underlying problems and is an opportunity to successfully avert potential future suicides.

1.2 Trends and Statistics

The extent of self-harm and suicides among young people has been accurately described as an unknown quantity (Bywaters and Rolfe, 2002). Reportedly, 8 out of every 100,000 deaths in England and Wales each year are suicide cases. There are an estimated 25,000 adolescent self-harm presentations annually in hospitals in England and Wales (Hawton et al, 2000) and government research report that as many as 1 in 17 young people have attempted to harm themselves. Suicide is the second most common cause of death among 15- to 34-year olds. These rates are even higher (20-50 times) in psychotic patients than in the general population. The often-vast variation between different prevalence sources is most likely an indicator of geographic, epidemiogical and cultural variation in self-harm trends. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Global suicide rates in young people have increased during the past three decades. According to the Office of National Statistics (1999), 1.3% of 5-10 year olds have tried to harm, hurt or kill himself/herself. More than four times this proportion (5.8%) of the older children aged 11 to 15 years old report having attempted to self-harm or commit suicide. Most child and adolescent mental the health services take the school-leaving age of 16 as their upper limit. Thus most available statistics are only for children up to the age of 16. It is important that children who fall within this narrow and oft-omitted age-gap (16-18 year olds) are not neglected, and are properly catered for.

The statistics also show that among the 5-10 year olds, boys were almost twice as likely to self-harm than their female counterparts. Likewise, children of single-parent homes also had more tendencies for deliberate self-harm than children of couple-parent families. Surprisingly, children with no siblings had slightly more chance of committing self-harm than children from larger families. 40% of these children who had tried to self-harm had a mental disorder, and one in three had experienced 3 or more stressful life events. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

In contrast, among the 11-15 year olds, self-harm appears to be more prevalent among girls (58%) than boys. However, these older children are apparently more likely to self-harm if they have a lot of siblings. 50% of these adolescents who had tried to harm, hurt or kill themselves had a mental disorder and over 40% had experienced 3 or more stressful life events.

Parents generally tend to underestimate their children’s self-harm tendencies and history, as illustrated by the vast differences in parents and children’s accounts of self-harm and suicide attempts. This gives an insight into the level of shrouding and secrecy that is associated with these phenomena and casts doubts on the validity and reliability of these widely accepted statistics. Stigmatisation and ostracization commonly associated with suicide and self-harm victims and families is the most likely reason behind under-reporting and denial. In addition, prevalence of suicides is largely underestimated because of reluctance of coroners to classify cause of death as suicides, especially in children. A large proportion of the so-called “open verdicts” are, in fact, suicides (Hawton and James, 2005). Self-harm techniques such as self-cutting usually go unnoticed. As the most common method of DSH by teenagers, the implications are that the rates of self-harm amongst adolescents are grossly under-reported. Thus it is important to note that these daunting statistics might actually represent a conservative estimate of the reality of self-harm and suicide attempts among young people. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Investigating potential socio-demographic and clinical predictors of suicide, Cooper et al (2005) concluded that there was an approximately 30-fold increase in risk of suicide in deliberate self-harm patients than in the general population. Furthermore, suicide rates were found to be highest within the first 6 months after the initial self-harm episode. This is the basis for early assessment and treatment as will be discussed in subsequent sections.

Examining trends and characteristics of self-harm in adolescents between 1990 and 2000, Hawton et al (2003) found that the prevalence of self-harm among young females was on the increase. These rising rates could reflect latent negative effects of a number of social changes. Possible reasons for this increase include increased rates of family breakdowns, increasing rates of substance misuse, media influences and common peer behaviours. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

In a self-report survey, Hawton et al (2002) studied the prevalence of deliberate self-harm in adolescents aged 15 and 16 years old, and the factors associated with it. In this age group, females were more likely to self-harm than males. Ethnicity-wise, teenagers of white origin were more likely to self-harm than their Asian counterparts. Black young people were the least likely to self-harm. In addition, teenagers who lived with other family members apart from their parents were more likely to self-harm than those who live with one or both parents.

Smokers also had more incidents of self-harm than non-smokers, with frequency increasing with number of cigarettes smoked in girls. Similar trends were observed with young people who consumed alcohol. Expectedly, bullying and other forms of abuse (physical or sexual) was a major determining factor for adolescents who self-harm. Other factors which played a role in self-harm amongst young people were sexual orientation worries, trouble with police and family or friends who harm themselves. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Although self-harm is observed in all age-groups, it has an average age of onset of 12 years old (Fox and Hawton, 2004). Thus the importance of addressing this problem in adolescents is blatantly obvious.

1.3 Risk Factors

Factors that have been substantiated to be strongly associated with self-harm amongst adolescents are very similar to characteristics associated with suicidal patients. These include:

• Depression
• Substance misuse
• Physical or sexual abuse
• Low self esteem
• Physical ill-health
• Disputes with parents, siblings or friends
• School or work problems

In an ecological and person-based study, Hawton et al (2001) investigated the influence of the economic and social environment on deliberate self-harm and suicide. Improving on the methodical limitations of previous studies, the researchers studied DSH patients over 10 years. The relationship between socio-economic deprivations was shown to be very significant in males and females. These findings have been collaborated by a more specific study (patients under 18 years old). Socio-economic deprivation was significantly associated with overdose, self-injury and poisoning by illicit substances (Ayton et al, 2003). Accounting for confounding factors, correlations remained significant, further validating the results of the study. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Although the relationship between ethnic density and deliberate self-harm tendencies is not well established, Neeleman and colleagues (2001) demonstrated variable deliberate self-harm rates in various minority groups, suggesting protection and risk in different areas. This is a gap in the literature for future research. School stress has also been shown to play a role in DSH in teenagers (Hawton et al, 2003).

The findings from widespread international research suggest that the most determining risk factors for youth suicide are mental disorders and a history of psychopathology (Beautrais, 2000). Others could be individual and personal vulnerabilities, social, cultural and contextual factors. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Possible motives for self-harming behaviour other than death are highlighted below (Hawton and James, 2005):

• To escape from unbearable anguish.
• To change the behaviour of others.
• To escape from a situation.
• To show desperation to others.
• To make others feel guilty.
• To gain relief of tension.
• To seek help.

Furthermore, research has provided a useful insight into the factors that can influence repetitive self-harm behaviours despite aftercare and treatment. This is important in the assessment of patients who have self-harmed to identify those who are likely to self-harm again and prevent such episodes. Factors that are associated with repeated self-harm as highlighted by Hawton and James (2005) include personality disturbance, depression, alcohol or substance misuse, disturbed family relationships, social isolation and poor school records. Hawton et al (1999) demonstrated that self-harm repeaters differed from the non-repeaters in having higher scores for depression, hopelessness and trait anger, and lower scores for self-esteem. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Specific reasons that have been cited for self-harm by young people, as highlighted by the National Inquiry (2006) include:

· Bullying

· Strained relationships with parents

· Parental divorce

· Unwanted pregnancy

· Worry about academic performance

· Childhood abuse (sexual, physical or emotional)

· Low self-esteem or rejection

· Problems to do with race, culture or religion

2. Responding To Young People Who Self-Harm
2.1 Guidelines And Evidence For Good Practice

The National Institute for Clinical Excellence (NICE, 2004) has proposed guidelines for the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. In addition, The Royal College of Psychiatrists (RCPSYCH) also provides guidance on managing young people up to the age of 16 who deliberately harm themselves. Such guidelines are readily applicable to the Health service i.e. Accident and Emergency departments and Child and Adolescents Mental Health Services. Integrating these treatment guidelines and the findings of related research, the management of these young self-harm patients will be extensively discussed under the following sub-titles: NURS 6541 – Primary Care of Adolescents and Children Essay Paper

• Assessment
• Treatment planning
• Admission to hospital
• Treatment options
• Medical and surgical management
• Referral and discharge following self-harm
• Pharmacological interventions
• Family support
• Prevention

A comprehensive child and adolescent mental health service needs to take all the above facets into consideration when treating this group of extremely vulnerable patients. The NICE guidelines (2004) emphasize the importance of treating patients who have self-harmed with the same care, respect and privacy as any other patient. In fact, the likely distress associated with self-harm may necessitate additional care and tact when dealing with these patients. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Also, health services are urged to provide appropriate training to all staff (clinical and non-clinical) that has any form of contact with the patients to fully equip them with the necessary skills and knowledge to effectively understand and care for people who have self-harmed. Ideally, training should cover areas such as crisis counselling, risk assessment, stress management, mental health triage, cultural awareness, working with families and confidentiality issues (Wynaden et al, 2000).

Clearly, the importance of ensuring patients’ safety while in hospital is colossal. These patients should be offered an environment that is safe, supportive and minimises any distress. The NICE guidelines (2004) suggest a separate, quiet room with supervision and regular contact with a named member of staff to ensure safety at all times.

2.1.1 Assessment

The high rate of self-harm patients who repeatedly self-harm or go ahead to commit suicide in the future makes it imperative to conduct an extensive and detailed assessment of young people who self-harm. Young people who have self-harmed in a potentially serious or violent way should be assessed either by a child and adolescent psychiatrist, a specialist mental worker, a psychologist, a psychotherapist or a psychiatric nurse (Hawton and James, 2005). The NICE guidelines propose that all people who have self-harmed should be offered this preliminary assessment at triage, regardless of the severity of the attack. Apart from the obligatory emergency physical assessment, this will give an insight into the patient’s mental health, the level of distress and their willingness to co-operate with the medical team. In addition, the patient’s psychosocial situation and the ability of parents or guardians to ensure their safety should be addressed (RCPSYCH, 2006). NURS 6541 – Primary Care of Adolescents and Children Essay Paper

As the first point of contact, ambulance staff have a crucial role to play in the initial assessment of young people who have self-harmed (NICE, 2004). The Australian Mental Health Triage Scale is a validated comprehensive assessment scale that provides a means of efficiently rating clinical urgency so that patients can be seen in a timely manner. This scale has been shown to improve staff confidence and attitudes in dealing with clients with mental health problems, thus improving patients’ outcomes in the long-run (Broadbent et al, 2004).

Research has shown the importance of cultural, ethnic and racial awareness and sensitivity in the assessment process. Some cultures regard suicide attempts as taboo, and it is always good practice to take such factors into consideration. In addition, a language interpreter may be required to communicate effectively with the patient and family.

2.1.2 Treatment Planning

Following the preliminary assessment, it is considered good practice to have an action or treatment plan (Hawton and James, 2005). The treatment plan should take into account all aspects of the patient’s management in hospital, ranging from treatment options to pharmacological and psychological interventions to discharge planning. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

2.1.3 Admission To Hospital

At this point, temporary admission should be considered especially for patients who are who are very distressed, for people who may be returning to an unsafe or harmful environment and for people in whom psychosocial assessment proves too difficult for any number of reasons (NICE, 2004). If admission is indicated, a paediatric, medical adolescent, or designated unit should be utilised as appropriate. Despite the NICE guidelines, some schools of though believe that regardless of the toxicological or physical state of the young person, hospital admission is desirable, so that adequate further physical and psychosocial assessments can be carried out, and management/crisis interventions can be planned and initiated (Hawton and James, 2000). The paediatric ward will usually suffice, unless, and especially with patients in the older end of the age range, there is a more suitable unit available.

Waterhouse and Platt (1990) investigated the difference in outcomes between self-harm patients who were admitted to hospital and those were discharged as outpatients. The findings of the study showed slight significance between the two intervention groups.

It is the role of the admitting staff to obtain agreement for the mental health assessment of the patient from parents or relevant guardians, and to alert all members of staff of each young person’s needs. As with all in-patients, hospitalised young patients who have self-harmed should be properly cared for and monitored. In addition, responsibilities of staff of the mental health team will include providing consultation to the young person and his/her family, the paediatric team and staff of the social services and education departments. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

The Crisis Recovery Unit at the Bethlem Hospital in London, a national specialist unit for people of 17 years and above who repeatedly self-harm, have a different and slightly radical approach to the in-patient treatment of these patients (Mental Health Foundation, 2006). Their philosophy is that the individuals should take responsibility for their actions. This practice-supported technique focuses on helping young people realise for themselves that self-harm is not an effective strategy for dealing with their problems. It encourages these patients to talk about their problems and explore alternative coping strategies, including strategies for dealing with the urge to self-harm. However, the effectiveness of such an intervention in younger patients (11-16) is not certain, as these children might not be mentally mature for such self-realisation tactics. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

2.1.4 Treatment Options

Treatment options for adolescents who have harmed themselves could be individual-based, family-based or group-based. Individual-based interventions include but are not limited to problem-solving, cognitive behavioural therapy and anger management. Family therapy could be in the form of problem-solving or structural or systemic therapy, and group therapy could involve any of these techniques performed in teams or groups.

Problem-solving Therapy

Problem-solving therapy or brief psychological therapy as it is otherwise known, is a brief treatment that is aimed at helping the young patient to acquire basic-problem solving skills to identify and prioritise their problems (Mental Health Foundation, 2006). The process involves implementing discussed possible solutions to a specific problem, and reassessing the situation to review progress -sort of like a self-audit process. The basics of problem-solving therapy as identified by Hawton and James (2006) are highlighted below: NURS 6541 – Primary Care of Adolescents and Children Essay Paper

· Identifying and deciding what problems to tackle first

· Agreeing goals of therapy with the patient as much as is possible

· Working out steps to achieve goals

· Deciding how to tackle the first step

· Reviewing progress

· Dealing with psychological factors that obstruct progress

· Working through subsequent steps

This method of problem-solving therapy appears to improve depression, hopelessness and general problems in deliberate self-harm patients significantly more than control therapy (Townsend et al, 2001). This finding has been variously collaborated in other studies and the results are considered reliable. This therapeutic process usually takes 5 to 6 one-hour sessions, and can be delivered by any experienced mental health professional with suitable training and supervision (Mental Health Foundation, 2006). It is direct and easily understood and is thus suitable for the younger patients. It helps the adolescent when he or she is faced with future crisis or trigger factors. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Cognitive Behavioural Therapy

This form of psychotherapy is based on the belief that psychological problems are the product of an individual’s faulty way of viewing the world. In this case, the therapist aims to modify the patients’ cognitive processes and beliefs using techniques that are similar to those described above (problem-solving therapy), but with behavioural techniques.

Although widely used adopted in psychotherapy in the treatment of depression, cognitive behavioural therapy (CBT) has limited evidence of use in self-harm patients. Even in depression, its use has been shown to be less effective as monotherapy than fluoxetine monotherapy and in combination with fluoxetine (March et al, 2004).

Dialectical Behaviour Therapy

Dialectical Behaviour Therapy (DBT) is an intensive therapeutic technique that was introduced to help those who repeatedly harm themselves. It could involve as long as a full year of individual therapy, group sessions, social skills training and access to crisis contact (Mental Health Foundation, 2006).

Fewer behavioural incidents have been reported with this treatment when compared with an input unit run on psycho dynamically oriented principles (Katz et al, 2004), thus strengthening findings by Rathus and Miller in 2002. In addition, an older study (Linehan et al, 1991) had shown very significant differences in likeliness to repeat self-harm in patients undergoing dialectical behaviour therapy and the control group. The NICE guidelines (2004) suggest the use of dialectical behaviour therapy in self-harm patients who have a diagnosis of borderline personality disorder, but stress that this should not preclude the use of other strongly validated psychological treatments with vast evidence-based support. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Family Therapy

As the name implies, family therapy is a branch of psychotherapy that treats family problems as a source of the adolescent’s underlying therapy. Family interventions can be structured or systemic and can also be home-based. Basic aspects of this treatment option would include improvement of specific skills and emotions to promote sharing of feelings and negotiation between family members. Elements of assessment of families of self-harm victim should include (Hawton and James, 2005):

· Family structure and relationships

· Recent family life events, e.g. death, relocation, divorce e.t.c.

· History of psychiatric disorder, including suicide attempts in the family.

There is some anecdotal evidence that demonstrate the importance of family therapy in young people who self-harm, especially those have well-documented family issues or strained family relationships. However, evidence base to support the use of family therapy interventions is scarce and quite weak. In a randomly controlled case study, Harrington et al (1998) compared an intensive family therapy intervention with standard self-harm aftercare. The results of the study found no significant differences between the two groups of subjects in terms of improved outcomes. NURS 6541 – Primary Care of Adolescents and Children Essay Paper

Group Therapy

Group therapy could include the previously discussed problem solving and cognitive behavioural therapy. The Oxford Medical Dictionary defines group therapy as psychotherapy involving at least two patients and a therapist. Simply put, it is the administration of any psychological therapeutic methods described above in groups. Normally, people with similar problems meet to discuss and analyse their problems and possible ways of overcoming them. Although this intervention could be time-saving, the possibility of confrontation and tension between the group members is a potential barrier to its effective implementation. Also, the negative connotation of suicide and self-harm might prevent patients from effectively participating in such group sessions.

In a small-randomised parallel trial in Manchester, England, Wood et al (2001) strove to evaluate the effectiveness of group therapy for repeated deliberate self-harm in adolescents by comparing combination of routine care and group therapy with routine care alone. Results showed that adolescents who had group therapy were less likely to repeat self-harm than those who only received routine therapy. NURS 6541 – Primary Care of Adolescents and Children Essay Paper