CASE STUDY
The name of the service user has been changed

Situation: Shona Simmons is a 13-year-old girl whose mother has a dependency on class A drugs. Her father left when Shona was five and hasn't seen her since. However, his family has remained in touch and Shona's two uncles are often at the house. They, too, have addiction problems and regularly invite their associates into the house. With her mother unable to cope and the drug lifestyle of the house, Shona was taken into care. However, having sabotaged four foster care placements in a matter of weeks through absconding, physical and verbal abuse and damage to property, Shona was placed in a local residential unit specialising in young people's aggressive and challenging behaviours.

Problem: Shona, despite her chaotic lifestyle, had been relatively stable in her education. However, she started passing out and having convulsions at school. The doctor believed that there wasn't a physical reason for this and suggested that some underlying mental health problem might be the cause. She was referred to the child and adolescent mental health service. A therapist working with her began to untangle some of Shona's emotional feelings and considered that these feelings were being converted into physical outcomes. However, Shona would not talk directly about these feelings because, it was assumed, she was frightened and worried. Using creative writing therapies, it became apparent that physical and sexual abuse had figured in the past, and that she had been self-harming, unbeknown to anyone, for about a year.

PRACTICE PANEL - Liverpool Children and Families team
Steve Oliver - team manager adoption service ; Jill Thorburn - team manager looked after children service ; Joyce Msiska - social worker, family support service ; Vince Bartley - senior practitioner ini Prescot Drive short term breaks unit ; Angela King - family support co-ordinator

PANEL RESPONSES

Steve Oliver
The social worker should have explored the whereabouts of Shona's father - absent since his daughter was five - as one of the principles of the Children Act 1989 is promoting family contact. Although he might be unable to care for Shona he may be able to play some role in her life. His absence from her life will have affected Shona as she will have been old enough to remember him.

Shona's life seems to have been chaotic and unstructured. Given her dependency and lifestyle, her mother may not have been in a position to protect her daughter. This placed Shona in a vulnerable position and compromised her safety. Indeed, she is now disclosing sexual and physical abuse.

Shona's only stability appears to have been school. It is imperative that social workers sustain this while considering her placement. Shona's psychosomatic physical symptoms in school may be because she is trying to contain what she perceives as negative behaviours. She is attempting to contain her physical and verbal outbursts in school. The social worker should explore the reasons why school has been such a stabilising factor, which might include good relationships with teachers.

These are important factors in trying to develop suitable long-term care plans for Shona. If she is going to succeed in making the transition into adulthood she will need to be stabilised in the residential unit but consideration needs to be given to finding permanent, experienced foster carers who will be able to help her feel safe and secure in a functioning family setting. A foster placement will also be more likely to provide a setting where Shona could form appropriate and secure attachments to her carers. She will need to be fully consulted throughout this process as she is likely to continue to rebel against any placement she has not been in agreement with or emotionally ready for.

The social worker needs to ensure that school staff are involved in Shona's behaviour management plan and that they are aware of actions they should take if Shona self-harms in school. They may well provide pastoral support staff and a "safe place" for her to go if she needs it.

Jill Thorburn
It is not surprising that Shona has broken down her placements in a fostering setting. She has no experience of living in a family which is not dysfunctional. She is angry and lashing out. This may be symptomatic of the fact, she has not learned to express her feelings or emotions verbally.

That she self-harms is again an expression of her frustration and inability to articulate her emotions. Social workers and carers should view her self-harming as her way of coping with her experiences. It is likely she will continue to self-harm until she finds different coping mechanisms and ways of self-expression.

In her care setting Shona should be encouraged to take responsibility for self-harming. This can take the form of cleaning her wounds and ensuring she has notified her carer of any incident. She should not be made to feel her behaviour is wrong as this is her only way of coping with what has happened to her.

Another factor which should be considered is that the major role models in Shona's life have also been self-harmers. From an early age Shona will have seen people injecting class A drugs. It may be possible to draw parallels in a child's mind between withdrawing blood in the process of taking intravenous drugs and doing so by cutting. Both are ways of using self-harm to cope with life.

It may appear that Shona is unwilling to talk about her experiences. It may well be that this is because either she is trying to protect her mother or that she is too afraid to do so. However, because she has begun to open up during the use of creative therapies this is likely to suggest an inability to access or express her emotions. This type of therapeutic intervention is clearly working and should be continued. There should be an element of the therapy being didactic in its nature so that Shona learns new ways of self-expression and self-analysis.

Sometimes when very young children experience abuse and trauma before they have developed language it is more difficult to explore past trauma. The reason for this is that the child remembers the experience in feelings rather than words. This may be why Shona is exhibiting physical responses to her early trauma.

USER VIEW
Although this is clearly a serious situation, there are aspects of Shona's life that can be seen as slightly more positive. To best support Shona, we should build on these positive aspects, writes Mark Houston. 

Bearing in mind that Shona has recently had a chaotic and unstable time, it is important that she has some continuity and so she should continue living in the specialist unit. This provides a secure environment, where not only can she feel safe, but staff can monitor her non-intrusively. 

Having said that, it is equally important that she spends time out of this facility, in order to not become institutionalised and too reliant upon it.

The fact that a child and adolescent mental health services therapist has been able to untangle some of Shona's difficulties is encouraging and suggests that, with the correct approach, it is possible to further untangle her problems. The therapist needs to continue to work with her, perhaps further exploring more creative ways of expressing herself. 

It must be remembered, however, that this will  take time. Shona needs to build trust with the therapist and, since her past experiences are so painful, she may take time to be able to  communicate what has happened and how it has affected her emotions.

For example, constantly seeing the use of highly dangerous drugs and the damaging effects, including physical and sexual abuse, must have had a serious psychological impact on her. This is particularly poignant given she is only 13. 

The fact that Shona is self-harming is concerning. This may be due to severe frustration and low self-esteem and so I would suggest that part of the solution be to boost her morale. 

Maintaining her involvement in school is essential. The fact that this has been the most stable aspect in her life suggests that a positive way forward would be for the school to continue to play a major role in her future. As well as enabling her to keep up in terms of educational progress, it will help to maintain Shona's social contact. Reduced social contact could lead to social difficulties in the future. 

The school should help Shona engage in  extra-curricular activities. Of course, extra human resources would be needed to protect her from self-harming. This should be provided by the school and the local children's services department. She would also benefit immensely from peer mentoring if this service is available.  

Mark Houston is a care leaver