Psychosocial risk assessment

Aim

To guide staff with the assessment of psychological risk in children.

Key points

• In most cases the young person with suicidal ideation or self-harm will need to be assessed by the Mental Health Nurse and/or the psychiatric registrar
  
  • In these cases the assessment by ED staff is an abbreviated one to exclude organic pathology and should not take more than 20 minutes, including the mental state examination and physical examination
• Situational crisis may be managed in the Emergency Department with senior medical input and possibly social work involvement.  

Importance of engaging with the child or adolescent

• Start by making a connection with the child or young person.
• Inquire about how things are for the young person in a non-judgemental and respectful manner.
• Use open ended questions and adopt a non-judgemental and curious approach when engaging with the young person.
• It is essential that the young person is seen on their own for part of the assessment. This will allow for sensitive matters to be discussed and also allows them the opportunity to answer questions honestly.

Explore potential triggers

• Enquire about any recent stressful events that may have occurred.
• Reflect and inquire about what impact this has had on them.
• Don’t assume what they might be feeling as a result of that stress.
• Allow them the opportunity to speak openly.

Medical examination

• Be alert for signs of intoxication and past drug use
• Neurological examination including pupil size and response
• Observe for signs of personal neglect
• Assess nutritional status
• Assess thyroid status
• Observe for signs of recent abuse
• Assess whether there is any immediate need for sedation or the need for an antidote

Signs and Symptoms of Depression

• Ask about sadness
• Ask about the extent of sadness and how often it occurs
• Are there triggers for it or does it occur ‘out of the blue’
• Has there been any loss of interest in usual activities. e.g. not catching up with friends or attending school
• Has there been any difficulty sleeping especially initiation of sleep, frequent waking or hypersomnia
• Has there been a change in appetite, (reduced or over eating)
• Has there been reduced energy or lassitude (especially on waking)
• Has the young person been more irritable than usual?

Suicidal ideation and self-harm

• Ask about suicidal ideation (in the context of sadness)
• Ask about frequency of suicidal ideation
• Ask if it was a deliberate overdose or a self-harm episode which brought them to hospital on this occasion, and whether they intended to kill themselves
• Ask about previous ideation or attempts
• Ask about current plans or intent to suicide
• Evaluate the plans in place (i.e., the possibility of high lethality suicide attempts vs vague thoughts of suicide and “plans”).

Mental state examination

During your assessment, note the following: (largely observational)

• Orientation: in time, person and place
• General appearance
• Behaviour, agitation, distress, psychomotor retardation
• Speech: Pressured or slowed?
• Mood: depressed or inappropriate
• Thoughts: are they logical, thoughts of despair or grandiose 
  • Memory and cognition
  • Insight and judgement.

Medical history

• Ask about past psychiatric history or history of previous suicide attempts
• Ask about drug or alcohol use (past or present).

Family, social supports and mental health services

• Ask the young person about their family and social network.
• Adolescents who cannot identify an adult to whom they are strongly positively ‘connected’, are at higher risk of attempting suicide.
• Ask about current engagement with mental health services e.g., school programs, private psychologist, CAMHS.
• Discuss with a senior member of staff.
  • These patients should be discussed with the ED consultant or, after midnight, the Senior ED registrar. Often a psychiatry assessment is indicated.

References

1. A Clinician's Handbook of Child and Adolescent Psychiatry By: Christopher Gillberg (Editor), Richard Harrington (Editor), Hans-Christoph Steinhausen (Editor) Cambridge University Press.
2. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 
4. Clinical Handbook of Psychological Disorders in Children and Adolescents
5. A Step-by-Step Treatment Manual By: John C. Piacentini (Editor) 2017

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