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Youth and Family Crisis Assessment

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Title: Youth and Family Crisis Assessment


1
Youth and Family Crisis Assessment
  • Presented by

2
Meet the Presenters
  • Jill Chaffee, MSW, jillchaffee_at_nwpass.com
  • Himanshu Agrawal, M.D. , himanshu_at_nwpass.com
  • Angela Fredrickson, LCSW, angela_at_nwpass.com
  • David Swenson, Ph. D, david_at_nwpass.com

3
Why you should care
  • Law enforcement
  • Social Worker
  • Tax Payer
  • Family Member/Advocate

4
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

5
Overview of Western Region Grant
  • Certifying counties (DHS 34)
  • Training
  • Stabilization services

6
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

7
Goals of Emergency Services/Crisis Program (DHS
34)
  • Quality of Service
  • client centered
  • utilizing least restrictive options
  • community-based
  • ensuring consumer satisfaction (client,
    family,law enforcement, social worker, community
    partners)

8
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

9
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

10
Goals of Emergency Services/Crisis Program (DHS
34)
  • 4. Risk Management
  • philosophy
  • shared risk
  • documentation
  • risk taking, creative thinking, and problem
    solving

11
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
12
Emergency Detention Process
Detention papers filed with the court
Person signs voluntary admission
Probable cause hearing within 72 hours excluding
weekends
Probably cause found-date set for final hearing
Probable cause not found-dismissed
Final hearing
Six month commitment
Dismissed
13
No matter how big the problem, dont rush to
solve it. Check with others, sit on it awhile and
see what develops.
14
Interviewing-Overview
  • Building Rapport
  • Assessor Behavior
  • Intervention Donts
  • Basic Crisis Strategies
  • Validate Emotions
  • Assessment Tools

15
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

16
Assessor Behavior
  • 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
  • dont sweat the small stuff

17
Intervention DONTS
  • DONT ignore, minimize or joke about life
    threatening statements
  • DONT be afraid to inquire about or discuss
    whether they have considered violence
  • DONT be judgmental (e.g., its wrong, a sin,
    etc.)
  • DONT act shocked, repulsed, rejecting
  • DONT call the bluff or challenge to do it
  • DONT analyze or over-interpret motives
  • DONT try to argue them out of it
  • DONT moralize or give advice
  • DONT promise to keep the violence intention or
    discussion secret
  • DONT give up just because they dont want to talk

18
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

19
Basic Crisis Strategies for Youth and Families
  • Pay attention to affect rather than content of
    the statement
  • focus on the actual suicidal thought
  • focus on the emotions related to the thought
  • avoid getting swept away with the other details

20
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

21
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

22
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 buts

23
Assessment Tools (handouts)
  • Suicide checklist
  • Specific risk factors for suicide

24
The 4 P Model
  1. Predisposing Factors
  2. Precipitating Factors
  3. Perpetuating Factors
  4. Protective Factors

25
Family history
Conception
26
Family history
Conception
Birth
In-utero exposure
27
Medical Hx TBI, Sz, DM, Hep C etc
Family history
Conception
Birth
In-utero exposure
28
Medical Hx TBI, Sz, DM, Hep C etc
Family history
Conception
Birth
Drugs
In-utero exposure
29
Medical Hx TBI, Sz, DM, Hep C etc
Family history
Conception
Birth
Drugs
In-utero exposure
30
Definitions of the 4 Ps
  • Predisposing Factors-factors or conditions that
    render an individual vulnerable to disease or
    disorder
  • Precipitating Factors-an element that causes or
    contributes to the occurrence of a disorder or
    problem
  • Perpetuating Factors-factors that cause to
    continue the situation or condition indefinitely
  • Protective Factors-factors serving or intending
    to protect the person or improve the situation

31
Biological Psychological Social
Predisposing Factors Precipitating
Factors Perpetuating Factors Protective Factors
Biological Psychological Social
Biological Psychological Social
Biological Psychological Social
32
BIOLOGICAL
PSYCHOLOGICAL
SOCIAL
  • Unemployment
  • Singledom
  • Homeless
  • Low Income
  • Little religious support
  • Abuse or neglect
  • Recent loss
  • Impulsivity
  • Depression
  • Aggression
  • Family history
  • Prenatal issues
  • Medical illnesses
  • Chemicals

33
4 P Tool
Predisposing Precipitating Perpetuating Protective
Bio
Psycho
Social
34
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

35
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-Benzos, Alcohol, Opiates,
    Cocaine, Paxil, Effexor

36
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history FASD Medical Conditions Chemical Use Alternative Medicines Agitators
Psycho
Social
37
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)

38
Stress
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.

39
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

40
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.

41
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.

42
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
43
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

44
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.

45
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
46
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

47
Neurological Dysfunction in Offenders
Headaches, seizures, hypoglycemia, dizziness
26 Repeat offenders but only 5 of 1st time
offenders had maternal drug abuse
Nature nurture
Poor coordination, odd appearance, speech
vision problems
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)
http//www.acs.appstate.edu/dept/ps-cj/neurology.h
tm
48
Medication Risks
  • time to reach therapeutic levels
  • interaction effects with illicit drugs
  • side effects toxicity
  • dietary restriction with MAOI
  • hoarding drugs for overdose

49
Medication Risks
  • substance abuse or relapse
  • selling medications
  • defiance noncompliance
  • may require close medical supervision
  • only for symptomatic treatment

50
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic 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 Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide
51
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

52
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

53
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

54
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic 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 Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide
55
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

56
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 teens job to learn about
    social behavior and identity.

57
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic 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 Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide Interpersonal losses Legal problems Friend has attempted/completed suicide Academic difficulties Coming out Parental job loss Change in family membership
58
Perpetuating Biological Factors Factors that
maintain the behavior or prevent resolution
  • Poorly controlled medical conditions
  • Diabetes
  • Cushings disease/ Addisons 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).

59
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic causes Poorly controlled medical conditions Ongoing drug use Chronic sleep deprivation Chronic 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 Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide Interpersonal losses Legal problems Friend has attempted/completed suicide Academic difficulties Coming out Parental job loss Change in family membership
60
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

61
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic causes Poorly controlled medical conditions Ongoing drug use Chronic sleep deprivation Chronic 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 factors Continuation and reinforcement of poor problem solving Mental Health Disorders Lack of healthy intervention for child/family
Social Sexual Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide Interpersonal losses Legal problems Friend has attempted/completed suicide Academic difficulties Coming out Parental job loss Change in family membership
62
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

63
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic causes Poorly controlled medical conditions Ongoing drug use Chronic sleep deprivation Chronic 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 factors Continuation and reinforcement of poor problem solving Mental Health Disorders Lack of healthy intervention for child/family
Social Sexual Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide Interpersonal losses Legal problems Friend has attempted/completed suicide Academic difficulties Coming out Parental job loss Change in family membership Continuation of precipitating factors Parental MH/AODA Abuse/neglect Poor parent-child communication Social isolation Mistrust of helping-professionals, stigma
64
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

65
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic causes Poorly controlled medical conditions Ongoing drug use Chronic sleep deprivation Chronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc). Healthy living (nutrition, sleep, exercise, stress management No drug use No exposure to chemicals in uterus No schizophrenia or bipolar in family No 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 factors Continuation and reinforcement of poor problem solving Mental Health Disorders Lack of healthy intervention for child/family
Social Sexual Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide Interpersonal losses Legal problems Friend has attempted/completed suicide Academic difficulties Coming out Parental job loss Change in family membership Continuation of precipitating factors Parental MH/AODA Abuse/neglect Poor parent-child communication Social isolation Mistrust of helping-professionals, stigma
66
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

67
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic causes Poorly controlled medical conditions Ongoing drug use Chronic sleep deprivation Chronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc). Healthy living Negatives No drug use No exposure to chemicals in uterus No schizophrenia or bipolar in family No traumatic brain injury
Psycho Attachment issues Abuse, neglect, traumatic stress Mood Disorders Features of Borderline and Antisocial Personality Disorder Impulsivity Poor Problem Solving Stressful events Post-Traumatic Stress Disorder Impulse control disorder Mood disorder Continuation of psychological and social predisposing factors Continuation and reinforcement of poor problem solving Mental Health Disorders Lack of healthy intervention for child/family Cultural/Religious beliefs Ongoing access to effective mental health/substance use treatment Skills in problem solving, interpersonal communication, distress tolerance
Social Sexual Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide Interpersonal losses Legal problems Friend has attempted/completed suicide Academic difficulties Coming out Parental job loss Change in family membership Continuation of precipitating factors Parental MH/AODA Abuse/neglect Poor parent-child communication Social isolation Mistrust of helping-professionals, stigma
68
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

69
Predisposing Precipitating Perpetuating Protective
Bio Genetics Family history Medical Conditions Chemical Use Agitators Chemical use Drug-drug interactions Adverse effects of prescribed meds Head trauma Seizures Metabolic causes Poorly controlled medical conditions Ongoing drug use Chronic sleep deprivation Chronic pain Painful/debilitating diseases (arthritis, lupus, multiple sclerosis, psoriasis, etc). Healthy living Negatives No drug use No exposure to chemicals in uterus No schizophrenia or bipolar in family No 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 events Post-Traumatic Stress Disorder Impulse control disorder Mood disorder Continuation of psychological and social predisposing factors Continuation and reinforcement of poor problem solving Mental Health Disorders Lack of healthy intervention for child/family Character development Exposure to positive role models Reflecting on experience Consistency of consequences
Social Sexual Orientation Childhood sexual and physical abuse/neglect Poverty/disadvantaged environment Peer group, bullying Discrimination Family history of suicide Interpersonal losses Legal problems Friend has attempted/completed suicide Academic difficulties Coming out Parental job loss Change in family membership Continuation of precipitating factors Parental MH/AODA Abuse/neglect Poor parent-child communication Social isolation Mistrust of helping-professionals, stigma Existence of even one positive adult relationship Engagement in effective mental health treatment Limited access to means for violence Stability within the family School based resources Community involvement
70
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
cousins 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 thats 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.
71
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 dads 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 doesnt 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 doesnt 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.
72
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 wasnt strong
enough. Janny also reports she has cut her
forearms a gazillion times since age 8 or 9,
but doesnt 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 werent
around, Janny listed many things and stated, I
guess I would miss life I cant 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.
Jannys mood was stable and even elevated
throughout assessment. Janny was not visibly sad
in any way, but instead smiling and joking around.
73
Predisposing Precipitating Perpetuating Protective
Bio
Psycho
Social
74
Case Example Development of antisocial and
psychopathic behavior
75
Case Example Antisocial Personality
What happens to nice kids
That makes them go bad?
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Hare characteristics
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)

Factor 1 Callous emotional and interpersonal
detachment affective impairment Factor 2
Chronic and socially deviant antisocial behaviors
lifestyle
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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
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Inattention Carelessness Not listen Failure to finish forgetful Hyperactivity Excessively run climb Fidget motion Cant 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
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Loses temper Argues with adults Defies rules Annoying Blames others Easily annoyed Angry Spiteful vindictive
Oppositional Defiant Disorder
Inattention Carelessness Not listen Failure to finish forgetful Hyperactivity Excessively run climb Fidget motion Cant 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
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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
Conduct Disorder
Oppositional Defiant Disorder
Loses temper Argues with adults Defies rules Annoying Blames others Easily annoyed Angry Spiteful vindictive
Inattention Carelessness Not listen Failure to finish forgetful Hyperactivity Excessively run climb Fidget motion Cant 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
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Development of behavior disorders
  • Environmental
  • pop. density
  • poor housing
  • mobile residents
  • discrimination
  • media violence
  • cultural norms
  • no support svc.
  • discrimination
  • crime rate
  • Infancy
  • Prematurity
  • low birth weight
  • brain injury
  • attachment
  • hyperreactive
  • colicky
  • unhealthy
  • disability
  • pain
  • multiple placements
  • Peers
  • delinquent/deviant peers
  • antisocial sibs
  • bullying
  • rejection by norm group
  • attention/recognition
  • belonging
  • act out
  • revenge

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

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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)
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(No Transcript)
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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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Before you leave
  • Fill out training feedback form
  • any suggestions for spring training
  • Pick up CEU and/or participation certificate
  • Check out

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When struggling enlarge the field
  • Dont try to do everything on your own use
    teamwork for interventions, sharing, support,
    feedback, debriefing,
  • etc

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