youth and family crisis assessment presented by:

Youth and Family Crisis Assessment

Presented by:

Meet the Presenters

Jill Chaffee, MSW, [email protected] Himanshu Agrawal, M.D. , [email protected] Angela Fredrickson, LCSW, [email protected] David Swenson, Ph. D, [email protected]

Why you should care:

Law enforcement Social Worker Tax Payer Family Member/Advocate

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

Overview of Western Region Grant

• Certifying counties (DHS 34)• Training• Stabilization services

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

Goals of Emergency Services/Crisis Program (DHS 34)

1. Quality of Service client centered utilizing least restrictive options community-based ensuring consumer satisfaction (client, family,law

enforcement, social worker, community partners)


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


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


4. Risk Management philosophy shared risk documentation risk taking, creative thinking, and problem solving

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

Emergency Detention Process

Person signs voluntary admission

Probable cause hearing within 72 hours

excluding weekends

Probable cause not found-dismissed

Probably cause found-date set for final hearing

Final hearing

Six month commitment

Dismissed

Detention papers filed with the court

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

Interviewing-Overview

Building Rapport

Assessor Behavior

Intervention Don’ts

Basic Crisis Strategies

Validate Emotions

Assessment Tools

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

• 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

Assessor Behavior

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

Intervention DON’T’S

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


•Pay attention to affect rather than content of the statement

focus on the actual suicidal thoughtfocus on the emotions related to the thoughtavoid getting swept away with the other details


Immediate Problem Solving remain present-focused guide parents and youth to find ways to

tolerate the affect generated by the Precipitating Factors


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

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”

Assessment Tools (handouts)

Suicide checklist Specific risk factors for suicide

The 4 P Model

1. Predisposing Factors

2. Precipitating Factors

3. Perpetuating Factors

4. Protective Factors

Family history

Conception

Family history

In-utero exposureConception Birth

Family history

In-utero exposure

Medical Hx

TBI, Sz, DM, Hep C etc

Conception Birth

Family history

In-utero exposure

Medical Hx

TBI, Sz, DM, Hep C etc

DrugsConception Birth

Definitions of the 4 P’s

1. Predisposing Factors-factors or conditions that render an individual vulnerable to disease or disorder

2. Precipitating Factors-an element that causes or contributes to the occurrence of a disorder or problem

3. Perpetuating Factors-factors that cause to continue the situation or condition indefinitely

4. Protective Factors-factors serving or intending to protect the person or improve the situation

Predisposing Factors

Precipitating Factors

Perpetuating Factors

Protective Factors

Biological

Psychological

Social

Biological

Psychological

Social

Biological

Psychological

Social

Biological

Psychological

Social

BIOLOGICAL

•Unemployment•Singledom•Homeless•Low Income•Little religious support

•Abuse or neglect•Recent loss•Impulsivity•Depression•Aggression

•Family history•Prenatal issues•Medical illnesses•Chemicals

PSYCHOLOGICAL SOCIAL

Predisposing Precipitating Perpetuating Protective

Bio

Psycho

Social

4 P Tool

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

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


Bio Genetics

Family history

FASD

Medical Conditions

Chemical Use

Alternative Medicines

Agitators

Psycho

Social

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)

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.

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

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.

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.


Bio Genetics

Family history

FASD

Medical Conditions

Chemical Use

Alternative Medicines

Agitators

Psycho Attachment issues

Abuse, neglect, & traumatic stress

Mood Disorders (Depressive, Anxious, Bipolar)

Features of Borderline and Antisocial Personality Disorder

Impulsivity and Poor Problem Solving

Social

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

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.


Bio Genetics

Family history

Medical Conditions

Chemical Use

Agitators






Social Sexual Orientation

Childhood sexual and physical abuse/neglect

Poverty/disadvantaged environment

Peer group, bullying

Discrimination

Family history of suicide

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

http://www.acs.appstate.edu/dept/ps-cj/neurology.htm

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Physical Head injuries Health Family Abuse Family AODA

Repeat violent offenders Repeat nonviolent offenders Ist time Offenders

Poor coordination, odd appearance, speech & vision problems

Headaches, seizures, hypoglycemia, dizziness

Neurological Dysfunction in Offenders

26% Repeat offenders but only 5% of 1st time offenders had maternal drug abuse

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)

Nature nurture

Medication Risks

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

Medication Risks

• substance abuse or relapse

• selling medications

• defiance & noncompliance

• may require close medical supervision

• only for symptomatic treatment


Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators

Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes






Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide

Precipitating Psychological Factors:Events, cognitive & emotional triggers

Interpersonal Conflict and Separations Previous Suicide Attempt

– The best predictor for future suicidal behavior is past suicidal behavior

– Also the single most important predictor of future completed suicide.

Substance use– Found in great frequency among youth who

attempt suicide and is a strong risk factor. Poor problem solving and impulsive

decision making

Factors in choice of methods used in adolescent suicide attempts

Availability/accessibility Most common method in US regardless of race, gender, age is

firearms. Suicide probability increases fivefold when a firearm is kept in

the home One study suggested availability of guns contributed more risk

than psychopathology

Socio-cultural acceptance Familiarity with use Social or behavior suggestion

Factors in choice of methods used in adolescent suicide attempts

Saliency – suggestion by publicity, news, drama The magnitude of suicide increase in in direct proportion to the

amount, duration, prominence of media coverage of an event

Personal, symbolic meaning of the act or setting Intentionality and rescue-ability

The greater the intent, the higher level of lethality of method However, lethality does not always match the intent









Interpersonal Conflict and separations

Previous suicide attempt

Substance use

Poor problem solving and impulsivity


Precipitating Social Factors: Factors that contribute to the occurrence of a problem

Losses – most importantly interpersonal losses breakup of a romantic relationship, divorce, relative or

friend death, disciplinary crisis, humiliation, arguments

Arrest/Legal problems Friend has attempted/completed suicide Academic Difficulties Coming out and disclosure Parental job loss Residence change Change in family membership

Precipitating Social Factors

Studies show an increase in suicide attempts in individuals who have suicide attempts/completions in their social networks.

Adolescents are at highest risk of experiencing suicide clusters.

Adolescents are highly susceptible to suggestion and imitative behavior– A primary mode for learning for this age group– Essentially, it is a teen’s job to learn about social

behavior and identity.











Substance use



Interpersonal lossesLegal problemsFriend has attempted/completed suicideAcademic difficultiesComing out Parental job lossChange in family membership

Perpetuating Biological Factors:Factors that maintain the behavior or prevent

resolution

Poorly controlled medical conditions– Diabetes– Cushing’s disease/ Addison’s disease– Thyroid and parathyroid conditions– Seizures

Ongoing drug use Chronic sleep deprivation Chronic pain (incl fibromyalgia ) Painful/debilitating diseases (arthritis, lupus, multiple

sclerosis, psoriasis, etc).




Poorly controlled medical conditionsOngoing drug useChronic sleep deprivationChronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc).








Substance use




Perpetuating Psychological Factors:Factors that maintain the behavior or

prevent resolution

The continuation of both psychological and social predisposing factors

Continuation and reinforcement of poor problem solving

Mental Health Disorders Lack of healthy intervention for child/family












Substance use


Continuation of psychological and social predisposing factorsContinuation and reinforcement of poor problem solvingMental Health DisordersLack of healthy intervention for child/family



Perpetuating Social Factors:Factors that maintain the behavior or prevent

resolution

Continuation of precipitating factors Parental Mental Disorders/Substance use Abuse/neglect Poor parent-child communication

child views parent as uncaring and/or overprotective

Social isolation Mistrust of helping-professionals, stigma












Substance use





Continuation of precipitating factorsParental MH/AODAAbuse/neglectPoor parent-child communicationSocial isolationMistrust of helping-professionals, stigma

Protective Biological Factors:Factors that protect the person, prevent further

deterioration, or improve the situation

Healthy living (nutrition, sleep, exercise, stress management)

Positives– No drug use– No exposure to chemicals in uterus– No schizophrenia or bipolar in family– No traumatic brain injury





Healthy living (nutrition, sleep, exercise, stress management No drug useNo exposure to chemicals in uterusNo schizophrenia or bipolar in familyNo traumatic brain injury



Mood Disorders Features of Borderline and Antisocial Personality Disorder




Substance use






Protective Psychological Factors:Factors that protect the person, prevent

further deterioration, or improve the situation

Cultural/Religious Beliefs

Ongoing access to effective mental health/substance use treatment

Skills in problem solving, interpersonal communication, emotional regulation, and distress tolerance





Healthy living NegativesNo drug useNo exposure to chemicals in uterusNo schizophrenia or bipolar in familyNo traumatic brain injury

Psycho

Attachment issues


Mood Disorders Features of Borderline and Antisocial Personality Disorder

Impulsivity & Poor Problem Solving

Stressful eventsPost-Traumatic Stress DisorderImpulse control disorderMood disorder


Cultural/Religious beliefsOngoing access to effective mental health/substance use treatmentSkills in problem solving, interpersonal communication, distress tolerance




Protective Social Factors:Factors that protect the person, prevent further

deterioration, or improve the situation

Existence of even one positive adult relationship Engagement in effective mental health treatment Limited access to means for violence Educated caregiver within the home Stability within the family School based resources Community involvement





Healthy living NegativesNo drug useNo exposure to chemicals in uterusNo schizophrenia or bipolar in familyNo traumatic brain injury






Stressful eventsPost-Traumatic Stress DisorderImpulse control disorderMood disorder


Character development Exposure to positive role modelsReflecting on experienceConsistency of consequences




Existence of even one positive adult relationshipEngagement in effective mental health treatment Limited access to means for violenceStability within the familySchool based resourcesCommunity involvement

Case Example: Internalizing Behavior

Clients name is Janny. Janny is a 13-year-old female. This worker spoke to Janny at the local police department.

Janny went to the Dells on a field trip for school today. Janny stated that her “ex-friend” called her stupid and she got angry at that. On the bus ride home she took her cousin’s swimsuit and tied it around her neck. Janny stated, “I must have done it really well”, because her friends near her could not get it untied. Janny explained that her friends began crying and that’s when the teacher came back and had to cut it off her neck. Janny expressed she has thought a lot about suicide lately, but stated that she does not know why she did that today. Janny commented that if one bad thing happens, she starts a whole lot of negative thinking and that becomes all she can think about. Janny felt that this incident was not planned, but just happened because she got angry.

Janny listed other current stressors in her life. Janny stated that she is moving with her mom to another, more expensive apartment and she is worried they will not be able to afford it. Janny is supposed to go to her dad’s for one month, but she does not want to. She is agreeing to go because he threatens her with taking away child support from her mom. Her mom is already depressed and doesn’t need the extra stress from her alcoholic father. Janny stated that she has gained a lot of weight recently and has also had a hard time sleeping. She was told this could be from a thyroid condition that she has, or it could be her depression. Janny recalls she has been out of her thyroid medicine for several weeks now. Janny is diagnosed with depression and is seeing Jenn Smith and Dr. Hyde from ABC Clinic in Town. Janny stated that she gets along well with her therapist and she is taking 20mg Prozac as prescribed. Janny continues to suffer from many symptoms of depression and feels like the medications are not working. Janny relayed that she is not currently suicidal. Janny stated that today she did feel like she wanted to die, but not as much now. Janny stated that she has had suicidal thoughts since 3rd grade, but the past three – four months they have been getting worse. Janny stated that she thinks about suicide a lot, but doesn’t always want to do it. Janny states that she has looked up a website on ways to commit suicide and stated that “it was weird”. Janny stated that she has also read a book on depression and this worker believes she has good insight into her illness.

Janny stated that she does not have a plan for suicide. Janny stated that she hung herself from a shower stall at school three months ago, but the sweater she used ripped and wasn’t strong enough. Janny also reports she has cut her forearms ‘a gazillion times’ since age 8 or 9, but doesn’t know why she does it. Janny stated that she went to an assessment center because of that and does not want to go back. Janny works at Burger King and enjoys that. She also enjoys smoking pot. Janny stated that she also enjoys reading, walking, horseback riding, baby-sitting and animals. Janny stated that she listens to music to cope with feelings. Janny is looking forward to the County Fair because she is submitting a recipe. Janny is also looking forward to summer and sleeping in. When asked if there was anything she would miss if she weren’t around, Janny listed many things and stated, “I guess I would miss life… I can’t believe I did that today.” Janny stated that she would feel safe tonight and recognizes that certain things trigger negative feelings. Janny stated that she would ask for help when these negative and suicidal feelings come back. Janny stated that she would read, jog around the block or call the crisis line if she began to feel bad again. This worker was very familiar with Janny from a previous position and believes to have a good rapport with Janny. Janny was cooperative. Janny’s mood was stable and even elevated throughout assessment. Janny was not visibly sad in any way, but instead smiling and joking around.


Bio

Psycho

Social

Case Example: Development of antisocial and psychopathic

behavior

What happens to nice kids…

…That makes them go bad?

Case Example: Antisocial Personality

Hard core: antisocial & psychopathic personality (PCL-R)

1. Glibness/superficial charm (1)

2. Grandiose sense of self-worth (1)

3. Pathological lying (1)

4. Cunning/manipulative (1)

5. Lack of remorse or guilt (1)

6. Shallow affect (1)

7. Callous/lack of empathy (1)

8. Failure to accept responsibility for own actions (1)

9. Need for stimulation/proneness to boredom (2)

10. Parasitic lifestyle (2)

11. Poor behavioral controls (2)

12. Early behavior problems (2)

13. Lack of realistic, long-term plans (2)

14. Impulsivity (2)

15. Irresponsibility (2)

16. Juvenile delinquency (2)

17. Revocation of conditional release (2)

18. Promiscuous sexual behavior (T)

19. Many short-term relationships (T)

20. Criminal versatility (Hare, 1986) (T)

Factor 1: Callous emotional and interpersonal detachment; affective impairment

Factor 2: Chronic and socially deviant antisocial behaviors & lifestyle

?

http://i.a.cnn.net/cnn/2005/LAW/06/27/rader.transcript/vert.rader.pool.jpg

http://www.dc.state.fl.us/oth/timeline/images/1999/Wuornos.jpg

• Irritability• Mood swings• Unpredictable• Reactive

• Anxious• Difficult to

console• Easily frustrated• Highly sensitive

• Recklessness • Self-injury• Depression• Suicidal

gestures• Threats to others

Mood Disorder

Common progression of mental disorders toward disruptive behavior


• Anxious• Difficult to console• Easily frustrated• Highly sensitive

• Recklessness • Self-injury• Depression• Suicidal gestures• Threats to others

Mood Disorder

• Inattention• Carelessness• Not listen• Failure to finish• forgetful

• Hyperactivity • Excessively run

& climb• Fidget & motion• Can’t sit still

• Impulsivity• Blurts out• Interrupts• Not wait turns

ADHD




Mood Disorder


• Hyperactivity • Excessively run &

climb• Fidget & motion• Can’t sit still


• Loses temper• Argues with

adults• Defies rules

• Annoying• Blames others• Easily annoyed

• Angry • Spiteful &

vindictive

ADHD

Oppositional Defiant

Disorder




Mood Disorder

• Aggressive toward people & animals

• Fighting• Use of weapons• Manipulative

• Destructive of property

• Firesetting • Forced sexual

activity • Run away

• Deceit & theft• Serious rule

violation• Breaking &

entering• Truant • Sub. abuse


• Hyperactivity • Excessively run &

climb• Fidget & motion• Can’t sit still


• Loses temper• Argues with adults• Defies rules

• Annoying• Blames others• Easily annoyed

• Angry • Spiteful &

vindictive

ADHD

Oppositional Defiant

Disorder

Conduct Disorder

Development of behavior disorders

Pre-family• poverty• single• unwanted• MI (depression)• AODA• teen/immature• abused• antisocial• divorce• assortative mating• transgenerational

problems

Infancy• Prematurity• low birth weight• brain injury• attachment• hyperreactive• “colicky”• unhealthy• disability• pain• multiple placements

Family• cohesion• flexibility• poor boundaries• inconsistent discipline• poor supervision• marital relationship• handle emotions• poor role modeling• criminality• physical, emotional, sexual abuse• explicit sexuality• disorganization• cold, rejecting• large family• father absence• long unemployment

Peers• delinquent/deviant peers• antisocial sibs• bullying• rejection by norm group• attention/recognition• belonging• act out• revenge

PROBABLE OFFENSE

Environmental• pop. density• poor housing• mobile residents• discrimination• media violence• cultural norms• no support svc.• discrimination• crime rate

Legal/Offense• Hx of violence• Type/frequency/severity• Non-violent offending• Early onset of violence• Past supervision failure• Domestic violence• Escalating pattern• Victim age vulnerability• Deviant arousal

Capacity• Low IQ• LD• ADHD• FAS/FAE• Bipolar• PDD• Brain injury

http://photos10.flickr.com/13275045_afd171f3f0_d.jpg

Meet the psychopath….

parental alcohol abuse & paternal abandonment

exposure to father beating brother to death multiple head injuries from parental abuse,

fighting, recklessness learning disabilities peer teasing & rejection; introverted & shy

as a child; charming as adult compulsive gambling tortured & killed animals, first murder age

14, claimed 200 people

Richard Kuklinsky(The “Iceman”)

Small Groups

Describe afternoon process review scenario locate 4 Ps locate Bio, Psycho, Social of 4 Ps complete Assessment

Process focused Large group review

Before you leave

Fill out training feedback form any suggestions for spring training

Pick up CEU and/or participation certificate Check out

When struggling enlarge the field

Don’t try to do everything on your own– use

teamwork for interventions, sharing,

support, feedback, debriefing,

etc…

Thank you

youth and family crisis assessment presented by:

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