Youth and Family Crisis Assessment

1. Youth and Family Crisis Assessment Presented by:

2. Meet the Presenters • Jill Chaffee, MSW, jillchaffee@nwpass.com • Himanshu Agrawal, M.D. , himanshu@nwpass.com • Angela Fredrickson, LCSW, angela@nwpass.com • David Swenson, Ph. D, david@nwpass.com

3. Why you should care: • Law enforcement • Social Worker • Tax Payer • Family Member/Advocate

4. Goals of today: • Learn tools and methodology to complete a crisis assessment • The Four P concept • Understanding and appreciating the role of mental illness in crisis situations • Evaluate, manage, and document risk

5. Overview of Western Region Grant • Certifying counties (DHS 34) • Training • Stabilization services

6. Goals of the grant • Reduce inappropriate/unnecessary restriction of rights by using more restrictive placement than needed • Improve access to community based least restrictive options

7. Goals of Emergency Services/Crisis Program (DHS 34) • Quality of Service • client centered • utilizing least restrictive options • community-based • ensuring consumer satisfaction (client, family,law enforcement, social worker, community partners)

8. Goals of Emergency Services/Crisis Program (DHS 34) 2. Efficiency • understanding the costs and benefits of the program • understanding pro-active planning for crisis • understanding a crisis before it becomes a crisis • fewer and fewer hospital and beds are available

9. Goals of Emergency Services/Crisis Program (DHS 34) 3. Outcomes Expected • avoid unnecessary hospitalizations • engage in evidence-based best practices by law enforcement teaming with mental health • state budget requires this consultation • serve clients in the the community • preserve families

10. Goals of Emergency Services/Crisis Program (DHS 34) 4. Risk Management • philosophy • shared risk • documentation • risk taking, creative thinking, and problem solving

11. Emergency Detention Process Reason to believe person is mentally ill and dangerous to self or others or impaired judgment and dangerous to self or others Emergency Detention Person handcuffed and taken via police to locked facility Detention papers filed with the court

12. Emergency Detention Process Detention papers filed with the court Person signs voluntary admission Probable cause hearing within 72 hours excluding weekends Probably cause found-date set for final hearing Probable cause not found-dismissed Final hearing Dismissed Six month commitment

13. No matter how big the problem, don’t rush to solve it. Check with others, sit on it awhile and see what develops.

14. Interviewing-Overview • Building Rapport • Assessor Behavior • Intervention Don’ts • Basic Crisis Strategies • Validate Emotions • Assessment Tools

15. Build Rapport • take an interest in the child/adolescent • ask about what he/she likes to do,collect, music interest etc. • find things you have in common • acknowledge his/her achievements

16. Assessor Behavior • be calm • be respectful even when they are not • have a few clear rules • give clear, direct, simple messages • be consistent • avoid confrontations in front of others • start fresh every day • give choices • use positive reinforcers whenever possible • don’t sweat the small stuff

17. Intervention DON’T’S • DON’T ignore, minimize or joke about life threatening statements • DON’T be afraid to inquire about or discuss whether they have considered violence • DON’T be judgmental (e.g., it’s wrong, a sin, etc.) • DON’T act shocked, repulsed, rejecting • DON’T call the bluff or challenge to do it • DON’T analyze or over-interpret motives • DON’T try to argue them out of it • DON’T moralize or give advice • DON’T promise to keep the violence intention or discussion secret • DON’T give up just because they don’t want to talk

18. Basic Crisis Strategies for Youth and Families • Explore the current problem • identify the Precipitating Factors of the crisis • stay present focused – parents and youth • avoid historical factors

19. Basic Crisis Strategies for Youth and Families • Pay attention to affect rather than content of the statement • focus on the actual suicidal thought • focus on the emotions related to the thought • avoid getting swept away with the other details

20. Basic Crisis Strategies for Youth and Families • Immediate Problem Solving • remain present-focused • guide parents and youth to find ways to tolerate the affect generated by the Precipitating Factors

21. Basic Crisis Strategies for Youth and Families • Obtain a commitment to a plan of action • a series of steps that will help all parties get through the crisis by tolerating it and not engaging in self-harm/suicide/harm to others • trouble shooting • include a plan for follow-up

22. Validate Emotions • Validation is a way to let people know that their emotions/actions/thoughts make sense given what they have experienced in life. • Validation does not equal agreement. Validation is about letting others know you hear them and understand what they are trying to communicate. • Try to avoid the “but’s”

23. Assessment Tools (handouts) • Suicide checklist • Specific risk factors for suicide

24. The 4 P Model • Predisposing Factors • Precipitating Factors • Perpetuating Factors • Protective Factors

25. Family history Conception

26. Family history Conception Birth In-utero exposure

27. Medical Hx TBI, Sz, DM, Hep C etc Family history Conception Birth In-utero exposure

28. Medical Hx TBI, Sz, DM, Hep C etc Family history Conception Birth Drugs In-utero exposure

29. Medical Hx TBI, Sz, DM, Hep C etc Family history Conception Birth Drugs In-utero exposure

30. Definitions of the 4 P’s • Predisposing Factors-factors or conditions that render an individual vulnerable to disease or disorder • Precipitating Factors-an element that causes or contributes to the occurrence of a disorder or problem • Perpetuating Factors-factors that cause to continue the situation or condition indefinitely • Protective Factors-factors serving or intending to protect the person or improve the situation

31. Biological Psychological Social Predisposing Factors Precipitating Factors Perpetuating Factors Protective Factors Biological Psychological Social Biological Psychological Social Biological Psychological Social

32. BIOLOGICAL PSYCHOLOGICAL SOCIAL • Family history • Prenatal issues • Medical illnesses • Chemicals • Abuse or neglect • Recent loss • Impulsivity • Depression • Aggression • Unemployment • Singledom • Homeless • Low Income • Little religious support

33. 4 P Tool

34. Predisposing Biological Factors:Relatively stable factors that increase vulnerability • Genetics/Family History • Exposure to chemicals during pregnancy • Alcohol (FASD) • Early age of onset • Medical Conditions • Seizures • Traumatic Brain Injury • Mental Retardation • Diabetes • Developmental Disorders, Autism Spectrum Disorders • Sleep Deprivation

35. Predisposing Biological Factors:Factors that increase vulnerability to a condition • Chemical Use • Alternative medicine • Agitators • Adderall, Ritalin, Cocaine, Meth, Steroids, Alcohol, Anti-psychotics • Withdrawal from-Benzo’s, Alcohol, Opiates, Cocaine, Paxil, Effexor

37. Predisposing Psychological Factors:Relatively stable factors that increase vulnerability Attachment issues Abuse, neglect, & traumatic stress Mood Disorders (Depressive, Anxious, Bipolar) Features of Borderline and Antisocial Personality Disorders Impulsivity and poor problem solving (interpersonal)

38. Stress Attachment, Abuse, and Mental Health • Attachment difficulties and abuse history often go hand in hand and often are present for those with mental illness. • Comorbidity of mental disorders is the rule rather than the exception among adolescents • 90% of individuals who completed suicide were found to have a diagnosable mental health issue • To further complicate matters, such disorders look very different in children and adolescents as compared to adults.

39. Depression in children and adolescents • Symptoms unique or especially important to teen/child depression • Sadness is often replaced by irritability and anger • Risk-taking and/or acting out behavior • Isolation from friends • Drop in school performance • Vague body complaints

40. Personality Disorders and Adolescence • Personality is still developing in adolescence • Characteristics of personality disorder are still identified in adolescents • The current review of the literature shows Personality Disorders are as great a risk factor for suicide as depression and schizophrenia. • The combination of such personality patterns and a tendency for impulsive aggression raises risk.

41. Impulsivity • Research shows that completed suicides are often impulsive acts by adolescents – only 25% show evidence of planning. • Studies show a great deal of ambivalence in terms of intent to die in adolescents who attempt suicide. • Aggression with impulsivity has been linked to suicidal behaviors in children and adolescents.

43. Predisposing Social Factors: Factors that increase vulnerability to a condition • Sexual Orientation • Childhood sexual and physical abuse/neglect • Poverty/disadvantaged environment • Peer group, bullying • Family conflict/functioning • Unemployment • Discrimination • Family history of suicide

44. Predisposing Social Factors: Factors that increase vulnerability to a condition • In most cases a predisposing factor alone is not enough to initiate a crisis. • Available data are mixed regarding the impact of socioeconomic status and the effect of family stress. • Suicidal ideation has been associated with presence of parental mental illness, low levels of parental emotional support and low levels of emotion expression within the home. • Family history of suicidal behavior significantly increases risk • 5 times more likely in offspring of mothers who have completed suicide • 2 times more common in offspring of fathers who have completed suicide.

46. Precipitating Biological Factors:Factors that contribute to the occurrence of a problem • Chemical use • Acute intoxication • Withdrawal • Accidental ingestion • Drug-drug interactions • adverse effects of prescribed meds • Head trauma • Seizures • Metabolic causes • Glucose • Steroids

47. Neurological Dysfunction in Offenders Headaches, seizures, hypoglycemia, dizziness Nature nurture 26% Repeat offenders but only 5% of 1st time offenders had maternal drug abuse Poor coordination, odd appearance, speech & vision problems 83% of felons report that they suffered a head injury prior to their first encounter with police; some as late as age 30 (Sarapata, Herrmann, Johnson, and Aycock ,1998) http://www.acs.appstate.edu/dept/ps-cj/neurology.htm

48. Medication Risks • time to reach therapeutic levels • interaction effects with illicit drugs • side effects & toxicity • dietary restriction with MAOI • hoarding drugs for overdose

49. Medication Risks • substance abuse or relapse • selling medications • defiance & noncompliance • may require close medical supervision • only for symptomatic treatment