Simulation Scenario—Adolescent Risk Assessment Transcript

Kate Freeman: My name is Dr. Kate Freeman. I'm an advanced trainee in general pediatrics and a medical education registrar here in Perth, Western Australia. This video will demonstrate and discuss the Adolescent Psychiatric Risk Assessment. This video has been made possible by a grant from the WA Clinical Training Network, and we are grateful for their assistance.

Dr. Sarah is interviewing 14-year-old Heidi in the emergency department. Heidi has a history of depression and self-harm. Her mother is concerned that Heidi is planning to kill herself tonight, and Dr. Sarah has been asked to undertake a risk assessment. Another doctor has already medically cleared Heidi. Dr. Sarah has gained consent from Heidi's mother and is now interviewing Heidi alone.

It's important that the interview is conducted in a private and safe location within the emergency department. Don't forget to gain collateral history from family members and carers and use an adolescent-specific risk assessment pro forma if your health service has one.

Dr. Sarah notices Heidi's general appearance, including her mode of dress, in this case appropriate casual attire, as well as her level of concentration and orientation to time, place, and person. Dr. Sarah begins by introducing herself, explaining what she would like to do, gaining informed consent, and establishing the boundaries of confidentiality.

Sarah: Hi, Heidi. My name is Dr. Sarah. I'm one of the emergency doctors. I'd like to have a chat with you about what's been going on, how you've been feeling, so we can find out how best to help you. Would that be all right?

Heidi: Yeah.

Sarah: Thanks. So everything we talk about will be confidential unless I think that you're at risk of being seriously harmed, or someone else is, or they are being seriously harmed. In that case, I'd need to tell someone so we could make sure that person is safe. Is that OK?

Heidi: Yeah, that's OK with me.

Sarah: So it seems like your mom's pretty worried about you. But I'm curious, are you worried or concerned about anything at the moment?

Heidi: No, everything is fine. Yeah.

Sarah: How's your mood been recently?

Heidi: Like crap.

Sarah: Crap. Why? How?

Heidi: Just crap. It's just I don't care about anything. I don't want to do anything.

Kate Freeman: Dr. Sarah is making an assessment of Heidi's mood. This is subjective. In this case, crap. And affect, which is an objective assessment. In this case, depressed or flattened. During the interview, Dr. Sarah also notices Heidi's behavior, including levels of eye contact and cooperativeness, voice and language, and motor activity.

Sarah: So how have you been spending your time filling up your days?

Heidi: Just lying in bed all day, doing nothing, just thinking. I've got these thoughts.

Sarah: Yeah. Go on.

Heidi: These thoughts of dying.

Sarah: You think about dying?

Heidi: All the time. Just every day.

Sarah: Do you think about how that could happen?

Heidi: I think I'll probably jump off a bridge.

Sarah: Yeah. Which one?

Heidi: There's a really high bridge near my house called the Swing Bridge.

Sarah: Why that one?

Heidi: Well, it's really high, so I know I'll die if I jump off. But there's also a train track underneath. So if the fall doesn't kill me, then the train will.

Sarah: Have you made any plans about actually going there?

Heidi: Just thinking. I'm thinking all the time.

Sarah: And what's stopped you from going there?

Heidi: My mom. She'd probably be really upset if I did it, but things have just gotten worse. And I can't take it anymore.

Sarah: Do you think about how you could get to the bridge?

Heidi: Yeah, well, I've been looking at bus timetables today, the bus goes by the bridge. Yeah, I think I'm going to do it tonight. I just can't take it anymore. She can't treat me this way.

Sarah: OK.

Kate Freeman: The doctor is assessing Heidi's risk of suicide. She is considering the ongoing nature of the thoughts and presence of a plan and intent to act on it, as well as whether there are any acute precipitants, which increase risk, such as a family argument in this case.

Sarah: Have you ever done anything else to hurt yourself?

Heidi: Like what?

Sarah: I know sometimes when people are feeling crap and struggling with stuff like you are, they can do other things to hurt themselves like burning or cutting.

Heidi: Yeah. I cut up my legs.

Sarah: When was that?

Heidi: Today. Yesterday. Every day.

Sarah: Have you ever done anything else to hurt yourself?

Heidi: No, just cutting.

Sarah: OK. Heidi, do you ever have thoughts about harming anyone else?

Heidi: No. I never harm anyone else.

Kate Freeman: Dr. Sarah is assessing Heidi's risk of deliberate self-harm. In a similar way to assessing risk of suicide, she is considering the ongoing nature of the self-harm and presence of a plan, ongoing intent, and a recent history of self-harm. It's also important to consider the access to means of self-harm and potential lethality of the methods used. Risk of harm to others, self-neglect, and accidental self-harm can be assessed in a similar way. It's also important to consider whether the patient or another young person is at risk of harm from others and whether Child Protective Services need to be involved.

Sarah: Do you ever have the experience of seeing things or hearing things that other people can't hear or see?

Heidi: No, I don't think so.

Kate Freeman: Assess for disturbances in perception that can be auditory or visual. It's also important to assess the level of protection and supervision that the family or caregivers are able to provide for the young person and what other protective factors there are.

Sarah: Who are you living with at the moment?

Heidi: Just mom and Jack. He's my younger brother. Yeah.

Sarah: How are things at home?

Heidi: Not good. Mom's always having a go at me, and today we had a massive fight. It's just getting worse, and she can't treat me this way. And Jack's three, so he gets what he wants.

Sarah: Do you have someone you can talk to about what's been going on, how you've been feeling, about these thoughts, about wanting to die?

Heidi: I talk to Sophie. She's my friend. She wants to die too, so I know she won't tell anyone.

Kate Freeman: Thought processes and content can also be evaluated. Consider whether the following are present, obsessive cognitions, poverty or flight of ideas, delusional beliefs, or tangential thought flows.

Sarah: Heidi, I know that some young people have had experiences with drugs and alcohol. Can I ask you a bit about that?

Heidi: Yeah.

Sarah: Thanks. Do you drink alcohol?

Heidi: Yeah, sometimes, just with my mates.

Sarah: Have you had anything alcoholic to drink today?

Heidi: No.

Sarah: What about other drugs like pot, ice, ecstasy, other people's prescription drugs?

Heidi: No.

Kate Freeman: Dr. Sarah is assessing the influence of drugs and alcohol on Heidi's risk.

Sarah: Heidi, is there anything that you want to tell me or let me know about what's been going on?

Heidi: No.

Sarah: Any questions for me?

Heidi: No.

Sarah: All right. Thank you so much for talking to me today. I appreciate it. I'm worried about some of the things you've told me, and I'm especially worried that you might be at risk of hurting yourself. So I'd like to ask one of my specialist colleagues, John, to come and have a chat with you. He's a mental health nurse. So he specializes in talking to young people who've been struggling with their mood or are at risk of hurting themselves. Would that be OK?

Heidi: That's OK.

Sarah: Thanks. He's normally about half an hour, but it can take a little bit longer. Can I get you something to drink while you wait?

Heidi: Yeah, that's fine. Can I have a Coke?v

Sarah: Sure.

Kate Freeman: The doctor is assessing Heidi's risk of absconding. She assesses willingness to accept further assessment, attitude to receiving help, any plans to abscond, and level of insight into current difficulties. She also considers Heidi's risk of impulsivity or agitation, which might elevate her risk. Dr. Sarah then phones John, the psychiatry liaison nurse, and hands over to him using the iSoBAR framework.

Sarah: Hi, is that John, the mental health nurse? Hi, my name's Sarah. I'm one of the ED residents. Yeah, I have just conducted a psychiatric risk assessment on a young lass in ED, and I've got some concerns I'd like to discuss with you. Yeah, the client is Heidi. She's a 14-year-old girl with a history of depression and self-harm. Her mom brought her in today, and she's not comfy taking her home because she's worried she'll try and end her life tonight.

Yeah, so when I saw Heidi, she says that she's got some ongoing thoughts about jumping off a bridge near her house. She planned to go there tonight, and she'd been looking up bus timetables about how to get there. So I'm worried she might act to be impulsively in the context of having some recent arguments with her mom. She regularly cuts her legs, deliberate self-harm. And she's been medically cleared, no drugs and alcohol on board.

Yep. Currently, she's calm. She's oriented. She was cooperative with the assessment. And Heidi and her mom consented for you to come and assess her as well. So she's happy to stay here in ED until you're available. Can you come and see her and see whether she needs to be admitted or whether she needs Acute Community Intervention Services? Yeah, I think her risk is acutely elevated to herself. OK. Thanks. Bye.