Adolescent Mental Health Assessment ... .au



Canberra Health ServicesOperational Procedure Adolescent Mental Health Assessment and ReferralSchool Youth Health NurseContents TOC \o "1-2" \h \z \u Contents PAGEREF _Toc534885234 \h 1Purpose PAGEREF _Toc534885235 \h 2Scope PAGEREF _Toc534885236 \h 2Alerts PAGEREF _Toc534885237 \h 2Scope PAGEREF _Toc534885238 \h 2Section 1 – Background PAGEREF _Toc534885239 \h 3Section 2 – Mental Health Consultation PAGEREF _Toc534885240 \h 4Section 4 – Self Management Plan PAGEREF _Toc534885241 \h 9Section 5 – Mental Health Services in the ACT PAGEREF _Toc534885242 \h 9Section 6 – Ongoing care PAGEREF _Toc534885243 \h 11Section 7 – In the event of a suicide or attempted suicide PAGEREF _Toc534885244 \h 12Section 8 - Support for SYHN PAGEREF _Toc534885245 \h 13Implementation PAGEREF _Toc534885246 \h 13Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc534885247 \h 13References PAGEREF _Toc534885248 \h 14Definition of Terms PAGEREF _Toc534885249 \h 16Search Terms PAGEREF _Toc534885250 \h 16Attachments PAGEREF _Toc534885251 \h 16Attachment A: Mental State Examination PAGEREF _Toc534885252 \h 18Attachment B: Kessler Psychological Distress Score PAGEREF _Toc534885253 \h 19Attachment C: Generalised Anxiety Disorder Assessment PAGEREF _Toc534885254 \h 20Attachment D: SCOFF Questionnaire PAGEREF _Toc534885255 \h 20Attachment E: The CRAFFT Screening Interview PAGEREF _Toc534885256 \h 22Attachment F: Suicide-Screening Questions PAGEREF _Toc534885257 \h 24Attachment G: Protective and Risk factors PAGEREF _Toc534885258 \h 25Attachment H: Mental Health Triage Scale PAGEREF _Toc534885259 \h 27PurposeThis procedure provides the School Youth Health Nurse (SYHN) with: Strategies to engage young people who require support for their mental health A process to assess the mental health of young people who access the SYHN programA process to support young people to develop strategies for good mental health including a self-management plan to manage self-injury and suicidality Referral pathways for young people experiencing mental distress Advice on how to provide support to young people who are experiencing mental health concerns within the school setting A Process to respond to suicide or suicide attemptsInformation on how to access supports for self-care Back to Table of ContentsScopeAlertsThe SYHN program is not a specialist Mental Health service. The School Youth Health Nurse: Has an obligation to respond, and provide referral for, any incident in which a young person is expressing suicidal ideas or exhibiting suicidal behavioursIs required to approach all identified suicidal intent as a significant and imminent riskWill be alert to risks to the safety of young people, and practice within legislation and CHS policy for mandatory reporting.If there is uncertainty regarding acute risk this should immediately be discussed with the Schools Clinical Nurse Consultant (Schools CNC).The SYHN will adhere to CHS policies and procedures relating to young people and mental health including: Initial Assessment and Management of People Vulnerable to Suicide ProcedureChild Protection Policy and GuidelinesBack to Table of ContentsScopeThis procedure applies to Level 2 Registered Nurses working in the Women Youth Children Community Health SYHN program.Back to Table of ContentsSection 1 – BackgroundSYHNs provide: Developmentally appropriate, inclusive and holistic care that is focused on the health and wellbeing of young people. Each consultation is approached with respect, empathy and sensitivityTrauma informed care, with a strong focus on supporting young people to make healthy life choicesMental health and wellbeing education Early intervention and referral to targeted health services Insight and consideration to barriers to healthcare including poor past experiences and difficulties with accessibility of services. This may include considering and addressing financial barriers, transport barriers, if a service is youth focused and/or culturally appropriate A consistent, dependable and trustworthy serviceA family partnership approach.Strategies SYHN use to engage a young person may include:Being curious; taking an interested and non-judgemental stanceUsing a strengths-based approachAsking open ended questions Employing a collaborative approach to health care needs using motivational interviewing techniques to engage the young person in their own health care goalsProviding reassurance and validation Creating an environment where young people feel safe to disclose Normalising seeking mental health care, including seeking support for suicidal thoughts and self-harm. SYHNs promote and foster the relationship between the young person and their care givers. SYHNs aim to engage parents/carers to support the young person’s mental health and wellbeing, acknowledging that they are best placed to provide access to mental health care, promote wellbeing and to keep their young people safe. Young people accessing the SYHN attend voluntarily. Confidentiality It is essential to promote young people’s access to health care by providing a service that respects confidentiality The SYHN will act in the best interests of the young personThe SYHN may assess the young person as a mature minor if they have a reasonable belief that the young person is capable of giving informed consent; being able to demonstrate sufficient understanding of their health needs and the care that is requiredDocumentation should include the rationale for treating the young person as a mature minorThe SYHN must comply with mandatory reporting requirements. The safety of the young person is paramount. Where there is risk of harm the SYHN must prioritise safety over confidentiality and advise the parent/carer (when safe to do so). This includes when: The young person is at risk of deliberate self-injury or ending their lifeThe young person is at risk of harming someone else or committing a serious criminal offenceThe young person is being threatened or harmed (physical/sexual abuse) The young person is experiencing neglect or emotional abuse including exposure to family violence.Where it is deemed that the safety of the young person would be compromised by disclosure of mental health concerns to parents/carer the SYHN will discuss with the Schools CNC and report concerns to Children and Youth Protective Services.Schools CNC Contact: 62055006 0478 408 859Children and Youth Protective Services (CYPS)Contact: 1300 556 728Stigmatising languageSYHN’s avoid using stigmatising terminology such as ‘committed suicide’ ‘successful/unsuccessful suicide’ or ‘failed attempt’. Appropriate terminology to use is ‘died by suicide, death by suicide, ‘ended his/her life’, and ‘attempted to end his /her life’.Back to Table of Contents Section 2 – Mental Health ConsultationThe SYHN will: Discuss confidentiality and limitations with consideration to mandatory reporting requirements and the young person’s safetyProvide a safe and supportive environment for young people to:Discuss their mental health Disclose a history of trauma, bullying or other factors that may affect mental health and wellbeing.On presentation the young person’s reasons for the consultation will be discussed, and a psychosocial assessment undertaken, including an assessment of need for mental health care, education and/or referral. Where indicators for mental health concerns are noted an Adolescent Mental Health Assessment is advised. The following attachments are available reference tools to assist in informing the Adolescent Mental Health assessment. Scores will be recorded within student files.Mental State Examination (Attachment A)Indicators for depression: Kessler Psychological Distress Scale (Attachment B)Indicators for anxiety: Generalised Anxiety Disorder Assessment (Attachment C)Indicators for disordered eating: SCOFF questionnaire (Attachment D)Indicators for substance misuse: CRAFFT Screening Interview (Attachment E)Indicators for suicide risk: Ask Suicide-Screening Questions: (Attachment F)Definitions of Risk and Protective factors (Attachment G)These attachments provide indications only. SYHN may independently assess the young person’s safety to be at risk. SYHN are to have a low threshold for concern, aiming to put supports in place to best keep young people safe. Consultation may include:Areas of concern and vulnerability:Background factors that make the young person more likely to have mental health concerns for example family breakdown, trauma, Lesbian Gay Bisexual Trans and/or Intersex (LGBTI) etc. (predisposing factors)Current issues or events that are impacting the young person’s mental health (precipitating factors)Factors that may exacerbate the young person’s mental health concerns (perpetuating factors)Identify protective factors like: The young person’s demonstrated strengths and resilienceThe effective coping mechanisms they have discussedThe protective and/or supportive relationships they have discussed (Attachment G)Aim to finalise the consultation with a review of the information they have shared, the action planned by the SYHN, and a focus on the young person’s identified strengths and protective factors. ReferralFollow Mental Health Triage Scale (Attachment H): Continue to advocate for and facilitate accessing the support of parents/carersConsider utilising school support staff including School Psychologists Consider referral to programs or small groups to build protective factorsWhen writing referral letters use CHS letterhead. State the reason for referral including supportive screening tool if used, for example Kessler Psychological Distress Scale results.DocumentationDocument the consultation, the tools used and referrals made in the young person’s clinical recordRecord demographic and consultation content in SYHN data collection document Record contact on ACTPAS. Back to Table of Contents Section 3 - Additional considerationsTrauma historyWhen a young person discloses a history of trauma that is impacting their mental health: Respond with empathy and:Listen carefullyControl expressions of panic/shockTell the young person that they are believedReassure the young person that telling their story was the right thing to doTell the young person that what happened was not their faultAcknowledge that it is often hard to talk about traumaAdvise the young person what the SYHN plans to do with the disclosure.Clarify if the young person is safe or if they have any injuries. Identify if there is the likelihood of further trauma.Enquire if the young person’s parent/carer is aware of the history of trauma. Seek consent to discuss with parent/carer, or to support the young person while they disclose. If young person declines consent, explore concerns, and encourage communication with parent/carer if safe for the young person to do so.Consider referral to appropriate services. See Attachment IFollow mandatory reporting guidelines.If requested to give a formal statement to police refer to the CHS Medico-legal Coordination Team on 5124 9563 or email CHS.medicolegal@.au Contact the Schools CNC or Central Manager for guidance.Self-injuryRespond with empathy and remain calm. Provide validation and reassurance. In the event of a disclosure of self-injury, consideration should be given to:Methods and frequency of current and past self-harmCurrent and past suicidal intentIndicators for depression and their relationship to self-harmAny history of mental illness and its relationship to self-harmAny specific factors preceding self-harm, such as specific affective states or emotions and changes in relationshipsSpecific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harmCoping strategies that the young person has used to either prevent self-harm or to keep themselves safe in the past Significant relationships that may either be supportive or potentially damaging (such as abuse or neglect) and may lead to changes in the level of riskImmediate and longer-term risks.Consider coexisting risk-taking behaviours, such as engaging in unprotected sexual activity, exposure to unnecessary physical risks, drug misuse or engaging in harmful alcohol intake. When assessing risk, also consider access to tools for self-injury, for example razor blades or sharp objects. When self-injury is present aim to create a Self-Management Plan with the young person: See section 4On first presentation of recent self-harm, or when self-harming behaviour escalates: Always advocate for a family partnerships approach to supporting young people who are self-harming If the young person’s safety is at risk advise parents/carers and provide them with information and referral. Aim to enhance the parent/carer feeling empathy for their young person, and aim to increase parent/carer understandings of mental health It is mandatory under the Children and Young People Act 2008 to report all non-accidental physical injury, and there is no requirement that this non-accidental injury be caused by another person. Thus self-harming behaviours resulting in a physical injury may under the Act be classified as non-accidental injury.However, making a Child Concern Report in response to self-harming remains a grey area. SYHN may contact CYPS or CHS Child Protection Liaison about a young person who is self-harming to discuss their concerns and determine if a mandatory report is advisedBe alert to the possibility of abuse or neglect, as self-harm may be an indicatorConsider advising school staff to ensure safety and provide an additional support for the young person in the school setting. Ideally the young person will nominate preferred school staff members.Follow Mental Health Triage Scale (Attachment H) for further referral advice. Suicidal ideation The only way to assess suicide risk is to ask a young person directly whether they are experiencing suicidal thoughts or engaging in suicidal behaviours. If indicators for mental health concerns are identified, questions should be asked to identify if there is suicidal intent.Respond with empathy and remain calm. Provide validation and reassurance. Factors to consider when assessing suicide risk include??: Mental stateWithdrawal and isolation Recent significant stressors Suicidal thoughts, behaviours or exposure to the death of another person by suicideAccess to the material required to enact suicide plan*Coping skills Supports and help-seeking capacity Response for living and barriers to self-harm. *Have they already accessed, for example, taken an overdoseQuestions to ask could include??: Have you thought about ending your life?What has happened to make life not worth living?What specifically have you thought about doing to yourself?Have you taken any steps towards doing this? Have you thought about how/when/where you might do this? Have you thought how your death would affect your family and friends? Have you spoken to your friends/family about how you feel?Have you ever tried to end your life before?Have ever made a plan to end your life in the past?What makes it more likely that you will act on your suicidal feelings?What has stopped you from acting on your thoughts so far?Careful consideration needs to be given to previous suicidality, as well as to the intensity of the ideation, the planning involved and the access to means??. Follow Mental Health Triage Scale (Attachment H) for referral. When a young person discloses current or recent suicidal ideation: Always advocate for a family partnerships approach to supporting young people who are experiencing suicidal ideation When the young person’s safety is at risk advise parents/carers and provide them with information and referral. Aim to enhance the parent/carer feeling empathy for their young person, and aim to increase parent/carer understandings of mental health Making a Child Concern Report in response to suicidality remains a grey area. SYHN may contact CYPS or CHS Child Protection Liaison about a young person who is experiencing suicidal ideation to discuss their concerns and determine if a mandatory report is advisedBe alert to the possibility of abuse or neglect, as suicidality may be an indicatorAdvise school executive to ensure safety while at school and provide an additional support for the young person while in the school setting.When suicidal ideation is present aim to create a Self-Management Plan with the young person.Back to Table of Contents Section 4 – Self Management PlanThe aim of a self-management plan is to provide a tool to assist the young person in managing their intense emotions, and to redirect their thoughts away from self-injury and/or suicide. Self-management plans should be created in collaboration with the young person and include: Identifying warning signs and triggers for escalation of suicidality - for example, lack of sleep, substance use, conflictStrategies that reduce escalation of suicidal thoughts - for example, mindfulness, music, exerciseSupports that reduce escalation of suicidal thoughts – for example, talking to a friend, long hug from parent, school support staffSupports from professional services - for example Kids Helpline, emergency services, mental health clinicianOther considerations include: Encourage the young person to involve others, such as family, friends or school support staff, in the self-management plan. This may include talking through the plan with them, and/or providing them with copies. Supporting the young person and their family to remove access to the means of suicide or self-injury. This will include being aware of the young person’s suicide plan, and/or preferred means of self-injury – for example medication, sharp objects or rope. An electronic self-management plan is available at .au/get-support/beyondnow-suicide-safety-planning Back to Table of Contents Section 5 – Mental Health Services in the ACTConsider the individual needs of the young person, the barriers for accessing a given service (financial, transport etc.) and the availability or capacity of the service to provide appropriate, targeted and timely care. SYHN are encouraged to investigate the youth focused mental health services available in their area, as well as to be aware of the Adolescent Psychologists and identified youth friendly General Practitioners that are locally available. SYHN need to aware of the services below, including their referral criteria: School Psychologists Provide services to students that address educational, social, emotional and behavioural needs; either individually or in groups. They are located in all secondary schools. Child & Adolescent Mental Health Services (CAMHS)Provides free assessment and treatment 7 days a week during business hours, for young people experiencing moderate to severe mental health concerns. To make a referral, contact 5124 1407 or Fax 6205 2627.For after hours, please contact CATT on free call 1800 629 354.Access Mental Health Team (AMHT)Provides a free 24-hour, seven day a week service used for assessment and treatment of mentally ill people in crisis situations.Contact on 1800 629 354 (24 hour service) or 6205 1065.Headspace Provides support for young people who are experiencing mild to moderate mental health concerns and/or substance use issues, and their family and friends. Contact on 6201 5343 (Bruce) or 6298 0300 (Queanbeyan) Junction Youth Health Service This is a free primary health care service providing holistic care (Medical Service and Youth Workers) that includes counselling services.Contact on 6232 2423 (Canberra City).Winnunga Nimmityjah Aboriginal Health Service Provides free culturally safe and holistic health services to Aboriginal and Torres Strait Islander people, including mental health care.Contact on 6284 6222 (Narrabundah).Other contacts that may be useful to provide include:Lifeline provides a free and confidential telephone crisis support service 24-hours, 7 days a week by calling 13 11 14Suicide Call Back Service provides a free phone counselling service for anyone affected by suicide 24-hours, 7 days a week by calling 1300 659 467Kids Help Line provides a free counselling service for kids and young people aged 5-25 years, 24-hours, 7 days a week by calling 1800 55 1800Back to Table of ContentsSection 6 – Ongoing careThe SYHN program does not provide intensive counselling; “repeated or ongoing application of measures focused on producing a psychological or emotional response or change” (School Youth Health Nurse Program Memorandum of Understanding) but may consider the need to provide ongoing support until the young person is able to access an appropriate mental health service. If there is an undue gap in accessing mental health services that impacts the safety of a young person, discuss with Schools CNC and follow Incident Management Procedure. When the barrier to accessing mental health care is as a result of parental medical neglect follow mandated reporting guidance as per Child Protection Policy. Mental Health Promotion and Wellbeing supports:Opportunistically aim to:Consider individual learning needs and developmental stage to provide individualised evidence based mental health tools and education, with the aim of fostering wellbeing, including reinforcing the young person’s resilience, strengths and protective factorsSupport and build on existing protective factorsProvide information on accessing mental health care, for future needs, and for peer support, including mental health support phone numbersNormalise consultation with health professionals regarding mental health Normalise and promote communication with parents/carers regarding mental health. Supporting young people with diagnosed psychological conditions in school:Young people with diagnosed psychological conditions may also continue to attend school while accessing mental health care externally. These young people may require additional support but are well enough to attend school. The SYHN may support the young person by:Working with the young person to modify their self-management plan as their needs changeObserving fluctuations in mental health Liaising with the young person’s mental health professionals and parents/carersBuilding the young person’s mental health literacy Referring into appropriate school based small groups Accessing the support processes within the school Supporting the use of tools that enhance wellbeing, for example mindfulness.Back to Table of Contents Section 7 – In the event of a suicide or attempted suicideWhen a suicide occurs the school community, families, staff and other young people are often deeply affected. The risk of suicide increases for vulnerable members of the school community, with young people being particularly susceptible to the contagion effect. ACT Education and Training Directorate has processes in place to support the school community in the event of a completed suicide. SYHN are encouraged to be a participant of the post-vention support provided within their school. This may include:Advocating for schools to access post-vention services through external agencies like HeadspaceBeing available in the school for additional days to allow vulnerable young people to access the service Providing additional support to other members of the school community; school staff, parents or carers.SYHN are required to follow the Significant Incident Procedure in the event of a suicide or attempted suicide by a young person who has accessed the SYHN program for support within the previous three months. SYHN are required to report verbally to the Schools CNC or Central Manager and submit an Incident Notification through Riskman. Providing follow up care to attempt survivors A history of a suicide attempt is a significant vulnerability factor for future suicide attempt. Improving the care a young person receives after a suicide attempt is important in reducing future vulnerability and to support the young person’s recovery. SYHN are not a specialised mental health service, but when a young person who accesses the SYHN program is returning to school after surviving a suicide attempt, the SYHN may consider the following:Reviewing the mental health care supports; providing a referral if no mental health care in placeProviding phone numbers to mental health services including CATTLiaising with the young person’s mental health care provider for insight into the ongoing care being provided to the young person, the level of risk to safety for the young person and for strategies for appropriate support at school, if well enough to attend Reviewing the young person’s clinical record via Clinical Record Information System (CRIS) after a CHS admission Advocating for supports within the school environment Checking in regularly with the young person. Liaising with their mental health care provider when signs of deterioration are notedConsidering building mental health literacy including education on activities that promote mental health, for example self-care through meeting sleep needs, incorporating exercise, improving nutrition, mindfulness etc.Advocate for the young person to remain in the care of their family when acutely unwell – schools are not equipped to ensure safety when young people are actively suicidal Follow procedure on Page 6 and 7 for Self-Injury and Suicidal Ideation as indicated.Back to Table of Contents Section 8 - Support for SYHNSupporting young people with mental health concerns, especially where suicide or suicide attempts have occurred, may have the potential to impact the mental health and wellbeing of SYHNs. Support for staff will include: Support to access mental health focused professional learning Women Youth and Children Community Health Program (WYCCHP) Clinical Reflective Practice Framework: group Clinical Reflective Practice with the option of individual sessions for short periods as neededPeer Review: weekly meetings with the SYHN team and Schools CNC providing an opportunity for case presentation, peer education and debriefingAccess to the Employee Assistance Program Access to ‘My Health’: Staff Health and Wellbeing Schools CNC and Central Manager are both available for debriefing, clinical advice and support. Back to Table of Contents Implementation Becoming familiar with the procedure and being able to locate it in the Policies/Clinical Guidelines Register will be included in the orientation process to the SYHN program. SYHN will be supported to refer to and follow the procedure through Peer Review and the supervision and guidance of the Schools CNC.Back to Table of Contents Related Policies, Procedures, Guidelines and LegislationPoliciesChild Protection Policy Consent and Treatment Policy Incident Management PolicyProceduresChild Protection GuidelineChild Concern Reporting ProcedureClinical Handover Procedure Initial Management, Assessment and Intervention for People Vulnerable to Suicide ProcedureIncident Management ProcedureClinical Records Management ProcedureLegislationCrimes Act 1900 (ACT)Mental Health Act 2015 (ACT)Carers Recognition Act 2010 (Australian Government)Human Rights Act 2004 (ACT)Children and Young People Act 2008 (ACT)Privacy Act 1988 (Australian Government)Information Privacy Act 2014 (ACT)Health Records (Privacy and Access) Act 1997 (ACT)Frameworks Child Protection Practice Paper WYCCHP Clinical Reflective Practice FrameworkMemorandum of Understanding School Youth Health Nurse Program Memorandum of Understanding and Program Management Guidelines June 2009Back to Table of ContentsReferencesACT Government Community Services, Keeping Children and Young People Safe – a shared community responsibility (2014) Australian Family Physician. ‘Help us, she’s fading away’ How to manage the patient with anorexia nervosa. Volume 43, No.8, August 2014 Pages 531-536 Australian Research Alliance for Children and Youth, Violent and Antisocial Behaviour among young adolescents in Australian Communities; An Analysis of Risk and Protective Factors (2009) Accessed at Blue, BeyondNow – Your Suicide Safety Planning App (2018) .au/get-support/beyondnow-suicide-safety-planning Beyond Blue, SenseAbility is a strengths-based resilience program designed for those working with young Australians aged 12-18 years. Available at JM, Cohen E. Getting into Adolescent’s Heads. Contemporary Paediatrics (1988) 5:75–90.Goldenring JM, Rosen DS. Getting into Adolescent heads: an essential update. Contemporary Paediatrics (2004); 21:64Headspace Psychosocial Assessment Version 2.0 (2013) Headspace, The Australian Psychological Society (2007) See Young People Training, : Understanding Self Harm for Professionals Health Pathways ACT and Southern NSW (2016) HEEADSSS assessment Accessed at RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003 Feb;60(2):184-9.Melvin G. Risk Assessment and Initial Management of Suicidal Adolescents. Australian Family Physicians: Addictions June 2014 Mental Health First Aid Australia. Suicidal thoughts and behaviours: first aid guidelines (Revised 2014). Melbourne: Mental Health First Aid Australia; 2014 Mind Matters. Developing Resilience, Matters. Protective and Risk Factors National Institute for Health and Clinical Excellence. Self-harm: longer-term management. (Clinical guideline CG133). 2012. A. RACGP Clinical Guidelines Illicit Drug Use, ’Connell et al, National Research Council and Institute of Medicine of the National Academies, Preventing Mental, Emotional and Behavioral Disorders Among Young People: Progress and Possibilities (2009) Accessed at Orygen, The National Centre of Excellence in Youth Mental Health, Clinical Practice in Depression and Suicide: Managing ongoing suicidality in young people diagnosed with major Depressive Disorder, 2017 Royal Children’s Hospital Melbourne: Mental Status Examination Clinical Guideline (MSE)Victorian Government Department of Health, State Wide Mental Health Triage Guidelines (2010) Available at health..au/mentalhealthWall L. Higgins D and Hunter C. Child Family Communication Australia Information Exchange (2016) Trauma Informed Care in Child/family Welfare Services Accessed at Back to Table of ContentsDefinition of Terms Young person: student in ACT Education Directorate secondary school Back to Table of ContentsSearch Terms Mental health, adolescent, depression, anxiety, mandatory, mature minor, young person, School Youth Health Nurse, suicide, suicidal ideation, self-injury, self-harmBack to Table of ContentsAttachmentsAttachment A: Mental State Examination Attachment B: Kessler Psychological Distress ScoreAttachment C: Generalised Anxiety Disorder Assessment Attachment D: SCOFF QuestionnaireAttachment E: Substance Use and Choices Scales Attachment F: Suicide Risk Assessment Attachment G: Risks and Protective Factors Attachment H: Mental Health TriageDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 10 January 2019Entire documentED WYCCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameAttachment A: Mental State Examination Royal Children’s Hospital Melbourne Clinical Guideline .au/clinicalguide/guideline_index/Mental_State_Examination/ Attachment B: Kessler Psychological Distress ScoreKessler Psychological Distress Scale (K10) All of the time (score 5)Most of the time (score 4)Some of the time (score 3) A little of the time (score 2) None of the time (score 1)Questions: Scores1. In the past 4 weeks, about how often did you feel tired out for no good reason? 2. In the past 4 weeks, about how often did you feel nervous? 3. In the past 4 weeks, about how often did you feel so nervous that nothing could calm you down? 4. In the past 4 weeks, about how often did you feel hopeless? 5. In the past 4 weeks, about how often did you feel restless or fidgety? 6. In the past 4 weeks, about how often did you feel so restless you could not sit still? 7. In the past 4 weeks, about how often did you feel depressed? 8. In the past 4 weeks, about how often did you feel that everything was an effort? 9. In the past 4 weeks, about how often did you feel so sad that nothing could cheer you up? 10. In the past 4 weeks, about how often did you feel worthless? Total:K10 Score: Likelihood of having a mental disorder (psychological distress) 10 - 19 Likely to be well 20 - 24 Likely to have a mild disorder 25 - 29 Likely to have a moderate disorder 30 - 50 Likely to have a severe disorder Alternatively access at Beyond Blue: This score is to be used to indicate need for referral. It is not a diagnostic tool. Referral for further evaluation is recommended should the score be 20 or above. Clinical judgement needs to be used in conjunction with K10 score. Attachment C: Generalised Anxiety Disorder AssessmentGeneralised Anxiety Disorder Assessment (GAD 7)Not at all (score 0)Several days (score 2)More than half of the days (score 3) Nearly every day (score 4) ScoresQuestions: Over the last 2 weeks, how often have you been bothered by the following problems? 1. Feeling nervous, anxious, or on edge2. Not being able to stop or control worrying3. Worrying too much about different things4. Trouble relaxing5. Being so restless that it is hard to sit still? 6. Becoming easily annoyed or irritable7. Feeling afraid as if something awful might happenTotal: GAD 7 score: Likelihood of being affected by anxiety 0 - 5 Likely to be well 6 - 10 May have mild anxiety11 - 15 May have moderate anxiety 16 - 21 May have significant anxietyAlternatively access screen at Beyond Blue: This score is to be used to indicate need for referral. It is not a diagnostic tool. Referral for further evaluation is recommended should the score be 10 or greater. Clinical judgement needs to be used in conjunction with GAD 7 score. Attachment D: SCOFF Questionnaire SCOFF Questionnaire Questions: SDo you make yourself Sick because you feel uncomfortably full?CDo you worry you have lost Control over how much you eat?OHave you recently lost more than One stone (6.35 kg) in a 3-month period?FDo you believe yourself to be Fat when others say you are too thin?FWould you say Food dominates your life? Total: If the patients answer ‘Yes’ to 2 or more then there is a high index of suspicion that they have an eating disorder and require referral for assessment For more information: This score is to be used to indicate need for referral. It is not a diagnostic tool. Referral for further evaluation is recommended should the score be 2 or more. Clinical judgement needs to be used in conjunction with SCOFF score. Attachment E: The CRAFFT Screening Interviewleft25844500819156847840This score is to be used to indicate need for referral. It is not a diagnostic tool. Referral for further evaluation is recommended should the score be 2 or higher. Clinical judgement needs to be used in conjunction with CRAFFT score 00This score is to be used to indicate need for referral. It is not a diagnostic tool. Referral for further evaluation is recommended should the score be 2 or higher. Clinical judgement needs to be used in conjunction with CRAFFT score 90170248285 00 Attachment F: Suicide-Screening QuestionsScreening Questions:Do you feel sad or down more than usual? Have you ever felt that way in the past? For how long? Have you lost interest in the things you usually like doing? Are you having trouble sleeping? Do you find yourself spending less and less times with friends or family? Would you rather just be by yourself most of the time? Why? Probing questions: Have you ever tried to hurt yourself (e.g. cutting) to calm down or feel better?Have you started using alcohol or drugs to help you relax, calm down or feel better? Have you thought you would be better off dead or wished you were dead? Have you thought about suicide? Do you have a suicide plan? -18505719603300 This score is to be used to indicate need for referral. It is not a diagnostic tool. Referral for further evaluation is recommended should the score be 2 or higher. Clinical judgement needs to be used in conjunction with suicide screening questions. Attachment G: Protective and Risk factors Common protective factors for mental health difficulties-14986037020500Common risk factors for mental health difficulties-16192518986500 Attachment H: Mental Health Triage ScaleDescriptionResponse Typical Presentation School Youth Health Nurse response Additional support Current actions endangering self or othersImmediate referralAttempt to end life/serious self-harm Overdose or other medical emergency Violence/threats of violence & possession of weapon Dial 000 to request emergency services supportInform school Principal Inform parents/carerRemain with young person until parents/carer and/or emergency services arrive (if safe) Consider de-escalation techniques (if safe) Submit mandatory reportFollow up with young person and/or family at a later dateWill need ongoing support staff to be nominated within the school setting including school psychologistHigh risk of imminent harm to self or others, and/or high distress, especially in absence of supports Immediate referral Acute suicidal ideation or risk of harm to others with clear plan, means and/or history of self-injury/suicide attempts/aggression High risk behaviour associated with perceptual/thought disturbance or impaired impulse control Rapidly increasing symptoms of psychosis and/or severe mood disorder or current intoxication Unable to care for self or do activities of daily living Requires priority assessment by specialist mental health service or GPContact CAMHS on 6205 1971Inform parents/carer Inform school PrincipalWrite a referral letter to GP/CAMHS Submit a mandatory report (Dial 000/Emergency services if parent/carer is unwilling/unable to take immediate action)Remain with young person until parents/carer arrive (if safe)Consider de-escalation techniquesConsider mindfulness/stress management techniques. Give validation and reassurance Give contact numbers for afterhours mental health support Follow up with young person and/or familyWill need ongoing support staff to be nominated within the school setting including school psychologistModerate risk of harm and/or significant distress Referral within 24 hoursContact parents same daySignificant distress associated with serious mental health concerns including depression/anxiety but not suicidalSelf-harmEarly signs of psychosis Requires priority assessment by specialist mental health service or GP Refer to CAMHS on 62051971 or Headspace on 62015343. Write a referral letter to GP/CAMHS/HeadspaceInform parents/carer of need for mental health care, including a Mental Health plan from GP Give contact numbers for afterhours mental health support Consider linking to appropriate websites/appsConsider mindfulness/stress management techniquesConsider need for mandatory reportFollow up with young person and/or familyWill need ongoing support staff to be nominated within the school setting including school psychologistConsider referral to small groups in schoolNo risk of harm in short term Referral within weekIndicators for mild to moderate depression, anxiety, adjustment or developmental disorder. Low self-esteem, poor body image, disordered eating, interpersonal conflict including bullyingRequires specialist mental health assessment. Is stable and at low risk of harm in short term.Mental health history requiring non-urgent reviewRefer to Headspace on 62015343Give contact numbers for afterhours mental health supportSupport communication with parent/guardian Consider writing a referral letter to GP Provide ongoing support until able to access MH service Consider mindfulness/stress management techniquesConsider linking to appropriate websites/appsFollow up with young person and/or familyProvide additional support through nominated school support staff including school psychologistConsider referral to small groups in schoolNo risk of harm to self/others. Requires support Support contact with mental health serviceNo or limited protective factorsDifficulties with anger, truanting, family conflict, low mood, stressed Provide formal or informal referral to a targeted appropriate service Consider mindfulness/stress management techniquesEncourage and offer to support communication with parent/carer Consider linking to appropriate websites/appsGive contact numbers for mental health support servicesFollow up with young person and/or familyConsider referral to appropriate small groups within school Mental health promotion or educationInformation on mental health Asking questions around mental health Family or friends affected by mental illnessProvide education and health promotion around mental health and wellbeingProvide information on services to support mental health and wellbeingGive contact numbers for mental health support services and links to appropriate websites/appsAdapted from Victorian Government Department of Health, State Wide Mental Health Triage Guidelines (2010) health..au/mentalhealth ................
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