Crisis Intervention Training
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Crisis Intervention Training Children and Adolescents
Transcript of Crisis Intervention Training
Crisis Intervention Training
Children and Adolescents
Mark Rovick, DOChild and Adolescent Psychiatrist
Medical DirectorCatalpa Health, Appleton
Assistant ProfessorMedical College of Wisconsin
[email protected] 920-284-7558
My Background 5 Years Psychiatry Residency 1 Year Hennepin County MN Psych ER 4 years active duty USAF
Crisis Response Team 6 months deployed ‘outside the wire’ AFG
FOB hopping Combat Stress Control Team
5 1/2 years locally Live downtown Appleton
What is a Psychiatrist?“specialists in the doctor-patient relationship”
Medical Doctor specializing in the diagnosis and treatment of mental illness
Medical Sub-Specialty –4 years of post-graduate residency training
Child and Adolescent Psych – 2 years of Fellowship training
Study, prevent and treat mental disorders
Topics Need for children’s mental health?
What is Stress?
What is a Crisis?
Suggestions to De-escalate
Case Examples
Summary and questions
Childhood Mental illness
“An estimated 1 in 10 children and adolescents in the United States suffers from mental illness severe enough to cause some level of impairment.”
“fewer than 1 in 5 of these ill children receives treatment.”
National Institute of Mental Health, 2008
Youth Risk Behavior StudyWisconsin 2011
Wisconsin Youth Risk Behavior SurveySuicide
12.8
15.3
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ge consideredsuicide
made aplan
15% of WI high school students “seriously considered” suicide in the past year
7.3% indicate that they “attempted suicide” at least once in the last year
Wisconsin 2011
Deaths Suicide 737 Heart Disease 18,678 Cancer 12,605 Motor Vehicle 620 Homicides 148 HIV 47
8 Children under 14 years of age died by suicide 115 Youth age 15 – 24 died by suicide
Some stark statistics
Suicide is 5th leading cause of death in age group birth to 14 270 unnecessary deaths nationally
Suicide is 2rd leading cause of death in age group 15 to 24 Behind accidents 4,139 unnecessary deaths nationally 3 times more suicides than homicides
Suicide 2nd leading cause of death among college students
Each year more than 500,000 youth attempt suicide
Numbers Locally?16,353
Kids between ages 5-18 US Census Data 2009 20% Prevalence in Primary Care
Outagamie County – 31,711 6,342 with Mental Health
Diagnosis
Winnebago County – 24,865 4,973 with Mental Health
Diagnosis
Calumet County – 8,679 1,736 with Mental Health
Diagnosis
Fond du Lac County – 16,511 3,302 with Mental Health
Diagnosis
8 county Fox Valley region, there are 9,996 kids under the age of 18 with clinical mental health diagnoses who do not receive care
Local Numbers
Child and Adolescent Psychiatric Diagnoses?
Diagnostic and Statistical Manual - IV Text Revision (DSM-IV TR)
Impulse Control ADHD, Oppostional/Defiant, Conduct
Depression suicidality
Anxiety Panic, Obsessive-Compulsive, selective mutism
Bipolar Affective Disorder mood swings and violence (homicidal or suicidal or both) even minute to minute variability
Psychosis PTSD, trauma, drugs, BPAD, Schizophrenia
Developmental Delay Cognitive disorders, MR, Autism, Asperger’s
Attachment Issues trust everyone, or no one
Eating Disorders Anorexia, Bulemia
Tic Disorders Tourette’s
Stress
Strain Deviation from normal shape, purpose, orientation
Normal physical/chemical response Threat Danger Real or imagined
Long-term Health problems – high Bp, heart dz, stroke Delayed academic or social development
Good Stress vs. Bad Stress Good
Physical Performance Mental agility
Bad Irritable Poor health Panic Depression Paranoia
Autonomic Nervous System Survival Mechanism – ‘under attack’ “Fight-or-flight”
3 options: fight, flight, freeze
“Adrenaline Rush” Extremely Strong High Pain Tolerance Increased Heart Rate and BP Anxiety, Shakiness Pupillary dilation or constriction Skin Flushing Anger/Violence Low Frustration Tolerance Poor consideration of consequences Limited hope for future Impulsive Thoughts to harm self or others Confusion Neuro-vegetative Slowing “shut down” Poor ADLs
Types of Anxiety Generalized Anxiety Disorder - chronic, excessive worry about multiple areas of life
(e.g., family, school, social situations, health, natural disasters)
Separation Anxiety - excessive fear of being separated from their home or caregivers
Specific Phobia - fear a specific object or situation (e.g., spiders, needles, riding in elevators, Arachibutyrophobia)
Social Phobia - anxiety in social settings or performance situations
Panic Disorder - unexpected, brief episodes of intense overwhelming fear or dread without an apparent trigger, characterized by multiple physical symptoms (e.g., shortness of breath, increased heart rate, sweating)
Obsessive-Compulsive Disorder - repetitive mental acts or behaviors (“compulsions”) to alleviate anxiety caused by disturbing thoughts, impulses, or images (“obsessions”)
Post-Traumatic Stress Disorder – ‘Fight or Flight’ symptoms (e.g. nightmares, feelings of detachment from others, increased startle ) following exposure to a traumatic event
Depression in Kiddos Irritability
Anger
Change in school performance
Inability to enjoy previously fun activities
Low frustration tolerance
Psychosis in Kiddos
Lots of kids have imaginary friends and report ‘non-real’ experiences
Schizophrenia in Adults – 1%
Schizophrenia in kids - 0.01% - very rare
Visual hallucinations are very rare
Auditory hallucinations much more common – a narrating or demeaning voice, or two voices talking to each other about the patient
Command hallucinations to kill self or others also common
Autism and Asperger’s Autism
impaired development, social interaction, limited or even absent communications
Narrow/repetitive behavior/interests Usually cognitively impaired Relate to people as objects
Asperger’s Impaired social interaction (norms),
nonverbal communications Narrow/repetitive behavior/interests Often highly intelligent ‘little professors’
Can be quickly overstimulated
Crisis Sudden loss of the ability to use effective problem-solving and coping skills
Stress or strain too great - “out of control”
Regression to primitive or earlier stage of development
Number of events or circumstances can be considered a crisis: life-threatening situations natural disasters (such as an earthquake or tornado) sexual assault criminal victimization medical illness mental illness thoughts of suicide or homicide drastic changes in relationships (death of a loved one or divorce, break-up) insurance change “ran out of meds” no food parent relapsed chemical use or withdrawal
Crisis Escalation Cycle • Uncertainty • Questioning • Refusal • Demanding • Generalized Acting Out • Specific Acting out • Recovery • Rapport • Cooperation
Crisis Intervention
Methods to offer immediate, short-term help to individuals who experience: Emotional Mental Physical Behavioral distress or problems
Purpose Reduce the intensity of an individual's emotional, mental, physical
and behavioral reactions to a crisis
Help individuals return to their previous level of function
Develop new coping skills and eliminate ineffective ways of coping withdrawal/isolation violence substance abuse
Individual is better equipped to cope with future difficulties.
Process Talk about what happened
Explore feelings about what happened
Model ways to cope and solve problems
Aim to assist the individual in recovering from the crisis
Prevent serious long-term problems from developing
Length Therapy model Several hours Weekly Minimum 4 weeks
NOT WHAT WE ARE DISCUSSING Immediate Short Single episode
Response to Crisis Emotional reactions
Fear Anger Guilt Grief
Mental reactions Poor concentration Confusion Nightmares
Our personal reactions ‘Counter-transference’
Physical reactions Headaches Dizziness Fatigue Stomach pain
Behavioral reactions Sleep disturbance Appetite problems Social isolation Restlessness Aggression
Key Points Safety
Basic Child Needs
Parent Needs
Family System
De-escalation of crisis
For the Officer Stay Calm
Less anxiety than the civilians
Voice soft and comforting
Non-threatening demeanor
Safety for self and others
Reassurance that things will be okay Remember feeling ‘under attack’
Body Language Always allow an escape route
May seem counter to Police SOP
Keep voice slow and low
Simple language Small words Short sentences
Move head to level of child
Social
Consider Basic Needs
Snacks in car for kids
Toys
Ask children questions
Let them speak
Help model correct boundaries and problem solving for kids and parents
If concerned about safety or complexity engage County Crisis
Safety “Have you ever thought life wasn’t worth living?”
“Have you thought about how you’d die?”
“Have you ever practiced it to just see?”
“Do you have a therapist or psychiatrist?”
“Has this happened before?”
Self-injurious behaviors (shallow cutting, scratching)
Chemical use (EtOH, THC, Huffing, Rx abuse, Mr. Smiley)
Risky behavior, thrill-seeking (choking game)
Suicide Assessment‘SAD PERRSONS’
Sex Age Depression/Anxiety Previous Attempts Ethanol Abuse Rational Thinking Impaired Relative Suicide Social Supports lacking Organized Plan No Significant Other Sickness/Stressors
Beware! Irrational thinking
Do not confront psychotic thoughts
Extreme Impulsivity
Psychosis
Poor future planning No thought of consequences
Medications Overdose Interaction Withdrawal exacerbation Mixture with alcohol or street drugs Side effects
Safety Interventions Chapter 51 WI Act 444
Separate and de-escalate Different room Outside Don’t leave kids alone
Careful with physical restraints Remember poor reality testing High pain tolerance
Ask about medication compliance
Ask about suicide
Case Examples First Step?
Safety?
What more do we need to know?
Authority? Parent Guardian Paperwork
Follow-up?
Case example #1Tom is a 16 y/o foster child threatened to kill his foster brother with a knife Foster mother called the police Fearful for her family Just brought to the home for respite Do not know him very well ? history of a mental illness Tom has medications Does not like to take them because they make him
feel “like s---”.
Case example #1 3 foster homes in the past two years Tom is angry, pacing the floor You are having difficulty understanding him Slight body odor and he does not appear to
have showered in days He tells you to leave him alone “…I hate cops…”
What are your thoughts and areas to consider?
Thoughts
?
Case example #2 Jody is a 9 y.o. female child Her mother dialed 911 after a fight at home Diagnosed with depression, ADHD and
oppositional defiant disorder Jody locked herself in the bathroom and her
mother heard her sobbing Mother told her to open the door but she did not
respond Mother’s boyfriend broke the door down and
Jody began screaming and hitting him.
Case example #2 You notice that Jody has multiple parallel new
and healing cuts on her arms Boyfriend had scratches on his face per Mom You have tried to talk to Jody, but Jody spit in
your face Jody tells her mother that she just wants to ‘be
left alone’ Mother thinks that calling 911 was a mistake The boyfriend is nowhere to be found.
Thoughts
?
Stress the importance of seeking assistance and that this is not a sign of weakness
Stress how a mental health professional can: Help uncover potential causes of stress Further assess the problem or concern Define and provide appropriate treatment
Questions
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