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Suicide Stats & Demographic Factors (Adults/General Pop)
- 34k + die in the US each yr from suicide

- 4th leading cause of death for adults 18-65 in US

- Great majority of people who die by suicide have diagnosable mental or subs abuse disorder (mostly depressive disorder)

- Males 4x more likely than females to COMMIT suicide; Females 3x as likely to ATTEMPT

- Gay & Lesbian youth at greater risk

- 8-25 attempted suicides for every death
Suicide Risk Factors (Adults/General Pop)
- Hx of previous attempts (best predictor)

- White Male <30 or >65

- Living alone, lack of social supports; single, separated, divorced, widowed

- Psychiatric disorder; esp depression, anxiety, personality disorder, schizophrenia

- Subs abuse

- Fx Hx of suicide

- Medical problems

- Hopelessness

- Losses (job, financial, relationship)

- Easy access to firearm, lethal methods

- Recent hospital discharge or recent start on antidepressants
Protective Factors Against Suicide (Adults/General Pop)
- Effective & accessible clinical care/Tx

- Restricted access to lethal methods

- Learned problem solving, conflict resolution skills

- Family & community support

- Cultural & religious beliefs discouraging suicide/promoting self-preservation

- Absence of psych disorder, subs abuse

- Presence of dependent children 
Behavioral Warning Signs for Suicide (Adults/Gen Pop)
- Giving away belongings

- Getting legal affairs in order (ie a will)

- Dramatic increase in mood

- Verbal threats of suicide, expressions of despair

- Has a suicide plan; makes a suicide note

- Visits medical provider

- Engages in risky behaviors

- Ask about body/organ donation

- Sx of severe depression       
Assessing Lethality in Adults/Gen Pop
SW must gather and weigh:

- Risk & protective factors
- Psych & subs abuse Sx
- Social supports & deterrents
- Info regarding suicide plan:
  > Frequency, type & duration of suicidal thoughts
  > Access to methods
  > Ability to control suicidal thoughts
  > Ability to not act on suicidal thoughts
  > What worsens/improves mood?
  > What consequences to action? What deterrents?
  > Rehearsing suicide or imagining own funeral?
  > Using substances to cope w/ feelings? 
 - What measures does client require for safety?
Considerations & Process for Involuntary Commitment
Criteria for involuntary hospitalization: danger to self, danger to others, inability to care for self

Must obtain approval from managed care company before hospitalizing client.

Explain process to client prior to initiating to avoid confusion

Must get release of info prior to communicating w/ managed care company!    
Stats & Demographic Factors for Youth Suicide
- 3rd leading cause of death for youth 10-19 yrs in US

- White males highest rate; Native Am rates also high

- Firearms most common method (60%)
Youth Suicide Risk Factors (In addition to risk factors among adults/general pop)
- Aggressive, impulsive, disruptive behavior

- Exposure to suicide from peers or media

- Availability of guns in the home (most common location of youth suicide by firearm) 

- Incarceration (high rates in juvenile detention)

- Remember Sx of depressive disorder often look differently in youth population
Protective Factors Against Youth Suicide
- Individual genetic/neurological makeup

- Attitudinal/behavioral characteristics

- Environment

- Learned skills in prob solving, conflict resolution, impulse control

- Fam & commuity support

- Access to effective & appropriate clinical care

- Support for help seeking

- Restricted access to lethal methods

- Cultural & religious beliefs discouraging suicide
Youth Suicide Prevention Strategies
**Ability to resist suicide is not permanent; prevention Tx should be ongoing

- Early detection and Tx of depression, subs abuse, aggressive behaviors

- Limit access to lethal methods

- Media education & limited media coverage of suicide

- Access to effective mental health care for clients, family, friends     
Warning Signs of Youth Suicide
- Depressive Sx (change in eating/sleeping, etc)
- Withdrawal
- Violent, rebellious behavior
- Subs use
- Unusual neglect of appearance/hygene
- Marked personality change
- Persistent boredom
- Physical complaints
- Loss of interest in formerly enjoyed activities
- Not tolerating praise or rewards
- Verbal hints/comments
- Suddenly cheerful after being depressed
- Signs of psychosis
- Putting affairs in order, giving away possessions
Factors Affecting Accuracy of Lethality Assessment
Circumstances of Evaluation - structured approach using clinical instruments increases accuracy

Length of assessment period - making assmt in brief time period (few months) increases accuracy
Risk Factors of Violence/Homicide
- Violent Hx - past Hx always best predictor; compounding risk w/ each violent act
- Hx of violent suicide attempts
- History of using weapons against others
- Criminal Hx; antisocial behavior
- Subs use
- Dual Dx - sub w/ psych disorder
- Psych Sx including:
  > Psychotic Sx (paranoid, neg Sx)
  > Depression
  > Brain injury/illness
  > Personality disorders (BPD, APD)
* Low IQ + APD is high risk combo  
- Hx of impulsivity
- Anger w/o empathy
- Military Hx; conduct during
- Frequent job firings/quittings
- Male (among mental health pop, rates gender =
- Young (18-24) 
- Low SES, poverty, low ed.
- Low IQ
Considerations for Violent Risk Assmt
- Take all threats seriously!

- Gather specific info regarding how threat would be carried out and expected consequences

- Elicit info regarding grudge lists, violent fantasies, future victims

- Assess suicide risk (HI comorbid w/ SI)

VERY IMPORTANT: Take detailed Hx of violence & use appropriate risk assmt instrument!
2 Diff Types of Risk Factors for Violent Behavior
Static risk factors (ie, violent Hx, demographic factors)

Dynamic risk factors (ie, psych Sx Tx, subs use, access to weapons, living situation)

Interventions should of course target Dynamic (changeable) risk factors - each client has unique set to consider as part of individualized violence prevention plan
Types of Violence Prevention Tx
Pharmacotherapy

Substance abuse Tx

Psychosocial Tx

Removal of weapons

Increased supervision
Early Vs. Late Onset Youth Violence
2 general onset pathways to youth violence = before & after puberty

Youths who become violent before age 13 generally commit more/serious crimes for longer time

Most youth violence begins & ends in adolesence (in transition to adulthood)

Most aggressive children/w/ behavioral disorders DO NOT become serious violent offenders


30-40% of young males, 15-30% females report committing serious crimes       

Successful interventions must target lifestyles & not only behavior

Interventions should be targeted early (preventative) AND at late onset Sx.    
Risk Factors for Early Onset Youth Violence
6-11 years

Individual Factors:
Substance Use
Being Male
Aggression (for males)
Psych condition
Hyperactivity
Antisocial behavior & beliefs (incl. lying)
Exposure to media violence
Low IQ

Family Factors:
Low SES
Antisocial parents
Poor parent-child relations
parental separation
abusive parents

School:
poor attitude

Peers:
weak social ties
antisocial peers

Community:
none listed              

Risk Factors for Late Onset Youth Violence
12-14

Individual Factors:
Substance Ab/use
Being Male
Aggression (for males)
Psych condition
Hyperactivity
Antisocial behavior & beliefs (incl. lying)
Exposure to media violence
Low IQ
Difficulty concentrating
Physical violence/abuse
Crimes against persons

Family:
Low SES
Antisocial parents
Poor parent-child relations
parental separation
abusive parents
low parental involvement
family conflict (for males only)

School:
poor attitude
poor performance

Peers:
weak social ties
antisocial, delinquent peers
gang membership

Community:
neighborhood crime, drugs
neighborhood disorganization
Protective Factors Against Youth Violence
Any age

Individual Factors:

Intolerant toward deviance
High IQ
Being female
Positive social orientation
Perceived sanctions for misbehavior

Family: 
warm, supportive parents/adults
parents' positive eval of peers
parental monitoring

School:
commitment
recognition for involvement in conventional activities

Peers:
friends who engage in conventional behavior
Key Components to Effective Youth Violence Prevention
Address BOTH individual & env'tal factors (individual skills/competencies, parent effectiveness training, changes in peer group involvement

Quality of IMPLEMENTATION as well as design 

In schools, most effective Tx target social context

Inv't in gangs/delinquent peer group 2 primary predictors of violence - few programs dev'ped to address these

Nearly 1/2 violence prev pgms ineffective (some harmful)
Child Abuse & Neglect Definitions
Child refers to person under 18, EXCEPT in sex abuse (states determine age)

Any recent act/failure to act on part of caretaker which results in death, serious phys or emo harm, sex abuse or exploitation, or which present an imminent risk of serious harm.

Neglect more specifically: failing to meet child's basic needs (phys, emo, edu) 

*each state required to specify own definitions based on civil/criminal statues*
Forms of Abuse
Physical (phys injury)
Sexual (exposing to sexual contact, activity or behavior)
Emotional (psych, verbal/mental injury) 

*emotional abuse almost always companied by other forms
Prevalence of abuse
Occurs across all demographic groups, though is most prevalent in impoverished areas
Factors Assd W/ Abuse
Parents' Stressors (Hx of abuse, single parenthood, social isolation, lack of ed a/b child dev't, low self-esteem/confidence, low IQ, poor communication/impulse control/prob solving skills)

Poor parenting skills (rigid/authoritarian/lax/ inconsistent discipline)

Env'tal stressors (unemployment, $ probs/poverty)

Families (marital conflict/power imbalance, IPV, subs abuse)

Society/Culture (acceptance of phys punishment, viewing children as possessions, econ depression/poverty)

Child (special needs, preemie, chronic health condition, physical disability, behavior probs which overwhelm parents' coping)
Effects of Child Abuse
- brain damage/cognitive deficits

- socioemo probs (vary according to duration/intensity/dev't age @ time of abuse)

- withdrawal
- aggression
- bedwetting/regression
- depression, self-mutilation, suicide
- hypervigilance, anxiety, insomnia
- pseudoadult behavior
- compulsivity
- drop in school performance
- delinquency, truancy, running away
Sexual Abuse Prevalence in Boys vs. Girls
Girls 3x more than boys
Risk Factors for Child Sexual Abuse
- 7-14 yrs old
- parental absence
- isolation
- depressed

Risky Family Env't: 
- social isolation
- few boundaries
- Parents have abuse Hx
- Domineering father/absent or withdrawn mother
- parentified child    
Child Sexual Abuse Perpetrator Characteristics
- Most often male
- If male, most likely use coersion; females more likely use persuasion
- Well known to child & fam - create opps to be alone w/ child
- Usually unassertive, withdrawn, emotionless
- Little satisfaction w/ sexual relationships
- Lack of emotional control
- Hx of abuse
- Hx of subs use
Indicators of Child Sexual Abuse
- Physical injuries in genital, rectal areas. Child w/ STI

- Extreme changes in behavior (regression, fears/anxiety, withdrawal, recurrent nightmares, sleep disburbances. Unusual interest or knowledge of sexual matters. Self-injurous behaviors, or delinquent behaviors such as truancy, running away. Fall in school performance. 

- In older girls, sexual promiscuity, sexual victimization, adolescent prostitution.
Traumatic Sexualization
Aversive feelings abt sex, overvaluing sex, sexual identity problems, hypersexual behaviors or avoidance
Betrayal
Feelings Assd W/ Sexual Abuse Victimization
Stigmatization: "damaged goods syndrome" assd w/ feelings of guilt/shame & self injurous/self destructive behaviors, including those aiming to provoke punishment

Betrayal: loss of trust assd w/ sexual abuse. Can mean unwilling to invest in others, act out, or engages in exploitative relationships

Powerlessness: perception of vulnerability & victimization - can lead to desire to control, identification w/ aggressor, dissociation & other avoidance responses
Factors influencing the effect of sexual abuse on child
- Age of victim (@ time of abuse & of assmt)
- Sex of victim and of offender
- Extent & duration of abuse
- Relationship of victim to offender
- Reaction of others to abuse/disclosure
- Interval btw abuse & info gathering
- Compounding life conditions/experiences
Immediately after disclosure, child is more at risk of
Emotional maltreatment -

disbelief, blame, pressure or rejection by family members 

**Parental support one of most significant factors in child's adjustment after abuse**
Role of Child Protective Services/Dept of Children & Families
mandated by federal law to asses & investigate reports; responsible for coordinating all providers supporting child victims

Goal is to protect children and support families.

If offender is not in caretaker role, law enforcement assume responsibility for investigation
6 Stages of CPS/DCF Process
1. Intake
2. Initial assmt/investigation: must gather info to determine 1) if abuse occurred, 2) risk of further abuse, 3) if child is safe @ home & if not, what to do to ensure safety & keep family together 4) if need to continue invlm't to prevent future abuse
3. Family assmt
4. Case planning
5. Service provision
6. Evaluation of family progress & case closure - when risks of abuse have been sufficiently reduced or eliminated so family can protect child/meet needs w/o CPS invlm't
Definition of Elder Abuse
Any act intended to cause injury, pain to person age 60+
Causes of Elder Abuse
- Caregiver stress
- Cycle of violence (intergenerational, learned behavior)
- Personal problems of abusers (subs abuse, psych Dx, $ probs, etc)
Impairment of older adult (special needs stresses caregivers & creates vulnerability)
Types of Elder Abuse
In addition to general types, elder abuse also might be:

- Financial/material exploitation 
- Self-abuse/neglect (behavior threatening own welfare)
- Other types such as criminal victimization

** Medical professionals plays crucial role in identifying victims.
** 2/3 are physically abused/neglected
** Avg age is 80
Areas of Assessment in Cases of Elder Abuse/Neglect
- Cognitive status of older person
- Requiring empowerment vs. protective approach
- If older adult in imminent danger
- Concerns of self-determination, autonomy
- How to balance needs of elder vs. caregiver system
- social & financial resources
- Abuse patterns
- Cultural beliefs, traditions

**Need to use standardized assmt (assessing depression & substance abuse); and team based approach
Guidelines for Working w/ At Risk Elders
- Awareness of own assumptions, stereotypes
- Necessary modifications due to age, functioning
- Effort to overcome hesitation to engage/receive help
- Warm, supportive, non-confrontational
- Structured & directive
- In the present focus
- Awareness of potential counter/transference issues (parent/child patterns)
- Convey respect w/ language (formal names)
Special Considerations when working w/ Elders
- autonomy & self-determination issues regarding placement
- depression & suicide risk
- substance abuse/dependency
- potential need for guardian
Types of Intervention Techniques w/ Elders
Direct Techniques:
- Stimulate life-review, reminiscience (history telling, creating story/meaning)
- Sensory training & remotivation techniques
- Reality orientation (for mild dementia), validation intervention (for severe)
- Group work (socialization & support)    

Indirect:
- Intervene w/ natural support system (fam)
- Referral to basic needs, support resources
- Healthcare - independent living support
- Homecare
- Day treatment
- Out/Inpatient svcs
- Fam svcs (incl respite, adult day care, reassurance calls, friendly visiting, emergency response)
- Case Mgmt
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