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"I'M NOT GOING TO SCHOL TODAY"
Transcript of "I'M NOT GOING TO SCHOL TODAY"
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.
Children who have significant difficulties attending school for many reasons
2% - 5%
many factors involves
If RR don’t return to normal – assume sedation is due to other reasons
Side effect of neuroleptics
Every 5-10mins for one hour, thn 1/2ly tilll ambulatory
If asleep/unconscious – continuous use of pulse oximetetry
After any parenteral drug use, monitor:
KNOW THE MEDS BEFORE U PRESCRIBE
Pharmacology in management of violence
IF U REALLY HAVE TO…..
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
is possibly physically ill
the need to titrate doses to effect.
When verbal de-escalation is not enough:
Levels of observation:
Within eyesight observation
Within arms length 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
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
No pressure to neck, thorax, abdomen, back and pelvic area
Consider rapid tranquilization
DO NOT USE deliberate application of PAIN
How to do it
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).
Observation for 24 hours, identify risk of crisis
Ensuring safety of patients and others
Prevent destruction of property
providing appropriate activity during the observation
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
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
Acute Behavioral Disturbances
Danger of Restraint
What is seclusion?
What is restraint?
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
- psychiatric illness
- individual roles
- team work
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
No physical Restraint
family involvement in management
Empowering the staff
General concept of intervention
social skills training
setting up rewards or contingencies based on school attendance
teaching children to use helpful thoughts and actions when they are worried or fearful
Be alert for
of school refusal
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
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.
dr nor rahidah abd rahim
school refusal team of Hospital permai
"SCHOOL REFUSAL TEAM"
GETTING CHILDREN BACK TO SCHOOL
To provide a
mental health support
and understanding to school teachers and counselors of warning signs of school refusal
increase school days
to the school for child and adolescent who have been completely absent from school
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
1 to 1 therapy
GENERAL CONCEPT OF INTERVENTION
consultant child and adolescent psychiatrist
(child and adolescent psychiatry fellow)
medical social welfare officer
All the cases that are referred for school refusal
(in hospital, with parents, with school)
less 2 weeks
NO NEED INTERVENTION
BUT .... IF TOO CAUSING TOO MUCH DISTRESS
WHAT OTHER FACTORS THAT LEADS TO SCHOOL REFUSAL BEHAVIOR
Observational/interview/ self report
Functional analysis (descriptive and experimental)
What is the maintaining factor?
What is the next treatment?
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?
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
stressful life event
death of love ones
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
anxiety related to the future, friends, world
SCHOOL REFUSAL - IS A SYMPTOMS OF DISORDERS
significant distress to parents
poor academic progress
escalate family conflicts
the story of TGJ
what is the PROBLEMMMMM?
run away from home
why is school so important?
iT is A coMplex Social SystEM!!!!!
the tug of war
a child will refuse school when there are stronger reasons for
TOW - occur daily... but usually, ATTENDING SCHOOL WINS
CAN U GIVE EXAMPLES?
5.3% cases -
pure school refusal
27% - learning disability
number of patients with school refusal behaviour(x) : 5.3%< X < 27%
lets take a break...
do you always go to school?
how to manage school refusal?
you never walk alone
SCHOOL REFUSAL - distressing symptoms
treatment/intervention - good outcome
80% success rate