A Report on Children with Learning Disabilities who Engage in Self-harm

 A Report on Children with

Learning Disabilities

Who Engage in Self-Injury

By

Gayle De Souza

GM6005

Aims and Learning Outcomes

The aim of this report is to critically analyse self-injury behaviours in children with learning disabilities and the impact of improved communication on challenging disruptive behaviours. After reading this report it is hoped that you should:

• Be able to define self-injury and possible causes
• An awareness of alternative methods of non-verbal ways of communicating
• Be able to acknowledge  the importance of cultural diversity when participating in assessments

Contents Page

Introduction and identification of needs        pages      4 - 5

Communication/Self-Injury                                pages      6 - 9

Cultural Needs                                                pages    10 - 11

Further Discussion/Conclusion                        pages    12 – 13

References                                                        pages    14 - 15

Appendix:

*Case Study and rationale for

choosing case                                                 page 16

*Fig.1. Main reasons indicated

for self-harming                                            page 17

*AAC Tools brief description.                       page 18

Introduction

This report will attempt to identify and analyse the child’s needs indicated in the case study (see appendix Case Study).  These needs will be further discussed with supporting literature around the issues of self –injury and the ability of children with learning disabilities to communicate their needs although experiencing severe language impairments.   In order to assess needs, a robust and holistic assessment needs to be undertaken.  Assessment is an activity that involves gathering data and interpreting the significance of that data and any further action that may need to be taken. Assessment is not static and should be continuous to account for the fluctuations and variations in the needs of the individual. There are varying levels of assessment from the more formal structural data to the less formal subconscious assessment.  Casey (1988) provides a model of assessment that is holistic and family-centred to include the child and family’s need for support, information and teaching.  In respect of patient confidentiality the child in the scenario will be referred to as Shelly to protect patient confidentiality and anonymity in accordance with the Nursing and Midwifery Council professional code of conduct: standards for conduct, performance and ethics (NMC 2004).  

Shelly was statemented and attends a special school for children with learning disabilities. Shelly needs to enhance her communication strategies and social interactions, which in turn may reduce some of her disruptive self-injury behaviours.  The family also need to be more involved in the use of alternative augmentative alternative communication systems (AAC).  Shelly’s needs have been identified as the following:

1. Communication strategies to develop social interaction
2. Multi-disciplinary care planning/working holistically.
3. Need to reduce self-injury behaviour and need for restraint
4. Need for Family-centred care
5. One to one interventions/care/working
6. Medical interventions
7. Cultural needs
8. Need to increase mobility

Issues raised

• The complexity of self-harming in learning disabled children and the effect of the environment.
• Cultural identity should form an integral part of an assessment of need.  
• The importance of achieving an effective communication strategy to reduce frustrations.

The focus of this report allows the scope for three areas to be considered. The three identified areas this report will focus on will be Self-injury in disabled children, communication strategies and cultural needs.

Communication/Self-Injury

Shelly has limited communication and the frustrations she exhibits correlates with the literature in this area.  Children who are unable to verbalise are more likely to feel frustrated and display challenging behaviours because of their inability to be understood. (Hernadez-Halton et al 2000) would suggest that verbal communication constitutes the most important instrument of change. Communication can be divided into four main areas verbal, non-verbal, paralinguistic and written communication. However people with learning disabilities may not be able to utilise all aspects of communication and are encouraged to utilise strategies that best meet their needs. There are many factors that affect communication, verbal and non-verbal communication need to be congruent to be effective in relaying the appropriate assigned message. Birdwhistell (1970) estimated that between 65% and 70% of social interactions are perceived non-verbally.  It could be considered that all behaviours are a way of communicating and the key to understanding the individual would be achieved by acknowledging the subtle cues entwined within their individualised behaviours. This is particularly salient in Shelly’s case in which her behaviours are not fully understood, although her behaviour is different in different environments.  Manolson (1992) suggests that with patience and time it could be possible to discover what a child will respond to, or turn away from, and the unique way they articulate this should be observed and acted upon. The resource implications of Manolson’s  suggestions would be vast and would require a lot of one to one working to establish patterns of behaviour although the idea is sound.  The staffing ratios in special schools would not facilitate one to one working for all students, although research would suggest there would be a marked increase in the child’s communication systems. The use of augmentative and alternative communication (AAC) systems have long been recognised as important tools in aiding communication in children with learning disabilities, these include British Sign Language, Makaton, PECS, eye pointing and speech generating devices (see appendix AAC Tools.). The picture exchange communication system (PECS) has been instrumental in enabling Shelly’s to communicate her choice and has resolved some disruptive behaviours experienced around snack time and free play.  Jones et al. (1995) stated the success of AAC interventions is highly dependant on the family’s involvement and their shared commitment to the goals of the interventions.  This is an area that needs to be fully explored with Shelly’s family as the use of PECS is not consistently used in her home environment.  This may raise issues for the family with regards further training or involvement in the school environment to gain a more meaningful understanding of its application.  The importance of the environment in which challenging or disruptive behaviours occur is an important insight into the difficulties an individual may be experiencing.  Barol (1996) concludes that in over three quarters of the situations where she has been consulted to assess a disruptive individual’s behaviour including self -injury, a persons behaviour changes for the better when their needs are met and this may mean adapting their environment to meet their needs to facilitate this. Shelly self-injures on a daily basis and a cycle of medication, restraint and removal becomes the daily cycle in which all key professionals play an active role.  Jones et al (2004) considers that oppression and abuse are the context in which people with learning disabilities self-harm,  this has been given credence as a possible explanation in the general population on self-harm  and yet there is very little literature regarding this subject for people with learning disabilities.  Self-injury can be defined as the “repeated, self-inflicted, non-accidental injury, producing bleeding or other temporary or permanent tissue damage (Schneider et al 1996).  There is a distinction made by some authors between self-harm (used in mental health settings) and self –injury (used in learning disabilities services), self injury tends to include cutting, burning and carving behaviours (Favazza 1996).   Whereas head-banging, biting, scratching, hair pulling and pinching are seen as self-injury.  The distinctions between the two labels is contested by several authors and it is suggested that it is far  ‘less recognised’  that learning disabled individuals may self-injure for similar reasons to those attributed to non-learning disabled individuals (see appendix Fig 1.) It could be argued that the focus on the label detracts from the joint frustrations that all children who engage in these activities are screaming for, ‘understanding’. Non- learning disabled and learning disabled children experience common themes of powerlessness and feelings of vulnerability.  Babiker and Arnold (1997) suggests that both non-learning disabled children and learning disabled children could relate to feelings of powerlessness, rejection, abuse and vulnerability.  Emerson and Walker (1990) found that two thirds of people with learning disabilities used self-injury as they had no expressive form of language   When researching self-injury it becomes quite apparent that the devaluing labels used to describe these behaviours indicates society’s perception of it being ‘unacceptable’, as individuals are reduced and labelled by their self-harming behaviour.  In recent years there has been development in recognition of the multi-factorial basis of self-injury with a desire to provide humane and practical interventions. Emerson (2001) suggests that the behavioural approach is the most influential strategy for reducing self-injury in individuals with learning disabilities today.  Whilst there are a variety of behavioural approaches, restraint is still a common physical intervention used with children with learning disabilities. The Human Rights Act (1998) sets out important principles to protect individuals from abuse by the state or people working for these organisations. The schools and health and social care services owe a duty of care to their pupils. Therefore the importance of planned physical interventions and risk assessments need to be used in a holistic manner with the minimum of reasonable force.