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Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department...

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The Normal Human Response to Trauma Alasdair Vance and Jo Winther Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital
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Page 1: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

The Normal Human Response to Trauma

Alasdair Vance and Jo WintherAcademic Child PsychiatryDepartment of PaediatricsUniversity of MelbourneRoyal Children’s Hospital

Page 2: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Outline of presentation

1. The vast range of human life experiences2. The definition of trauma 3. Trauma types: initial versus few months later responses4. Vulnerability-risk and Protective-resilience models5. Biological factors6. Psychological factors7. Social factors8. Cultural factors9. Practical tips - Jo Winther10. Clinical illustrations – Jo Winther

Prof. A. Vance

Page 3: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Person A: 36 man, bankteller, obsessive-compulsive, MVA onthe way to work, major depressive episode, 8 months to get better

Person B: 26 man, intelligence operative, tortured and escapes, ASDsymptoms, 8 weeks to be back at work

Person C: 45 man, cleaner, avoidant, told burglar in building afterwards, develops ASD symptoms, receives counselling, develops PTSD, rehabilitation program still going at 12 months

Person D: 18 year old girl, released from 6 years imprisonment witha paedophile, countless episodes of rape, physical abuse and neglect,refuses counselling, being a ‘victim’, becomes a nurse and marries

Page 4: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Individual:Biological factorsPsychological factorsSocial factorsCultural factors

Person

Environment

Prof. A. Vance

Page 5: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 6: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 7: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 8: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 9: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

2. Definition of Trauma‘throw out, alter’

- injury living tissue by an external agent- disordered behavioural and/or psychological stateresulting from a severe mental, emotional stress and/orphysical injury

- initial effect: Acute Stress Disorder- delayed effect: Post Traumatic Stress Disorder

Prof. A. Vance

Page 10: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

2. Acute Stress Disorder

- extreme traumatic, terrifying, horrifying eventexperienced, witnessed, learnt about family/close friendrespond with intense fear, horror, helplessness, disengaged/agitated behavior (children)

- within one month and symptoms resolve within one month

- psychic numbing, dazed/less aware of surroundings,derealisation, depersonalisation, dissociative amnesia

Prof. A. Vance

Page 11: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

2. Acute Stress Disorder

- re-experiencing phenomena: recurrent, distressing,memories, dreams, symbols of traumatic event

- avoidance phenomena: places, situations, thoughts, feelings, conversations, decreased recall aspects trauma event(s),decreased future

- hyperarousal phenomena: sleep change, irritability, decreased concentration, increased vigilance, increased startle response

Prof. A. Vance

Page 12: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

2. Acute Stress Disorder

- duration: 2 days – 4 weeks

- significant impairment home, family, work, educationallife domains

- not due to substance abuse/dependence disorder, medical disorder, brief psychotic disorder, pre-existing psychiatric disorder

Prof. A. Vance

Page 13: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

2. Post Traumatic Stress disorder

- extreme traumatic, terrifying, horrifying eventexperienced, witnessed, learnt about family/close friendrespond with intense fear, horror, helplessness, disengaged/agitated behavior (children)

- lasts more than one month, chronic if more than 3 months,delayed if onset after 6 months from traumatic event(s)

Prof. A. Vance

Page 14: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

2. Post Traumatic Stress disorder

- re-experiencing phenomena: recurrent, distressing,memories, dreams, symbols of traumatic event

- avoidance phenomena: places, situations, thoughts, feelings, conversations, decreased recall aspects trauma event(s),decreased future

- hyperarousal phenomena: sleep change, irritability, decreased concentration, increased vigilance, increased startle response

Prof. A. Vance

Page 15: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

2. Post Traumatic Stress disorder

- significant impairment home, family, work, educationallife domains

- not due to substance abuse/dependence disorder, medical disorder, psychotic disorder, pre-existing psychiatric disorder-especially OCD,malingering

Prof. A. Vance

Page 16: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

3. Trauma types (National Child Traumatic Stress Network)

- physical abuse- neglect- sexual abuse- psychological maltreatment- complex trauma: multiple and/or prolonged episodes

- refugee and war zone trauma- terrorism- natural disasters

Prof. A. Vance

Page 17: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

3. Trauma types

- medical trauma- domestic violence- community school violence- traumatic grief

Prof. A. Vance

Page 18: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Individual:Biological factorsPsychological factorsSocial factorsCultural factors

Person

Environment

Prof. A. Vance

Page 19: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

4. Vulnerability-risk model

- Zubin and Spring proposed model

- interplay between individual and environmentcrucial; a true interaction effect

- biological, temperamental, psychological, social,cultural vulnerability

Prof. A. Vance

Page 20: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Zubin and Spring, 1977Prof. A. Vance

Page 21: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 22: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

4. Protective-resilience model

- Seligman developed model as part of positive psychology

- interplay between individual and environmentcrucial; a true interaction effect

- biological, temperamental, psychological, social,cultural resilience

Prof. A. Vance

Page 23: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 24: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 25: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

4.

- for some factors, risk and resilience are opposite endsof the same spectrum (eg empathic relationships)

- for other factors, risk and resilience are two separatedomains that a person can be high or low on(eg cognitive strategies)

Prof. A. Vance

Page 26: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Individual:Biological factorsPsychological factorsSocial factorsCultural factors

Person

Environment

Prof. A. Vance

Page 27: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Trauma specific factors

- living through trauma event(s)- being physically injured- seeing others hurt and/or killed- experiencing intense horror and/or fear- experiencing extra loss after trauma event(s)loss loved ones, pain, injury, loss job, home, etc

Prof. A. Vance

Page 28: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 29: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 30: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 31: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Region of activation BA C (mm) ZControl Group greater than ADHD-CT GroupParieto-Occipital

R Precuneus 19 24 -70 32 3.53R Cuneus 19 32 -90 28 2.82

Posterior ParietalR Inf. Parietal 40 36 -40 50 2.82

Frontal/SubcorticalR Caudate Nucleus, Body 18 -12 22 2.82

Vance et al, Mol Psych 2007 N=24, CBCL inattention subscale T score: 72.14 (9.43)

Page 32: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 33: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Prof. A. Vance

Page 34: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

5. Biological factors: Irritability, Mood lability

Mood

Euthymia

Time

Prof. A. Vance

Page 35: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

5. Biological factors

Arousal dysregulation: impaired physiological arousaldecreased habituation

Mood dysregulation: increased irritabilitydecreased emotional salience

Prof. A. Vance

Page 36: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

5. Biological factors

- Executive functioning deficits

Response disinhibition: motor and cognitionsuboptimal response speed and accuracy

Working memory deficits: verbal and visuospatialdecreased span and strategy

Prof. A. Vance

Page 37: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

6. Psychological factors

- dissociation: helpful initially, longer duration=increased risk- helplessness- coping strategy- able to get through trauma event(s)- able to learn from it- able to respond effectively despite fear- feel good about one’s actions- good cognitive skills – attention, problem solving- temperament; adaptive, good self-regulation-impulses/emotions- positive self-perceptions

Prof. A. Vance

Page 38: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

7. Social factors

- degree of social support after trauma- ability to seek, find and maintain social support- ‘warmth’of relationships: empathy, attunement- family structure, expectations and monitoring- low parental discord- prosocial, competent, supportive family/peer group- ‘collective efficacy’ school, neighbourhood environment

Prof. A. Vance

Page 39: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

8. Cultural factors

- individual versus group cultural focus

Prof. A. Vance

Page 40: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Young people exposed to trauma may react in a variety of ways :

• Aggressive behaviour• Staring episodes• Eating and sleep disturbances• Difficulty concentrating• Exaggerated startle response• Irritability and outbursts of anger• Hypervigilance – jumpy or fidgety or having trouble

staying in their seat• Restricted range of emotions• Guilt • Clinginess and fear of separation• Crying or giggling without obvious reason

Page 41: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Developmentally specific responses to disasters and trauma vary in children of different ages:

• Younger children commonly express new fears, separation anxiety, clinginess and show ‘regressive’ behaviours

• School age children describe difficulty concentrating or having fun. Learning and behavioural problems, aggressive behaviours and withdrawal

• Adolescents are at particularly high risk as their reactions can include increased risk-taking behaviours including fighting, substance and alcohol abuse, heightened sexual activity and suicidal thoughts

Page 42: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Practical tips when working with the young person

• Ensure people closest to the young person provide information and support

• Protect the young person from public curiosity• Provide reassurance (the world has not completely

changed)• Don’t be afraid to talk about the events – using factual

information• When discussing the event with the young person keep it

simple and be honest • Find out what they think and feel – allow them to guide the

discussion, give them time to ask questions, discuss their feelings and emotions, and correct misperceptions with accurate but age appropriate explanations

Page 43: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Practical tips when working with the young person

• Reassure the young person by verbally acknowledging and normalising their experiences. Listen to what they say and acknowledge with them the awfulness of their experience

• Inform them that what they are feeling is very normal for someone who has been through a traumatic event and to give themselves time to adjust

• Sometimes stories about other young people in a similar situation can help them feel more in control

• Take the young person’s lead on when, what and how much to say

• Accept that some young people do not want to talk (they might express themselves through writing or drawing)

Page 44: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Practical tips when working with the young person

• Assess the situation and gather information• Seek crisis intervention if required• Include young people in mourning rituals and processes• Keep memories alive (mementos, photographs, a

keepsake)• Ensure that they are spending some time doing nice things

(going for walks, seeing friends, doing fun things)• Help the young person find a legitimate course of action if

they wish (donate pocket money, send some toys or clothes)

• Don’t over focus on the event – resume normal patterns of activity as soon as possible

Page 45: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Practical tips when working with the young person

• Allow re-emergence of grief• Assist the young person to manage

difficulties with concentration (time management skills, study skills and relaxation skills)

• Anticipate increased behavioural and emotional problems and decreased capacity to learn - but don’t let the behaviour get out of hand before treating it as you would at any other time

Page 46: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Tips for working with families

• If parents are not doing well young people may experience increased distress and symptoms

• Discuss with them that it is OK to share their own grief – not to hide their sadness. This will help young people to feel more normal about their feelings.

• However if they are really distressed it may not be helpful to share feelings because it is important that young people know that parents are in control and can keep them safe

• Provide practical support as required• Problem solve for individuals and families

(housing , basic life issues)

Page 47: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Tips for working with families• Be aware of the other losses associated with the

major loss or death (loss of income, family networks, household and security)

• Family and marital problems can occur (crowded living conditions, loss of employment, forced separations)

• Connect them with the limited resources that are available

• Help them build resilience by developing a sense of routine and normality in their lives, re-establishing safety

Page 48: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Tips for working with families

• Remind parents to let the young person’s teacher or child care worker know what has happened so that they can be ready to support the young person

• Ensure that they are restricting the young person’s availability to media

• Provide awareness training about the effects of trauma and where they can get help from if they need it

Page 49: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Tips for you as a worker• Work out your own needs first –think about what

this disaster means for you before working with young people

• Your reactions will influence the young person’s• Don’t feel that you have to have all the answers• Don’t take it personally if they want to be alone

sometimes• Don’t take their anger or other problems

personally – they are part of the normal response to trauma

Page 50: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Tips for you as a worker

• The job is to evaluate if a person is able to be resilient and recover or if a referral for treatment is needed

• Don’t hesitate to get more advice and help• ‘Vicarious traumatisation’ – take time out,

participate in other professional activities that are not disaster related to achieve continuing balance and resilience for this difficult work

Page 51: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Key elements of a safe healing environment (Perry & Dobson, 2009)

• Information• Predictability• Structure• Patience• Compassion• Physical activity• Productivity• Hope

Page 52: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

When to refer?If the young person is experiencing:

• Re-experiencing the traumatic event / flashbacks / images• Severe and continued sleep disturbance / nightmares• Severe anxiety when separated from loved ones • Withdrawing from their friends and/or family• Avoiding thoughts, feelings or things that remind them of

the event• A depressed or irritable mood (and getting angry easily)• Behavioural problems at home or school• Self-doubt or other significant changes in emotions or

personality• Difficulty concentrating on and remembering other things• Substance use, dangerous behaviours, or unhealthy sexual

activity among adolescents

Page 53: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

PTSD is not the only issue:

• Symptoms of ‘depression’ were more prevalent than posttraumatic stress symptoms (Hurricane Katrina) – loneliness, sadness and anger

• Substance abuse (self medicating)

Page 54: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Individual Case – Leigh

•10 year old, boy•Referred as his mother had been murdered•He was removed from his father’s care as he was suspected of murdering his mother•Child protection and his ‘aunty’ were concerned for his mental state•One month into seeing Leigh his father suicided

Page 55: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

• Completed a clinical assessment to:

– Find out what Leigh was like prior to the incident (baseline behaviour)

– Find out how he was coping after the incident (including risk assessment)

– To assess what protective factors were present in Leigh’s life (caring school who were monitoring him closely, supportive and very loving ‘aunty’, uncle and cousin who had taken him in and reported that they would be involved in his long term care)

Page 56: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Intervention provided:

• Psycho-education with aunt/uncle and the school staff regarding what symptoms to look for

• For the first two months weekly sessions with aunt to discuss general parenting/caregiver issues and check in regarding Leigh’s behaviour/mental state

• Aunt could phone me at anytime (working hours) for a consultation if required

• Fortnightly sessions with Leigh to find out how his week had gone, build rapport, check risk factors – no therapy!

• Weekly phone calls to the school to check Leigh’s behaviour/mental state

• Then monthly for six months• Then closed the case ensuring that the family knew what to

look for and how to re-refer

Page 57: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Whole school response – after the bushfires

• Formed a mini team (CAMHS and School Support Services)

• First day of school, before school meeting with the teachers to provide psycho-education about normal responses to trauma

• Start of the school day met with students to discuss normal responses to trauma and introduce clinical staff

• Provided consultation to the Principal regarding how to structure the school week and provided assurance that they were doing the right thing

• Hung out in the staff room before school, lunch time and after school

• Hung out in the school yard during recess and lunch and engaged in general chat with students

Page 58: Alasdair Vance and Jo Winther Academic Child Psychiatry ... · Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital. ... • School

Whole school response – after the bushfires

• Provided individual session times for students that teachers were concerned about – filtered by the school nurse (psycho-education regarding normal reactions, risk assessments and discussion regarding strategies to manage these reactions)

• For the next month provided clinicians two days a week to touch base with the school and at risk students

• Ensured staff knew what to look for and how and where to make referrals if required in the future


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