Case Study: ‘Lisa’ referred to CAMHS

Lisa is 15, she took an overdose last night of a small amount of Ibuprofen, Paracetamol and Codeine, and scratched her left wrist. She complains of school problems and of people on the street, where she lives, annoying her. She denies wanting to kill herself and is unable to articulate why she did this. There have been previous episodes of scratching her left wrist. Lisa and her mother have asked for help.

Summary of the case

Lisa presents as unhappy about several aspects of her life. It feels as though her current state is very much a reflection of the impact of past events together with her current situation, particularly her educational status, including poor attendance and academic underachievement. There is also a combination of difficult and overwhelming family relationships and an abusive boyfriend. Lisa also experiences hostility, as do the family generally, where they live. They are a Gypsy/Roma Traveller (GRT) family in settled housing. It is highly probable they will be evicted from their home within the near future. The family are seeking legal advice in this respect.

There is no current intention to self-harm although Lisa has threatened mum with repeating an overdose if mum insists she attend school.

Early development

Mum described Lisa being born at term via a normal delivery and she was bottle fed. Mum felt Lisa was ‘maggoty’ (mum’s words) as a baby, which I interpreted to mean a bit niggling and unsettled at times, which mum agreed with. There were some difficulties going to others an around separating from mum when Lisa started at nursery school. Lisa walked at 11 months and met other developmental milestones within normal ranges.

Home

It certainly felt as though there were many difficulties at home. Lisa’s younger brother has a diagnosis of ADHD, which puts quite a strain on the family. It sounded as though there is quite a lot of fighting at home between Lisa’s older brother and the younger brother, which Lisa becomes embroiled in. There had also been serious worries earlier this year over mum’s health with a query over a brain tumour. Mum’s understanding is that she is now in the clear.

Relationships

I was concerned to hear Lisa has a boyfriend who is physically abusive towards her. Despite being beaten up by him Lisa expresses a wish to continue the relationship, which mum is unhappy about. Lisa has other peer appropriate friendships and obviously gets on well with mum despite very fraught situations at home.

Emotional state

Lisa described her mood as ‘OK’ most of the time, scoring 5 on a scale of 1–10 with 1 being sad and 10 being happy. Mum felt Lisa was ‘down in the dumps’ most of the time. Lisa was certainly tearful about the boyfriend situation and about what happens at home. Sleeping and eating was normal, although Lisa acknowledged irregular eating and has lost weight, although this does not appear to be of concern at the moment.

Education

What was clear was that there have been long-term and current difficulties. Lisa could not tell the time from the wall clock during the appointment; neither can she read beyond a basic minimal level. Attending and leaving 3 different primary schools and now being at her third secondary school has probably not been helpful to say the least. These moves have understandably been difficult to negotiate and make any sense of. The main theme seems to surround behavioural issues. Lisa reported getting into trouble frequently. She also felt she had been misunderstood and unfairly treated over a recent minor incident where other pupils took some charity pens.

Plan agreed with Lisa and her mum

I will contact school and the Education Welfare Officer to establish what help Lisa can receive and arrange a meeting with the above, Lisa, and her parents. I will meet with Lisa to offer some 1:1 work focussing on choices she is able to make in order to appropriately manage relationships and decision making and keeping herself safe. I am going to ask our child and adolescent psychiatrist to see Lisa and explore/rule out the possibility of any other underlying difficulties given Lisa’s brother has ADHD.

Think about the case of Lisa in relation to the above and the risk and resilience theories discussed in the CAMH chapter.

You could also consider Lisa using the following points:

Lisa is at greater risk of developing mental health problems because:

• There are family relationship problems with reports of violence between her brothers at home.
• She is in an abusive relationship with a boyfriend.
• She has a sibling diagnosed with ADHD.
• Mum has had a significant illness.
• The family are at risk of eviction from their home.
• Lisa and her family are from an ethnic minority culture as a GRT family.
• Lisa has poor academic achievement and much lower educational skills than her chronological age.
• Lisa has had multiple school moves.
• As an adolescent Lisa is also dealing with this turbulent developmental stage.
• On a positive note Lisa and her mum have asked for help and Lisa does have positive supportive peer friendships that are appropriate. There is a strong family network of support as is often typical in GRT culture.

You can probably appreciate Lisa feels quite overwhelmed with her current situation which has precipitated her into adopting cutting herself as a way of managing her feelings. Being able to help and support Lisa with some aspects can offer alternative ways of coping that are more appropriate. In Lisa’s case it is really important to attend to the contextual factors, particularly her schooling and education experience, as a priority together with her relationship choices and in time improving her self-esteem and self-efficacy. We are always reminded that although cutting as a form of self-harm may appear about coping it is on the same continuum as suicidal ideation and is at risk of further deterioration if there is no help or intervention.

As discussed above, children and young people who self-harm are often described negatively as ‘attention seeking’ or their behaviour is a ‘cry for help’ by others around them and perhaps of more concern by the professionals they come into contact with often in busy A&E departments. We need to positively provide the attention that is required in a caring, empathetic and curious way. Presenting for help as Lisa did, is a window of opportunity for engagement and possible suicide prevention (Owens et al, 2016).