Treating Children in Crisis

1. Treating Children in CrisisBobbi O’Kelley, MSCPBehavioral Health Clinician and Intake ManagerNorth Star Hospital, Bragaw CampusApril 2008

2. Treating Children in Crisis • The word “crisis” was selected in this title to provide an all-encompassing word to describe children in distress…whether it be physical, emotional, psychological or otherwise (often times, all of the above). • This presentation primarily focuses on assisting children who experience psychological and/or emotional distress.

3. Behavioral Health Perspectives to Consider During Disaster Relief

4. BEHAVIORAL HEALTH PERSPECTIVES The term “Behavioral Health” has grown in popularity to describe various aspects of the psychology field including: • psychiatric disorders • substance abuse disorders • co-occurring (psychiatric and substance abuse) disorders – sometimes referred to as “dual diagnosis”

5. Presentation Points of Interest • Understanding Trauma and PTSD • Distinguishing Acuity Level in a Crisis • Treatment Options • De-escalation Techniques • After Care • Q & A • Quiz • References • Resources

6. What’s in it for you? • The ideas contained in this presentation are designed to equip you with tools and knowledge that will assist you to effectively intervene with children in crisis or distress. • It is NOT designed for you to practice psychotherapy with children in crisis or distress, a separate approach that requires specialized training/education.

7. Typical traumatic events are natural calamities, violence, serious accidents, the death, injury, or serious illness of next of kin, and war-related stress. Trauma is a painful emotional experience, or shock, that creates substantial and often lasting damage to the psychological development and well-being of the individual. What is Trauma?

8. Types of Trauma in more detail • Examples of Natural Disasters Earthquakes Tornadoes Floods Mudslides Volcanoes Avalanches Fires Hurricanes Tsunamis Heat Waves

9. (Types of Trauma in more detail Cont.) • Well Known Global Disasters Natural Hurricane Katrina (‘05) Tsunami – Indian Ocean/SE Asia (‘04) Earthquakes: Alaska ’64, San Francisco, Kobe, Pakistan Pandemic Flu – 1918, 1968 Man-made 9-11 Twin Towers Attack (‘01) Plane crash Riots War

10. (Types of Trauma in more detail Cont.) Beyond natural disaster or war, trauma comes in a variety of “packages” including, but not limited to: - domestic violence - seeing someone (or animal) die or get injured - heightened conflict between any two or more persons - seeing or being in a vehicle, airplane or ATV accident - experiencing or seeing abuse of any kind, including neglect - rape or sexual exploitation - school violence - scary movies/films

11. Traumatic events are exceptional situations of helplessness & distress that a person experiences at first hand, witness or hears about, and which jeopardize the physical and/or psychological integrity of the individual or those close to him/her. Trauma can appear after a single event, a series of events, or a particularly upsetting period of life of a traumatic nature. (What is Trauma? Cont.)

12. Post-Traumatic Stress Disorder How do you know when a child has PTSD?

13. In this section, you will learn what to look for when determining if a child suffers from PTSD Helpful points to remember • If a child has endured a traumatic event, or series of events, s/he may not necessarily have a diagnosis of PTSD but may still be in crisis. • It is helpful to understand the signs and symptoms of PTSD in order to best assist those responding to trauma. • It is a good idea to do a thorough screening for each child as trauma, like grief, is processed differently depending on the individual.

14. PTSDSigns and Symptoms per the DSM-IV-TR General Signs/Symptoms • Distress affecting social, occupational or other major areas of functioning • The person experienced or witnessed a life-threatening event • Duration of disturbance exceeds one month

15. (GeneralSigns/SymptomsCont.) • Social, Occupational and Other Areas of Functioning Affected may include: • Tantrums (beyond normal development) • Disinterest in once-enjoyed activities • Difficulty making/keeping friends • Minimal interaction with others • Increased sibling rivalry • Poor concentration • Limited or no play • Dropping grades • Restlessness

16. A Tragic Day for Susie Scenario: Susie is 7 years old. She remembers the way the raindrops hit the harbor’s calm waters that morning. As she was getting her red rubber boots and yellow slicker on, Susie heard a loud thunderous sound followed by yelps not only in her house but out on the street. Susie dashed outside to find the villagers running and shouting “tsunami!” while the family radio reported a recent earthquake 150 miles southeast of this ordinarily peaceful community. Susie knew something was terribly wrong. It dawned on her that her dad, uncle, and little brother had left early that morning to go fishing. Susie would soon find out that they, and 15 other villagers, had perished leaving her, her mom and new baby brother...

17. (PTSD Signs/Symptoms cont.)Revisiting the Event(s) • Recurrent distressing recollections of event i.e. images, thoughts • Acting or feeling as if the traumatic event was recurring i.e. flashbacks • Intense psychological distress at exposure to cues that resemble event • Repetitive play in which themes of trauma may be expressed

18. (Revisiting the Event(s) Continued) Using Susie’s story… Example of distressing recollections of event: Susie cannot stop hearing the radio blaring news of the earthquake in her mind. Example of acting or feeling as if the traumatic event was recurring: Susie’s heart rate begins to race at the sight of the ocean’s (usual) waves rolling in.

19. (Revisiting the Event(s) Continued) Example of intense psychological distress at exposure to cues: Every time Susie puts her red boots and yellow slicker on, she feels like disaster is imminent. Example of repetitive play in which themes of trauma may be expressed: Susie makes a boat out of clay and uses her Barbie doll to pretend to save her dad, uncle and brother.

20. Disorganized or agitated behavior Response includes intense horror, helplessness or fear Persistent avoidance of stimuli associated with trauma Symptoms of increased arousal i.e. poor sleep and concentration, anger (PTSD Signs/Symptoms cont.)Behavioral/Functional Impairments

21. (Behavioral/Functional Impairments Continued) Example of Disorganized or agitated behavior: Upon cleaning her room, Susie experiences unexplained rage and throws all of her clothes on the floor. Example of horror, helplessness or fear: Susie goes for a walk with her mom and baby brother on the docks and begins screaming uncontrollably when the rain starts to fall.

22. (Behavioral/Functional Impairments Continued) Example of Persistent avoidance of stimuli associated with trauma: Susie gets invited to go fishing every week-end for a month and vehemently refuses to go each time. Example of Symptoms of increased arousal: Susie establishes a pattern of not falling asleep right away at bedtime frequently calling for her mom and needing reassurance.

23. PTSD Types Onset and Duration of PTSD Acute: when the duration of symptoms is less than 3 months. Chronic: when the symptoms last 3 months or longer. Delayed Onset: at least 6 months have passed between the traumatic event and the onset of the symptoms.

24. PTSD Types • In cases of trauma addressed so far, i.e. natural disaster, acute type would be most pertinent for the purposes of this training. • If a child’s PTSD has evolved from acute to chronic type, longer term psychotherapy is likely needed/recommended. • Immediate intervention would not be relevant for delayed onset type.

25. Recognizing Acuity in Trauma Questions to ask in a crisis: - Can this crisis be managed safely at home? - Is the child at imminent risk for further harm? - What supports and/or resources are currently in place for this child?

26. Recognizing Acuity or Potential for Harm • When you are making a determination about whether or not the child can be kept safe at home, it is important to obtain information from the child (if the child is able to communicate) and from the caregiver or parent directly. • Be alerted to statements like (parent): “my child is totally out of control” or “as soon as I turn my back, my child does something dangerous”; (child) “I just don’t see any point in living anymore” or “at least if I died, I could be with my sister again”. These statements, or variations of statements like these, should be taken seriously. • A child or caregiver/parent revealing the potential for harm to self or others should be calmly met with compassion and concern by the provider.

27. How might you know that there is imminent risk for the child? • Suicidal or homicidal statements/gestures • Self-harming statements/gestures • Reports of high risk behaviors • Self-Medicating • Aggressive toward others • Active psychosis i.e. hallucinations • Unable to manage self-control; impulsive • Depressive symptoms affecting basic functioning • Unsafe and/or destructive behaviors in the community * Corresponding examples on next slide…

28. (imminent risk for the child cont.) Detailed Scenarios of High Risk Behaviors: • The child states “I wish I was dead” • Cuts are discovered on the child’s arm • Neighbor reports that the child snuck out at midnight • The child comes home reeking of marijuana • Principal and teacher report fist fight at lunch • The child reports hearing voices others can’t hear • Shopkeeper nabs child for shoplifting soda • Sleep and diet take a turn for the worse • Policeman arrests the child for slashing tires

29. Treatment Options - Inpatient Hospitalization - Medication - Crisis Intervention - Safety Planning - Outpatient Counseling/Therapy - Play Therapy - Art Therapy - Family Therapy - School Counselor - Pastoral Counseling

30. (Treatment Options Cont.) Inpatient Hospitalization Medication: a tool prescribed by a psychiatrist, or regular doctor, to stabilize mood, assist with anxiety, help sleep, and/or curb other symptoms Crisis Intervention: provider or parental efforts to safely lessen the intensity of an emergency situation Safety Planning: a measure or tool created in conjunction with a treatment team, i.e. nurse, doctor, & therapist, to teach a child and family how to safely manage a crisis

31. (Treatment Options Cont.) Outpatient Counseling/Therapy Play Therapy: A more natural means of expression to work through traumatic or other issues Art Therapy: Art supplies are used to assist children work through traumatic or other issues Family Therapy: Assist child & family members with tools, i.e. communication, to more effectively cope at home

32. (Treatment Options Cont.) School Counselor – this avenue provides an outlet in which to obtain support in the school setting Pastoral Counseling – reflective of the family belief structure, pastoral counseling can serve as spiritual support and guidance

33. De-Escalation Techniques and TipsAssisting Children with Coping Skills Self Time-out Journaling Deep Breathing

34. (De-Escalation Techniques Cont.) Self Time-out: Suggesting a self time-out allows the child to remove him or herself from a situation that is creating distress. Journaling: Encouraging writing as a tool to express thoughts and feelings can be a helpful alternative to spoken communication. Deep Breathing: Taking deep breaths is helpful to a child that is growing agitated or angry – 10 deep breaths can do wonders!

35. Normalizing Validation of Feelings Redirection Guided Imagery Reflection (De-Escalation Techniques Cont.)Ideas for Providers

36. (Ideas for Providers Cont.) Example of what you might say to a child by using a normalizing technique… “Susie, it is normal to feel angry when those you love die.”

37. (Ideas for Providers Cont.) Example of what you might say to a child by using validation of feelings… “It’s okay to cry and feel sad. I see that you are upset and having a hard time.”

38. (Ideas for Providers Cont.) Redirection: An example would be to take a child who is angry and direct them to a different activity i.e. “let’s go over here and water paint.” Guided Imagery: This may take a little more prep, i.e. using a CD, to assist the child to “visit” a place that is calm and peaceful. Reflection: This simply means that you echo what the child expresses, i.e. “I hear that you feel sad, Susie…”

39. Sensory Toys Puppets Music Drawing Sculpting (De-Escalation Techniques Cont.)Creative Outlets for Children

40. (Creative Outlets for Children Cont.) “The most effective kind of education is that a child should play amongst lovely things” - Plato

41. After-Care Considerations If a child has been hospitalized for acute symptoms/behaviors… - Assist family with discharge planning - Discuss child’s support system - Address medication and outpatient services - Recommend family therapy - Create a safety plan

42. Q & A Are there any Questions?

43. Are you ready to take the Quiz? 1.The term “behavioral health” is best described by the following (select one): a. PTSD b. psychiatric disorders c. substance abuse and co-occurring disorders d. b and c e. none of the above

44. (Quiz Cont.) 2. “PTSD” stands for (select one): a. post-traumatic stress disease b. post test savory dessert c. post-traumatic stress disorder d. post-traumatic strain disorder e. none of the above

45. (Quiz Cont.) 3. A child that merely witnesses, but does not experience first-hand, a traumatic event would not develop PTSD. (select one) a. TRUE b. FALSE

46. (Quiz Cont.) 4. Which of the following PTSD types is most pertinent to providers intervening in a crisis? a. acute b. delayed onset c. chronic d. b and c e. none of the above

47. (Quiz Cont.) 5. A child who sees an image of a traumatic event in her dream state likely suffers from… a. behavioral impairments b. general signs and symptoms c. revisiting the event d. a and b e. none of the above

48. (Quiz Cont.) 6. Examples of Imminent Risk include all examples except the following (select one): a. expressing wanting to die b. consuming alcohol as a minor c. riding a four-wheeler d. spray-painting graffiti after curfew e. skipping two meals a day

49. (Quiz Cont.) 7. Family Therapy is only utilized in an inpatient hospital setting. a. TRUE b. FALSE

50. (Quiz Cont.) 8. All of the following examples are de-escalation techniques except one (select one): a. journaling b. deep breathing c. watching television d. self time-out