Archive

Children and young people with mental health needs who exhibit challenging behaviour often become children lost to or failed by the system. In Southampton the Behaviour Resource Service (BRS) was set up to meet the needs of these young people, such as 14-year-old Sadie Caine.

Sadie was identified as one of 50 children in the area with highly complex needs, a high proportion of whom, unsurprisingly, were looked-after children. She was referred to the service's on-site residential unit, managed by Jamie Schofield.

The four-bedded residential unit, staffed by mental health nurses and social workers, provides one-to-one staffing 24 hours a day for young people aged between 13 and 18 who are placed on a six-week assessment.

Sadie's unpredictable behaviour was compounded by her problems with drugs and alcohol. She had problems sleeping and become anxious and aggressive at bedtimes. Around bedtimes, her aggression resulted in worrying periods of restraint. Although the unit's mental health nurses have access to medication, none had been administered in the project's three-year life. However, Schofield concedes, sedation was considered for the first time. "It was a dilemma - some thought it would be better to use injections than the possible harm from restraining her. Others said that, as she was anxious enough, how more anxious might she feel if she thought we were going to be dosing her up?" Sedation was ruled out.

Sadie then disclosed for the first time a traumatic sexual assault that she had suffered. For the team it was rewarding that Sadie trusted them with this painful disclosure and it helped explain her aggression in terms of post-traumatic stress.

However, despite this progress, Sadie was proving too difficult to manage effectively in the residential unit. "We basically couldn't keep her safe but we still wanted to do the work - so we moved her to a secure unit," says Schofield. "It was difficult. She had built up some good relationships and having disclosed to us we didn't want her to feel we were dumping her out somewhere. So the message was: 'You're moving because of the safety aspect - but we don't want to give up on you'. And we continued our work with her."

The team began exploring placement options "because we thought she needed something much longer term owing to her post-traumatic stress," says Schofield. "Our big worry was the courts at this time. But we managed to persuade them that a custodial sentence would not be in her interest." To this end, a psychiatric hospital with secure and open sections was identified.

Schofield believes that the crux of the intervention with Sadie was the personal engagement. "She'd never had anybody to engage with. This is something we work very hard at. For Sadie, this was very much about finding individuals whom she trusted. We built a lot around the fact that she was a fantastic drawer and a really good footballer, and concentrated on what she was good at." But, in essence, given her post-traumatic stress, it was "lots and lots of listening, really".

Sadie was given a weekly journal to complete. Each morning she and staff would plan her day. "This would include some educational bits because she was out of school. And we'd get her to fill in her journal at the end of the day but well before her bedtime, concentrating on what she had achieved. This helped because, if 9pm was the time she would normally blow, at about 8pm we'd be filling the journal in with all the positives about her day," says Schofield. Sadie remained in the hospital for about a year - successfully graduating to the open unit. She returned to Southampton last year, since when her behaviour was much better managed and she remained crime-free.

However, Sadie has since committed another assault, having become involved with an old acquaintance. Although seen as a one-off, it was a serious enough offence to see her placed back into the psychiatric unit.

Despite this setback, the team are rightly proud of their work with Sadie. Without the support of the BRS it's safe to surmise that Sadie would have been imprisoned. Now, she has hope.

Case notes

Practitioner: Jamie Schofield, residential team manager, Behaviour Resource Service (BRS). 

Field: Assessment of children and young people with complex mental health needs and behavioural difficulties. 

Location: Southampton 

Client: Sadie Caine is a 14-year-old girl whose family has been known to social services for some time. 

Case history: Sadie was involving herself in crime almost daily. An   aggressive young person, she was often arrested for assaulting police officers. Placed in a secure unit, she was referred to the BRS community team for assessment. Sadie would regularly harm herself and had twice taken an overdose. However, because of her behaviour, the BRS community team referred her to the residential unit, believing this to be a more appropriate setting. But at this time Sadie's criminality had meant that a court appearance was imminent and a custodial sentence was very likely. 

Dilemma: Sadie's behaviour is pushing her towards a custodial sentence but time is needed to build up a relationship and trust - time that might not be available. 

Risk factor: A custodial sentence could permanently damage any attempt to rehabilitate Sadie, but her aggressive and destructive behaviour puts her and others at serious risk of harm. 

Ooutcome: Sadie's residential placement in a psychiatric hospital was successful and she returned home to live a crime-free life for a year, but has now been placed back into psychiatric care.

Arguments for risk 

• Drawing on their experience and skills, the team managed to engage with Sadie and once this proved possible there was a good opportunity, if she could be kept out of prison, that positive therapeutic work could be successfully carried out - albeit at first under secure conditions. 
• That Sadie disclosed the sexual assault not only confirmed her engagement by the team and Sadie's trust in them, but also made her aggression more understandable: she was suffering from post-traumatic stress. 
• The team knew that, if trigger points could be countered with positive work, Sadie's aggression - which had landed her with the strong possibility of a custodial sentence - might be better managed. Her aggression increased at bedtimes as her attack had taken place late at night. 
• While recognising Sadie's potential to return to the community and mainstream services, it was clear that this would take time - and a safe, longer-term placement was required.   

BOXTEXT: Arguments against risk 

• Even though engagement had taken place, Sadie was still exhibiting aggression to staff with whom she had formed attachments. This would suggest that it would always be a risk placing her anywhere other than a secure placement, as she clearly could not control her behaviour.  
• Sadie's targeting of police officers, in particular, for assault, showed a lack of respect for authority and even suggested a desire to be arrested and imprisoned. Her self-harming and overdosing point to her inability to cope alone. Perhaps she subconsciously knew she was unsafe in the community and desired a secure place where she could be "made" to be safe. 
• Despite having been crime-free for a year upon her return to Southampton she has fallen in with one of her old acquaintances and has committed another serious assault. There may be valid claims that she acted against her own better judgement and that it was a one-off, but that must be little comfort to the victim.

Independent comment 

 Adolescents who have complex needs, especially those with post-traumatic stress disorder arising out of earlier abuse, pose the single most anxiety-provoking challenge to services, writes Dr Susan Bailey. 

Such young people are highly likely to fall into any gaps in service provision, presenting to services as disruptive, with self-harming tendencies and dangerous behaviour. 

Initiatives such as the Behaviour Resource Service provide a bridge with safety rails to take the young person from chaos to safe autonomous thinking and choices in adult life. To work, these initiatives require structural agreement by senior officers in health, social care, education and justice that accepts life cannot be risk-free. And it is vital that the officers will not allow themselves to be driven by a blame and shame culture. 

Rejecting easy options, such as medication to control, takes great honesty, courage and a supportive team. Listening therapy is the most difficult to do, but is most likely to be needed and wanted by the young person. 

Whatever further criminal behaviour occurred or may occur, for a critical part of this young woman's life, her needs were understood and met. The hope is this acted as a true turning point for her, increasing her internal resilience, whatever the future holds. The real test of innovative services will be if this turning point helps young people in the safe parenting of their own children. 

Dr Susan Bailey is a child and adolescent forensic psychiatrist.