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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)
Goals of Emergency Services/Crisis Program (DHS 34)
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
Goals of Emergency Services/Crisis Program (DHS 34)
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
Goals of Emergency Services/Crisis Program (DHS 34)
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
Basic Crisis Strategies for Youth and Families
•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
Basic Crisis Strategies for Youth and Families
Immediate Problem Solving remain present-focused guide parents and youth to find ways to
tolerate the affect generated by the Precipitating Factors
Basic Crisis Strategies for Youth and Families
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
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
Predisposing Precipitating Perpetuating Protective
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.
Predisposing Precipitating Perpetuating Protective
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.
Predisposing Precipitating Perpetuating Protective
Bio Genetics
Family history
Medical Conditions
Chemical Use
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 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
0
10
20
30
40
50
60
70
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
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
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 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
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
Psycho Attachment issues
Abuse, neglect, & traumatic stress
Mood Disorders (Depressive, Anxious, Bipolar)
Features of Borderline and Antisocial Personality Disorder
Impulsivity and Poor Problem Solving
Interpersonal Conflict and separations
Previous suicide attempt
Substance use
Poor problem solving and impulsivity
Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide
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.
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
Psycho Attachment issues
Abuse, neglect, & traumatic stress
Mood Disorders (Depressive, Anxious, Bipolar)
Features of Borderline and Antisocial Personality Disorder
Impulsivity and Poor Problem Solving
Interpersonal Conflict and separations
Previous suicide attempt
Substance use
Poor problem solving and impulsivity
Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide
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).
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
Poorly controlled medical conditionsOngoing drug useChronic sleep deprivationChronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc).
Psycho Attachment issues
Abuse, neglect, & traumatic stress
Mood Disorders (Depressive, Anxious, Bipolar)
Features of Borderline and Antisocial Personality Disorder
Impulsivity and Poor Problem Solving
Interpersonal Conflict and separations
Previous suicide attempt
Substance use
Poor problem solving and impulsivity
Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide
Interpersonal lossesLegal problemsFriend has attempted/completed suicideAcademic difficultiesComing out Parental job lossChange in family membership
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
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
Poorly controlled medical conditionsOngoing drug useChronic sleep deprivationChronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc).
Psycho Attachment issues
Abuse, neglect, & traumatic stress
Mood Disorders (Depressive, Anxious, Bipolar)
Features of Borderline and Antisocial Personality Disorder
Impulsivity and Poor Problem Solving
Interpersonal Conflict and separations
Previous suicide attempt
Substance use
Poor problem solving and impulsivity
Continuation of psychological and social predisposing factorsContinuation and reinforcement of poor problem solvingMental Health DisordersLack of healthy intervention for child/family
Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide
Interpersonal lossesLegal problemsFriend has attempted/completed suicideAcademic difficultiesComing out Parental job lossChange in family membership
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
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
Poorly controlled medical conditionsOngoing drug useChronic sleep deprivationChronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc).
Psycho Attachment issues
Abuse, neglect, & traumatic stress
Mood Disorders (Depressive, Anxious, Bipolar)
Features of Borderline and Antisocial Personality Disorder
Impulsivity and Poor Problem Solving
Interpersonal Conflict and separations
Previous suicide attempt
Substance use
Poor problem solving and impulsivity
Continuation of psychological and social predisposing factorsContinuation and reinforcement of poor problem solvingMental Health DisordersLack of healthy intervention for child/family
Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide
Interpersonal lossesLegal problemsFriend has attempted/completed suicideAcademic difficultiesComing out Parental job lossChange in family membership
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
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
Poorly controlled medical conditionsOngoing drug useChronic sleep deprivationChronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc).
Healthy living (nutrition, sleep, exercise, stress management No drug useNo exposure to chemicals in uterusNo schizophrenia or bipolar in familyNo traumatic brain injury
Psycho Attachment issues
Abuse, neglect, & traumatic stress
Mood Disorders Features of Borderline and Antisocial Personality Disorder
Impulsivity and Poor Problem Solving
Interpersonal Conflict and separations
Previous suicide attempt
Substance use
Poor problem solving and impulsivity
Continuation of psychological and social predisposing factorsContinuation and reinforcement of poor problem solvingMental Health DisordersLack of healthy intervention for child/family
Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide
Interpersonal lossesLegal problemsFriend has attempted/completed suicideAcademic difficultiesComing out Parental job lossChange in family membership
Continuation of precipitating factorsParental MH/AODAAbuse/neglectPoor parent-child communicationSocial isolationMistrust of helping-professionals, stigma
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
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
Poorly controlled medical conditionsOngoing drug useChronic sleep deprivationChronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc).
Healthy living NegativesNo drug useNo exposure to chemicals in uterusNo schizophrenia or bipolar in familyNo traumatic brain injury
Psycho
Attachment issues
Abuse, neglect, & traumatic stress
Mood Disorders Features of Borderline and Antisocial Personality Disorder
Impulsivity & Poor Problem Solving
Stressful eventsPost-Traumatic Stress DisorderImpulse control disorderMood disorder
Continuation of psychological and social predisposing factorsContinuation and reinforcement of poor problem solvingMental Health DisordersLack of healthy intervention for child/family
Cultural/Religious beliefsOngoing access to effective mental health/substance use treatmentSkills in problem solving, interpersonal communication, distress tolerance
Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide
Interpersonal lossesLegal problemsFriend has attempted/completed suicideAcademic difficultiesComing out Parental job lossChange in family membership
Continuation of precipitating factorsParental MH/AODAAbuse/neglectPoor parent-child communicationSocial isolationMistrust of helping-professionals, stigma
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
Predisposing Precipitating Perpetuating Protective
Bio GeneticsFamily historyMedical ConditionsChemical UseAgitators
Chemical useDrug-drug interactionsAdverse effects of prescribed meds Head traumaSeizuresMetabolic causes
Poorly controlled medical conditionsOngoing drug useChronic sleep deprivationChronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc).
Healthy living NegativesNo drug useNo exposure to chemicals in uterusNo schizophrenia or bipolar in familyNo traumatic brain injury
Psycho Attachment issues
Abuse, neglect, & traumatic stress
Mood Disorders (Depressive, Anxious, Bipolar)
Features of Borderline and Antisocial Personality Disorder
Impulsivity and Poor Problem Solving
Stressful eventsPost-Traumatic Stress DisorderImpulse control disorderMood disorder
Continuation of psychological and social predisposing factorsContinuation and reinforcement of poor problem solvingMental Health DisordersLack of healthy intervention for child/family
Character development Exposure to positive role modelsReflecting on experienceConsistency of consequences
Social Sexual OrientationChildhood sexual and physical abuse/neglectPoverty/disadvantaged environmentPeer group, bullyingDiscriminationFamily history of suicide
Interpersonal lossesLegal problemsFriend has attempted/completed suicideAcademic difficultiesComing out Parental job lossChange in family membership
Continuation of precipitating factorsParental MH/AODAAbuse/neglectPoor parent-child communicationSocial isolationMistrust of helping-professionals, stigma
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.
Predisposing Precipitating Perpetuating Protective
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
?
• 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
• Irritability• Mood swings• Unpredictable• Reactive
• 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
• Irritability• Mood swings• Unpredictable• Reactive
• 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
• Loses temper• Argues with
adults• Defies rules
• Annoying• Blames others• Easily annoyed
• Angry • Spiteful &
vindictive
ADHD
Oppositional Defiant
Disorder
• Irritability• Mood swings• Unpredictable• Reactive
• Anxious• Difficult to console• Easily frustrated• Highly sensitive
• Recklessness • Self-injury• Depression• Suicidal gestures• Threats to others
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
• 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
• 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
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
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When struggling enlarge the field
Don’t try to do everything on your own– use
teamwork for interventions, sharing,
support, feedback, debriefing,
etc…
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