The BRIS report 2012

theme

Mental illness

BRIS Offices BRIS (National Association) Box 3415 SE-103 68 Stockholm Tel: +46 (0)8 598 888 00 Fax: +46 (0)8 598 888 01 E-mail: [email protected] BRIS region Nord (Northern Region) Kungsgatan 36 SE-903 25 Umeå Tel: +46 (0)90 203 65 10 Fax: +46 (0)90 203 65 11 E-mail: [email protected] BRIS region Väst (Western Region) Hvitfeldtsgatan 14 SE-411 20 Göteborg Tel: +46 (0)31 750 11 30 Fax: +46 (0)31 750 11 31 E-mail: [email protected] BRIS region Mitt (Central Region) SE-115 26 Stockholm Tel: +46 (0)8 598 888 10 Fax: +46 (0)8 598 888 11 E-mail: [email protected] BRIS region Syd (Southern Region) Östra Rönneholms vägen 7 SE-211 47 Malmö Tel: +46 (0)40 690 80 70 Fax: +46 (0)40 690 80 71 E-mail: [email protected] BRIS region Öst (Eastern Region) Korsgatan 2, Hus E SE-602 33 Norrköping Postal address: BRIS SE-601 86 Norrköping Tel: +46 (0)11 440 05 50 Fax: +46 (0)11 440 05 51 E-mail: [email protected]

bris 

  – Children’s Rights in Society – is an ngo, a voluntary organisation with no party political or religious affiliation, which supports children and young people in distress and is a link between children, adults and the community. The core of bris’ services is comprised of the bris 116 111, the bris-mail and the bris-chat, to which children and young people up to the age of 18 can turn anonymously and free-of-charge when they need support from an adult. bris also works as an opinion maker and referral organisation to increase adults’ respect for children as individuals. bris works for the full application of the principles established in the un Convention of the Rights of the Child. bris uses its collective knowledge of the situation of children and young people to inform, influence, and create opinion in children’s rights issues at various levels. bris also accepts calls from adults who need someone to talk to about their own children or the children of others.

bris was founded in 1971 and is organised into one national office and five regional offices. The offices are located in Malmö, Göteborg, Norrköping, Stockholm and Umeå. BRIS’ services are based on volunteer work and financial grants and donations from both private and public donors. bris has a total of about 600 volunteer workers who man bris 116 111, the bris-mail and the bris-chat. These volunteers are recruited, trained and supervised by employed bris personnel. The bris Adult Helpline – about Children is usually manned by employed bris representatives and costs as much as a regular phone call.

bris 116 111 – for those up to age 18. Monday to Friday: 3:00 pm – 9:00 pm Saturday, Sunday and holidays: 3:00 pm – 6:00 pm bris Adult Helpline – about Children Monday to Friday: 10:00 am – 1:00 pm 077-150 50 50 www.barnperspektivet.se for adults who have questions about children

The BRIS-mail The BRIS-mail provides personal responses within a few days. In the Discussion Forum, which is also on BRIS. se, children and young people can communicate with each other under the supervision of an adult moderator. On the BRIS-chat, you can chat directly with an adult at BRIS. www.BRIS.se

Contents 28

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4 7

A word from the Chairman BRIS’ demands in 2012

33

An 23 SUPPORT ambiguous and

contradictory mission

has 27 Everyone a responsibility 28 Insufficient access to school

8 BRIS helps

9 30 Mental 10 THEME illness 33 16 BULLYING Struggling in 38 silence Take us more seriously

psychologists

Nobody should be lost The important calls Statistical summary 2011

Children 20 SORROW often alone in their sorrow

tel +46(0)8-598 888 00 www.bris.se PG 901504-1

Publisher BRIS, Barnens Rätt I

Editor Cecilia Nauclér/Peter Irgens

Samhället (Children’s Rights In Society)

Art director Helena Lunding

Address BRIS-tidningen

English translation Semantix

Box 3415

Responsible editor Eva Waltré, Acting

SE-103 68 Stockholm

Secretary General of BRIS

Sweden

Cover Susann Karlsson Nemirovsky

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the Bris-report 2012

The Board

text

Cecilia Naucler

photo

Johan Bergling

In 2011, focus was on making it possible for BRIS 116 111 to be open around the clock. The Chairman of the Association Board of BRIS, Lars-Johan Jarnheimer, hopes to be able to begin reaping the fruits of the hard work of 2012.

A word from the

Chairman In 

2011, bris’ association board decided that it was time for bris to make it clear that bris exists for all children – always. The decision was based on the children’s need for bris and their faith in the work of the organisation, which can be seen in the large number of calls to bris 116 111 when the helpline is not open. Consequently, one of the organisation’s most important objectives is to extend the opening hours of bris 116 111 to being open around the clock. “The work of making round-the-clock opening hours possible has been laborious,” says Lars-Johan Jarnheimer, Association Chairman of bris. “But the hard work is also beginning to pay off.” “Higher availability in bris 116 111 for all children, around the clock, is beginning to take shape and I hope that we will have something in place sometime in 2012. Higher availability demands more resources and one of the absolutely most important priorities for the organisation has been and is increasing and stabilising bris’ financing. bris has made strong efforts in its fundraising methods, from somewhat unstructured fundraising to a strategic, well-thought out and professional fundraising organisation. However, this means

2012 • the BRIS report

that bris must do even more,” says Lars-Johan Jarnheimer. “We compete with organisations with significantly larger marketing and media budgets that work incredibly professionally with fundraising. Compared with them, bris is not yet really caught up, largely because bris actually conducts daily support services that demand a lot of attention. But we are working hard to catch up on the fundraising side.” Lars-Johan Jarnheimer notes that the corporate social responsibility work of the business community has changed so that it is significantly more important for the companies to show some form of social commitment. Cooperation today requires a mutual give-andtake between the partners and three important examples of this are bris’ cooperative efforts with Skandia, Tele2 and Astra Zeneca. “In our cooperation with them, bris’ knowledge constitutes a part of their own business. Our knowledge is of use for them. “The giving-and-taking may never, however, risk watering down bris’ brand,” emphasizes Lars-Johan Jarnheimer. bris’ ethical standards are very high and we can never sell our soul for a little more money.” He is not worried that the greater need 4

the Bris-report 2012

The Board

We are all basically driven by the same thing, to help as a many children as we can, and this demands a social commitment and professional fundraising.

for revenue would mean that the social commitment in the organisation will have to come second. Rather, they go hand in hand. “bris needs strong finances at the same time that the organisation cannot survive without its volunteers. We are all basically driven by the same thing, to help as a many children as we can, and this demands a social commitment and professional fundraising. Our volunteers are the organisations unsung heroes and it will always be this way. “These two legs are also necessary for bris to be able to develop in pace with the children’s needs. The world is spinning ever faster and the likelihood is growing that more and more children will get caught in the middle,” confirms Lars-Johan Jarnheimer. “If bris is to be able to still be a strong organisation in ten years’ time and be able to

welcome all children – always, resources are needed.” In addition to the work on higher availability and financing, the fact that bris has changed its Secretary General for the first time in 12 years consumed a large part of the Board’s work during the year. “Another explicit goal during the year was that bris would strengthen its position as a children’s rights organisation. On this front, bris has come a long way,” says Lars-Johan Jarnheimer. “The large media attention on our launches and seminars, both nationally and regionally, shows how important many people feel that bris’ work is. The large demand for bris’ knowledge also shows that the organisation has a voice that counts and is taken seriously.”  

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the BRIS report • 2012

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the Bris-report 2012

BRIS demands

illustration tanja metelitsa

2012 • the BRIS report

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the Bris-report 2012

BRIS demands

BRIS’ DEMANDS IN 2012 BRIS believes that:  Further resources should be allocated to student health services so that more positions can be filled, especially the number of school psychologists.

 BRIS 116 111 should be open around the clock. BRIS wants to be able to offer all children the possibility of getting help and support whenever they need it, regardless of the time of day. For victimised children, rapid contact with an adult can be crucial after physical and sexual abuse, but on-call social services are not always available in every municipality. In addition to this, making first contact with a government agency may be a step that is far too big for many children.

 In the regions or municipalities where there are confirmed lacks and collaboration among authorities does not work, the decision-makers in charge of healthcare issues should:

 The un Convention on the Rights of the Child should be incorporated into Swedish legislation requiring that the child’s best interests be satisfied in all decisions concerning the child.  Decision-makers that are responsible for healthcare issues at the regional and municipal levels should accept responsibility and introduce compulsory workgroups concerning young people with mental illness at every healthcare centre in the country, if such groups are not already in place.



– Provide clearer mandates to the operations that are responsible for the work with mental illness for children and young people and



– Distribute clear information to children and young people on where they can turn if they feel they have mental health issues.



– Create conditions for extra lessons and help with homework for children who have poor mental health. If these demands are not met, BRIS feels that:

 The responsible decision-makers, at the national, regional and municipal level, are in violation of the right of children to care pursuant to the Health and Medical Care Act and the UN Convention on the Rights of the Child.

 The workgroups should consist of the professions of counsellor, psychologist, nurse and doctor, as in the student health services.

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the BRIS report • 2012

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the Bris-report 2012

Web evaluation

text

Mia Berg

photo

Private and Johan Bergling

BRIS helps It is now proven – BRIS’ supportive contacts make the children feel better and let them know what they should do. In short: BRIS helps! This is what fresh research from Linköping University shows.

T

freely. It is important that the children feel that bris takes them seriously and listens to them. Several children wrote that it was the first time an adult did so. “They also said that the support from bris meant that they had more faith in themselves and regained their belief in the future. Most felt that the advice they received from bris about how they could handle the situation would work.” There were exceptions. Some of the children said that they felt worse directly after the contact, but then better again ten days later. Kjerstin Andersson’s interpretation of this is that the children had weighty issues that meant that the advice they received from bris felt difficult to follow. However, these children also said that they felt that they were Kjerstin Andersson is a researcher at Tema helped by the contact with bris.

bris’ support services are in demand by children and young people is not in question. However, there has been some doubt from outside the organisation as to how much e-mailing and chatting with bris actually helps children. These doubters may have now gotten their answer. In 2011, bris’ internet-based contacts were scientifically evaluated for the first time. Now, it is clear that bris makes a difference. Kjerstin Andersson is a researcher at Tema Barn, an interdisciplinary research centre in Child Studies at the Department of Thematic Studies at Linköping University. Together with her colleague Karin Osvaldsson, she conducted the evaluation of bris’ contacts with children via chat, e-mail and the discussion forum. “We wanted to see if the children perceived any difference after the supportive contact, and also find out if the effect lasted or if it was only transient,” she says. Children who contacted bris by chat and e-mail were asked if they wanted to be included in the study. If they said yes, they were asked to answer some questions immediately before the contact, directly after it and again ten days later. The questions were about how they felt at the different times, how serious they felt the problem was that they were seeking help for, and the degree to which they felt that they could do something about the problem. “What we could see was that the children felt better right after the contact with bris, and ten days later, they still felt better than they did beforehand. So the children are helped and the effect lasts,” says Kjerstin Andersson. he fact that

Barn, an interdisciplinary research centre in Child Studies at the Department of Thematic Studies at Linköping University.

Surprisingly positive In addition to the questions to those who used chat or e-mail, a questionnaire was also sent out to those who used the bris Discussion Forum. And the results were surprisingly positive. “No adults are involved there, but rather it is the children themselves who support each other. And there were many who thought that it felt important to be able to help others, at the same time that they themselves felt that they were helped by discovering that they were not alone in their problems.” The evaluation revealed that the children choose their means of contact with care. Most begin by surfing around bris.se, and then they check out the Discussion Forum to see if anyone has thoughts that are similar to their own. Then they try e-mail or chat. Many hesitate to call because they are afraid of starting to cry on the phone, that somebody at home will hear them calling or that the person who answers will recognise their voice. “Anonymity came up the whole time as an important factor in the evaluation. The children choose bris because they can be anonymous, in which case chat and e-mail feel safer to start with. They gradually work their way up to picking up the phone,” says Kjerstin Andersson.  

BRIS takes young people seriously The score was also high in responses to the direct question as to whether the children feel that bris helps: nearly seven on a scale of nine. The view of what it is that helps grew forth when the children were allowed to write 2012 • the BRIS report

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the Bris-report 2012

Web evaluation

Eva Waltré, Acting Secretary General of BRIS

Take us more seriously to get it in black and white that bris helps the children and young people? “This is something that we at bris have sensed and believed in the entire time. This is why it is important that it was now possible to confirm scientifically – that we make a difference. The fact that the children feel that we listen to them and take them seriously is especially strong since this is one of the goals of our support services. “I thought it was exciting to see how important the bris Discussion Forum is for the children, both for realising that they are not alone in their problems, and because it serves as a gateway to e-mailing and phoning. It becomes very clear that it is important that we offer the children several ways of contacting us. “For us, the results also mean that we have something concrete to show in the contact with the media and politicians. In the Netherlands, one views these kinds of activities as a given part of what society should offer their citizens, which is why they are fully financed by the state. Most citizens in Sweden also view bris’ support services as a given, but here, we only receive 3 percent of our financing from the state. I wish that politicians and decision-makers would take the support that we offer a bit more seriously.”

how does it feel

Eva Waltré, BRIS

The Evaluation 4 The evaluation addressed children who contacted BRIS by e-mail, chat and the discussion forum during the spring and summer 2011. In total, 6,193 children were asked if they wanted to complete the questionnaire on the Internet. Ultimately, 925 children and young people participated. The average age was between 13.2 and 14.5 in the various studies. The questions were asked as digital surveys on the computer. The BRIS contacts by phone were not included in the evaluation for technical reasons. A summary of the evaluation conducted at Tema Barn is available at www.BRIS.se http://www.bris.se/upload/ Articles/BRIS_evaluation_of_ webbased_serv_exe_sum. pdf

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the BRIS report • 2012

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the Bris-report 2012

Support

Hjälp = Help

2012 • the BRIS report

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factual material photo text

Karin Johansson

Johan Bergling

the Bris-report 2012

Mental illness

Cecilia Nauclér and Karin Johansson

illustrations

Thomas Fröhling

Lena Sjöberg, Söderberg Agentur

THEME

Mental Illness

Psykisk ohälsa

BRIS often hears children’s deepest secrets, the things they do not tell anyone else. The anonymity and BRIS’ contact-response methodology in never placing blame make it possible for them to dare to open up. In these accounts, it comes forth that many children with mental illness do not tell anyone how they are actually feeling, not even when they have sought help. Consequently, the BRIS Report 2012 focuses on the causes of children’s difficulties in getting help and on what they need from the adult world.

B

etween 2004 and 2007, bris’ contacts about mental illness increased by 33 percent, from 3,951 contacts to 5,243. In 2011, bris had 4,545 contacts about mental illness, which corresponds to 17.5 percent of the total number of contacts, which means that mental illness is still a common reason for children and young people to contact bris. The children who contact bris sometimes speak of severe psychological symptoms, such as sleeping and concentration difficulties, eating disorders, self-destructive behaviour and thoughts of suicide. For some of the children, the contact with bris is the first time they sought help, and the first time they tell anyone how they actually feel. Others have sought help, but still do not tell anyone certain important things, not even the therapist. Karin Johansson, investigator at bris, has read a large number of the children’s accounts and she sees many reasons that children have not been able to talk about certain things and also do not get the help that they need. One of the main reasons is feelings of guilt and shame. “It is incredibly difficult to talk about things one is ashamed of. Many not only feel a sense of shame and guilt over what they have been subjected to, but also about the fact that they feel bad. Feelings of guilt and shame close the door between their internal world and surroundings, and it is particularly prominent in children subjected to very traumatic

events such as sexual abuse,” explains Karin Johansson. There are also other reasons that they feel guilty, such as medication that does not work or conversational therapy that does not help. They view the fact that treatment does not work as further proof that there is something wrong with them, and the expectations from their surroundings and the feeling that they should be grateful for the treatment they receive increase the sense of guilt in the child. The worry of other people about their health also causes many not to tell. “When the children notice that others are worried about them and that this worry can become suffering for parents, for instance, they try to protect the adults by not saying more than what they feel their parents can handle hearing. The child does not want to further burden his or her parents or anyone else that may worry.” They can try to calm their parents by lying and saying that they feel better. “It is extra difficult to tell if the child was doing poorly previously and then saw the stress it entailed for the whole family. If the child notices that the parents feel better again, he or she does not want to cause a new period of difficulty for them.” The children’s thoughts about what the therapist expects can also make it difficult to tell and the children may, for example, tell a therapist that they feel better because they think that that is what is expected of them. 11

the BRIS report • 2012

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the Bris-report 2012

Mental illness

Children who have undergone themselves with selfvarious kinds of treatment over destructive behaviour. an extended period of time and Children can feel that who have been assessed to have a parent’s health and recovered from their mental life are in danger if they illness, may have difficulty say how they feel and talking about a relapse or children do not dare take that they even feel worse than that risk.” before, because the child Children subjected This worry does not want to disappoint the to mental and/or physical is often based on adults. abuse, sexual abuse or previous experience bullying can be prevented Difficulties in describing the and rarely seems problems and finding the right from telling someone out words can also contribute to the of fear for the perpetrator. unfounded. children not talking about their Karin Johansson The perpetrator has often situation. threatened reprisals if the “This is mainly true of younger children who child tells, but there are also children who do not feel that it is enough to say that they imagine what could happen. feel bad or that they need help, but rather they And just imagining what could happen if all have to have finished, clear formulations to be information came out can be so frightening that believed and taken seriously.” the children choose not to tell anyone. They describe for bris how they are suffering “Thoughts of compulsory psychiatric care in some way, but do not believe that their and being committed to a psychiatric clinic are description will sound serious enough for anyone what causes the most worry. This worry is often to understand. based on previous experience and rarely seems unfounded.” When no one asks Worry that the adults will not maintain In the accounts conveyed to bris, there are also the secrecy is also a reason for them not to tell. children who have tried to tell an adult at, for Some children have told an adult at school, for instance, their school or the social services, but instance, who then told either the child’s parents have not been believed, or the child has felt that or somebody else at the school. their troubles were not taken seriously. They There are also children who feel that telling then have an even harder time to tell somebody. is not a good idea because they cannot see that There are also children whose treatment it will lead to any change for them. Some have is focused on symptoms and not underlying been victimised their entire childhood by sexual, causes, which means that the child has a hard physical or psychological abuse and cannot time talking about matters that nobody asks imagine that this victimisation could end. about, i.e. the causes. Others do not believe that discussions can A common reason that the children do not have any effect on how they feel or that they talk about how they feel is the concern that could feel better and therefore refrain from their parents will find out what they said. This telling anyone. concern is present in meetings with the social services, child psychiatric services and school Relationships and trust staff and is often based on experience of their “The fact that the children do not tell adults parents’ previous reactions. and that the adults cannot read the children’s “The children are worried that their parents signals is due to a lack of a relationship and trust will be angry or disappointed, or punish the between them,” says Karin Johansson. child for telling an outsider. There are also “If the adults are incapable of establishing a children whose parents have not been capable of trusting relationship, the children will not tell taking in the child’s account without beginning them things. This permeates everything. The to feel bad themselves. children dare tell adults how they feel and what “Parents can blame themselves and punish they think in the situations where they feel safe, 2012 • the BRIS report

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the Bris-report 2012

Mental illness

Statistics, theme mental illness 2011 Contact topics, Theme Mental Illness Topic

Number

% of contacts

Suicide/ suicidal thoughts

1,593

6.2%

Selfdestructiveness

1,402

5.4%

772

3.0%

Other mental illness

Eating disorders

2,464

9.5%

Total Theme*

4,545

17.5%

ntot = 25,900 * Because every contact can deal with more than one topic and all of these are documented, the sum of the figures exceeds the total.

Advice to those

Gender distribution by topic Topic

% Girls

% Boys

Gender not mentioned

Suicide/suicidal thoughts

87.1%

12.2%

0.7%

Selfdestructiveness

91.4%

7.5%

1.1%

Eating disorders

95.9%

3.2%

0.9%

Other mental illness

84.8%

14.2%

1.0%

Total Theme

87.0%

12.1%

0.9%

who meet children with mental health problems

Average age by topic Topic

Ave. age

Other mental illness

13.8

Self-destructiveness

14.3

Suicide/suicidal thoughts

13.9

Eating disorders

14.1

Total for topic

14.1

Mental illness in the various channels BRIS 116 111

BRISmail

BRISchat

Total all child contacts

Number about mental illness

1,433

1,897

1,215

4,545

Total number in each channel

13,440

7,394

5,066

25,900

= % in each channel

10.7%

25.7%

24.0%

17.5%

KEEP IN MIND the importance of a safe relationship. Establish trust, even if it takes time. If you see the child is not doing well, do not be satisfied if the child says he or she is fine. Ask again. DARE TO ASK, even about the most difficult topics. “Do you think a lot about death? Have you tried to hurt yourself or attempted suicide?” If the child does not have such thoughts, you cannot incite them by asking. DO NOT GO BEHIND the child’s back and do something that the child does not know you are going to do, like telling somebody else. Instead, you can provide information about how the child can get help and about what you intend to do. Try to the furthest possible extent to get the child on board. IF YOU MUST do something that the child does not want, explain to him or her why you have to act the way you do. VIEW THE CHILD with respect and as an actor in his or her own life. Do not assume that the child’s parents are wellfunctioning, even if you might have had that impression. BE FLEXIBLE with the way the child wants to tell. Give the child the opportunity to tell in other ways such as writing, e-mailing, chatting or texting. Supportive conversations need not take place face to face.  READING SUGGESTIONS: “Ledsna barn” (Sad children) Available for download in Swedish from the National Board of Health and Welfare website: http://www.socialstyrelsen.se/ publikationer2010/2010-3-7

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the BRIS report • 2012

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the Bris-report 2012 * B HT = Children’s Helpline/ BRIS 116 111 BM = The BRIS-mail BC = The BRIS-chat

Mental illness

History, contacts about mental illness Suicide, etc. Year

Channels*

Total contacts

2004

BHT+BM

2005

BHT+BM

2006 2007

Selfdestructiveness

Eating disorders Number

%

%

Other mental illness

Number

Number

%

%

%

Number

22,133

1,583

7.2%

1,541

7.0%

895

4.0%

1,419

6.4%

3,951

17.9%

1,664

11.5%

19,239

1,488

7.7%

1,576

8.2%

633

3.3%

1,621

8.4%

4,001

20.8%

1,483

13.8%

BHT+BM

21,273

1,851

8.7%

2,121

10.0%

782

3.7%

1,847

8.7%

4,871

22.9%

1,954

16.9%

BHT+BM

21,401

1,987

9.3%

1,942

9.1%

864

4.0%

2,583

12.1%

5,243

24.5%

1,920

16.6%

2008

BHT+BM+BC

21,848

1,798

8.2%

1,541

7.1%

770

3.5%

2,038

9.3%

4,377

20.0%

1,781

13.7%

2009

BHT+BM+BC

21,611

1,515

7.0%

1,353

6.3%

774

3.6%

2,112

9.8%

4,118

19.1%

1,563

12.7%

2010

BHT+BM+BC

23,728

1,604

6.8%

1,448

6.1%

726

3.1%

2,280

9.6%

4,274

18.0%

1,461

11.0%

2011

BHT+BM+BC

25,900

1,593

6.2%

1,402

5.4%

772

3.0%

2,464

9.5%

4,545

17.5%

1,433

10.4%

2012 • the BRIS report

%

Tot mental illness, only BHT

Number

trust the adult and feel that the adult can take care of what they tell them in a respectful way. It is often the children’s bad experience of relationships with adults that cause them not to tell. They do not trust the adults, especially if the child has tried to tell, but not found the treatment the child had hoped for. And the longer something is kept secret, the more difficult it gets to tell. Understanding the difficulties So in order for the adult to be able to take the child in, considerable “A while ago, she asked how demands are placed on the things were going with food, adult understanding the child’s but I just lied, because I have difficulties to feel a sense of no intention of saying that it is going bad now when I need to trust. “Such a relationship takes get thin and emaciated.” time to build up,” says Karin Johansson, and the more insecure the child is, the “And I don’t want dad to be with me at the psychiatric longer it takes.” services. Then, it doesn’t feel Karin Johansson notes like I can be honest.” that the children do not tell everything, even to Bris, although they tell “Because mum got angry at me since I did what I did a lot. Above all, they leave out the (understand her) and felt like details of abuse, but nonetheless I did, I didn’t say that I really tell what happened to them, wanted to die.” although in more general terms, which is actually what can lead to “Almost everyone thinks a recovery from mental illness on it’s fine now, don’t want the long term. to disappoint them.” “The memories can pop up in the form of flashbacks, and if they do not talk about them, there is a risk that the memories will not stop disturbing them. So putting whatever is spinning around in their heads into words increases the child’s understanding and provides a greater distance to what happened. The memories will not go

Number

Tot mental illness

away, but the child can live with them IF they tell somebody who can take in the account in a positive way.” “There are several different reasons for the fact that the adults around the children who contact bris have been incapable of taking in their accounts,” says Karin Johansson. “Ignorance is one, a lack of resources is another, or legislation concerning secrecy and reporting obligations may be applied in a way that causes limitations.” “There is often also a lack of knowledge in conversational techniques, how to talk with children, and knowledge in how children think.” For some children, it is very difficult to talk about difficult things face to face, which is noticeable in the bris-mail and the bris-chat. Karin Johansson confirms that children need various channels to talk; some may need to chat or e-mail with their therapist to be able to talk. “Treatment must be flexible, based on the child’s needs and situation.” Sometimes, the adults are just simply thinking about it the wrong way. An example of this is when parents insist on sitting in on counselling sessions with the child psychiatric services because the parents are often under the impression that it is the relationship between the child and the parent that is wanting and that is what must be treated, not the individual child. “But this leads to the child not having the courage to talk, particularly if the mental illness is due to something being wrong in the relationship between the parent and the child.” 

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the Bris-report 2012

Support

Do you have questions about children and young people? Welcome to BRIS’ Har du funderingar om barn website for adults!till och unga? Välkommen

BRIS webbplats för vuxna!

Barnperspektivet.se is BRIS’ website for adults. Adults with questions can turn to this website. Read, discuss and Barnperspektivet.se är BRIS webbplats för vuxna. Dit kan du som find support. The website is based on BRIS’ many years of är vuxen vända dig med funderingar. Läs, diskutera och hitta stöd. knowledgeutgår and experience of conversations children av Webbplatsen från BRIS mångåriga kunskap with och erfarenhet and young people. Welcome! samtal med barn och unga. Välkommen!

[THECHILDPERSPECTIVE.SE] BRIS FOR ADULTS [substantial parts of www.barnperspektivet.se are translated]

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They called me names when I walked by in the hallway, they rang my mobile, texted, left messages, posted on Facebook, on my blog, on msn…. For a while, I didn’t even have the courage to go to school because I felt so bad and knew they were waiting for me there. Girl, age 15

At school, I was really bullied for my weight. They spread false rumours. I cried every day. I said to mum that I didn’t have the strength to live any longer. Came down with anorexia and bulimia. Lost 18kg in 3 months. In school, I’ve been picked on and bullied since I began. I don’t know, I’m beginning to give up. I think a lot about killing myself and if things keep going like this, I don’t know if I can handle it. Boy, age 14

Girl, age 17

I was bullied from year 6 until year 9. Nobody did anything and that scares me too. Will nobody do anything if something were to happen now or in the future either? Girl, age 18

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Mia Berg

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Stina Svanberg

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the Bris-report 2012

Bullying

Thomas Fröhling

Being bullied means slowly being broken down, until self-confidence is at its lowest and the feeling of being excluded infects every part of everyday life. In the long run, these feelings can lead to selfdestructiveness and thoughts of suicide.

Struggling in

silence T

the person being frozen out and disregarded. The pain on the inside and outside of the person being pushed and beaten. The humiliation of the person called a whore or a fatso. The defencelessness of the person who receives insulting messages on his or her phone or computer. Being bullied means slowly being broken down, until self-confidence is at its lowest and the feeling of being excluded infects every part of the day-to-day. Growing numbers of children contact bris and say that they are bullied. Of 5,093 contacts that were about bullying in 2011, Gunnel Johnsson, bris Representative, read 500. They are harrowing tales of children who are struggling – often in silence. “They are ashamed of being bullied and themselves take the blame for what is happening. The children describe how the bullying continuously lowers their selfconfidence, and the question “what am I doing wrong?” comes back again and again,” she says. Although it is in school that they are bullied, the feeling of being worthless and excluded takes hold of the children and stays with them to the stall or handball practice. Hurting so much on the inside, a pain that is invisible, is tough. This is why several of the children describe how they begin to scratch, stab, burn and cut themselves. By developing a self-destructive behaviour, they make the pain

more physical and it feels easier to handle. Others protect themselves from the bullies by skipping school and isolating themselves. Quite a few have thoughts of suicide, like a girl who wrote “I have no right to be here”.

he loneliness of

But do the children ask for help? “First, I want to say that it is so strong of those who dare to tell somebody, some find support in teachers and parents when they do. But most of them do not dare tell an adult near them about what is happening to them. The bullying has caused them to stop believing in themselves and, consequently, they are afraid of not being believed by the adults when they tell their story,” says Gunnel Johnsson. Unfortunately, many adults also have a tendency of further reinforcing this feeling. “They often tell them to get out of the way when the bullies come, or not to care about what the bullies say. That is like saying that the bullying victim is the one who is doing something wrong, and that if he or she just acted differently, the problem would go away.” BRIS when there is no solution The children turn to bris when they no longer see any solution to the problem. Some have tried to get help, but have not succeeded. Others call bris to tell somebody for the first time and practice finding the right words to describe what happened to them. And to find 17

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Hi i’m a 14-year-old girl and am in year 8. I’ve been bullied since i began school and now it’s just gotten worse. And i just feel that i can’t cope any more if they continue. Feel so damned bad and i just want to die! PLEASE HELP ME

Bullying

Girl, age 14

I am bullied at school, not “teased” but really bullied. Now, I don’t like places where there are a lot of people and I can’t talk about it with anyone. I don’t know why it’s like this. I cut myself on the arms to show on the outside how I feel on the inside.

But they’re so mean that I’m really been bullied and frozen out. Now my parents have forbidden me from going to school. Now we are just waiting for me to get home schooling. I can’t ride the bus and can’t go to town and I like can’t do anything on my own out in society. Girl, age 14

Girl, age 13

Hi! I’m an 18-year-old girl who’s put up with bullying since I was 7. I’ve changed school three times because of bullying. At secondary school the problems began again. I am mentally and physically exhausted by all stress from the bullying. I see both a psychologist and a counsellor, but I don’t think it helps anymore. Please, I want to know what I am doing wrong ?!

the trust that somebody will listen to what they have to say. “There are a lot of committed and reasonable parents and other adults, but at bris, we have something many of them do not: time to listen to the whole story, ask questions and listen to the answers,” says Gunnel Johnsson. When bris gives advice, it is not about avoiding the bullies. Instead, the volunteers relieve the children’s sense of guilt by telling them that it is the bullies who are in the wrong. They let the children know that the Education Act does not permit bullying and that the school has a responsibility to help children in distress. The children also get help in seeing which adults they have around them and where help might be found. Bullying and BRIS The goal is always for the child to 4 BRIS had 5,093 contacts find the courage to get help from about bullying in 2011. This is somebody they trust. Sometimes, 19.7 percent of the total number of contacts. This is an increase numerous discussions are necessary from 2010, when 4,073 contacts before they reach that point. concerned bullying. “Children can get more help from bris than just having a call or a chat session. For example, we can contact the headmaster of the school and say what the child is subjected to. However, it is somewhat uncommon for children to request this help since it means that they must give up their anonymity.” Something that struck Gunnel Johnsson when she read the accounts was that several of 2012 • the BRIS report

the bullied children spoke of substance abuse and abuse at home. “That makes it even more difficult for the children to tell about the bullying. There may be a teacher who could listen, but then the parents are brought in and the problems at home also become visible. Then, they prefer to remain quiet about their problems. I thought a great deal about this: they are doubly victimised, what do these children have to hold on to?” Another thought was that most of the children were 14 years old. This is a time in life when one’s own identity is taking shape in interaction with the surroundings. What happens with one’s identity then, when nearly all response from others is negative? “And when things do not work with friends, these young people are referred back to their homes, right at the time that they should actually be liberating themselves from home. It is no good start in adult life,” she says. However, even if the picture looks incredibly bleak, she nonetheless sees a brighter pattern – a great deal of help is not needed for it to get better. Having the chance to tell somebody. Somebody taking them seriously and listening. Just that somebody says that it is not the person who is bullied who is doing something wrong means that one can retain an inherent sense of value. Enough value to base one’s life on.

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Do you meet Möter duchildren barn and young people och unga i ditt in your work?

arbete?

The bris Academy offers föreläsningar lectures and training BRIS-akademin erbjuder och based on bris’ many BRIS yearsmångåriga of knowledge and utbildningar utifrån kunskap experience of conversations with children and och erfarenhet young people. av samtal med barn och unga.

Vill duyou vetalike mer? Would to know more? Visit bris.se/brisakademin Besök bris.se/brisakademin (In Swedish only)

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Now even stronger! 20 tablets against Sorrow Take them all! FORGET EVERYTHING!

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text

Åsa Lekberg Steinsvik

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Johan Bergling

illustrations

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Sorrow

Thomas Fröhling

Children often

alone

in their sorrow

Children who are grieving need support. If children are left alone with their sorrow, the risk of mental illness increases. Sofia Grönkvist, BRIS, meets an extra vulnerable group: children who have lost a family member to suicide. It is important that these children are addressed so that they will be able to live a good life as adults.

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here are many events in a child’s life that mental illness, which in the worst case can lead can lead to sorrow. Moving away from to themselves committing suicide as adults. one’s best friend, parents who separate or somebody close who falls seriously ill or Many feelings in sorrow even dies. Regardless of the underlying causes, Sorrow after suicide is in many ways similar to sorrow is about trying to understand what sorrow after another loss, but also comprises happened and making space for thoughts feelings of guilt, shame, anger and a lack of and feelings and finding a balance between understanding from the surroundings. remembering and the new situation. Sorrow “During the support weekends, affected is there to process the loss so that the pain can families can meet other families in the same hurt less. situation. Through talks, exercises and lectures, “Sorrow is not a disease or mental diagnosis, they share their experiences and feeling however, children need support in handling associated with the sorrow. These meetings have their sorrow. Sorrow not dealt with can lead helped many families to move on,” says Sofia to mental illness that can be expressed in Grönkvist. various ways, such as problems sleeping, “When grieving the loss of a family member, eating disorders, anxiety, depression, selfthe children often put the lid on because they destructiveness and suicidal thoughts.” do not want to burden their parents who Sofia Grönkvist, bris Representative, has are already beside themselves with grief. For extensive experience of grieving their friends, they often want children. Since 2009, she has everything to seem normal, worked with Save the Children and it is rare that children Sorrow & BRIS and the Red Cross on “support have another adult to turn to. 4 In 2011, BRIS had 2,541 contacts about sorrow, weekends for families struck Children are often alone with which is 9.8 percent of the by deaths by suicide”. This their sorrow, regardless of the total number of contacts is a particularly vulnerable cause.” during the year. This is a slight increase from 2010 group as research shows that A child who does not get when the number of children who have been struck help in understanding and contacts about sorrow by a suicide in the family run dealing with the sorrow is at was 2,227, or 9.4 percent of the total number. a greater risk of developing risk of handling feelings that

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Sorrow

It is important that these children are addressed so that they will be able to live a good life as adults. Sofia Grönkvist

and mental development is so intensive. They cannot simply take a break from life and devote all their time to grieving. Children and young people also do not have the same tools as adults and in purely intellectual terms, they cannot understand that sorrow is something that one can learn to live with in time. “During the support weekends, we work with the entire family although focus is on the children. We work with both children and adults on the same theme in parallel.” If the entire family gets help, both individually and together as a group, their chances improve of coping with the crisis together. “Children seem to have a hard time processing their sorrow unless their parents have come a bit of the way with their own grieving process. We have also seen that when parents and children receive support at the same time, they have an easier time of making progress together in the grieving process,” says Sofia Grönkvist and explains that the families that have received this kind of support feel that they learn how to handle sorrow at home in regular life. How they should talk and relate to each other. “Many families feel that life has become easier to live.”

are difficult to understand in a way that can become destructive to the child’s future development. Young people therefore need help in understanding and putting their feelings into words and making the incomprehensible more understandable and meaningful again. “If children and young people get help in dealing with their sorrow, they can have a better chance at a good life,” says Sofia Grönkvist. Not like the sorrow of adults To be able to be a support for grieving children, it is important to understand that children grieve differently than adults. The feelings of a grieving child can be so strong and incomprehensive that they are difficult for the child to handle. Children often take breaks in their sorrow because their physical The worst thing is that I’m completely changed. Who am I now? The only thing I think about is not thinking about it.

It’s strange, but it just gets worse. It’s been 2 years since mum died and I hate myself. There’s only one way not to feel like this.

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Ulla Tillgren

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Johan Bergling

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Support

Thomas Fröhling

An ambiguous and contradictory mission The healthcare centres do not feel that it is their responsibility and the queues to the first visit to the child and youth psychiatric services (BUP) are growing longer. This is what the situation looks like in many places in Sweden, according to a report from the National Board of Health and Welfare.

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t is unclear where children and young people between the ages of six to 18 should turn when they are doing poorly. Despite hundreds of millions of SEK in government grants, general stimulus funding and a stronger care guarantee, there is no cohesive care chain for children and young people. The result of this may be that children and young people are bounced around and nobody takes responsibility. “You have to be fortunate enough to grow up in a municipality where child healthcare centres, school health services, healthcare centres and child and youth psychiatric services know what they should do. It should be clear who has the responsibility for preventing mental illness in children and young people, but this is far too rare,” says Marie Collberg, Inspector at the Eastern Supervisory Unit of the National Board of Health and Welfare. “Poor mental health can develop into mental illness if nobody notices it. Those who are most vulnerable and lack natural protection are at risk of being left without

necessary care. Children and young people can simply be lost. The most important thing of all is to identify them and given support and help in time.” Continuous follow-ups The National Board of Health and Welfare has had the Government’s assignment of distributing many hundreds of million SEK in government grants to county councils. The objective has been to make healthcare for children and young people with poor mental health more readily available. The National Board of Health and Welfare has conducted continuous follow-ups and evaluations of the efforts done. The picture that comes forth is ambiguous and contradictory. There are still major deficiencies in the municipality’s and county council’s work. Since 2009, the queues to an initial consultation at BUP have grown instead of decreased, and municipalities and county councils have difficulty in collaborating and agreeing. Over the years, deficiencies have been discovered in many stages. In some places, there is a lack of specialist physicians, patient records are sub-standard and documentation is deficient. This impacts children, young people and their families, who are in great need of professional help.

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Comprehensive picture not available It indicates that all child healthcare clinics County councils have become better at asked believed that they had a clear mandate reporting waiting times to child psychiatric to prevent mental illness in children. But services, but there is still no comprehensive alarmingly, only 10 of 44 school health service picture of how many children and young people units said that they had a clear mandate to seek support and care for poor mental health prevent mental illness in the students, 16 units in Sweden. The National Board of Health and lacked such a mandate entirely. In addition, Welfare is planning on being able to provide only 13 of 26 healthcare such a summary in summer 2012 and show centres said that it was In the what the reinforced care guarantee has meant to their job to prevent mental interviews, children and young people. illness among children and it became apparent “It is more mixed up for children and young people. Of 76 youth that many children young people with poor mental health than for counselling centres, 39 felt adults,” Marie Collberg summarises. “Adults that they had been charged and young people can turn to the local healthcare centre and then with working preventively. currently have to adult psychiatric services in the next step. Those questioned in the severe problems If you are a child or teenager, you can contact survey felt that it was that should not school health services, the healthcare centre, unclear who was responsible the youth counselling centre or child and youth for preventing mental illness remain untreated. psychiatric services. How can you figure out in children and young where you can get help if the municipality Marie Collberg people aged six or older.” or county council does not know who is responsible?” Collective knowledge needed According to the National Board of Health In order to provide the right help and support and Welfare, there is a group of children and as early as possible, the National Board of young people who are doing worse. For example, Health and Welfare notes that healthcare must the number of boys and girls who act out and be easy to access, that preventive efforts must have self-destructive behaviour is increasing be pursued and that specialised care must be and psychological problems in children seeking provided within the child and youth psychiatric asylum are also on the rise. services. In spring 2011, the Board confirmed “Young people and their relatives have that nearly all county councils still lacked presented complaints to the National Board of collective knowledge of how healthcare for Health and Welfare and said that it has been mental illness for children and young people difficult to get adequate help,” she adds. worked. Clear roles and mandates are still Problems and deficiencies remain despite missing in several county councils. The National investments being made at all levels. Board of Health and Welfare then required that “Upon inspection, it came forth that there the county councils present how they intend to is a kind of immeasurable need with regard provide their operations with such mandates to interventions. In the interviews, it became so that it becomes clear who is responsible for apparent that many children and young psychiatric healthcare. people currently have severe “Most problems that should not operations do Who takes care of children remain untreated,” says Marie not have an and young people with mental Collberg. organised overall illness A national review has been collaboration 4 Barn och ungdomar med psykisk conducted and is presented in with others. ohälsa – Vem tar hand om dem? [Children the report Barn och ungdomar Young people and young people with mental illness – who takes care of them?] (only available med psykisk ohälsa – Vem who are on the in Swedish) http://www.socialstyrelsen.se/ tar hand om dem? [Children line between the publikationer2010/2010-12-13 and young people with mental child psychiatric 4 Psykisk hälsa, barn och unga – synkronisering av insatser [Mental illness - who takes care of services and adult health, children and young people – them?]. psychiatric services synchronisation of efforts] (only available in Swedish) http://modellomraden.skl.se/ 25

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may, for example, have a hard time getting emergency help,” says Marie Collberg. However, there are bright points in the work of improving healthcare for children and young people with mental illness. Since 2009, there are 14 model development areas throughout Sweden, from Norrbotten to Skåne. They will serve as inspiration to improving the situation for children and young people everywhere. The Government assigned the Swedish Association of Local Authorities and Regions (salar) to lead this work. Can influence The areas shall develop practically functioning models for work and collaboration methods between schools, the social services and healthcare and provide the right help at the right level. A holistic thinking should apply. It is of central importance that the child or teenager and the family should feel that they can influence their life situation and that help is available there when needed. The objective is for the work to make a real difference so that nobody is “lost along the way”. The areas have formulated clear targets for what they want to achieve, and have decided which organisation and approach is needed to get there. The next step begins in January 2012 and will continue for three more years. Municipalities, county councils and regions shall develop and intensify the work of a so-called first line of defence for the mental health of children and young people so that it becomes clear where they should turn when they are doing poorly. The work should also be focused on children who are at risk of faring badly and finding methods for common leadership and management. The connection between school performance, mental health and social investments is also included in the work intended to provide children and young people as good healthcare as they deserve.

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text

Ingvor Farinotte

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Support

Everyone has a responsibility There are routines for identifying students with mental illness, such as at the regular health check-ups with the school nurse. However, these visits are not always enough.

not have access to a relevant referral body. In terms of children and young people with serious psychiatric problems, such as eating disorders or depression, this should be the child and youth psychiatric services.” However, children with mild mental problems may need a different service to turn to. Many parents feel that going to the child psychiatric services is too large a step. “Children up to age 6 regularly visit the child healthcare clinic, which is a support for both physical and mental Facts problems, with a natural proximity 4 Nils Lundin is the Chief to healthcare. Then there is nothing Youth Medical Officer at like the child healthcare clinics during the Helsingborg General Hospital. He is also the Chief the school years, which I think there School Medical Officer and is a great need for,” says Nils Lundin. Operational Director for “In Helsingborg, we therefore have School Health Services in the City of Helsingborg. “Parental Support 6 to 12”, which is a similar support to parents and children 4 The “Blue Camel” is an in the age group after the end of the operation that seeks to combat physical, mental advice and support function of the and social problems among child healthcare clinics.” young people at an early For the teenage group ages 13-20, stage through counselling (serving as a sounding there is the “Blue Camel”, a kind board). Parents and young of “teenage healthcare clinic” that people between the ages functions as a support for parents and of 13 and 20 can turn to the Blue Camel and come and young people with poor psychosocial talk about school problems, health. Operations thereby relieve the friends, conflicts in the family, burden on both student health services poor self-confidence, etc. and child psychiatry services. 4 DISA is a method of Nils Lundin feels that many schools preventing stress and work for disease prevention and health depressive symptoms among teenage girls. promotion where they work with social You can download an and emotional training. He mentions information brochure on the DISA method as an example of a the DISA method here (information in Swedish): good model for how to prevent mental http://www.folkhalsoguiden. illness in teenage girls. se/informationsmaterial. “I would say that the mission of aspx?id=719 student health services as specified in the Education Act – and by the National Board of Health and Welfare with regard to the responsibilities of the school nurse and the school doctor – is clear. Then it is up to each municipality and school how to allocate their resources in the best way to meet the needs they see in each school.”

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tudent health services , together with other adults at school, naturally have a responsibility for the students who suffer from mental illness, according to Chief School Medical Officer Nils Lundin in Helsingborg. In response to the question of whether the resources suffice for identifying children and young people who are affected, Nils Lundin says that it depends entirely on how many students are in a catchment area and the supply of expertise in student health services. The need is covered in some municipalities and not in others. There are recommendations in the trade associations of the various professions as to how large the supply of staff should be in relation to the number of students. In terms of the role of the school psychologist, it is most often described as a more consultative measure compared with e.g. educators and other adults with student responsibility, not that the school psychologist should see and treat individual students. “A group of students with mental illness who may be difficult to identify are highly performing girls with sleeping disorders, depression and anxiety, who do not seek help themselves. The same is true of the “quiet boys”. They are not among the students that do not meet their academic targets or act out in the school environment and are identified and examined.” The Education Act includes a rule that states that students shall be offered a health checkup with the school nurse in kindergarten, year 4, year 7 or 8 and in the first year of uppersecondary school. “This is when we have a chance at identifying children and young people with psychological problems,” says Nils Lundin. “The problem can sometimes be that the school nurse does

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Support illustrations

text

Ingvor Farinotte

photo

Johan Bergling

Lena Sjöberg, Söderberg Agentur

Even though the Education Act had been made more stringent in terms of access to a psychologist and counsellor in the student health services, more than one in three headmasters say that demand is greater than the supply. One out of four says that access to a counsellor is also insufficient.

Access to school t n e i c psychologist insuf fi Only one school psychologist for 1,600 students 4 The Swedish Society of Psychologists also conducted a survey among Swedish schools (nearly 4,000 compulsory and upper-secondary schools in Sweden were contacted) to find out if they meet the more stringent requirements regarding student health and access to a school psychologist. The survey showed that there is one full-time school psychologist on average for around 1,600 students. The Society’s recommendation is around 500 students per full-time psychologist. In terms of full-time positions, there are around 642 school psychologists in all of Sweden. The distribution varies widely between the municipalities and ranges from one psychologist per 47,500 students (in the Municipality of Sälen-Malung) and one per 225 students (in the Municipality of Nykvarn). For more information, see www.psykologforbundet.se

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1 J uly 2011, the new Education Act entered into effect with more stringent requirements of schools providing students access to a school nurse, school doctor, counsellor, psychologist and staff with expertise in special education. “The requirement that there should be access to a school nurse and a school doctor is nothing new,” explains Anna Rydin at the Swedish Schools Inspectorate. “What is new is the requirement of access to a school psychologist, counsellor and staff with special education expertise.” In the first half of September 2011, the Swedish Schools Inspectorate conducted flying inspections at 764 compulsory schools where they checked what the access to these resources looked like and if the supply was perceived as meeting the needs. “Just over one out of three headmasters felt that the need in the student body was greater than what was covered by the access to the school psychologist. One out of four headmasters also felt that the access to a counsellor was insufficient for the what was needed,” says Anna Rydin, who is the project manager in charge of the inspections. “We also saw a difference between independent (voucher) schools (which constitute 16 percent of all schools) and the municipal schools,” she continues. “Satisfaction was higher at the independent schools where the headmasters felt that the access to psychologists n

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and counsellors was able to cover the needs.” The headmasters are responsible for how the student health services are organised at the school, but the school operators and the municipality bear the utmost responsibility. The new law entered into effect on 1 July and inspections were conducted as early as September, which contributed to many schools not yet having time to make any major changes to meet the new requirements. However, many had begun recruitment and prepared to adapt to the more stringent requirements. “We can only monitor if the schools comply with the requirements in the Education Act,” says Anna Rydin, “which states that there should be access to a school psychologist/ counsellor, but nothing about how extensive this access should be. For the Swedish Schools Inspectorate’s part, we are therefore unable to say if student health services identified students with mental illness who do not seek help. However, we can make an assessment as to whether access is substantial or not. The existence of an overall psychologist function that one could ask questions of over the Internet or by similar means does not count as substantial access. In the future, the matter of access to the various competencies that should be a part of student health services will be a compulsory component of the Swedish Schools Inspectorate’s annual inspections. “It is deeply alarming that so many

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operational managers feel that the school resources are insufficient, especially when society’s other resources in municipalities and county councils are not always adequate for young people in need of support. The risk is great that many young people suffering from worry and anxiety will not get the support they need and that students in need of special support or special education resources will not be properly evaluated and will thereby lose the opportunity of achieving passing marks and getting access to further education. The most vulnerable children and young people are the ones who are at risk of not receiving the help they need,” says Ann-Marie Begler, Director General of the Swedish Schools Inspectorate, in a debate article on the Inspectorate’s website. After the audit, each school has received a response from the Schools Inspectorate as to how they assess the school’s capacity to live up to the more stringent requirements. The few schools that said no to the question of whether there is access to the various competencies receive an official summons from the Schools Inspectorate to ensure that the problem is resolved as soon as possible because it is required by law. Excuses such as a lack of resources are not accepted. If the matter is nonetheless not resolved, the municipality (operator) can be ordered to undertake measures and if another three months pass and nothing has changed, the municipality can receive an order with a fine. “These are the means of persuasion at our disposal. As soon as it becomes a matter of an obligation to pay, things begin to happen,” concludes Anna Rydin.

Results of the Swedish Schools Inspectorate • There is access to a nurse at 99 percent of the schools. 13 percent of the headmasters feel that the school nurse’s time is insufficient. • There is access to a school doctor at 98 percent of the schools. 16 percent of the headmasters feel that the school doctor’s time is insufficient. • There is access to a school psychologist at 96 percent of the schools. A full 35 percent of the headmasters feel that the school psychologist’s time is insufficient. • There is access to a counsellor at 93 percent of the schools. 24 percent of the headmasters feel that the counsellor’s time is insufficient. • There is access to special education at 99 percent of the schools, but 20 percent of the headmasters feel that the access to this expertise is insufficient to satisfy the need.

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Mental illness

text

Ulla Tillberg

photo

Johan Bergling

Interdisciplinary efforts with a team comprised of social workers, special educators and psychologists have made Hamnen (or the “Harbour” in English) in Värmdö a successful concept. Here, children with mental illness and their parents can get help before the problems get too large.

Nobody should be lost V

ärmdö is a child - rich , archipelago municipality just outside Stockholm where one out of four residents is under the age of 18. In the mid-2000s, there were indications that many children and young people were faring poorly. Reports to the social services increased and many sought out the child and youth psychiatric services. The school counsellors also noticed another alarming trend. Students who acted out, were plagued by stress, worry, anxiety and depression did not get support anywhere. They fell between the cracks. The school health services, healthcare centre and child psychiatric services were unable to identify their needs. This is when the idea behind Hamnen was born, a clinic for children and young people with poor mental health. Hamnen is unique in Sweden. Children, young people and families in Värmdö can turn to Hamnen and quickly receive support when life feels tough. Social workers, psychologists and special educators provide “first aid” so that they do not lose their foothold. “We devote a lot of time to getting parents and children to talk. We become a link

2012 • the BRIS report

between them. Many have stopped talking with each other when they come here and are upset about it. The situation comes to an impasse,” says Klara Sternbrink, psychologist and unit manager for the psychosocial team at the Gustavsberg Healthcare Centre and the psychologists at Hamnen. “A teenager might have a chance for the first time to tell her parents that she feels sad and abandoned. What has begun as a row at home might just be sadness,” she adds. Interdisciplinary approach the key Hamnen follows an interdisciplinary approach that has proven to be very successful. Here, a team of social workers and special educators from the municipality work together with psychologists from the county council. The Municipality of Värmdö and the Stockholm County Council share operational responsibility for Hamnen. The objective is to ensure that nobody gets lost and that important preventive efforts have an impact on the families’ lives. The problems should not have time to grow too large and impossible to master. The location of Hamnen is easy to reach, 30

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Mental illness

Psykisk ohälsa

quite the opposite. “Most people who contact Hamnen have heard about the clinic through school. But it is also common for young people to tell their friends about us. That’s an extra good sign,” says Inger Hanérus, a social worker, who like Klara Sternbrink has been involved since the beginning. Feelings in words At the clinic, the families can get help Facts about Hamnen • Established in September 2008 and in developing common has just concluded its third year of strategies, breaking operations. negative spirals and • An equal number of boys and girls generally seek help and support. using tools that support • The average age is 11.5 and most are their children better. ages 6-17. Children and young • 41 percent seek help for behavioural problems and acting out. people have time to put • 33 percent seek help for anxiety, their feelings into words worry, stress or depression. here and they are listened to. “Just the meeting with us can change at the Gustavsberg Harbour, next to the child something. The parents healthcare clinic and the general healthcare might understand for the first time how their clinic. The name in itself describes what you children are feeling. Sometimes we do not need can get help with. Hamnen, Swedish for to involve the children. It might be the adults “harbour”, is meant to be a safe place where who need support in order to have the energy to families can seek protection, support and help be parents,” continues Inger Hanérus. in rough weather and when daily life becomes In an evaluation of the work of the clinic, difficult to cope with. This may, for example, some parents write: “We are so incredibly be a matter of children who feel alienated or satisfied and recommend anyone who has often get into trouble, parents who feel they problems with their child to seek help at are inadequate, or young people who often feel Hamnen. We have an entirely different child tired and sad. at home today. She is social and happy and can The clinic opened in September 2008 and is handle her anger much better than before.” currently well-known among Värmdö residents. If the clinic had not existed, the parents said that they would have sought help at It is not considered odd or shameful to go there, 31

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Mental illness

Inger Hanérus, social worker at Hamnen.

child psychiatric services (35 percent) or the However, sometimes it is mum or dad who is healthcare clinic (15 percent). One out of five in the greatest need of support. parents would not have sought help elsewhere. “Sometimes we discover that the parents “We fill a void,” confirms Inger Hanérus. have their own problems and we can then Cognitive behavioural therapy (cbt) is the quickly refer them to the adult psychiatric basis for all efforts made. The therapy tries to services, or make sure they receive help at the change thoughts, habits and behaviours. If the healthcare centre or social services,” says Klara mental problems of the children or teenagers Sternbrink. are severe, they receive assistance in getting Personnel from the municipality are the ones the right treatment in the child and youth who have the initial contact with those who psychiatric services. contact Hamnen, first by phone. The families “Anxiety and sometimes must complete a form online even depression are where they each rate how they Hopefully, exacerbated if the right view their living situation. treatment is not provided in “Cooperation and we come in time. This is why preventive when problems are communication between efforts are so valuable. family members is what the small or medium Hopefully, we come in vast majority need help and sized. when problems are small or support with,” she says. “This medium sized. Mental help Klara Sternbrink is especially clear among those plays a major role for school who have separated. We also attendance, quality of life meet many concerned parents and how the entire family feels,” says Klara of teenagers. Sometimes, there is something to Sternbrink. be worried about, sometimes not. Sometimes, “Asking questions like “Have I understood parents need to learn to let go of some of the you right?” can only help a young person control of their older children.” put difficult matters into words. Sometimes Hamnen receives proof on a daily basis treatment is necessary, sometimes just that they play an important role for children, discussion, talking in peace and quiet. It is young people and families. What is behind this important to find the children with large needs success? early in life so that the right resources can be “We try to be clear and straight forward. applied. Everyone benefits from this.” We are not vague at all,” say Inger Hanérus and Klara Sternbrink at the same time. Parents need support The feedback of children and young people is important and concerns coping with everyday life better: “Now, I can ride the bus again without a panic attack”, “Life feels easier”, “I have begun playing ping pong!” 2012 • the BRIS report

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text

Cecilia Nauclér

photo

Stina Svanberg

illustrations

the Bris-report 2012

Test & pranks

Thomas Fröhling

“The majority of the answered calls to BRIS 116 111 are other calls, which means prank calls, test calls, silent calls or calls that are hung up as soon as BRIS answers. These calls are just as important as the supportive, advising calls because they are often a way of testing how contact with BRIS actually works,” explains Eva Stenelund, BRIS Support Services Coordinator. “BRIS has therefore developed a conversational method to also address the children who have to try first before they can begin talking.”

The important calls A

round one out of five answered calls to bris 116 111 becomes a supportive call. The rest of the answered calls are prank calls or test calls, which can range from screaming, sexual expletives and words of abuse, to the child singing a song. Some children pretend that they called the wrong number and order a pizza, or they might play out a pretend story of violence at home. “Much of what is conveyed is what children are in the midst of, such as thoughts about sex and violence. The calls can also reflect what is happening in the surrounding world, like when Bin Ladin was in the media a lot, there were a lot of Bin Ladins that called. When children play out a made-up story, it is often rooted in curiosity as to what responses they would have

received if they had been subjected to violence. They are interested in knowing how one could talk about violence, and what one could do in such cases,” says Eva Stenelund, bris Support Services Coordinator. “However, even if there are a very large number of other calls on bris 116 111, they consume little time in bris’ support services, which is important to remember,” Eva Stenelund emphasizes. “The largest part of the time is devoted to supportive calls.” Availability is inviting “The reason for the amount of other calls is mainly that bris’ support services are so accessible – it is free, entirely anonymous and all 33

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Support

A Calzone (pizza) please ...

that is needed to call is access to a phone. This availability invites testing, and it is possible to call many times,” Eva Stenelund confirms. However, just because there are so many other calls, bris must also have an approach in addressing them. Because it is not unusual for children who are seeking help to say that they previously made prank calls and apologize for it. “It is actually pretty natural to have to test first before making a real call, so as to know that 2012 • the BRIS report

the person on the other end can cope, is decent and is somebody who can help.” So prank calling may be the only way a child can check if bris can really handle hearing a difficult account. It would also be very out of place to begin evaluating calls since one cannot know what situation the child on the other end is in. “It would also be very troubling if bris were only able to accept or talk with children who 34

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Test & pranks

behave as one thinks they should. This means, children who could calmly talk about what problems they have and what help they need. That is not what life looks like, and some can be very upset and angry when they call and of course this is reflected in the calls with us. We have to be there for them too.” However, those who answer bris 116 111 are naturally influenced by the other calls. For each new call they accept, they have to begin from the beginning and treat each new call with earnestness and respect. Managing this demands knowledge, says Eva Stenelund, and bris has therefore developed the COE method – Confirm, Offer and End. The method is mainly important in the calls where it is impossible to achieve a dialogue, such as when a group of children call and scream into the phone. “The confirmation can be based on the person answering saying that he or she hears that there are many people around, but that it is good they know the number to bris. Or that they confirm that they hear that the child is very upset and angry. We then offer the child a chance to call when he or she is alone, or when it is easier to talk. Then we end by telling the caller that we cannot make any more progress in the call and that we will hang up now. It is about concluding without the caller feeling hurt or brushed off. “For the children, it is actually nothing strange for the adult to end this kind of call, but rather the challenge for bris is to give the child something unexpected,” says Eva Stenelund. “The children might think that the adult will get angry and begin correcting them and educating them. To nonetheless be met with something respectful is often something that the children do not expect.” She can still understand why some children choose an aggressive approach when they contact bris because it may be a way for children to acquire power and control for a short while. “Because if you are powerless, having power can be a good thing. If the adults understand this, these calls become comprehensible.”

from scratch when sitting down to the phone.” At the same time, it is not uncommon behaviour for the children to test the adult world and stretch the limits. The difficult for those answering bris 116 111 is that they neither see the children nor know who they are. There is no relationship between the child and bris, and therefore it is important how bris treats those who call. “What is an advantage for the children, anonymity, becomes a greater challenge for us.” However, this challenge can be overcome as long as one addresses it. Because it is possible to catch a child even if he or she is fooling around or playing out a make-believe story. Some can have a shorter call about how it feels to talk with bris and others might call later that evening when they are alone, or call another day. “The child has been able It is to test and try, but still had a decent conversation and then it actually is less important to call and joke pretty natural to around. He or she has also gotten have to test first the feeling that you can actually before making a turn to bris if you want to talk.” “To keep the approach and real call. Eva Stenelund COE alive, there must be a continuous internal dialogue on the other calls, as there are so many of them and they are ever present,” emphasizes Eva Stenelund. The adults that answer need to be reminded of what they are doing and why so that they can serve as good supportive adults. “Otherwise, it is easy to end up in a private emotion when one’s patience runs out or one begins to get tired, and then act as adults do when they are tired and grumpy. And that is not how bris wants to act towards children.” Telling a dramatic, make-believe story can be bit exciting for a child, and a way to test putting oneself in situations and emotions that he or she knows exist, but has not experienced personally, thereby making them more comprehensible. Some children also believe that they have to have major problem to be allowed to call bris and therefore, make up a serious situation. However, once they have talked a while, they understand that they do not need to pretend, but rather can actually talk about how their day has been. “The challenge for us is therefore not to end the conversations when we hear that the story is made up. For the child, it may be important to feel that he or she may talk nonetheless, without being victimised. Those occasions exist.”

Aware of oneself “But even when one has the knowledge to address the other calls, it is important to be aware of oneself,” continues Eva Stenelund. “If you begin to get tired and have several other calls in a row, there is a risk that the person answering can fall into an educating and correcting tone. “It is important to take a break when running out of energy so that one can begin 35

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Test & pranks

Other calls – study November 2011

Between 7 November and 25 November, information was gathered on all calls to bris 116 111. A paper form with thirteen questions was completed for all test/prank calls, repeat calls, and prolonged silent calls.

The information was then entered into a database. During the period, there were 3,534 calls, which were divided into 770 supportive calls and 2,764 other calls.

Number of calls

The 2,764 other calls were distributed over the following categories:

22%

Supportive Other

3% 4%

N = 3,534

78%

11%

24%

58%

Call time

28%

Supportive Other

Test/prank Hang-ups

Call time 283 hours

Silent Habitual callers Other

72%

N = 2,764

Hang-ups are when the child hangs up as soon as the BRIS volunteer or representative answers, while silent calls last a little longer, but without the child saying anything. Habitual callers are adults who repeatedly call BRIS 116 111 even though it is not the right service for them, and “other” can e.g. be a very short referral response, adults being referred to the BRIS Adult Helpline or calls from the media. The vast majority of other calls are, however, prank and test calls.

2012 • the BRIS report

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facts/study

Peter Irgens

the Bris-report 2012

Test & pranks

Test/prank calls 64 percent of test/prank calls were from boys and 36 percent from girls. The average age was 12.9 years. In 37 percent of the test/prank calls, it was a single child who called, in 49 percent it was a child in a group of children who called and in 13 percent of the calls there were several children in a group who talked during the call. It is somewhat more common for single child callers to be boys.

In 1999, there was thus a larger proportion of other calls than in 2011. There were more habitual callers, 6.1 percent compared with 3 percent in 2011 and there were more hang-ups, 44 percent compare with 24 percent in 2011. In 2011, there was, however, a larger proportion of prank and test calls, 58 percent compared with 33 percent in 1999. Then as now, the boys accounted for approximately 60 percent of the test/prank calls and the average age was 13. The patterns for the call topics were also very similar between the two studies.

Call topics In 94 percent of the prank and test calls, there was information on the primary call topic: Humour/entertainment, sex and shouting/ swearing were the three most common topics for prank and text calls, followed by bullying and the unspecified “just wanted to talk”.

(”Övriga påringningar” [Other calls], Irgens & Moqvist/ BRIS, 2000)

Time taken Test/prank calls take 2.3 minutes on average. Comparisons with a similar study in 1999 In autumn 1999, a corresponding study was done of the other calls to the Children’s Helpline of the time (today’s bris 116 111). At the time, the helpline was bris’ only channel for communication with children and young people and there were therefore more calls. During a four-week period, there were 9,200 calls and 7,974 other calls were noted, or 86.8 percent of all calls.

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Statistics

Summary

Statistics 2011

In 2011, BRIS had 25,900 supportive contacts with children and young people on BRIS 116 111, the BRIS-mail and the BRIS-chat. This is a small increase from 2010, when there were 23,728 supportive contacts. With other calls to BRIS 116 111, BRIS had a total of 76,686 contacts with children and young people in 2011. The number of contacts on the BRIS Forum amounted to 38,484 in 2011, which means a strong increase since the year before.

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the Bris-report 2012

Statistics

No. of contacts Supportive contacts by channel 2011 BRIS 116 111 The BRIS-mail The BRIS-chat

19.6% 51.9%

Supportive child contacts 2002-2011 incl. Discussion Forum submissions 80,000

BRIS Discussion Forum The BRIS-chat The BRIS-mail BRIS 116 111

70,000 60,000

28.5%

50,000 40,000

Supportive contacts by channel 2010

BRIS 116 111 The BRIS-mail The BRIS-chat

13%

31%

56%

30,000 20,000 10,000 0

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Channel distribution Channel BRIS 116 111

Number 13,440

The BRIS-mail

7,394

The BRIS-chat

5,066

Total

25,900

BRIS SUPPORT SERVICES bris 116 111, the bris-mail and the bris-chat are staffed by the just over 600 people who work for bris on a volunteer basis. So it is one of these people who the children meet when they contact bris. In 2011, the number of supportive contacts increased in all three channels that bris has to offer children the support of an adult. As in the previous year, it is the contacts on the bris-chat that have increased the most, and the chatters constituted one fifth of all contacts in 2011. When children want to communicate with other children, they do so through bris’ Forums, which consist of the Discussion Forum, Source of Joy and My Poem. These contacts have also increased in 2011, which means that the total number of contacts in bris, both between adults and children and children and other children, increased since last year.

able to serve as the voice of children in outreach lobbying efforts. In documentation, every contact is judged to belong to two possible categories; the contact is categorised as either supportive or other. A contact is assessed to belong to the other category when the person contacting bris is silent and no conversation takes place. Such contacts also include when the child clearly wants to joke with, or test bris. A supportive contact is a contact in which the recipient deems that the child intended to establish a seriously meant contact with an adult at bris in order to get support, advice or information. When a contact is deemed to belong to the other category, no information is saved about the contact in bris’ database; the only information registered is that the contact took place. You can though read more about these contacts on pages (33-) 36-37. This means that the only thing that can be said of the other contacts is that they have decreased in terms of percentage since 2010, and the proportion of supportive contacts has instead increased.

SUPPORTIVE AND OTHER CONTACTS Every time a child contacts bris, certain information is saved in the bris database about the contact. This is done so that bris will be 39

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the Bris-report 2012

Statistics

Contact topics Topics that increased the most in 2011

Love

4,588

17.7%

3,877

16.3%

Loneliness

4,128

15.9%

3,740

15.8%

Sorrow

2,541

9.8%

2,227

9.4%

Other mental illness

2,464

9.5%

2,280

9.6%

Identity development

2,455

9.5%

2,334

9.8%

Leisure time

2,426

9.4%

2,075

8.7%

Sex

2,408

9.3%

2,242

9.4%

Body/appearance

2,227

8.6%

1,931

8.1%

Existential/life issues

2,066

8.0%

2,026

8.5%

Living arrangements

2,024

7.8%

2,041

8.6%

Stress

2,006

7.7%

1,801

7.6%

Divorced parents

1,758

6.8%

1,780

7.5%

Physical abuse

1,740

6.7%

2,166

9.1%

Suicide/thoughts of suicide

1,593

6.2%

1,604

6.8%

Contacts with authorities

1,549

6.0%

1,492

6.3%

Self-destructiveness

1,402

5.4%

1,448

6.1%

Neglect

1,363

5.3%

1,287

5.4%

Sexual abuse/molestation

1,351

5.2%

1,575

6.6% 4.4%

Adult substance abuse/risk use

1,196

4.6%

1,051

Psychological abuse

1,130

4.4%

1,165

4.9%

BRIS

1,047

4.0%

890

3.8%

Adult Physical/Mental illness

900

3.5%

865

3.6%

Eating disorders

772

3.0%

726

3.1%

Child’s Physical illness

752

2.9%

808

3.4%

Computers/mobiles/Internet

712

2.7%

608

2.6%

Pregnancy

587

2.3%

709

3.0%

Finances

507

2.0%

565

2.4%

Child’s substance abuse/risk use

465

1.8%

512

2.2%

GLBT issues**

453

1.7%

234

1.0%

Alcohol/drugs/tobacco

426

1.6%

512

2.2%

Criminality

425

1.6%

424

1.8%

Problems in the parental role

390

1.5%

402

1.7%

Legal issues

386

1.5%

475

2.0%

Multiculturalism/immigrant issues Other

308

1.2%

334

1.4%

1,140

4.4%

1,354

5.7%

Mental illness

4,545

17.5%

4,274

18.0%

Physical/psychological/ sexual abuse

3,308

12.8%

3,792

16%

n 2011= 25,900

2012 • the BRIS report

n 2010=23,728

40

6,000

4,000

4,128

18.5%

2,000

0

n 2011= 25,900 n 2010=23,728

* Because each contact can touch on more than one topic and they are all documented, the total percentage may exceed 100 percent. ** This topic was added in 2010 so the figure does not show the number of contacts over the whole year.

3,740

17.2%

4,387

s

4,073

18.0%

es

19.7%

4,659

lin

5,093

ne

Bullying/humiliating treatment Family conflicts

8,000

4,588

25.0%

3,877

5,943

Lo

24.2%

ve

6,265

Lo

26.0%

Fear/anxiety

5,093

30.4%

6,178

4,073

7,224

29.0%

7,517

34.9%

7,517

6,178

9,040

School

ho ol i tr ng ea /o t m ff e en ns t ive

Friends

2010 2011

Sc

%

lly

Number

Bu

%*

9,040

Number

7,224

Topic

Number 10,000

s

2010

nd

2011

ie

Contacts by topic – BRIS 116 111, the BRIS-mail & the BRIS-chat

Fr

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the Bris-report 2012

Statistics

Gender Comparison: Gender distribution 2010

Gender distribution 2011

1%

1.2% Girls Boys Not stated

20.5%

Girls Boys Not stated

22%

77%

78.3%

Age Average age/gender child contacts Gender

2011

2010

Boys

13.9

14.2

Girls

13.8

14.0

Total

13.8

14.1

n=23,082

BRIS’ SUPPORTIVE CONTACTS The supportive contacts made by children on bris 116 111, the bris-mail and the brischat constitute the basis of the outreach work as some information about the contact, such as what topic the contact was about, is documented by the recipient after the contact was concluded. In 2011, the supportive contacts most commonly concerned the topics of friends, school, fear/anxiety, family conflicts and bullying/ offensive treatment. These are the same topics that were the most common in previous years. The contact topics in which the greatest change occurred are the topics that were already large to start with, such as school, friends and bullying/humiliating treatment.

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Statistics

BRIS assignment services Number of assignments

Topics – Assignments

2011

2010

90

72

13

Family conflicts

13

Physical abuse

10

Other mental illness Bullying/offensive treatment

7

Problems with authorities

7

Sexual abuse/molestation

5

Suicide/thoughts of suicide

5

Neglect

5 0

3

6

9

12

15%

n=90

GENDER AND AGE One of the most important principles in bris’ work is that everyone who contacts bris is anonymous. The adults who interact with children on bris 116 111, the bris-mail and the bris-chat do not ask the children anything that would put the child’s anonymity at risk. In the cases that the child chooses to tell his or her gender, age and housing situation, this background information is documented, however. Looking at the gender distribution in terms of the children that were the subject of the bris contacts in 2011, it is clear that the girls still account for a larger part of the contacts. For the second consecutive year, the average age of the children who were the subject of the bris contacts has decreased somewhat. This is true both overall, as well as if boys and girls are studied separately.

of help the child needs from bris, and keep in touch until bris has completed the agreed assignment or until the child feels that the assignment should be concluded. Assignment contacts take place solely on the initiative of the child and bris only interfaces with professionals who work with children and young people. In 2011, bris had 90 assignments. Within the scope of every assignment, the number of individual contacts varied widely; some assignments consistent of just the first and only contact, while other assignments comprised multiple contacts and extended over a long period of time. In 2011, assignments most commonly concerned physical abuse. It was also common that they concerned living arrangements and family conflicts.

BRIS’ ASSIGNMENT SERVICES If a child that contacts bris needs more help from bris than can be offered by a volunteer, the child can be offered contact with one of the employed bris representatives. This contact between bris and the child is called an assignment, which means that the child has the opportunity of having repeated contacts with the same person in bris. An assignment means that bris and the child jointly decide what kind 2012 • the BRIS report

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Statistics

The BRIS forums Submissions published on the Discussion Forum 2007-2011 40,000

38,484

35,000 30,000

27,245 26,814

28,489

25,000 20,000 15,000

15,062

10,000 5,000 0

2007

2008

2009

2010

2011

BRIS’ FORUMS In addition to contact with adults, bris also provides the possibility for children to interact with other children and this takes place on the bris Forums. The forums offer children three possibilities of communication; the bris Discussion Forum, My Poem and the Source of Joy. Children may choose to write to My Poem or the Source of Joy to tell other children and young people how they feel. If, however, the children want to discuss matters with each other, they can do so on the bris Discussion Forum. In contrast to many other forums on the Internet, the bris Discussion Forum is moderated by adults to thereby follow the guidelines the organisation has concerning the services. These guidelines primarily mean that all submissions must be written in a way that anonymity is retained, and this also means that the adults at bris must ensure that only supportive communication takes place between the children. In 2011, the number of submissions to the Discussion Forum increased by 35 percent

compared with 2010 to reach the highest level since it began in 2003. When a child makes a submission to the bris Discussion Forum, he or she must choose one of the categories that bris has chosen in the forum in advance. This means that bris has some control over what the submissions are about. In 2011, the children chose to make submissions to the category on Love to the largest extent. The categories of Being Young and Feelings were also common during the year, and this distribution matches the distribution of previous years well.

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bris Box 3415 SE-103 68 Stockholm Sweden