Transcript Child with chronic abdominal pain

Child / young person
who has self-harmed
Child & Adolescent Psychiatry
A 14-year-old girl, 4th of 5 children, who lives
with her mother and siblings presents to
Accident and Emergency having taken 10
tablets of paracetamol. Her blood
paracetamol level indicates no need for Nacetylcysteine infusion. The rest of her physical
examination and blood tests are
unremarkable.
Learning Objectives
• By the end of the session you will be able to
– Identify the common forms of self harm and some predisposing
and precipitating factors
– Describe key questions in the history to identify features of the
self harm attempt that would suggest increased risk of
repetition and suicide
– Identify other psychiatric, social and demographic factors in the
history associated with risk of self harm
– Describe psychosocial treatment and risk
management for children who have self harmed
Self-harm and Suicide
• 7%-9% of adolescents will have self-harmed at in the
previous 12-months
– 12% episodes will lead to hospital presentation
• 15% of older adolescents report having had suicidal
thoughts in the previous year (3x more in girls)
• Actual suicide rates (15-24 year olds)
8 (males) and 2.3 (females) per 100,000
• Psychological post-mortem studies of suicides
show that a psychiatric disorder (usually depression)
was present in most at the time of death
Self-harm and Suicide
• Self-poisoning makes up 90% of self-harm cases referred to
hospital
• 30% of young people who self-harm report previous
episodes and >10% will repeat within a year
• 25% of those committing suicide have previously
carried out a non-fatal act
Features in history of the attempt suggestive of
↑ risk of repetition or suicide - “psychiatric red
flags”
• Choice of violent potentially
lethal method - e.g. massive
overdose, hanging, jumping from
height
• Belief about lethality of
chosen method
• Clear unambiguous wish to
die
• Final act in anticipation of
death - e.g. suicide note or text
• Evidence of planning
• Efforts to avoid discovery
• Regretting that method
failed
• Persisting suicidal intent
• Still hopeless
• Persistence of the trigger(s)
Other factors in the history associated with
↑ risk of actual suicide
• Older male (completed suicide)
• Psychiatric disorder
– eg. depression, psychosis, etc
•
•
•
•
•
Previous psychiatric admission
Conduct problems
Substance misuse
Past history of self harm
Social and emotional isolation
Bio-psychosocial framework for assessing risk for
psychiatric adjustment in children
Biological
(e.g. physical illness,
alcohol/drug intake;
psychiatric family history)
Psychological
(e.g. social isolation;
pessimism)
Social/Environmental
(e.g. Life stresses &
disappointments;
family/peer models;
poorly supportive
environment )
The likelihood of maladjustment increases cumulatively with more risk factors
Most
risk of maladjustment
risk
factors domain
in all three domains
and less
resiliency/protective
factors inwith
each
additional
Assessment
Systemic thinking – Contributing factors
Individual eg genetics,
physical illness, drug intake, pessimism,
psychiatric disorder
Family system eg family history, stresses,
poor emotional support
Work/school and peers eg
problems in peer relationships
‘Local’ community eg “epidemic”
National
Global
History of triggers
predisposing & precipitating
• Individual to the child
– Psychiatric disorder
(depressive disorder in 50%)
– Chronic physical problems
– Relationship problems /
Social isolation
– Disciplinary problems
– Substance abuse
• Broader environment
– Peer relationship problems
– Bullying in school or in the
neighbourhood
• Family system
– Parental psychiatric disorders
– Family history of suicide or
self-harm
– Poor communication / Lack of
support
– Intra-familial l conflict
– Broken homes, marital
difficulties
– Abuse and neglect
Screen for associated
mental disorder
• Depression
– low mood even before the self harm
– anhedonia, social withdrawal
– lethargy, reduced self esteem
– excessive & unreasonable guilt, hopelessness
– reduced sleep, appetite, concentration, energy…
Case
A 14-year-old girl, 4th of 5
children, who lives with her
mother and siblings
presents to Accident and
Emergency having taken 10
tablets of paracetamol. Her
blood paracetamol level
indicates no need for Nacetylcysteine infusion. The
rest of her physical
examination and blood tests
are unremarkable.
FORMULATION
Protective
Individual to
the child
Family
Broader social
Predisposing
Precipitating
Maintaining
What else would you like to know?
• The triggers?
• The overdose?
• Current mental state?
• Family & social history?
FORMULATION
Depressive disorder, high suicidal risk, disrupted family
Protective
Predisposing
Individual to
the child
Cannabis use
Family
Family history
of suicide,
personality
disorder, drug
abuse
Disruption,
Unsupportive
Poor
comunication
Broader social
Close to
grandmother
Precipitating
Maintaining
Family
unsupportive,
arguments,
poor
communication
Boy friend left
Lack of
Fight with friend confident
School
exclusion
Management (1)
• Help keep her/him safe
• Convey the message that what has happened is serious
• Allow time for further psychiatric, psychosocial and risk
assessments including social service referral and liaison with
school
– Admission to paediatric ward and psychiatric assessment
• Provide space and time for the acute crisis / emotional
distress to dissipate
– Admission to paediatric ward and psychiatric assessment
Management (2)
• Establish the nature of young person’s resources and
supports, and how the family has tackled serious problems in
the past
• Initiate psychological interventions e.g. problem solving and
alternative coping strategies
• Extended admission to an adolescent psychiatric unit may be
indicated for children at increased risk of suicide
Further treatment might include
– problem solving
– family therapy
– anger management
– Environmental/social
change
– cognitive behaviour
therapy
– treatment of any
underlying psychiatric
disorder
• such as temporarily
alternative
accommodation
Take home messages
• Self harm in childhood must be taken seriously
• Previous attempts and psychiatric disorder increase the risk
for recurrence
• Careful history is needed to elicit the triggers and nature of
the self harm and associated psychiatric and social
circumstances; it is critical for adequate risk assessment and
management
• A brief paediatric admission is helpful
for the majority cases
Learning Objectives
• By now you will be able to
– Identify the common forms of self harm and some
predisposing and precipitating factors
– Describe key questions in the history to identify features of the
self harm attempt that would suggest increased risk of
repetition and suicide
– Identify other psychiatric, social and demographic factors in the
history associated with risk of self harm
– Describe psychosocial treatment and risk
management for children who have self harmed