risk assessment and triage of children in school setting eugene grudnikoff md nov. 2, 2015...
TRANSCRIPT
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Risk assessment and triage of children in
school setting
Eugene Grudnikoff MD
Nov. 2, 2015
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Objectives• Why evaluate children in schools?
– Meaningful evaluation is possible– Familiar setting is the best setting– Evaluation make a difference
• How to evaluate a child in school?– Understand events that signify distress– Engage the child – Understand his/her distress– Assess Risk– Implement safe and effective plan (with
help)
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Why evaluate at school?
• Why Me?– Meaningful evaluation is possible
• Why at school?– Trusting relationship in familiar, safe
environment = best evaluation
• Why Evaluate at All?– Evaluation makes a difference
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In-School Evaluation Matters
48%
52%
No in-school evalAppropriate for ER
Inappropriate for ER
73%
27%
School Eval Done
Appropriate for ERInappropriate for ER
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Place of assessment in overall evaluation
Event Assessment Intervention
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Place of assessment in overall evaluation
Event• Suicidal thoughts• Suicidal behaviors• Self-injury• Other disruptions
Assessment Interventions
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Place of assessment in overall evaluation
Event• Suicidal thoughts• Suicidal behaviors• Self-injury• Other disruptions
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
Interventions
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Interventions
Event• De-escalate
Assessment Intervention• Engage resources• Safety plan• Long-term plan
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Why Children Act Out
Stressors/ RisksResources
Child’s Strengths
Anxiety
ParentsBullyingAcademic
stress
School
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Starting an Assessment
• Offer support
• Establishing rapport and trust
• Engage the child
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
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Examples
• 7-y.o. in cafeteria:– “I’m so hungry, I could die.”
• 14-y.o. teen comes to school with superficial cuts– “I was feeling alone after fight with boyfriend…”
• 17-y.o. who tells nurse he took 4 Benadryl– “Mom was yelling at me about grades, and I just
wanted to go to sleep and forget about it all ...”
• 13-y.o. who tells teacher he wants to die – “I often feel that I will kill myself before I’m 18.”
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Assessing suicidal thoughts, behaviors, and self- injury
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
• Understand trigger• Isolated vs. ongoing vs. developing event
• Understand intent• Suicidal / unsure vs. non-suicidal
• Understand suicidal behavior• Impulsive vs. planned• Seek help vs. avoid discovery• Low lethality vs. highly lethal
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Assessing suicidal thoughts, behaviors, and self- injury
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
Understand the trigger
Isolated event
Ongoing situation
Developing event
Lower Risk
Higher Risk
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Assessing suicidal thoughts, behaviors, and self- injury
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
Suicidal Intent
Ambivalent Intent
No Suicidal Intent
• Evaluation of intent: severity and persistence– What was the child was thinking about AT the TIME
OF the INCIDENT?– What is the child thinking about NOW?
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Assessing suicidal thoughts, behaviors, and self- injury
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
Understand Intent: Severity
No intent to end life
Suicidal Intent or
Ambivalent about Intent
Lower Risk
Higher Risk
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Assessing suicidal thoughts, behaviors, and self-injury
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
Understand Intent: Persistence
Lower Risk
Higher Risk
Resolving suicidality
Persistent suicidality
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How to ask about suicide• Be direct when asking the “S” question.
– BAD • You’re not thinking of hurting yourself, are you?
– Better • Are you thinking of harming yourself?
– BEST • Sometimes when people have had your
experiences / feelings they have thoughts of suicide. Is this something that you’re thinking about?
• Did you want to kill yourself when you …?• What stopped you? … • Are there reasons to live?
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Assessing suicidal thoughts, behaviors, and self-injury
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
Understand suicidal behavior
Lower Risk
Higher Risk
Impulsive
Seeks help
Low lethality
PlannedAvoids discovery
High lethality
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Assessing resourcesAssessment• Support and trust• Assess behavior• Assess resources• Assess risk
Lower Risk
Higher Risk
Close with parent(s)
• Home resources• School resources• Friends• Inner strengths
Recent divorce
Single parentSupportive
friends
Isolates selfReaches out
for help
Sees therapist
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Acute vs. Chronic Risk Factors
• Chronic Risk factors do not change– Prior suicide attempt– Family history of
suicide– History of trauma– History of depression– Gender dysphoria– … …
• Acute Risk Factors can be changed– Bullying– Depression– Anxiety– Grief/loss
Assessment• Support and trust• Assess behavior• Assess resources• Assess risk
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Some suicide warning signs are more serious than others
• Suicide note• Making final arrangements • Giving away prized possessions • Talking about death • Reading, writing, and/or art about death �• Hopelessness or helplessness • Social withdrawal and isolation • Lost involvement in interests & activities �• Increased risk-taking • Heavy use of alcohol or drugs
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Engaging Resources
Stressors and RisksResources
Child’s
StrengthsAnxiety
ParentsAcademic
stress
BullyingSchool
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Making the decision
• Gather the information• How do I remember all the stressors,
triggers, risk factors?– Use C-SSRS Check list
• Engage resources – Child, family, therapist, etc – No resources go to ER
• Develop safety plan– No safe plan go to ER
• Develop long-term plan
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When to go to ER
• A suicide attempt • Preparing for suicide
attempt• Persistent suicidality
with hopelessness (no reasons to live)
• Dysfunction with significant risk factors and no accessible resources
Question: When should a child go to the EMERGENCY Room?
When there is an Emergency
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Is there an Emergency?Examples: Suicide attempt; persistent intent; persistent suicidal thoughts with
hopelessness; significant self-injury (needs stitches, overdose)
Engage resources
Develop Short-term Plan
Evaluation and Assessment
De-escalate
No Resources
Develop Long-term Plan
Yes