Case Study: CAMHS Assessment and Risk Management MHS702

1. Awritten assignment/essay case study:STRUCTURE GUIDE MUST, SHOULD, COULD:

You will be familiar to written assignments by now. Below is an option to consider regarding structure for your case study assignment that follows the journey of a service user through engagement, assessment to evidence based treatment. This will include what you MUST include as this is directly relevant to the learning outcomes. What you SHOULD include relates to what is important to the module content and what you COULD include is relevant to essential mental health.

LO3 Health assessment strategies and tools - 800 words as a guide

You MUSTexamine a range of assessment strategies in relation to your case scenario/study - observation, history- timeline, records, family/ carrers, Mental State Examination (MSE), interviewing, physical health

You MUSTexaminea range ofappropriateassessment tools (at least 2) for your case study (If no tools were done, why not, which tools would have been appropriate, what does the evidence base say, critique tools/strengths vs limitations) - GAD, PSYRATS, PHQ-9, Strengths and Difficulties, HONOS, LUNSERS.

It isnt necessary to include the tools.

You SHOULD consider formulation and how this informs care planning and interventions

You COULD consider perspectives of mental health, pathophysiology and alternative perspectives.

What, why, reference, critique

LO4 Principles of risk assessment, risk management and positive risk taking- 600 words as a guide

• You MUST include principles of risk assessment - structured professional judgement, actuarial risk assessment
• YOU MUSTapplythis discussion to your case scenario
• You MUST include risk management in relation to your case scenario/study
• You MUST consider positive risk taking in relation to your case scenario/study
• You SHOULD critically discuss what the evidence says about risk and risk assessment
• You COULD consider reducing restrictive practices, service user perspectives

What, why, how, reference, critique

2. Case scenario young person

Susan has just been admitted to a CAMHS Tier 4 inpatient unit. You are a member of the nursing team and are involved in her assessment, care planning and overall care.

She is a 15-year-old girl presenting with impulsive and high-risk behaviour she has a history of self-harm both through cutting (mainly arms and upper thighs) and overdoses (paracetamol). This is an informal admission as Susan agrees that she is not coping at the moment and needs help; her parents have also requested that she be placed in foster care as they feel unable to cope with her behaviour at the moment.

History

Susans natural father (Jim) left the family home when she was 12 months old he has had no contact with the family since that time and her mother (Janet) is unaware of where he is currently living. Janet reports that she had been depressed following Susans birth this put a strain on the relationship then one day he just came home packed his things said he couldnt cope anymore and walked out and left them. Following Jim walking out of the family home Janet sank further into depression and started using alcohol as a way of coping. She progressed to using drugs as well and would often take Susan out with her to score. There were also a number of men in and out of the family home at this time. Over the years Janet slowly reduced her drug and alcohol intake and formed another relationship (Sam) when Susan was 5 years old; there are 2 other children from this relationship.

Susan had difficulties in both her primary and secondary schools with behavioural issues; social services became involved with the family when Susan made allegations that her step-father (Sam) had sexually abused her. Although this was investigated by the police no charges were brought and the step-father remained in the family home however Susan was placed on the child protection register. Janet never believed Susans allegations and repeatedly blamed Susan for making things difficult for the family and trying to come between her and Sam.

When in secondary school Susan was seen several times by the school nurse for superficial self-harm (cuts on both arms). Throughout this time she was also seen by her social worker but reported that she never developed a relationship with her, at her request she changed her social worker but again reported she was unable to relate to her in any meaningful way. Staff in the school also reported that Susan was difficult to relate to and never really seemed to form any firm relationships with any teacher she also struggled to maintain any friends often forming relationships with her peers which then would break down often resulting incidents of self-harm.

At 12 years of age Susan was referred by the school nurses to CAMHS Tier 3 services and seen by a therapist which initially seemed to be going well; unfortunately 3 months into the therapy the therapist left the service leaving Susan feeling abandoned, at this point she took her first overdose and was admitted to the local paediatric ward. Susan appeared to enjoy her time on the ward although the ward staff reported that she was often difficult to manage and appeared to be forming some unhelpful relationships with other young people on the ward at that time.

During this time Janet and Sam had another child and requested that social services place Susan in foster care as they were finding it difficult to manage her at home and felt that her behaviour was detrimental to the other three children. A placement has not as yet been found and Susan remains in the family home although often stays at friends houses when she can. Janet reports that she is not always sure where she stays or with whom but feels that the family functions much better when she is not around.

Tier 3 services prescribed antidepressants for Susan following her assessment and she is still on the medication although Janet is unsure how regularly she takes it. There have been a number of attempts by the Tier 3 service to involve the family in therapy but so far this has had limited success with the family often cancelling appointments or not turning up. When they do make the appointments it often ends in shouting matches between Susan; Janet and Sam. Susan has engaged with another therapist (a male) but following some concerns about the boundaries of that relationship, the therapist had given their personal mobile number to Susan to contact in an emergency, the team have decided that another therapist will be allocated however Susan has refused to meet any new therapist. Following 3 overdoses in 6 weeks and an increase in self-harm (cutting) Susan has now agreed to an in-patient assessment stating that she feels out of control.

3. SAMPLE OF HOW IT SHOULD BE STRUCTURED

Health Assessment Strategies and Tools

Health assessment strategies of Bella means the assessment methods adopted to collect comprehensive information about her health and welfare issues, (cited in Chambers, Forsyth and Janner, 2017), purposely to plan for her care.

Bellas informed consent and confidentiality should be obtained and maintained in her assessment process especially because a third party would be involved, but in certain circumstances, information can be divulged only if necessary for both clients safety interests and public protection (NMC, 2018). One of the health assessment strategies for Bella that would be done is physical health, for example, her physiological parameters such as blood tests (Savage, 1991; Hardy, 2013) to screen for any physical sickness that can cause mortality (Hallett and Hewison, 2012).

Also, other methods of assessment of Bella would be by observation, unstructured and structured interviews to obtain information on past medical health history, family history, past, and current medication, and alcohol/drug history; although the observation of Bella by the uses of sight, hearing, and smell is useful but required observational skill, however, is subject to a limitation of poor judgment because different people express their distress in different ways but as much as possible such kind of error would be minimized by taking cognizance of her cultural attributes (cited in Chambers, Fallon and G~, 2017).

In addition, Patient Health Questionnaire-9 (PHQ-9), is simple to use because it is a self-administered questionnaire to assess how she felt for the past two weeks; easy to score to show the symptoms she is presenting; PHQ-9 appears to be reliable and valid in the measure of depression, however, its scores may be inaccurate, if the client is not honest.(Kroenke et al; 2001). Additionally, Generalized Anxiety Disorder-7 (GAD-7) is useful to measure anxiety severity. GAD-7 is valid and efficient, but it is focused on only 1 anxiety disorder (Spitzer et al; 2006). The prominent advantage of PHQ-9 over GAD-7 is that PHQ-9 can assess suicidal thoughts and self-injury (Kroenke et al;2001).

Furthermore, Bellas Mental State Examination (MSE) is a good tool often used with effective communication and interpersonal skill to foster TR with a well-structured interview in partnership with the client to assess her appearance, behaviour, speech, mood and affect, thought content, perception, cognition, insight, and judgment (Assadi, 2020). For instance, amongst many things assessed her eye contact was poor, though improved in the course of the interview; her speech was hostile showing aggression calling her parents bad names and her dressing was incongruent with the meeting but in terms of perception, insight, and judgment it appeared Bella was not found wanting, though, she did not want to discuss her self-injury and denied ever taking an overdose of prescribed medication and that no-one could stop her; stated she has bi-polar on internets criteria and so forth; although, MSE serves as a source to obtain primary data from Bella, however, other vital information from her family, GP and friends were necessary (cited in Chambers, Fallon and G~, 2017). But the right empathy, respect, and trust offered to Bella to foster TR (Crits-Christoph et al; (2019) was to no avail as she did not reveal her thoughts during the interview which resonates in the study that perception of coercion can hinder engagement, however, establishing rapport with her with empathy continued to be paramount (Mallonee et al 2020).

Having identified Bellas health including her physical and mental state with symptoms of depression, anger, overdose, self-injury, excess alcohol consumption, misuse of cannabis and low mood, anxiety, and suicidal ideation, which suggests that shes at risk to herself and other people; the risks were categorized into static, for example, those that cant change include past medical history but can be used to predict repeated occurrence; and dynamic those that can change, for example, misuse of cannabis (Phull and Hall, 2015; Doyle & Logan 2012).

Risk formulation, in this essay, was based on the 5Ps model vis a vis presenting problem, predisposing, precipitating, perpetuating, and protective (Phull and Hall, 2015). The risk formulation, being a process between the assessor and Bella, is a working tool built on her collaboration, strengths, and resilience to suggest the appropriate steps for her care- planning and intervention (cited in Chambers, Fallon and G~, 2017), with a primary goal of preventing or managing the hurtful risks as well as encouraging the beneficial ones (Doyle & Logan 2012).

Risk assessment and risk management

Risk assessment and management are major functions of a mental health nurse and as such, Bellas risks posed to herself and to other people and from other people to her should be assessed and managed (cited in Higgins et al; 2016; Bowers,2011); Morgan (2004), argued that risk is not only the probability of a behaviour occurring potentially harmful but could be beneficial (cited in Higgins et al).

Structured Professional Judgement (SPJ) is one of the approaches to risk assessment because SPJ has the advantage of measuring/rating past and present risk factors which, therefore, provides a guide to predict any future occurrence; SPJ helps to group the risk factors into high, medium and low and as such, high-risk factors will be given highest priority with a view to preventing the client exhibiting them; however, the high-risk factors can change to low any time and vice versa; for instance, the presenting risks of aggression and suicidebeing expressed as high, medium/moderate and low can change and that is why the assessment should be a dynamic process (Doyle & Logan 2012). DH, (2007) suggested an unstructured clinical approach to risk assessment which can be carried out by a single nurse, but it is biased and haphazard (cited in Smith, Rylance and Simpson, 2012).

Although SPJ helps to decide on minimizing Bellas risks but may be limited in managing her intervention if the future occurrence is not well-formulated (Doyle &Logan 2012). Also, SPJ helps to estimate not only if she would repeat the conduct but at what severity. However, SPJ may be inadequate in that Bella may not even exhibit the behaviour or that there could be a significant future reduction in the behaviour; the predicted uncertainty is that a client that does not have any history of suicide or aggression may exhibit the actions than Bella; which suggests that nurses ought to be cautious whilst assessing the risk using SPJ because her contextual environment might have changed (Doyle &Logan 2012). In addition, using SPJ for Bella would be advantageous because it is evidence-based and decision-making from it, is transparent (cited in Smith, Rylance and Simpson, 2012).

On the other hand, the actuarial risk assessment of Bella, which is often based on statistical data that could predict the likelihood of behaviour could be adopted because it is much more reliable than the unstructured approach but not than SPJ but the combination of both may give better judgment (cited in Smith, Rylance and Simpson, 2012).

Having known Bellas risks including aggression, suicide ideation, and misused substances risk management then should be initiated to mitigate/minimize them, even though all risks may not be eliminated (cited in Morgan et al; 2016). For instance, a management strategy might be to inform the GP, police, and substance-misused services, for intervention such as medication and psychological (cited in Morgan et al; 2016), and NICE (2015) advises that Bella should urgently be referred to Specialist Mental Health Services due to the risk to herself and others. The limitationof risk management of Bella could be improper documentation of plans and the date of reviews and/or uncooperative from her (cited in Morgan et al; 2016). However, Bellas risk management, to be effective, should be collaborative and recovery-focused (Just et al;2021).

DoH (2009) described positive risk-taking of Bella as a plan for recovery in consideration of her safety, and the safety of others around her as well as improving her quality of life (cited in Just et al; 2021), based on her collaboration and strength, for instance, staff would take a positive risk if they were sure she is dependable and riskless (Just et al;2021).

Iozzino et al (2015) suggested that Bellas risk of aggression should not be underrated as they reported that about 17% of mental health patients committed violence either against other clients or staff, therefore, risks should be managed to build a system of health that is safe for all (Briner and Manser, 2013). Although Janse and Annatjie (2020) argued that a lot of work has been done on risk assessment in mental health settings which has influenced the provision of a level of care and treatment results, risk assessment practices are not standardized, and diverse screening tools are used, however, they need to be standardized to encourage evidence-based care, according to their argument.