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Risk assessment
is this person at risk to hurt themselves or other people?
short term goals
stabilization, barriers to care
long term goals
“magic wand”
clinical intervention
risk assessment
short term goals
long term goals
risk factors for suicide
gender, age, depression/hopelessness, prior SI/SA, exposure to suicide, neglect/abuse/trauma, substance use/abuse, prolonged stress, non-heterosexual orientation, non-suicidal self injury, access to lethal means
how do we directly assess suicide risk?
three factors
ideation - passive, active
plan
intent
safety planning
collaboratively generate coping strategies to manage suicidal and self-harm impulses
includes: actions/behaviors, thoughts, supportive individuals
builds hope
it is a process!
barriers to using safety planning
too distressed to use it
didn’t remember to use it
started to use it but it didn’t work
didn’t want to use it
obtain commitment to safety
work with client to commit to using safety plan for a specified period of time
if client is unable to give any commitment, assess need for stepped-up care
restricting access to lethal means
review availability of all lethal means (guns, medications, sharps, others specific to patient)
lethal means available = greater danger
means restriction saves lives
puts “time” between lethal “urge” and ability to act on “urge”
substance use/abuse and suicide
avoid during time of crisis
suicide warning signs
change in behavior or the presence of entirely new behaviors
particularly in relation to a painful event, loss, or change
changes in what person says, does, and their mood
unipolar depressive disorders
only depressive episodes
bipolar depressive disorders
manic and depressive episodes
episode
a time-limited period during which specific symptoms of a disorder are present
clinician will rate severity, note whether it is first episode or recurrence, and specify nature of symptoms
depressive episode
5 or more symptoms, nearly every day, lasts at least 2 weeks
*mood - depressed or irritable
*anhedonia
changes in eating/weight
changes in sleep
fatigue
low self-worth/guilt
lack of concentration/indecisiveness
thoughts of death or suicide
depression in preschoolers
may appear extremely somber and tearful, lacking exuberance, bounce, and enthusiasm; may display excessive clinging and whiny behavior around parents and fear of separation or abandonment; irritability
depression in school-aged children
increasing irritability, disruptive behavior, tantrums, and combativeness
depression in preteens
self-blame and low self-esteem, persistent sadness, and social inhibition
major depression
a pervasive unhappy mood disorder, more severe than the occasional blues or mood swings everyone experiences
10-20% of individuals experience significant depression at some time; 2-8% of children
disruptive mood dysregulation disorder
a chronic, severe persistent irritability
two main clinical features:
frequent verbal or physical temper outbursts
chronic, persistently irritable or angry mood
controversy about DMDD
new diagnosis, so minimal research
not enough published validity studies
extremely high co-occurrence with other disorders
Beck’s cognitive triad
negative view of
the self
the world
the future
Lewinsohn’s Behavioral View of Depression
stressor leads to reduction in reinforcers
person withdraws
reinforcers further reduced
more withdrawal and depression
behavioral activation/activity scheduling
a method for introducing mood-elevating activities into the youth’s day
improves mood by having youth select and regularly engage in activities that are fun, enjoyable and rewarding
activity selection essentials
connect doing and feeling
make a list
pick things and try them
CBT for depression
start with mood tracking
identify behaviors that impact mood
positive activity scheduling
teach cognitive restructuring
teach additional skills as needed
support networking
a set of strategies intended to connect individuals or families with other people
it increases access to resources and social supports
identify others who can provide resources/support AND develop skills to ask for support and to involve others when they need help
emotional support
showing empathy, compassion, warmth, and concern within the context of a trusting relationship
companionship support
provision of a sense of belonging
informational support
provision of advice or guidance
instrumental support
provision of concrete support in the form of money, materials, or services
effective support networking
expanding the network of immigrant families
connecting family without transportation to others who can provide a ride
connecting family seeking special education with other parents
ineffective support networking
case management
group therapy
spending time with others
support networking essentials
identify allies
recruit allies
promote commitment from allies
CBT-I (CBT for insomnia)
restrict time in bed (temporarily)
get up at the same time everyday
don’t go to bed unless you’re sleepy
don’t stay in bed unless you’re asleep
anxiety disorders are characterized by:
experience of physiological arousal
apprehension or feelings of dread
hypervigilance
sometimes a specific fear or phobia
some form of avoidance
tripartite model of anxiety
physiological responses
cognitive responses
overt behavioral responses
worry
thoughts about possible negative outcomes that are intrusive and difficult to control
considered a cognitive component of anxiety
OCD
an anxiety disorder characterized by recurrent obsessions OR compulsions that are inordinately time-consuming or that cause significant distress or impairment
obsession
a persistent and intrusive idea, thought, impulse, or image
compulsion
a repetitive and seemingly purposeful behavior performed in response to uncontrollable urges or according to a ritualistic or stereotyped set of rules
obsessions consist most often of:
contamination fears
fears of harming oneself or others
lack of symmetry
pathological doubt
compulsions can include:
cleaning
checking
repeating
ordering/arranging
counting
steps to exposure
key is to identify feared stimuli and reduce unhelpful conditioned responses
learn to rate anxiety
create fear hierarchy
rate SUDs
learn relaxation techniques - controversial
work way up hierarchy
trauma - general definition
results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being
acute trauma
single event
chronic trauma
repeated and prolonged
complex trauma
exposure to multiple traumatic events from an early age, often within the caregiving system or without adequate adult support that has short and long-term effects in many areas
racial trauma
experiences related to racism, racial discrimination, and race-related stressors, and can refer to a specific incident of racial discrimination or the ongoing, harmful emotional impact of racial discrimination that builds up over time
historical trauma
shared by a group of people within a society, or even by an entire community, ethnic, or national group
experienced by oppressed communities over generations
three criteria:
widespread effects
results in distress and collective loss
purposeful, often destructive, intent
impact of trauma
emotional reactions
psychological and cognitive reactions
behavioral and physical reactions
beliefs
DSM definition of trauma - PTSD
A. person must have exposure to actual or threatened death, serious injury, or sexual violence
direct experience, witnessing directly, learning the event happened to someone else, repeated extreme exposure
B. reliving the experience
C. avoidance of trauma-related stimuli
D. negative thoughts and feelings
E. trauma-related arousal or reactivity
core components of child trauma treatment
reestablishing physical and psychological safety
involvement of parents or caregivers
creating a narrative or story about what happened
correcting untrue or distorted ideas about what happened
teaching stress management and relaxation skills
exposure strategies
reasons to directly discuss traumatic events
gain mastery over trauma reminders
resolve avoidance symptoms
correction of distorted cognitions
model adaptive coping
identify and prepare for trauma/loss reminders
contextualize traumatic experiences into life
in vivo mastery of trauma reminders
mastery of trauma reminders is critical for resuming normal developmental trajectory
to be used only if the feared reminder is no longer dangerous
hierarchical exposure to innocuous reminders which have been paired with the traumatic experience
RAD and DSED
used to be one disorder
diagnosed between 9 months and 5 years
occur in extremely neglected and deprived children
extremely rare
awareness - trauma-informed care
everyone understands the impact of trauma
safety - trauma-informed care
ensuring physical and emotional safety
trustworthiness - trauma-informed care
maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries
choice - trauma-informed care
prioritizing consumer choice and control
collaboration - trauma-informed care
maximizing collaboration and sharing of power with consumers; integrating care
empowerment - trauma-informed care
prioritizing consumer empowerment and skill-building; relationships heal, recovery is possible
treatments of ODD and CD
punitive treatments appear to intensify rather than correct behavior
effective treatments tend to focus on the cohesive family model and behavioral techniques
parent training
general strategies:
focus on rewards, not punishment
ignore negative behaviors
token economies
general rules:
positive
specific
limited
achievable