Illinois EMSC 1

Psychobehavioral Objectives

Upon completion of this lecture, you will be better able to:

Describe appropriate interventions for a psychobehavioral emergency

Perform a mental status examination to assess a behavioral emergency

Demonstrate techniques for communicating effectively with a violent or suicidal student

Identify community resources that can help you deal with violent, mentally ill or suicidal students

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PSYCHOBEHAVIORAL EMERGENCIES

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PSYCHOBEHAVIORAL EMERGENCIES

2000 Surgeon General Report found that 11% of youth aged 9 – 17 years (approx 4 million) have a “major mental illness that results in significant impairment at home, at school and with peers.”

National Institute of Mental Health found that only a fifth of these children and adolescents actually receive mental health care

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COMMON PEDIATRIC MENTAL ILLNESSES

Depression Schizophrenia Anxiety disorders Eating disorders

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PSYCHOBEHAVIORAL EMERGENCIES

Knowledge of normal childhood and adolescent growth & development is imperative in order to appropriately differentiate normal from abnormal behavior.

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ASSESSMENT Mental Status Examination

(MSE) Previous history of violence Physical cues of escalation Substance abuse or use

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PSYCHOBEHAVIORAL ILLNESS

Use MSE for baseline data on behavior Understand normal emotional development Awareness of family member’s history Knowledge of common mental disorders

Depression Schizophrenia Anxiety disorders Conduct disorders Eating disorders Threat to self/others

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Signs of Distress

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MENTAL STATUS EXAM

APPEARANCE Grooming, posture, cleanliness

MOOD Relaxed, irritable,frightened

SPEECH Tone of voice, slurred, fast,

loud BEHAVIOR

Pacing, eye contact, slouched

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MENTAL STATUS EXAM

MEMORY Instant recall, recent

activities, current problem

REALITY ORIENTATION Day, time, place,

situation THOUGHT PROCESS

How the student thinks, are there hallucinations?

THOUGHT CONTENT What he/she says,

hopeless, suicidal?

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MENTAL STATUS EXAM

INSIGHT Ability to analyze, blaming others or lack of

responsibility for own behavior/situation JUDGMENT

Ability to make decisions, impulsive or superficial

PERCEPTION Awareness of self and thoughts, guilt or

indecisive

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EATING DISORDERS

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ANOREXIA AND BULIMIA

SYMPTOMS: Discolored teeth Poor nutritional status Pale skin Brittle hair Abrasions on knuckles Wearing inappropriate clothing, e.g. a bulky

sweatshirt in summer Making inappropriate body image comments,

e.g. stating she is “fat” when this is clearly not the case

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IMAGES

                                       

                                                   

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Conduct Disorders

Conduct disorders include a wide range of antisocial acts, such as:

Bullying Lying Stealing Truancy Cruelty

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BULLYING

MYTHS ABOUT BULLYING “ I was bullied at school and it

did me no harm.”

“Tell him to hit back - harder.”

“It’s character building.”

“That’s not bullying! It’s just kids teasing.”

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BULLYINGPOSSIBLE SIGNS OF BULLYING Children may:

Be frightened of walking to or from school

Not wanting to go to school Start doing poorly in school Become withdrawn Become anxious Attempt or threatened suicide Become aggressive and unreasonable

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HOW TO HANDLE A BULLY Take the bullying seriously Investigate all incidents Interview the bully and victim

separately Interview all witnesses Follow-up Document all incidents and

action taken

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VIOLENCE VIOLENCE IS AN ABUSE OF POWER! Youth learn to protect themselves

by use of weapons or joining gangs Behavior is learned, modeled or

justified as a survival coping mechanism

Rarely are adolescents violent just to be violent

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PLAN AND INTERVENTION

Policies and procedures for violent behavior are well thought out, clear and consistently enforced

Staff and students understand that a safe environment as top priority

Scene safety is part of primary assessment

Administrative support is readily available to the school nurse

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INTERVENTIONS REQUIRING PHYSICAL RESTRAINT

Never approach student alone, and be sure there are no weapons before approaching

Call for assistance, (staff experienced with such interventions)

Keep a distance and avoid standing directly in front of person. NEVER BLOCK AN EXIT!

Be concrete in directions to student but show concern about his/her situation

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INTERVENTIONS WHEN AGITATED BUT NOT VIOLENT

Talk in low, measured tones Verbalize empathy and that you will

assist the student to control his/her behavior

Walk while you talk - difficult to sit still if agitated

Restate what the student says: You are feeling angry What do you need to do?

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TRIAGE AND TRANSPORT

EMERGENT Student with a weapon Student “high” on drugs requiring restraint

URGENT Student exhibiting abnormal behavior

requiring referral and evaluation NON-URGENT

Student calmed by verbal intervention, able to return to class

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PREVENTION School aware that violence is reality Policy and procedures for early

intervention Campaign for school as “no

violence” zone Support groups for students Faculty inservice Peer counseling and mentor program

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ASSESSMENT OF SUICIDE

MSE DETERMINE SUICIDAL LETHALITY

Do you have a plan? How will you carry it out? Do you have access to completing the plan?

DETERMINE OTHER RELATED RISK FACTORS A family history of suicide The student lost a friend from suicide The student had a recent loss or perceived loss

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PLAN AND INTERVENTION

Based on assessment and lethality Relationship of warmth, genuineness,

and empathy Calm and affirmative Listen and reflect but non-judgmental Acknowledge that suicide is a CHOICE Explore feelings and discuss

alternatives

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TRIAGE EMERGENT

Suicide attempt or student has a plan and lethality is high.

Assure that student is never left alone. EMS transport, maintain ABCs.

URGENT Suicide ideation with or without a plan. Parent/guardian called in. Assure that student is never left alone. Immediate referral.

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EVALUATION AND FOLLOW-UP

De-briefing for involved school personnel

Validate school policy and procedures Revise procedures that did not work Continue or re-establish therapeutic

relationship with students returning to school

Educate students/staff about mental illness

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PREVENTION In-service education for school personnel on youth

stress including signs and symptoms of depression, substance abuse, and physical and sexual abuse

Implement a crisis intervention team in the school

Incorporate stress management, decision making skills, and interpersonal skills into the health curriculum

Develop a peer support program

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SUMMARYPsychobehavioral emergencies are inevitable,

but with planning and preventive measures, you may be able to avert some tragedies

Emergencies of this type demand specialized knowledge and skills, including excellent therapeutic communication techniques understanding of normal growth and development comprehensive network of mental health

professionals and resources in the community

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ANY QUESTIONS??