SCHOOL CRISIS PREVENTION & INTERVENTION: SUICIDE

SCHOOL CRISIS PREVENTION & INTERVENTION: SUICIDE David N. Miller University at Albany, S.U.N.Y. Richard Lieberman Los Angeles Unified School District Co-Chairs, NASP School Crisis Prevention & Intervention Workgroup - Suicide

The NASP School Crisis Prevention & Intervention Workgroup: Suicide • Connie Adams • Dixon Bryson • Wendy Carria • Ivan Croft • Elliott Davis • Kenneth Greff • Alan Hilden • Jennifer Kitson • Jack Martin • Scott Poland • Susan Ruof

Suicidal Behavior in Children and Youth: An Overview • Suicidal behavior includes suicidal ideation (thoughts), attempts, and completions • Suicide is the third-leading cause of death among children and adolescents in the U.S. • Suicide rate among children and youth has increased over 300% since the 1950s • A child or adolescent commits suicide in the U.S. approximately every 2 hours • Suicide rates highest among high school students, although there have been recent increases among middle school students

Suicidal Behavior in Children and Youth: An Overview • More children and adolescents die annually from suicide than from cancer, heart disease, AIDS, birth defects, and other medical conditions combined • Research suggests approximately 20% of high school students experience serious suicidal thoughts in a given year, and that about 4-8% make actual attempts • Over 2000 children and adolescents commit suicide annually • These statistics likely underestimate actual figures, although the degree to which this occurs is uncertain

Suicidal Behavior in Children and Adolescents: An Overview • In any given year in a typical high school class of 30 students: • 6 will seriously consider suicide • 2 to 3 will attempt suicide • 1 will make an attempt sufficiently harmful to require medical attention

Suicidal Behavior in Children and Adolescents: Demographics • Gender • Adolescent females attempt suicide at a rate of 2:1/ 3:1 compared to adolescent males • Adolescent males commit suicide at a rate of nearly 5:1 compared to adolescent females • Age • Rates of suicidal behavior increase as children get older, hitting peak in early 20s

Suicidal Behavior in Children and Adolescents: Demographics • Race • White males currently at highest risk • Other high risk groups: Native-American youth; African-American males • Limited data available on other groups • Geography • Highest suicide rates in Western states and Alaska • Lowest suicide rates in Northeastern states • Higher suicide rates in rural than in urban areas

Suicidal Behavior in Children and Adolescents: Demographics • When: • Slightly more suicides occur during Spring • Month with least amount of suicides: December • Suicide rates lower just before and during holidays • Where: • Most adolescent suicides occur at home, where primary means for suicide (typically firearms) are available

Suicidal Behavior in Children and Adolescents: Demographics • How: • Firearms are most popular method among both males and females who commit suicide in U.S. • Worldwide, hanging is the most frequently used method of youth suicide, and the second most popular method among U.S youth. • Risk of suicidal behavior a function of intent and lethality; students with high level of intent who use methods of high lethality (e.g., firearms) present greatest risk

Suicide Ideation, Attempts, and Completion • Three different types of suicidal behaviors (ideators, attempters, and completers) reflect different types of individuals • Typical youth suicide attempter: Adolescent female who ingests pills in front of her family during an argument • Typical youth suicide completer: Adolescent male who is a victim of a gunshot wound

Common Myths About Youth Suicide • Students who talk about suicide are just looking for attention • Listening to certain types of music (e.g., “heavy metal”) or engaging in certain activities (e.g., watching particular movies) causes people to become suicidal • Preventing access to lethal means will not prevent suicide - students will simply choose another method • Most dangerous myth: Talking about suicide will encourage suicidal behavior in students

Suicidal Behavior and Schools:Legal Issues • School districts have been found liable for not offering suicide prevention programs, for providing inadequate supervision of at-risk students, and for failing to notify parents when their children were suicidal • Liability issues are forseeability and negligence • Schools not responsible ultimately, but must demonstrate they made appropriate, “good faith” efforts to prevent suicide from occurring

Child/Adolescent Risk Factors in Youth Suicide • Previous suicide attempt • Current suicidal ideation, intent, and plan • Psychiatric Disorders and Problems • Depression • Hopelessness • Conduct problems • Drug and/or alcohol abuse • Impulse control problems (e.g., shoplifting; gambling; eating disorders; self-injury)

Child/Adolescent Risk Factors in Youth Suicide • Gay or lesbian sexual orientation • Unwillingness to seek help because of perceived stigma • Feelings of isolation or being cut off from others • Ineffective coping mechanisms • Inadequate problem-solving skills • Cultural and/or religious beliefs (e.g., belief that suicide is a noble or acceptable solution to a personal dilemma)

Environmental/Situational/Family Risk Factors in Youth Suicide • Access to lethal methods, especially firearms • Exposure to suicide and/or family history of suicide • Loss (e.g., death; divorce; relationships) • Victimization/exposure to violence (e.g., bullying) • School crisis (e.g., disciplinary; academic) • Family crisis (e.g., abuse; domestic violence; running away; child-parental conflict) • Influence (either through personal contact or media representations) of significant people who died by suicide • Barriers to accessing mental health treatment

Environmental/Situational/Family Risk Factors in Youth Suicide • Experiences of disappointment or rejection • Feelings of stress brought about by perceived achievement needs • Unwanted pregnancy; abortion • Infection with HIV or other sexually transmitted diseases • Serious injury that may change the individual’s life course (e.g., Traumatic Brain Injury) • Severe or terminal physical illness • Death of a loved one • Separation from family or friends

Suicide Clusters • Defined as more suicides or suicide attempts than expected, close together in time and location • Teens most susceptible to contagion • Appears to represent 1-5% of all suicides • Centers for Disease Control (CDC) estimates that 100-200 teens die in clusters annually • Media reporting may contribute to clusters

Youth Suicide Clusters:Community Characteristics • Lack of integration and belonging • Rapid community growth and large schools • High rates of substance abuse • Emphasis on material possession • Lack of mental health services and little awareness of problem of youth suicide • No 24-hour crisis hotlines • Lack of networking and coordination among community agencies

Warning Signs for Youth Suicide • Suicide threats • Suicide plan/method/access • Making final arrangements • Sudden changes in behavior, friends, or personality • Changes in physical habits and appearance • Preoccupation with death and suicide themes • Increased inability to concentrate or think clearly • Loss of interest in previously pleasurable activities • Symptoms of depression • Increased use and abuse of alcohol and/or drugs

Suicide Risk Assessment: Issues to Cover • What warning sign(s) initiated the referral? • Has the youth thought about suicide? • Has the youth tried to hurt himself/herself previously? • Does the youth have a plan to harm himself/herself now? • Has the youth told anyone about the suicidal plan, and what is the possibility of rescue?

Suicide Risk Assessment:Issues to Cover • Has the youth imagined the reaction of others to his/her death? • Has the youth made any final arrangements? • What method is the youth planning to use, and does he/she have access to the means? • What is the youth’s support system (e.g. parents, caregivers, other adults, friends, etc.) • What does the youth perceive as deterrents to suicide?

Suicide Risk Assessment: Interviewing Children and Youth • Calmly gather information • Be direct and unambiguous in asking questions • Assess lethality of method and identify a course of action • Use effective listening skills by reflecting feelings, remaining non-judgmental, and not minimizing the problem • Communicate caring, support, and trust while providing encouragement for coping strategies • Be hopeful; emphasize student’s worth • Determine if student has a thorough understanding of the finality of death

Suicide Risk Assessment:Interviewing Children and Youth • Gather information about youth’s and family’s history, with emphasis on suicide and substance abuse • Emphasize alternatives to suicide • Don’t make any “deals” to keep suicidal thoughts or actions a secret • Do not leave high-risk youth alone • Get supportive collaboration from colleagues • Be familiar with community resources • Outline the steps that will be taken to help the student • Keep detailed notes of procedures

“No-Suicide” or “Safety” Contracts • Widely used and recommended, but there is increasing controversy regarding their use • In reality, they are neither contractual nor ensure genuine safety • They tend to emphasize what students won’t do rather than what they will do • May be viewed by students as coercive, since failure to sign may force hospitalization • May give school psychologists a false sense of security • Better approach: Encourage students to commit to treatment rather than merely promising “safety”

Suicide Risk Assessment:Questions for Teachers • Have you noticed any major changes in your student’s schoolwork recently? • Have you noticed any behavioral, emotional, or attitudinal changes? • Has the student experienced any trouble in school? What kind of trouble? • Does the student appear depressed and/or hostile and angry? If so, what clues does the student give? • Has the student either verbally, behaviorally, or symbolically (in an essay or story) threatened suicide or expressed statements associated with self-destruction or death?

Suicide Risk Assessment:Questions for Parents/Caregivers • Has any serious change occurred in your child’s or family’s life recently? • (If yes) How did your child respond? • Has your child had any accidents or illnesses without a recognizable physical basis? • Has your child experienced a loss lately? • Has your child experienced difficulty in any areas of his/her life? • Has your child been very self-critical, or does he/she seem to think that you or teachers have been very critical lately?

Suicide Risk Assessment:Questions for Parents/Caregivers • Has your child made any unusual statements to you or others about death or dying? Any unusual questions or jokes about death or dying? • Have there been any changes you’ve noticed in your child’s mood or behavior over the last few months? • Has your child ever threatened or attempted suicide before, or attempted to harm himself/herself? • Have any of your child’s friends or family, including yourselves, ever threatened or attempted suicide? • How have these last few months been for you? How have you reacted to your child (e.g., with anger, despair, empathy)?

Special Issues in Suicide Risk Assessment: Self-Injury • Self-injury (also known as self-mutilation) involves the intentional self-destruction of body tissue without deliberate suicidal intent • Most typical form of self-injury is cutting • Self-injury appears to provide rapid but temporary relief from stress and tension, a sense of security or control, and/or decreases in distressing thoughts or feelings • Although youth who engage in self-injury are at increased risk for suicidal behavior, self-injury and suicide are two different types of problems and are not synonymous

Special Issues in Suicide Risk Assessment: Self-Injury • Making accurate distinction between suicidal behavior and self-injury is critical, because despite some similarities in appearance they serve different functions • An individual attempting suicide is trying to end his/her life, whereas the individual engaging in self-injury is typically trying to maintain it • In contrast to suicide completion, self-injury appears to be more prevalent in girls than boys • Self-injury typically begins in early adolescence and may persist for years if not adequately treated • The number of children and youth engaging in self-injury is likely underestimated and increasing

Suicide Risk Assessment:Selected Self-Report Scales • Adolescent Psychopathology Scale (APS) • Beck Scale for Suicidal Ideation (BSSI) • Children’s Depression Inventory (CDI) • Reynolds’ Adolescent Depression Scale, 2nd Edition (RADS-2) • Reynolds’ Child Depression Scale (RCDS) • Suicidal Ideation Questionnaire (SIQ) • Suicidal Ideation Questionnaire, Junior (SIQ-JR)

Predicting Probability of Suicidal Behavior • As with predicting probability of students engaging in school violence, this is difficult to do with a high degree of accuracy • As a “low base-rate” event, reliable and valid prediction of suicide at a precise or potential future time is virtually impossible • An added difficulty in accurate prediction is that suicidal behaviors are often temporally and situationally specific

Immediate Interventions for Suicidal Students • Assess severity of suicidal risk • Remove access to methods • Notify parents/caregivers and others as needed • Supervise student at all times • “Suicide-proof” the environment • Seek support and collaboration from colleagues • Mobilize a support team for student • Document all actions

School-Based Suicide Prevention Programs • Curriculum programs for students • In-service training for school personnel • Student self-report screening procedures

School-Based Suicide Prevention Programs: Curriculum Programs • Currently most investigated form of school-based suicide prevention • Goals of programs typically include: • Increasing student awareness • Training students to recognize warning signs • Providing students with available school and community resources

School-Based Suicide Prevention Programs: Curriculum Programs • Pros: • May change student knowledge and attitudes • May lead students to alert adults about peers • Potentially useful component of comprehensive suicide prevention program • Cons: • Many erroneously subscribed to “stress” model • Typically don’t examine effects on behavior • Criticized as inefficient • Suicidal youth often have limited peer networks

School-Based Suicide Prevention Programs: In-Service Training • Widely used model in schools • Typically includes following: • Discussion of warning signs • Discussion of sample cases • Referral procedures

School-Based Suicide Prevention Programs: In-Service Training • Pros: • Can lead to increased awareness among staff • May involve less risk and be less intrusive than other approaches • Found to produce positive effects on staff knowledge, attitudes, and referral practices • Cons: • Assumes staff can and will correctly identify suicidal students • Lacks efficiency and is a passive approach • One-shot in-service training often ineffective

School-Based Suicide Prevention Programs: Student Screening • Many researchers contend that direct assessment of students is an essential component of effective prevention • Reynolds’ 2-stage model: • 1. Initial self-report screening • 2. Follow-up individual interviews for those identified as at-risk

School-Based Suicide Prevention Programs: Student Screening • Pros: • Initial research promising • Uses more direct approach • Reliable and valid screening instruments available • Cons: • Will often over-identify students • More labor intensive than other procedures • May be less acceptable than other methods • Issue of timing of screening – When? How often?

School-Based Screening Programs • Teen Screen • www.teenscreen.org • Signs of Suicide (SOS) • www.mentalhealthscreening.org • (781) 239-0071 • Both have demonstrated effectiveness in identifying suicidal youth

Screening Programs:Signs of Suicide (SOS) • Two key components: educational video and questionnaire • Video is designed to teach teens warning signs of depression and suicide and the importance of getting help • Questionnaire designed to screen teens, with both subtle and direct questions about depression and suicide • Potentially at-risk teens flagged for further assessment and intervention as needed • Designated as an effective program by SAMHSA and has many sponsors, including NASP • Implemented in over 1500 schools nationwide

School-Based Suicide Prevention:Some Conclusions • A combination of primary and secondary prevention programs is recommended • Programs may be most effective when they involve multiple levels of influence and address multiple risk factors • Need to shift focus from prevention of separate disorders/problems to emphasis on healthy living and competency-based models

Suicide Postvention • Schools frequently not prepared for suicide, yet few events have greater impact on students, parents, and staff • Primary goal of postvention is to prevent further suicidal behavior and possible contagion effects

Suicide Postvention:Recommended “Dos” and “Don’ts” • Do plan in advance of any crisis • Do select and train a crisis team • Do verify that a suicide occurred • Do disseminate information to faculty, students, and parents; be truthful but avoid unnecessary detail • Do report information to students in small groups (classrooms) using fact sheets and uniform statements • Do not release information about the suicide in a mass assembly or over a loud speaker • Do have extra counselors available on site for students and staff

Suicide Postvention:Recommended “Dos” and “Don’ts” • Do not dismiss school or stop classes • Do not dedicate a memorial, fly flag at half-mast, or have a moment of silence for diseased; develop living memorials instead (e.g., student assistance programs) • Do allow students, with parental permission, to attend the funeral • Do not make special arrangements to send all students from a class or school to the funeral • Do contact the family and offer any assistance • Do collaborate with media, law enforcement, and community agencies

Suicide Postvention:Media Guidelines • Do not sensationalize with front page coverage and/or details of suicide method • Do not print pictures of deceased • Do not report the suicide as simplistic or romantic • Do emphasize that no one person or thing is to blame • Do provide information on suicide prevention • Do provide information about where students can go for help, including both school and community resources • Do emphasize that suicide is a preventable problem, and that we all have a role in it

References • Berman, A.L., Jobes, D.A., & Silverman, M.M. (2006). Adolescent suicide: Assessment and intervention, 2nd edition. Washington, DC: APA. • Brock, S.E. (2002). School suicide postvention. In S.E. Brock, P.J. Lazarus, and S.R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp. 553-576). Bethesda, MD: NASP • Kalafat, J., & Lazarus, P.J. (2002). Suicide prevention in schools. In S.E. Brock, P.J. Lazarus, & S.R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp. 211-223). Bethesda, MD: NASP. • Lieberman, R., & Davis, J. (2002). Suicide intervention. In S.E. Brock, P.J. Lazarus, & S.R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp. 531-551). Bethesda, MD: NASP. • Lieberman, R., & Poland, S. (2006). Self-mutilation. In G. Bear & K. Minke (Eds.), Children’s needs III. (pp. 965-975). Bethesda, MD: NASP. • Miller, D.N., & McConaughy, S.H. (2005). Assessing risk for suicide. In S.H. McConaughy Clinical interviews for children and adolescents (pp. 184-199). New York: Guilford.

Web-Based Resources • National Association of School Psychologists • www.nasponline.org • American Association of Suicidology • www.suicidology.org • American Foundation for Suicide Prevention • www.afsp.org • Centers for Disease Control • www.cdc.gov

SCHOOL CRISIS PREVENTION & INTERVENTION: SUICIDE