WHAT DO I DO NOW? Assessment, Triage and

WHAT DO I DO NOW? Assessment, Triage and

WHAT DO I DO NOW? Assessment, Triage and Referral of Behavioral Crises in Primary Care Richard J. Miller, MD, FAACAP, Director ACCESS Mental Health CT Wheeler Clinic Hub Kimberly Hoylst, LCSW Wheeler Clinic EMPS Disclosure: Richard J. Miller, MD Financial disclosure: Employed by Wheeler Clinic

ACCESS Mental Health CT, Hub Medical Director No commercial conflicts of interest Disclosure: Kimberly Hoylst, LCSW Financial disclosure: No commercial conflicts of interest Employed by Wheeler Clinic, EMPS program Learning Objectives After attending this session the participants will be able to: Describe some of the different ways risk of harm to self or others can present in the pediatric office.

Outline strategies to assess and triage risk of harm to self or others. Identify resources for treatment and guide families through the decision-making process regarding level of care and treatment options. AAP Behavioral Health Practice Readiness As part of the AAP Mental Health Initiative, the academy urges pediatricians to increase their scope of practice to expand their comfort and skills in diagnosing and managing mental health disorders. They note: Mental health care is mainstream pediatrics. Primary Care clinicians, if trained and supported, are ideally positioned to

identify children with mental health problems, to triage for emergencies, to initiate care and to collaborate with MH/SA specialists in facilitating a higher level of care when needed. Mental Health Initiatives. Advocacy and Policy, AAP health initiatives However Providers concerns about how to deal with crises and behavioral safety issues may create discomfort and present barriers to integrate mental health assessment and treatment into primary care practice. Here are a few of the things we heard in ACCESS

Mental Health when talking with some of our PCPs Im afraid to screen for depression or suicide because I dont know what to do if they score too high We werent trained in behavioral health. I know how to evaluate a medical issue, but this is much different. While in medical school I was taught in surgery not to cut until you were sure you knew how to handle what you find and how to close. When it comes to mental health, I dont To Help Address These Concerns Today We Will: Consider some of the statistics and presentations of danger to self or others as they may present in your practices.

Discuss how you may identify and assess behavioral safety issues in your primary care setting. Review treatment options available and how to refer based on the assessed level of risk. Where and how to obtain timely assistance and supports for you and your patients when addressing these issues. Review some practice changes that you may consider to better address behavioral crises in the office. The Scope of the Problem Nationwide, 17.0% of high school students had seriously considered attempting suicide (22.4% female, 11.6% male)

13.6% made a plan about how they would attempt suicide (16.9%F,10.3%M) And 8% had attempted suicide (10.6F,5.4%M) 2.7% made a suicide attempt that required medical treatment (3.6%F, 1.8%M) MMWR 2013 More Statistics While suicide is rare for prepubertal children, it is the 3 rd leading cause of death in 10-24 year olds (15%) CDC Mortality Data for 2010

Females are more likely to consider and attempt suicide, but males are more than 5 times more likely to complete suicide. 25-50% of visits to the primary care office are behavioral health related (Chun et al). Components of Safety Assessment 1. SCREENING 2. EVALUATION/Interview History of Presenting Problem Conduct Suicide/Homicide Behavior Inquiry Identify Risk Factors Signs, symptom and behaviors related to injury to self or others

Identify Protective Factors 3. RISK ASSEMENT, TRIAGE & PLAN Determine Risk Level Referral to Level of Care, Based on Risk Level 4. DOCUMENTATION and FOLLOW UP Adapted from :SAMHSA SAFE-T (Suicide Assessment Five-step Evaluation and Triage) www.sprc.com Presenting Problem Some patients present with chief complaints of self injury, suicidal or homicidal ideation or behaviors.

But many do not, and may not have told parents or other adults. Others may present with: Mood symptoms Substance abuse or acute intoxication Accidents (MVA (especially single car), falls, high risk taking behaviors. Acute psychosocial stressor or trauma (family, peer issues, bullying, academic, sexual or physical abuse, sexual identity issues, loss, etc.). Changes in school functioning (attendance, grades, peer conflict, social engagement, etc.) Chun, et al Dont Ask, Dont Tell

You need to ask about safety and suicidal or homicidal thoughts. If you DONT ASK, They WONT TELL. For those who tuned in to last months CT-AAP Webinar by ACCESS Mental Health CT. Dr. Kim Brownell and Dr. Barbara Ward-Zimmerman reviewed the use of scales to screen for mental health issues in the primary care office. Including: Broad screens (ex PSC 17 or 35) Problem specific screens (ex. PHQ-9) Why Screen?

Because You Cant Tell How Kids are Feeling Just By Looking At Them Angry Depressed Happy Anxious Bored

SCREENING When to Screen The American Academy of Pediatrics recommends that pediatricians routinely screen adolescents for behavioral issues and suicide risk factors. (Shain, BN) Especially important to screen patients who present with any of the significant risk factors. Most teens visit their PCP annually and many visit their primary care provider within a month preceding suicidal behavior. (Owens) When To Screen, continued For the suicidal patient, a visit with the primary care provider (PCP) may be the

only chance to connect with the health care system and access effective treatment. Consider: Only 32% of the individuals who died by suicide had contact with mental health services in the year before their deaths, but 75% of them saw their PCP. So screening for safety can save lives. (Suicide Prevention Resource Center, http://www.sprc.org/for-providers) How to Screen BEHAVIORAL SCREENING TOOLS This was covered in detail in last months CT-APP/ ACCESS Mental Health Webinar.

BROAD SCREENS These can be incorporated into general health appointments as well as patients who may present at risk. Some examples are: PSC-17 and PSC-35, they are free, easy to score and available in many languages. Even the Vanderbilt ADD scales include anxiety and depression screening questions. Items endorsed as positive, facilitate the evaluation and help to target follow up questions and further discussion. Targeted Screens for Depression and Suicide These are sensitive in identifying risk and can be very helpful in

initiating assessment. Here are some examples of the more common and easy to use screening tools. PHQ-9 PHQ-9A (modified for adolescents) ASQ Ask Suicide-Screening Questions (NIMH) Columbia Suicide Severity Scale Screener PHQ - 9 Patient Health Questionnaire (PHQ) Over the last 2 weeks, how often have you been bothered by any of the following problems? Checkbox Ratings: Not at all, Several days, More than half the

days, Nearly every day 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy Available at phqscreeners.com PHQ 9 continued 5. Poor appetite or overeating 6. Feeling bad about yourselfor that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the

newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself in some way PHQ-9A The PHQ-9 A adds these additional questions specifically targeted at adolescent suicide risk. Has there been a time in the past month when you have had serious thoughts about ending your life?

Yes No Have you ever, in your whole life, tried to kill yourself or made a suicide attempt? Yes No Modified with permission from the PHQ (Spitzer, Williams & Kroenke, 1999) by J. Johnson (Johnson, 2002) ASQ (Ask Suicide-Screening Questions) Not to be confused with Ages and Stages Questionnaires 4 simple questions marked Yes, No. or No Response. 96% Sensitivity! (Horowitz, et al, 2012) 1. In the past few weeks have you wished you were dead?

2. In the past few weeks, have you felt that you or your family would be better off if you were dead? 3. In the past week, have you been having thoughts about killing yourself? 4. Have you ever tried to kill yourself? Available Free @ nimh.nih.gov Columbia Suicide Scale Screener Another brief scale 6 Yes or No items 1. Have you wished you were dead or wished you could go to sleep and not wake up? 2. Have you actually had any thoughts about killing yourself?

3. Have you thought about how you might do this? 4. Have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them? 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Available at http://www.cssrs.columbia.edu/scales_practice_cssrs.html Question# 6 is an important question that is not on most other screeners 6) Have you done anything, started to do anything, or prepared to do anything to end your life?

Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didnt swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didnt jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc. In your entire lifetime, how many times have you done any of these things? EVALUATION INTERVIEW, SETTING Where possible, patients and parents/caregivers should be interviewed alone and together. Collateral information is imperative. Patients and families need to feel respected, taken seriously and that

the provider is concerned and acting in their best interest. Explain confidentiality. When imminent risk is concerned the usual rules of confidentially do not apply. Providers may disclose information or obtain information to or from collaterals in the service of safety. Providers need to maintain safety during the assessment including not leaving patient alone, and if possible away from dangerous equipment. INTERVIEWS Obtain a history of how the events and symptoms evolved over time. Note history of previous treatment. What helped, what didnt? Make note of acute and chronic precipitating factors, risk

factors, and protective factors in individual, family, social, academic and health domains. (We will discuss this in more depth later) SUICIDE/HOMICIDE INQUIRY General Guidelines Ask Patients (and caregivers) about Risk Directly. Asking patients about suicidal thoughts and behaviors does not increase risk. It actually decreases risk Use a non judgmental, matter of fact approach Dont Ask Leading Questions (Youre not thinking of hurting anyone are you?) Do ask in supportive non threatening manner. For example:

When people have strong feelings like you described they sometimes feel they cannot handle it anymore, has that happened to you? Have you ever seriously though about death or suicide? (think of those questions on the ASQ or other screener) SUICIDAL IDEATION Have you ever had impulses or thoughts about harming yourself or others? Have you ever felt hopeless, felt you cant handle things anymore? Have you ever had suicidal thoughts? Have you ever wished you were dead or wondered what it would be like if you were gone? Have you had any of these thoughts recently? When was the last time?

Ask about when the thoughts or behaviors occurred, what precipitated them and what did they actually do? When was it the worst? Passive ideation: It wouldnt bother me if I died vs. Active: I want to die or I wish I was dead (higher risk) SUICIDAL PLANS If suicidal thoughts were present, ask about plans. Did you think about how you might do it? Did you actually make plans? Where and when?

Means: Do they have access to the means to carry out the plan? Do you know where you would get a (gun, drugs, etc.)? Intent: Do they wish or expect to carry out the plan & what would happen? Lethality: How dangerous is the plan or behavior and how dangerous does the patient think it is? SUICIDAL BEHAVIOR/INTENT Preparations made Ask about the extent the patient if they want to die, expect to carry out the plan and if they expect it to be lethal?

What have they done so far to carry out the plan? What do they expect would happen? Past attempts, rehearsals or aborted attempts? Very high risk for repeat attempts What stops/would stop you? NSSI- NON SUCIDAL SELF INJURY Intentional Self mutilation, infliction of pain or self harm to ones body Very common (Girls>Boys). Check for signs on PE Injuries are usually superficial, low lethality and without suicidal intent

Cutting (esp. arms , thighs , abdomen) Burning

Branding Scratching Picking scabs or wounds that are healing Punching self or objects Bruising or breaking bones Some forms of hair pulling Excessive piercings or tattoos Other forms of bodily harm NSSI continued Many reasons. Ask why they do it. Its different for everyone, what does it do for you?

Punishment (self or others) To Bring the pain to the outside An attempt to externalize and control emotional pain, anger or anxiety. It makes me stop feeling. An attempt to suppress pain, anger or anxiety. (release of endorphins) A cry for help Re-enactment of abuse or trauma Do you know anyone else who does this? There is often a friend or relative

NSSI continued Patient does not have suicidal intent, but: But it can be accompanied by suicidal ideation. Can be to suppress or rehearse suicidal impulses Can lead to suicidal behavior if not treated Can be impulsive and reactive, or methodical and repetitive, even ritualized. Do they try to resist? If so can they? It is a desperate, mal-adaptive coping skill and needs intervention.

HOMICIDALITY Ask about: IDEATION: Have you ever had thoughts or wishes to hurt others. PLAN: Planned ahead or reactive to the moment then regretted. Lethality of plan Access to means (especially firearms) BEHAVIORS Previous episodes INTENT Extent of intention to harm. Superficial, serious injury or to kill? Intent to scare off threat (as in a bully) Level of risk

RISK FACTORS Lets go over some of the many factors that contribute to Risk so you can be aware of them while you interview patient and parent. It is important to screen for risk factors as they can have a major impact on outcome and treatment recommendations. Including whether or not if they are modifiable. Age is a risk, Children and teens do not yet have the long view perspective that things eventually will pass or get better. This comes with experience. In fact, temporary setbacks feel like permanent loss. Now = Forever.

RISK FACTORS TO BE AWARE OF Categories Individual Family Psycho/Social Environmental RISK FACTORS - INDIVIDUAL Previous attempts to harm self or others One of the strongest predictors, although most people who die by suicide die on their first attempt. (SPRC Suicide Prevention Primer)

Gender Females more likely to make attempts. Males 4-5 times more likely to be lethal. Mood Disorders Depression & Bipolar Disorder Anhedonia, hopelessness, insomnia Mood swings Psychosis, especially if command hallucinations Anxiety Severe panic (escape!) Impulse Control Disorders

Aggression Can shift from verbal to property to self or others . RISK FACTORS INDIVIDUAL Continued Substance Abuse Very High Risk (increase impulsivity, decreased inhibition, dysphoria) PTSD/History of Trauma or Abuse Always check for current or Past Trauma Can cause unpredictable reactivity Physical Illness Pain, loss of function (ex. athlete) Concussion

Gender Identity LGBTQIA individuals present significantly are at increased risk. RISK FACTORS - Family Family History of: Suicide or Attempt Violence/Abuse Mental Illness and Substance abuse Death or Loss of Significant Family Member Severe or Terminal Illness of Family Member Family Conflict

High Risk behaviors are often precipitated by family conflict Other Family Stressors (legal, financial, etc.) RISK FACTORS - Psychosocial Peer conflict Bullying, including cyber-bullying Loss of close friend Betrayal Break up Romantic Relationship Social Isolation Academic Difficulties or Failure

Legal Difficulties RISK FACTORS - Environmental ACCESS TO WEAPONS Very High Risk, Especially Firearms. ACCESS TO POTENTIALLY LETHAL MEDICATIONS OR DRUGS PROTECTIVE FACTORS Individual Willingness to seek and accept help Ability to cope with Stress, Resilience

Hopefulness Future Oriented Connection to others, caring how harming self or others would affect them. Religious affiliation PROTECTIVE FACTORS Environmental Supportive Family Nuclear Family Extended Family

Supportive Peers Caution if patient only shares risk issues with friends Connection to Other Supportive Adults Therapists, School Counselors, Teachers, Mentors, Clergy Religion/Spirituality ASSESSMENT & TRIAGE ASSESS RISK LEVEL: Putting it all together Risk assessment is a judgment based upon: History

Level of Suicidality/Homicidality Risk Factors Protective Factors Available Interventions can then be matched based on the assessed level of risk. LOW RISK - example Suicidal/Homicidal Ideation Thought or ideation without plan, intent or behavior Risk Factors Mild, modifiable or non-continuing Protective Factors

Strong protective factors Accepting of treatment MODERATE RISK - example Suicidal/Homicidal Assessment Ideation, with plan, but no intent, rehearsal, or behavior; past or present. Risk Factors Multiple risks some modifiable and some continuing non modifiable risk factors Protective Factors Few protective factors, supports

HIGH RISK - example Suicidal/Homicidal Assessment Persistent ideation, expressed intent and means to harm self or others. Previous self or other injurious behaviors, attempts or rehearsal. Risk Factors Severe behavioral illness with acute symptoms such as hallucinations, mania. Substance abuse. Access to means. Lack of available supports. Protective Factors Probably not relevant.

INTERVENTIONS- Available Levels of Care 911 ED/Hospital 211-1-1 EMPS Emergency Mobile Psychiatric Services Outpatient Services Enhanced Care Clinics Community Based Clinicians Primary Care Provider Other Community Resources ACCESS MENTAL HEALTH CT

911- High Risk Dialing 911 Will call emergency responders Police & Ambulance Police will assess the situation and act to provide safety. They may possibly decide to press charges or arrest the child based on their judgment (particularly in the case of an assaultive or threatening individual). Ambulance may be called to provide safe and or involuntary transfer to a hospital emergency room for assessment and treatment. Use in high risk situations where risk to self or others is imminent.

Hospital Emergency Department (ED) High Risk Emergency Department Provides: Medical Physical (and Laboratory) Assessment or Treatment Ability to medicate or sedate, if indicated Provide Behavioral Health Assessment Conducted by clinical masters level staff Consultation with APRNs, Psychiatrists, may be available. Some EDs have child trained staff others do not. Can facilitate admission to hospital level of care. Ability to restrain if necessary for safety. Provide a safe holding environment and observation

Hospital ED Consider if: Imminent Risk to self or others. Very High Risk, if admission to a hospital is likely indicated Involuntary Medical work up needed (such as due to ingestion or injury) Needs continued observation or acute stabilization in safe environment. Note: Will not provide follow up after discharge. But may refer to EMPS or recommend other outpatient treatment.

EMPS Emergency Mobile Psychiatric Services Emergency Mobile Psychiatric Services (EMPS) offers an immediate response to children and youth, ages 3 - 17, or 18 if still enrolled in school, experiencing behavioral health emergencies in the home, school and other community or hospital settings. The EMPS team is available 24 hours a day, seven days a week, all year long Mobile response hours are between the hours of 8 a.m. and 10 p.m. (1 p.m. to 10 p.m. weekends and holidays) This response helps to maintain youth safely in the community and often eliminates unnecessary emergency department visits or

subsequent inpatient admissions. EMPS- Emergency Mobile Psychiatric Services EMPS Provides Immediate access by dialing 2-1-1 and pressing 1 In-home or community response from a Masters Level clinician on our EMPS team, usually within 45 minutes of the initial call Clinical assessment and crisis safety planning Stabilization of the immediate crisis in the childs home, school or other community locations Brief in-home or community-based stabilization services and

linkage to treatment and other community resources EMPS - Continued Engagement of family members and caregivers in the treatment process Integration with community-based services, including outpatient treatment, intensive family preservation, in-home treatment, specialized education, substance abuse treatment, sexual abuse treatment and parental training Ongoing collaboration with multiple community providers to ensure appropriate care Can be appropriate for low to high risk situations.

OUTPATIENT TREATMENT (low to moderate risk) ECC (Enhanced Care Clinic) Multiple levels or care available Outpatient. Intensive outpatient/Partial Hospital Specialized treatments (CBT,DBT, intensive in home or other outpatient treatment Often provide same day or rapid intake Outpatient Community Based Treatment Community based, Private practitioner, group or clinic. May provide continuity of care Hours, services available and insurance participation vary

between practices and practitioners. PRIMARY CARE PROVIDERS Primary Care Providers Provide initial assessment and follow up Have trusted, often long term history with family and patient. Treatment monitoring and case management (Medical Home) Provide needed Support for Patient and Family. Encouragement, hope, education (verbal, handouts and resources) Follow up

Can Establish Interim Safety Plan If not being referred to 911 or Hospital or EMPS Make a Plan for Safety Dont - Suicide contracts (I promise not to hurt myself) are not effective. Do- Make a Plan for Safety when feeling distressed Individual Coping skills, distractions- Friends (for distraction not support), music, movies, etc. Family Discuss and list who they can talk to and when to seek them out.

PROVIDE A SAFE ENVIRONMENT (Remove firearms, sharps, dangerous medications , etc.) Professionals Who they can talk to, when to seek them out and contact information (pediatrician, therapist, guidance counselor, help line, etc..) PRIMARY CARE - Co-management of Patient Levels of co-management: Family + PCP monitoring and support Provide Education, supportive counseling and Case management

Mental Health Practitioner + PCP monitoring Refer for therapy, consider medication (I almost always recommend non medical Tx first) Mental Health Practitioner+ Prescribing PCP With or without consultative support of psychiatrist ( ACCESS-MHCT, Co-located or community APRN or Psychiatrist) Mental Health Practitioner + Prescribing Specialist + PCP monitoring and follow up. OTHER COMMUNITY RESOURCES

SCHOOL SYSTEM Establish collaborative COMMUNICATION School-based assessment Helpful additional collateral observers Accommodations and specialized services Counseling-individual and group SUPPORT GROUPS (CAMI, etc) RELIGIOUS INSTITUTIONS/ORGANIZATIONS ACCESS Mental Health CT Mission: to support pediatric primary care providers in meeting the needs of children and adolescents with mental health

problems The ACCESS Mental Health program consists of 3 expert pediatric behavioral health consultation teams Teams consist of a Child Psychiatrist, Licensed Behavioral Health Clinician, Coordinator and Family Peer Specialist Geographically located to cover the entire state 61 ACCESS Mental Health CT Hartford Hospital 855.561.7135

Wheeler Clinic, Inc. 855.631.9835 Yale Child Study Center 844.751.8955 ACCESS Mental Health What we do Free telephone consultation to primary care providers concerning their patients ages 018 often immediately, but at least within 30 minutes of the initial call Assistance with finding community behavioral health services Ongoing education about pediatric mental health assessment and treatment

Where indicated, a one-time non-emergency diagnostic evaluation to provide diagnostic clarification and treatment recommendations ACCESS Mental Health CT In a Crisis Situation ACCESS MH-CT can help: You can call us for guidance and support around risk assessment and triage issues, even while the patient and family are still in the office We can assist with helping to link with treatment resources for this patient. We can perform a one time non-emergency face to face consult with

the patient to help you with level of care or treatment decisions. We can assist with practice readiness to handle behavioral health issues. DOCUMENTATION & FOLLOW UP Document Risk Assessment Level of Risk Reasons for Interventions Referral

Level of Care Family agreement and understanding of plan Risk Reduction Family Steps to assure safety (supervision, treatment Removal of Firearms, dangerous drugs or other means. Follow Up When is next appointment? Other clinicians & collaterals (get releases signed if indicated) Screening tools as indicated.

Intro to Vignettes To see how this all fits together and can be applied in real time in your office, lets look at a few examples of patients as they may present in your practice. Well look at how they initially presented, what we found in our assessment of: History Suicidal/Homicidal Behavior Inquiry Risk Factors Protective Factors Then look level of risk and treatment options

Case Vignette 1 MARTIN Martin is a 15 year old male who you are meeting with today in your office due to his school contacting you. Martin has a history of being diagnosed with Autism Spectrum Disorder. You have set up a symptom focused patient appointment MARTIN - Interview In speaking with Martin, he reports that he has been very upset at school because peers have been calling him names and is also upset with his teacher due to feeling that they are not helping him with this situation. He makes comments that he feels they should pay for what theyve done and states that he

is so mad that he wants to do something. Martin denies any current suicidal or homicidal thoughts but does report feeling increased sadness, tearfulness and increased anger. He has occasional meetings with counselors at school but no outpatient therapy supports in place. MARTIN Identified Problem: Martin expresses feelings of anger, sadness, tearfulness SI/HI Inquiry: Passive homicidal ideation without identified plan/intent/means. Martin does not have any history of attempts or threats to harm or kill himself/others.

Risk Factors: Martin struggles with peer relational concerns, Affective regulation and has had recent changes within his mood, and increased anger. Protective Factors: Martin has a supportive family who is invested in keeping him safe, seeking help for him and he likes seeing the school counselor. MARTIN - Risk Assessment and Outcome Risk Assessment: Martin presents as Low to Moderate Risk due to denying suicidal or homicidal ideation currently. However he is unpredictable and still angry. Martin also has several protective factors in place at this time.

Intervention: Refer Martin to EMPS for crisis services at the time of your visit due to his level of risk. They will assess and provide clinical bridging until connected appropriate providers. Or consider referral to an ECC for immediate intake (ACCESS MHCT can help facilitate) Follow Up: Schedule a follow up appointment within the next 3 weeks with Martin. Collaborate with community providers (including Outpatient clinic or EMPS) for additional steps. Establish or continue to coordinate with school. TONY - Case Vignette 2 Mrs. Smith has brought her 12 year old son Tony to meet with

you today due to him being more tired and having difficulty focusing. Mrs. Smith is concerned that something medically is going on and wanted you to meet with him. TONY - Interview In speaking with Tony and his family: Tony stated that he feels very hopeless about the future and does not care what happens to him. TONY - Screening and SI/HI SCREENING: PHQ-9 is administered and Score 16 including 3 on #9

indicating that he had thoughts of hurting himself nearly every day. SUICIDAL IDEATION INQUIRY: He states that he has been having thoughts about wanting to kill himself and has already made plans to access a rope he found in the garage at home. He said that he plans to follow through with this plan today because he feels like he just cant take it anymore. TONY - Risk and Protective Factors RISK FACTORS: Tony revealed that his father yells a lot and parents argue.

Dad has a history of depression. He has access to means to carry out his plan PROTECTIVE FACTORS: Tony has a supportive family Does well academically in school Has religious affiliation and family is willing to engage in treatment. There are no firearms in the home. TONY Risk Assessment, Intervention & Follow Up RISK ASSESSMENT: Tony presents as High Risk due to his identified plan/intent and access to means. Additionally there is increased hopelessness and a timeline

for when the attempt will occur. INTERVENTION: Refer Tony to the hospital emergency department at time of visit due to high level of risk. FOLLOW UP: Schedule a follow up appointment within 1 week of discharge to see Tony, obtain further history from school/other collaterals and utilize behavioral check list with screening tools at next appointment. RAQUEL- Case Vignette 3 Raquel is a 13 year old female who comes to you today for her yearly physical exam. Youve been Raquels Primary Care

Physician since she was 5 years old and know the family very well. When meeting with you, Raquel often comes in very talkative and smiling. During her physical examination today, you notice a few superficial cuts on her left and right forearms. You ask Raquel how she got these, whereas she begins to cry and reports that she cut herself with a razor blade two months ago, but denies any desire currently or since then to cut herself again. She denies any substance abuse, sleep or appetite disturbance. RAQUEL - Office interview, continued You explain that given this is a safety issue you will need to

discuss this with her parent. After meeting with them together you are able to meet with mom and she is upset but very supportive. There is no history of depression in the family. Parents are divorced but father is also supportive. Raquel has many friends and is a good student and academically engaged. You know from your records that there are no contributing medical issues. RAQUEL- ASSESSMENT Identified Problem: After you found healed scars, Raquel

admitted that she cut herself two months ago due to experiencing feelings of sadness. SCREENING: While talking with mother you give a PHQ- 9 Raquel scores a 5 (Mild Depression) SUICIDAL IDEATION INQUIRY: Raquel reports that she has no desire now or in the future to cut herself again. Raquel also denies any access to razors, sharps, etc. She denies ever having suicidal thoughts or plans. RAQUEL- ASSESSMENT, continued RISK FACTORS:

Raquels maternal grandmother passed away three months ago whom Raquel was very close with. Raquel has engaged in cutting behaviors 2 months prior. PROTECTIVE FACTORS: Raquel has a supportive family. Engages in extracurricular activities. Wants help and would like to talk to a therapist. RAQUEL- Risk Assessment Triage and Outcome RISK ASSESSMENT: Raquel presents as Low/Moderate risk due to her history of engaging in cutting behaviors. Additionally Raquel has denied any current thoughts to engage in cutting

at the time of your interview. INTERVENTION: Refer to community based provider for individual therapy. Both parent and child agree with this recommendation. Utilize ACCESS Mental Health CT to assist with linkage to services and informing you of the resulting appointment. FOLLOW UP: Schedule a return symptom focused appointment and continue assessment. It would be beneficial to utilize screening tools, collateral information with at next appointment. PRACTICE CHANGE Routinely Screen for safety

Ask about thoughts of harm to self or others as you do about other high risk issues such as drugs, driving, sexual activity. Regularly Administer Behavioral Screening Instruments in your practice. Remember if you dont ask, they dont tell. Prepare Symptom Focused Packets (ready for you and your patients) Pick and include which follow up screens (ASQ, PHQ-9 etc.) your practice will use. Utilize observer questionnaires for obtaining collateral information (you can develop your own or ask ACCESS MH CT for ours) Include Safety Plan Sheet, when indicated. PRACTICE CHANGE- continued

Prepare list of referrals and contacts for different levels of care Prepare list of resources for patients and families Remember, ACCESS Mental Health CT is just a phone call away to: Help you sort through evaluation and options Assist with referral and linkage to services Provide continuing education on behavioral health issues. Provide non emergency one time consultations to help with treatment and level of care questions. UNDERSTANDING SUICIDE When people are suicidal, their thinking is paralyzed,

their options appear spare or nonexistent, their mood is despairing, and hopelessness permeates their entire mental domain. The future cannot be separated from the present, and the present is painful beyond solace. Kay Redfield Jameson Night Falls Fast: Understanding Suicide REFERENCES Fallucco et al. Teaching Pediatric Residents to Assess Adolescent Suicide Risk with a Standardized Patient Module Pediatrics Volume 125, Number 5, May 29010 Chun T, Katz E, Duffy S. Pediatric Mental Health Emergencies and Special Care Needs. Pediatric Clin N America 60 (2013) 1185-1201

Suicide Prevention Toolkit for Rural Primary Care Practices http://www.sprc.org/webform/primary-care-toolkit Practice Parameter For the Assessment and Treatment of Children and Adolescents with Suicidal Behavior, JAACAP, 40:7 Supplement, July 2001 Maslow G, Dunlap K, Chung R. Depression and suicide in children and Adolescents. Pediatrics in Review, Vol 36 No.7, July 2015 Mental Health Initiatives. Advocacy and Policy, AAP health initiatives Kahn L, Kinchen S, Shanklin S, et al. Youth Risk Behavior Surveillance - United States, 2013, MMWR 2014:63June 13 2014 Vol.63 (4):1-162 References, Continued Eaton DK, Kann L, Kinchen S, et al, Youth Risk Behavior Surveillance _ United States,

2011. MMWR Surveillance Summer 2012:61 (4) Centers for Disease Control and Prevention. Leading Causes of Death 199-2010. Atlanta (GA): Centers for Disease Control and Prevention; 2012 Horowitz L, Bridge J, Teach s, et al. Ask Suicide-Screening Questions (ASQ), Arch Pediatr Adol Med. 2012; 166(12):1170-1176 Shain BN, AAP Committee on Adolescence Suicide and Suicide Attempts in Adolescents. Pediatrics.2007;120(3):669-678 Owens C, Lloyd KR, Campbell J. Access to healthcare prior to suicide: findings from a psychological autopsy study, Br J Gen Pract. 2004,54 (501):279-281 Kay Redfield Jameson, Night Falls Fast: Understanding Suicide. Alfred A. Knopf. 1999 Foy J, Enhancing Pediatric Mental Health Care: Algorithms for Primary care Pediatrics, 2010;125;S109-125

RESOURCES ACCESS Mental Health CT Wheeler 855-631-9835, Hartford EMPS Dial 211 Option 1-1 Suicide Prevention Toolkit for Rural Primary Care Practices http://www.sprc.org/webform/primary-care-toolkit Includes information and tools to implement state-of-the-art suicide prevention practices in primary care settings. Although designed with the rural practice in mind, this toolkit is suitable for use in non-rural settings as well. National Suicide Prevention Hotline 1-800-273-TALK(8255) or text HI to 741741 to chat

AACAP.org - Fact for Families & Depression Resource Center ASQ: http://www.nimh.nih.gov/news/science-news/ask-suicide-screening-questionsasq.shtml 86 ACCESS Mental Health CT Hartford Hospital 855.561.7135 Wheeler Clinic, Inc. 855.631.9835 Yale Child Study Center 844.751.8955

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    Biosecurity Biosecurity Principles. Adapted from the FAD PReP/NAHEMS Guidelines: Biosecurity (2013). Biosecurity is a series of management practices designed to prevent the introduction or spread of disease agents on an animal production facility.
  • DDA Review - St. Johns County School District

    DDA Review - St. Johns County School District

    Midterm Exam Review. What is Art, 3-D art, Elements of Art, Principles of Design, Art Criticism, Clay Terms, Kiln Knowledge, Artists and Concepts. ... Symmetrical balance means that the elements on one side of an artwork is even to those...
  • Literacy objective: to understand the possible ideas in the ...

    Literacy objective: to understand the possible ideas in the ...

    Sonnet 43 How do I love thee? ... Literacy objective: to understand the possible ideas in the poem to erxplore th context of brownign and see how this affects meaning to select key language, devises and structure and learn them...
  • Introductory Material - Kent State University

    Introductory Material - Kent State University

    Examples: order between numbers, containment between sets, divisibility between positive numbers, etc. A set with a partial order is called a partially ordered set. A partial order which satisfies, for any a,b either aRb or bRa, is called total. Lower...
  • DOM Clock Distribution

    DOM Clock Distribution

    Times New Roman Garamond Default Design Clock Distribution for IceCube Big Picture Rubidium Oscillator Allan Variance Rubidium Clock Phase Noise Accuracy and Precision Inside the DOM Hub The DOR Card DOR_Rev1, Block Diagram Signaling Issues: Master Clock to DSB DSB...
  • What Policies the U.S. uses to Place Physicians

    What Policies the U.S. uses to Place Physicians

    Michelle A. Nuss, MD, Ben Robinson, MPA, and Peter F. Buckley, MD. Academic Medicine, Vol. 90, No. 9 / September 2015 . pp 1264-1268. The State of Georgia: Implemented an initiative to address physician shortages, especially in primary care and...
  • wou.edu


    Most landslides had a three to five year recurrence interval. Nearly half of the observed landslides occured during storms with less than 4 year recurrence interval. Erosion rate of the area comes out to 2400 tons per km^2 per year.
  • Language and Culture - Vanderbilt University

    Language and Culture - Vanderbilt University

    Definitions. Language . The words, their pronunciation, and the methods of combining them used and understood by a community. A systematic means of communicating ideas or feelings by the use of conventionalized signs, sounds, gestures, or marks having understood meanings...