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"I'M NOT GOING TO SCHOL TODAY"

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by

Rahidah Rahim

on 20 October 2015

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Transcript of "I'M NOT GOING TO SCHOL TODAY"

"I'M NOT GOING TO SCHOL TODAY"
DEFINITION
Porche et al (2011) estimated that psychiatric disorders are the cause for up to 46% of students who fail to complete high school in the United States.
SCHOOL REFUSAL
Children who have significant difficulties attending school for many reasons
2% - 5%
(Fremont 2003)
Severity:
frequent complaints
total absenteeism
CHALLENGING!!!!
many factors involves
If RR don’t return to normal – assume sedation is due to other reasons

Side effect of neuroleptics

Temperature
Pulse
Blood pressure
Respiration rate



Every 5-10mins for one hour, thn 1/2ly tilll ambulatory
If asleep/unconscious – continuous use of pulse oximetetry
ECG

After any parenteral drug use, monitor:

IM Antipsychotics

KNOW THE MEDS BEFORE U PRESCRIBE

Pharmacology in management of violence

Physical restraints

IF U REALLY HAVE TO…..

RESTRAINTS

All staff involved in rapid tranquillisation should be trained in the use of pulse oximeters.
familiar with and have received training in rapid tranquillisation, including:
the properties of benzodiazepines; their antagonist, flumazenil; antipsychotics; antimuscarinics and antihistamines
associated risks, including cardio-respiratory effects of the acute administration of the drugs,
particularly when patient:
is highly aroused
misusing drugs
is dehydrated
is possibly physically ill
 the need to titrate doses to effect.

Rapid tranquillisation

When verbal de-escalation is not enough:

Levels of observation:
General observation
Intermittent observation
Within eyesight observation
Within arms length observation

Observation

How to de-escalate a patient

a complex range of skills designed to abort the assault cycle during the escalation phase, and these include both verbal and non-verbal communication skills
(CRAG 1996).

De-escalation:

Antipsychotics continued

PO antipsychotics

IM LORAZEPAM

Pharmacological support: BDZ

everyone who restraints patients without following the stated procedure, is at risk of being sued by the patient…

Warning signs for observation

De-escalation

Overview

No pressure to neck, thorax, abdomen, back and pelvic area

Consider rapid tranquilization

DO NOT USE deliberate application of PAIN

How to do it

Psychoeducation

Adequate Rapid Tranquilization

The aim of this is to sedate the patient sufficiently to reduce their immediate suffering and minimise the risk of violence; it is not to treat the underlying condition (Taylor et al, 2005).

1-1 nursing

Observation for 24 hours, identify risk of crisis
Ensuring safety of patients and others
Prevent destruction of property
providing appropriate activity during the observation

Introduction

Violent - 30% of those attending psychiatric services for 1st time
present risk to self and other
Coercive interventions – seclusions and restraints
Restraints - inhuman, humiliating, can be fatal
Restraints rate - 0.1 - 31%
Reduction of seclusion and restraint - quality indicator of psychiatric service

Family involvement in management

family meeting
family intervention
early discharge
home care and visits
family support group

1-1 nursing observation chart

1-1 nursing (arm length nursing)

"the breach between what we know and what we do [can be] lethal"

Kay Redfield Jamison

TRAUMA
physical
psychological

Asphyxia
Aspiration
Blunt trauma
Rhabdomyolisis
Thrombosis
Acute Behavioral Disturbances

Danger of Restraint

What is seclusion?
Locked
Unlocked
Quiet Room

What is restraint?
mechanical
chemical
manual

NO physical restraint

implemented since JUNE 2010
first hospital in ASEAN to implement this policy

Restraints are therapeutic interventions

restraints are used without bias

Restraints keep the staff safe

Restraints are used when absolutely necessary and for safety reasons

Restraints keep the patient safe

Educate
- psychiatric illness
- communication
- individual roles
- strength
- CME/CPD
- team work

Breakaway technique

Empowering the staff

staff know how to de-escalate potentially violent situations

Restraint is not a punishment

staff is able to recognize a potentially violent patient

adequate and appropriate rapid tranquilization

Strategy for improvement

Psychoeducation

No physical Restraint

family involvement in management

Empowering the staff

1-1 nursing

General concept of intervention
child focused
home based
school based
relaxation training

social skills training

setting up rewards or contingencies based on school attendance


- setting

teaching children to use helpful thoughts and actions when they are worried or fearful
Be alert for
signs
of school refusal

separation-anxious children

Help them to feel more comfortable class

Assign a peer buddy

academic difficulties --> adjust assignments to the child’s level.

Provide a quiet and safe area in the school

make child feels safe at school
Parent training

help develop smooth and routines

provide to behaviors

ignoring behaviors and physical complaints that have no medical basis.

environment at home that is more FUN than school.

"SCREENAGERS"
dr nor rahidah abd rahim
school refusal team of Hospital permai
"SCHOOL REFUSAL TEAM"
core problem:
SCHOOL REFUSAL

aim:
GETTING CHILDREN BACK TO SCHOOL
the team
objective
To provide a
comprehensive assessment
and
intervention
To provide
mental health support
to
patient
,
family
and
teachers
To provide
psycho-education
and understanding to school teachers and counselors of warning signs of school refusal
To
reduced anxiety
and
increase school days

To encourage
reentry
to the school for child and adolescent who have been completely absent from school

target group

Exclusion criteria:
Those with moderate-severe mental retardation
Those who were under the care of other agencies – Social
Welfare Department or Juvenile homes or Nursing homes
lives outside of Johor Bahru

the activities
HOME VISIT
SCHOOL VISIT
1 to 1 therapy
GENERAL CONCEPT OF INTERVENTION
consultant child and adolescent psychiatrist
psychiatrist
(child and adolescent psychiatry fellow)
medical offifers
paramedics
counselors
psychologist
medical social welfare officer
occupational therapist
All the cases that are referred for school refusal
Multidisciplinary meeting
(in hospital, with parents, with school)
outreach programs
less 2 weeks
NO NEED INTERVENTION
BUT .... IF TOO CAUSING TOO MUCH DISTRESS
intervention
VS
SCHOOL REFUSAL
TRUANCY
WHAT OTHER FACTORS THAT LEADS TO SCHOOL REFUSAL BEHAVIOR
PARENTAL ANXIETY
ASSESSMENT

Observational/interview/ self report
Functional analysis (descriptive and experimental)
What is the maintaining factor?
What is the next treatment?
USE SRAS-R


What is the behavior problem?
Pinpoint exactly what is the school refusal behavior and the severity
How often child attends school?
What is done during daytime?
Pattern of attendance?
Identify stressors

MAINTAINING FACTORS
Monitoring
School attendance
Family
Logbook

school......
Schedule
Grades
Homework
Refer
when needed
SCHOOL REFUSL
INTRODUCTION
psychosocial setback
anxiety and emotional distress at the outlook of going to school
hinder functional capability
usually occur when.......
there is major changes in children's live
following vacations
following weekends
stressful life event
changing school
death of love ones
parental divorce
Babies
stranger anxiety, clinging to parents when confronted by people they don't recognize.

Toddlers (10 to 18 months)
experience separation anxiety, becoming emotionally distressed when one or both parents leave.

Kids (4 through 6)
anxiety about things that aren't based in reality, such as fears of monsters and ghosts.

Kids ( 7 through 12)
often have fears that reflect real circumstances that may happen to them, such as bodily injury and natural disaster

Adolescent
anxiety related to the future, friends, world

SCHOOL REFUSAL - IS A SYMPTOMS OF DISORDERS
left untreated.......
significant distress to parents
poor academic progress
escalate family conflicts
psychiatric disturbances
the story of TGJ
what is the PROBLEMMMMM?
2014
SCHOOL REFUSAL
medical problems
conduct problems
run away from home
management flow
why is school so important?
iT is A coMplex Social SystEM!!!!!
the obvious!
the tug of war
a child will refuse school when there are stronger reasons for
refusing
thn
Attending
TOW - occur daily... but usually, ATTENDING SCHOOL WINS
CAN U GIVE EXAMPLES?
5.3% cases -
pure school refusal
27% - learning disability
x%?
number of patients with school refusal behaviour(x) : 5.3%< X < 27%
SUMMARY
BULLYING
LGBT
lets take a break...
do you always go to school?
how to manage school refusal?
lets PLAY........
you never walk alone
SCHOOL REFUSAL - distressing symptoms
treatment/intervention - good outcome
80% success rate
multidisciplinary approach

thank you
Full transcript