 |
Module B6: Mental health
Entry Scenario
The entry scenario addresses a variety of issues and problems associated with the module topic. It may be used at the beginning of the course to stimulate the students to identify their own needs and interests. The results may be utilized by the individual to assess own learning process, or be integrated with class objectives.
A divorced mother comes to consultation with her son Bill, a 16 year-old only child, complaining about the fact that he is withdrawn and has hardly talked to her for two months. The boy himself denies any problem, despite the fact that he is skipping school often and his grades are dropping. The boys sees his father every two weeks, and the father, according to the mother, doesn’t seem to be troubled by his son’s situation. Until the age of 14, Bill was a bright, talkative, active kid. After his father left home two years ago to live with another women, Bill’s situation has gradually worsened, according to the mother, with a lot of conflicts around the issue of social outings and school duties, and a deterioration of his behaviour at school. Over the three last months, Bill skipped school several times because of headaches and stayed alone in his room, playing his guitar. He quit his football club 4 months ago, and has not seen his friends for two months. The consultation was prompted by the fact that the mother discovered an entire package of sleeping pills in her son’s desk.
General Goals for Learners
by completing the module the participant will be able to :
- List and recognize the main symptoms of mental health problems/disorders in adolescence
- Lay the foundation to investigate a situation symptomatic of mental health problems
- Interpret and evaluate symptoms of mental health problems, placing adolescent in the family/environmental context
- Initiate support therapy or referral to mental health professionals
- Recognize the risk of adolescent suicide, and manage crisis situations including suicide attempts and self-harm
Goal 1 : List and recognize the main symptoms of mental health problems/disorders in adolescence
Knowledge
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
A. List and characterize the main symptoms and manifestations of mental health problems and disorders. Mood: - functional symptoms
- depression
- anxiety
- sleep problems, fatigue
- withdraw, runaway
- delirium
Behaviour and cognition - conflicts
- school problems/refusal
- delinquency
- acting out
- identity problems (esp. sexual)
|
Reading Interactive lecture Group discussion
|
Introductory lecture to cover mood and behaviour symptoms. Trainer asks participants to describe how these symptoms could be elicited in a history taking, and how most adolescents would describe them. Address the implications of “functional symptoms” in adolescence such as headache, stomach-ache, and back pain. Incorporate into the discussion how “hidden agendas” and masked symptoms may be recognized in adolescents. Definitions issue: discuss the participants’ working definitions for adolescent mental health problems and mental illness, mental health and emotional well being. Optional activity: ask participants to estimate the percentage of the adolescent population that report symptoms of mental health problems within a given year. What are the trends? What variations by gender, SES, etc. can be noted?
|
Module B4 Refs. 1-5
|
|
B. List definitions of major disorders using both DSM-IV and ICD-10 classifications
|
Reading, quick review in plenary
|
Trainer provides quick review of definitions if needed.
|
Refs. 4,6
|
|
C. Understand how adolescent psychosocial development may precipitate mental health problems, and how certain resources may be protective.
|
Group work Group discussion
|
Display examples of literature and films that illustrate the occurrence of mental health problems during adolescence. Cite adolescent characteristics which may precipitate mental health problems: - biological factors
- environmental factors
Group discussion on the protective effects of the following resources: - relationships with others (connectedness with parents, peers)
- coping skills/styles
- beliefs, self-efficacy
- responsibilities in life
- involvement in social activity
|
Refs. 7-9
|
Skills
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
D. Recognize main symptoms of mental health problems in a given situation
|
Plenary with video, standardized or simulated patient and/or role play
|
Trainer sets up several situations featuring a distressed adolescent (depressed and anxious/angry and disruptive/etc) and asks participants to identify potential symptoms and manifestations of mental health problems.
|
|
Goal 2 : Lay the foundation to investigate a situation symptomatic of mental health problems.
Attitudes
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
A. Explore the role of physician’s preconceptions regarding “acceptable” behaviour, as well as his own beliefs regarding the appropriateness of using medications during adolescence
|
Small group discussion
|
In groups, participants discuss personal reactions to the entry scenario, if given that Bill would be one’s own son. Compare preconceptions and personal limits.
|
|
|
B. Examine how labelling, along with real and perceived stigmatisation, may affect/interfere with the investigation and care giving process.
|
Class discussion
|
Discuss the meaning of mental health problems and disorders in the participants’ own culture / community. Elucidate the ways in which stigmatisation (real and perceived) can operate to disadvantage an adolescent with problems. What attitude on the part of the professional can decrease the potential effects of labelling and stigmatisation?
|
|
|
C. Evaluate the participants’ own ability to engage in a problematic situation: - individual strengths and limitations
- potential support and supervision resources
|
Class exercise
|
Trainer elicits some examples from class of stressful patient cases the participants have been confronted with. Discuss criteria by which a practitioner may make a quick private assessment of whether he/she agrees to be involved in a difficult case.
|
|
Skills
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
D. Exhibit skill in establishing a trustful relationship with a distressed adolescent that permits an initial exploration of the situation. - interview skills needed
- consultation set-up (who comes)
- ground rules (goals, limits)
- confidentiality
|
Small group work Role Play Video
|
Case study: Rolf is brought to your consultation by his mother. Although he is reluctant to meet with you, his mother insists because Rolf cut his arm in front of her the day before. She thinks he is suicidal although Rolf says that everything is OK. Eventually he says that he just got mad because he mother was trying to control him again. In small groups, participants review the interviewing skills (e.g. tempo, balance, empathy vs. seduction) that may be particularly important in a situation with mental health issues.
Role play to practice the skills. Group members who observe the role play evaluate why and how certain questions are asked, and how the interviewer can achieve the trustful relationship. Identify the “successful” approaches. Using situations drawn from participants, from standard case studies or video, trainer asks participants to decide whether to see the adolescent alone, with his parents or both (and in which sequence).
|
Refs. 7-11
|
Goal 3 : Interpret and evaluate symptoms of mental health problems, placing adolescent in the family/environmental context
Skills
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
A. Utilize criteria that differentiate adolescents with temporary dysfunction from those who need mental health evaluation or/and referral. - severity of situation
- warning signs
- risks and resources
|
Video Role play Group discussion
|
Trainer presents the entry scenario or other case study for class to analyse using the following list: - Severity of situation
- accumulation of symptoms
- duration/persistence of symptoms (>3 m.)
- repetition of symptoms
- level of distress
- severity of functional impairment
- Warning signs (red flags):
- runaway
- suicidal threats
- self-harm
- Status of risks and resources
- personal
- familial
- social / peers
- environmental
|
Refs. 7-11
|
|
B. Assess family functioning for elements that contribute to the adolescent’s distress.
|
Role play
|
Assess congruence of the discourse: to what extent do father and mother have the same interpretation of the situation? Does the adolescent have the same interpretation as his parent(s)? If time permits, practice in role play an assessment of family structure and mode of functioning.
|
Module A2
|
Goal 4 : Initiate short support therapy or referral to mental health professionals
Knowledge
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
A. List psychological approaches that are useful for non-mental health professionals in clinical practice with adolescents.
|
Interactive lecture Patient input
|
Trainer provides guidelines and, where possible, observable examples of the following approaches: - cognitive behavioural therapy
- solution focused
- family / systemic therapy
- motivational interviewing
- brief interventions
- relaxation and hypnosis
|
Refs. 8,12,13-18
|
|
B. List psychotropic medications which have been shown to be effective and safe during adolescence; list potential harmful effects
|
Interactive lecture and plenary
|
Issues of medication to be covered in class discussion include, - considerations re. dosages (e.g. Tanner stage)
- effects on growth, puberty & metabolism
- risk of addiction
- paradoxical effects, side effects
- effects on learning
- risk of overdose (suicide)
|
|
Skills
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
C. Determine if and how to prescribe psychotropic drugs during adolescence - indications for psychotropic drugs
- considerations in prescription plan
- alternatives to medication
|
Small group work Videos Role play
|
Groups role play the situations to develop a treatment plan with the adolescent and his family. Discuss the following issues: - expected outcomes
- duration of treatment
- possible side effects
- monitoring, link with the school if appropriate
Case study: A 15 year-old girl and her parents ask you to prescribe sleeping pills because of an imminent exam. She has no other apparent health problem, and is a brilliant pupil. For the past several days, however, she has serious difficulty sleeping. It is extremely important for her to do well on the exam in order to be accepted for a special overseas project. Case study: A 16 year old boy is heavily depressed for several weeks and does not yet want to engage in a formal psychotherapy. His parents ask whether he should at least be put on antidepressants.
|
|
|
D. Identify situations which need referral to a mental health professional
|
Group work with role play
|
Case study: Helena has been repeatedly seeing her doctor for stomach-aches and has missed a lot of school classes. Her parents are currently engaged in a divorce process and Helena’s school grades have dropped. Despite several consultations that she has had with her general practitioner and a prescription for antidepressants, she is still very depressed and stays home most of the time not doing anything.
|
Module B4 Ref. 19
|
|
E. Provide the guidance and support necessary to introduce and maintain an adolescent in mental health care - dealing with resistance, fear, denial
- supportive actions/support therapy
- reassessment of situation
|
|
Case study: Mario was sent to a psychologist for the investigation and treatment of a severe depression with suicidal thoughts. He comes back to his primary care physician and says he doesn’t want to go to the psychologist anymore.
|
Refs. 20-23
|
Goal 5 : Recognize the risk of adolescent suicide and manage crisis situations, including suicide attempts and self-harm
Knowledge
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
A. Review the concepts of suicidal ideation and conduct.
|
Minilecture
|
Review includes distinguishing features of self-harm, suicide ideation, plans and attempts.
|
Refs. 24-25
|
|
B. Understand the factors contributing to the risk of adolescent suicide.
|
Class discussion
|
Review briefly common risk factors for suicide, and discuss the relationships between depression and suicide. Class compiles from experience symptoms suggestive of suicide risk and warnings of imminent gesture.
|
|
Attitudes
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
C. Increase awareness of factors that may influence professional’s emotionality and effectiveness during an emergency/crisis situation.
|
Group work
|
Participants reflect on personal background that could interfere with ability to deal effectively in suicide situations. Small groups discuss (from experience if possible) which attitudes are helpful to self, parents and patients. Case study: Rose, 16 years old, is brought to the office by her parents who want her to be hospitalized immediately. They say that their daughter has volatile moods, and has been getting angry and screaming for no reason. The morning of the consultation, Rose threatened her parents that she would cut herself with a knife. Rose has been doing well in school and wants to leave home against her parents’ wishes to live with her 20 year-old boyfriend. Her parents are too old fashioned, she says. Two years ago, Rose was admitted to the hospital for a suicide attempt. (self-poisoning). She refused a psychotherapeutic follow-up. The parents threaten to sue the doctor if he does not hospitalize their daughter.
|
|
Skills
Training Objectives
Key topics to be covered
|
Educational Methodology
|
Activities, Issues, and Questions
|
Pertinent resources
|
|
D. Provide assessment of suicide risk, and manage an at-risk adolescent.
|
Small group work Role play, videos Simulated patients
|
Participants familiarize themselves with the main topics to explore during assessment. - previous suicide attempts
- intention to die
- potential means for suicide attempt
- substance use/misuse
- psychopathology- family dysfunction or patient living alone
Case study: Paul is sent to you by the school nurse. The day before, he tried to jump off a bridge but was held back by a passer-by. He begs you not to tell the story to anyone, claiming that although he is still heavily depressed, he no longer wants to die. Case study: Carol, a heavily depressed 16 year-old girl has refused any medical treatment for her depression. Her friend’s mother calls the practitioner to explain that the day before, the friend has discovered a rope under Carol’s bed. The parents don’t know anything about the story. Case study: Sue is a 17 year-old who was removed from a threatening home environment and placed in a protected living house. Although she claims to have adjusted to her new situation, she has been overheard screaming abusively on the phone to her boyfriend. A case worker found a diary in which Sue writes scenarios of killing herself.
|
Refs. 18,24,26
|
|
E. Demonstrate skills in responding to a suicide attempt
|
Group work with discussion and role play
|
Case study: you are asked to see 19 year-old Monica at home, after she “accidentally” swallowed too many pain killers. Case study: you are asked to see John, a 14 year-old boy who has been hospitalised after having swallowed 30 capsules of Tylenol®; he is facing a serious hepatic failure. He doesn’t want you to meet with the family and promises he will never do it again. He refuses any further appointment. Questions for group work: - How do you set-up multidisciplinary assessment ?
- When do you hospitalise ?
- How do you cope with the denial of the patient and/or family?
- How do you plan and implement follow-up management after hospitalisation ?
|
Refs. 18,24,26
|
General Guidelines
All requests should prompt a proper answer. The goal is not so much to assess whether the adolescent is normal or abnormal, but to what extent he is suffering from the situation or to what extent his behaviour unbalances his family and socio professional environment.
All situations should be assessed in at least 3 to 4 consultations (goal 3) before any definite decision is made about the need for medication, support counselling or referral to a mental health professional (exception: life threatening crises).
The main aim of the first encounter is to establish a therapeutic alliance with the adolescent, not to review all his lifestyles
It is impossible to investigate and treat an adolescent without seeing at some point, preferably early in the process, his parents or guardians and get their approval about the follow-up.
References
- World Health Organisation. Invest in mental health. Geneva: Department of Mental Health and Substance Dependence, WHO, 2003.
- Rutter M, Smith D. Psychosocial Disorders in young people. Time Trends and Their Causes. New-York: Wiley, 1995.
- Meltzer H, Gatward R, Goodam R, Ford T. The mental health of children and adolescents in Great Britain (2nd. Edition). London: Office for National Statistics, 2000.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed ed. Washington, 1994.
- Costello E, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003; 60:837-44.
- Guelfi JD. Mini DSM-IV:Critères diagnostiques. Paris: Masson, 1996.
- Gardner W, Kelleher KJ, Pajer KA. Multidimensional adaptive testing for mental health problems in primary care. Medical Care. 2002; 40:812-23.
- Hack S, Jellinek M. Early identification of emotional and behavioral problems in a primary care setting. In: Juszczak L FM, eds., ed. Adolescent Medicine: state of the Art Reviews. Philadelphia: Belfus Ha, 1996:335-350.
- Bower P, Garralda E, Kramer T, Harrington R, Sibbald B. The treatment of child and adolescent mental health problems in primary care: a systematic review.[see comment]. Family Practice. 2001; 18:373-82.
- Rowland N, Bower P, Mellor C, Heywood P, Godfrey C. Effectiveness and cost effectiveness of counselling in primary care.[update in Cochrane Database Syst Rev. 2002;(1):CD001025; PMID: 11869583]. Cochrane Database of Systematic Reviews. 2001:CD001025.
- Miller W, Rollnick S. Motivational Interviewing: Preparing people for change. New-York: The Guilford Press, 2002.
- McClellan JM, Werry JS. Evidence-based treatments in child and adolescent psychiatry: an inventory. Journal of the American Academy of Child & Adolescent Psychiatry. 2003; 42:1388-400.
- Farmer E, Compton S, Bums B, Robertson E. Review of the evidence base for treatment of childhood psychopathology: externalizing disorders. J Consult Clin Psychol 2002; 70:1267-302.
- Frick P. Effective interventions for children and adolescents with conduct disorder. Can J Psychiatry 2001; 46:597-608.
- Kondo DG, Chrisman AK, March JS. An evidence-based medicine approach to combined treatment for ADHD in children and adolescents. Psychopharmacology Bulletin 2003; 37:7-23.
- Milin R, Walker S, Chow J. Major depressive disorder in adolescence: a brief review of the recent treatment literature. Canadian Journal of Psychiatry - Revue Canadienne de Psychiatrie. 2003; 48:600-6.
- Michael KD, Crowley SL. How effective are treatments for child and adolescent depression? A meta-analytic review. Clinical Psychology Review. 2002; 22:247-69.
- Greenhill LL, Waslick B. Management of suicidal behavior in children and adolescents. Psychiatr.Clin.North Am. 1997; 20:641-666.
- Saunders SM, Resnick MD, Hoberman HM, Blum RW. Formal help-seeking behavior of adolescents identifying themselves as having mental health problems. Journal of the American Academy of Child & Adolescent Psychiatry. 1994; 33:718-28.
- Walker Z, Townsend J. Promoting adolescent mental health in primary care: a review of the literature. Journal of Adolescence. 1998; 21:621-34.
- Witt JC, Vanderheyden A, Penton C. Prevention of common mental health problems among adolescents. National and local best practices in school-based health centers. Journal of the Louisiana State Medical Society. 1999; 151:631-8.
- Reviews NHSCf, Dissemination. The effectiveness of school-based curriculum suicide prevention programs for adolescents (Structured abstract). Database of Abstracts of Reviews of Effectiveness 2003; 1:1.
- Reviews NHSCf, Dissemination. Primary prevention mental health programs for children and adolescents
The effectiveness of school-based curriculum suicide prevention programs for adolescents (Structured abstract). Database of Abstracts of Reviews of Effectiveness 2003; 1:1.
- Brent DA. Assessment and treatment of the youthful suicidal patient. Ann.N.Y.Acad.Sci. 2001; 932:106-128.
- Spirito A, Overholser J. The suicidal child: assessment and management of adolescents after a suicide attempt. Child Adolesc Psychiatr Clin N Am 2003; 12:649-665.
- Hawton K, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van Heeringen K. Psychosocial and pharmacological treatments for deliberate self harm. Cochrane Database of Systematic Reviews 2003; 1:1.
|
|
Access to the curriculum 
to get a 
