Suicide Screening in Play Therapy Overview

1. Suicide Screening In Play Therapy SettingThis presentation is for read only purposes Lisa Cowart LPC, RPT-S, NCC

2. Introduction • Research is always changing so please review the literature and make your own educated choices and decisions of how to practice with the population you are serving and in the setting you provide service and within your skill set and training • Difficulty finding evidenced based research regarding younger children • Today is an overview the literature and practices I have become familiar with over the years

3. Statistics • Suicide is a global health issue as someone dies by suicide every 40 seconds somewhere in the world • Every year, nearly 1 million people die by suicide globally Tal Young I, Iglewicz A, Glorioso D, et al. Suicide bereavement and complicated grief. Dialogues in Clinical Neuroscience. 2012;14(2):177-186. • 90% individuals died by suicide had mental health issue or substance disorder (Tal Young I, Iglewicz A, Glorioso D, et al., 2012) • Nearly 80% of people experienced at least one type of childhood trauma who had attempted suicide O’Conner, Daryl, How we discovered the link between childhood trauma, a faulty stress response and suicide risk in later life. The Conversation. 2018. • More people die by suicide than homicide and wars. SUICIDE: WHAT THERAPISTS NEED TO KNOW There are many misconceptions about suicide. This continuing-education article helps to set the record straight. By Lisa Firestone, https://www.apa.org/education/ce/suicide.pdf

4. Statistics • 77 percent of individuals had contact with their primary care provider in the year before death by suicide. • 45 percent of individuals had contact with their primary care provider in the month before death by suicide. Mann, J.J., Apter, A., Bertolote, J., Beautrais, et al. (2005). Suicide prevention strategies: a systematic review. JAMA, 294(16), 2064-2074. Retrieved from http://www.daveneefoundation.org/wp-content/uploads/Suicide-Prevention-Strategies.pdf • Screening lowers suicide rates in adults.http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicideprevention.org/files/IDENTIFY.pdf

5. Adolescents • 15% of high school students have seriously contemplated suicide • 7% of high school students have made an attempt • Alabama Counseling Association Journal, Volume 38, Number 2 Suicide Interventions Targeted Toward At- Risk Youth Jennifer Langhinrichsen- Rohling, Ph.D., University of South Alabama, Department of Psychology Dorian A. Lamis, Ph.D., University of South Carolina Adrianne McCullars, Ph.D., University of South Alabama, Department of Psychology

6. Early Adolescents Children ages 12-14Sheftall AH, Asti L, Horowitz LM, et al. Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics. 2016;138(4):e20160436. doi:10.1542/peds.2016-0436 • Depression at higher rate in those who died by suicide • Impulsive responding may play a more prominent role • Arguments with family or significant others

7. Younger children 5-11 Sheftall AH, Asti L, Horowitz LM, et al. Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics. 2016;138(4):e20160436. doi:10.1542/peds.2016-0436 • Suicide is the 10th leading cause of death in elementary aged children (5-11) • More often males • Died at home by suffocation, hanging, • 1/3 had mental illness • ADHD and ADD was at a higher rate around 60% in this population than depression around 30% with this age group • Rate is on rise in AA males (in this study) • Often had relational problems with family or friends , arguments • Do not usually leave a note

8. 10 year old • Allegedly a 10-year-old female in Aurora Colorado who died by hanging in her closet according to multiple reports. • Allegedly her parents said she was confronting a bully. • The fight was recorded on a cellphone and uploaded to the app Musical.ly. at the end of October. • Two weeks following this fight and post the child attempted to die by suicide. • She spent two weeks on life support before dying in November. • Investigators were trying to still confirm the cause of her death. • And caution should be taken by attributing one factor to the cause. • After another Colorado child commits suicide, the search for solutions intensifies at schools and the statehouse • BY NIC GARCIA  -  DECEMBER 1, 2017

9. 16 year old California Boy • David Whiting wrote in Mercury news on March 28th, 2018, in article “Digital Lord of the Flies’: Teen Suicide Uptick began after Instagram, Snapchat launched” • Child commented that pressure for grades and college, social isolation, people constantly boasting about how great they are and all of the comparisons to one another contributed to his death. • He also emphasized how particular teachers made a difference one way or the other • http://google.com/newsstand/s/CBIw4JCx_Tc • https://www.mercurynews.com/2018/03/19/this-16-year-olds-suicide-letters-are-a-cry-for-help-and-a-national-call-for-change/ • https://www.mercurynews.com/2018/03/19/new-pressures-for-perfection-contribute-to-rise-in-teen-suicide/

10. Therapist • Seventy-one percent report having at least one client who has attempted suicide • 28 percent report having had one client die by suicide • SUICIDE: WHAT THERAPISTS NEED TO KNOW There are many misconceptions about suicide. This continuing-education article helps to set the record straight. By Lisa Firestone, https://www.apa.org/education/ce/suicide.pdf

11. YouthSheftallAH, Asti L, Horowitz LM, et al. Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics. 2016;138(4):e20160436. doi:10.1542/peds.2016-0436 • Most likely present with somatic complaints • If not asked directly about suicidal thoughts may not speak of them.47 • Use of suicide risk screening tools by pediatricians have been found to be associated with a 4-fold increase in detection of suicidal risk in youth • Adding to 1 extra mental health referral per week.

12. Screening for SuicideSheftallAH, Asti L, Horowitz LM, et al. Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics. 2016;138(4):e20160436. doi:10.1542/peds.2016-0436. • In a couple of studies examining precipitating circumstances to death by suicide, suicide intent in all age groups including youth suicide decedents was disclosed to another person before death with time for intervention in 29% of all suicide decedents. • Important for pediatricians, primary care providers, counselors, families, teachers, and peers to recognize and respond to the warning signs of suicide. • Proactively asking youth directly about suicidal thoughts is necessary as children and adolescents may not initiate these conversations

13. Recommendation by SPRC • Suicide in youth is the 2nd leading cause of death • National safety guidelines recommend that we screen children and adolescents for suicide risk • Asking children directly about thoughts of suicide is not harmful according to research. • Asking children directly about thoughts of suicide is important in the prevention of suicide and does not put ideas into the child’s head • https://www.sprc.org/sites/default/files/resource-program/asQToolkit_0.pdf

14. When Should Screening occur • Every client • Including existing clients • Especially when risk factors or life events determine screening is appropriate • If client screens positive for suicide risk then a full risk assessment, including risk formulation, should be completed for the client. • http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicideprevention.org/files/IDENTIFY.pdf

15. Where Clinical Setting • Outpatient • Hospital • Agency • Private Practice • School

16. What Population • In one study ¼ of children with suicidality under age of 12 had dx of ADHD Balazs J, Kereszteny A. Attention-deficit/hyperactivity disorder and suicide: A systematic review. World Journal of Psychiatry. 2017;7(1):44-59. doi:10.5498/wjp.v7.i1.44. • Sexual Abuse increased risk of SI after disclosure of abuse • Children with hx of abuse are at higher risk • Grief -individuals who have survived a loved one who died by suicide are 1.6 times more likely to have suicidal thoughts, 2.9 times more likely to have a plan for suicide, and 3.7 times more likely to have made a suicide attempt themselves Tal Young I, Iglewicz A, Glorioso D, et al. Suicide bereavement and complicated grief. Dialogues in Clinical Neuroscience. 2012;14(2):177-186. • Cluster B especially BPD are at higher risk • Chronic Pain are at higher risk • Bipolar are at higher risk • Depression higher risk

17. Gender • Females have more SI thoughts • Males have more completion rates

18. Who to screen • All ages including children

19. Historically • Previously, professionals used to believe children under 10 could not engage in suicidal behaviors due to lack of ability to make a mature concept of death due to concrete operational thinking not allowing them to conceptualize a plan and understand lethality and outcomes of their actions. Also they thought due to concrete thinking they could not understand the impact on others. • Currently professionals believe children as young as preschool have thoughts of suicidality and behaviors. • In one study children aged 5-10, 7 out of the 8 children involved intentional self poisoning. • One study revealed 1 five year old and 5 nine year olds completed death by suicide. • One study revealed of 16 children ages 2.5-5 year olds referred to them for serious self harm, 3 had one single event and 13 had multiple events of serious harm. • Tishler, Carl & Reiss, Natalie & R. Rhodes, Angel. (2007). Suicidal Behavior in Children Younger than Twelve: A Diagnostic Challenge for Emergency Department Personnel. Academic Emergency Medicine. 14. 810 - 818. 10.1111/j.1553-2712.2007

20. Perception of finality of death in Youth • Concrete verses abstract thinking (age 11) • Chronological age-usually by age 10 have a mature concept of death • Cognitive development plays a role in a child’s conceptualization of death and finality of death • Exposer to death assist in the concept of finality of death • Some contribute the immature concept of death in children to being a risk factor for suicide • Suicide Risk in Children By D.H. Granello|P.F. Granello — Pearson Allyn Bacon Prentice Hall Updated on Jul 20, 2010

21. When to screen • Phone intake • Intake in office • Each visit

22. Phone Intake • Name/ Physical Address/ DOB • Legal Guardian and Caregiver #, address • Reason for referral • Is there an abuse hx SA, PA, EA, N • Precipitating events/ losses, bullied, death • Mental Health Hx, • Previous/ Current Dx , Depression, Bipolar, ADHD, BPD • Previous/ Current Tx including inpatient admits • Previous response and commitment to treatment • Medications • Cognitive and Developmental Ability • Behavioral concerns, Impulsive, Violent • Gender, male vs females • Race/ethnicity, AA risk increasing • SI/HI (duty to warn), HI ^ • Suicide Plan ^ • Previous attempts ^ • Do they fall within my scope • Psychoeducation/ referrals

23. Initial Intake In Office • Hx. Will include mental health we just discussed because could be different person from the referral source who brought child • Sometimes individuals share more once in office after rapport • Brief Suicide Safety Assessmentincluding a screening tool https://www.sprc.org/sites/default/files/resource-program/asQToolkit_0.pdf • Research supports using a standardized screening tool along with clinical judgement is most effective • Research shows that a screening tool can identify suicide risk in individuals more reliably than just using clinical judgement. Sentinel Alert Event, A complimentary publication of The Joint Commission Issue 56, February 24, 2016

24. Two examples of Screening tools • CSSR Columbia Suicide Severity Rating Scale • PHQ- Patient Health Questionnaire

25. Cssr- Screener • Multiple languages over 100 • 5 minutes • Ages 5-65 (has a version of very young child and cognitively Impaired) • Self report, provider report, guardian, teacher reports • Teens and spouses • No training required • Very direct questions • Color coding to help you make decisions of low, medium or high • Available online http://cssrs.columbia.edu/

26. PHQ-9 • Parent/ guardian report • PHQ-2 • PHQ-9 • PHQ-A • No permission required to use • Instruction manual • Numerous Languages http://www.phqscreeners.com/select-screener/36 • Not as direct • https://echo.unm.edu/wp-content/uploads/2017/08/PHQ-Questions-2.pdf

27. Pros and Cons when using for SI screening • The sensitivity of Patient Health Questionnaire-9 item 9 was 92% and the specificity was 81%. The sensitivity of the C-SSRS was 95.0% and the specificity was 95%. • Patient Health Questionnaire-9 item 9 generated much higher rates of possible false-positive findings than the C-SSRS did. C-SSRS with clinical assessment may be a useful and efficient method of screening for suicidal riskif immediate clinical follow-up is available. • http://www.psychosomaticsjournal.com/article/S0033-3182(15)00079-1/pdf • Comparison of Electronic Screening for Suicidal Risk With the Patient Health Questionnaire Item 9 and the Columbia Suicide Severity Rating Scale in an Outpatient Psychiatric Clinic, Viguera, Adele C. et al., Psychosomatics , Volume 56 , Issue 5 , 460 - 469

28. Weekly/ or each Visit • Each visit use Update Questionnaire that you create (includes SI and HI question as well as any other changes such as address, placement, court, medications, mood, behaviors, concerns) clinician can read and answer with client or have guardian and client fill out. Must read before client leaves office. Preferably before session starts as that would allow you to do a risk assessment during the session time if there was a concern. • Each visit CSSR can be administered (could provide with Weekly Update) • Marsha Linehan- creator DBT training and certification, uses a rating scale of urge to kill self, urge to escape, urge not to be in therapy to assess • Use clinical judgement at each visit • Notice mood or behavior change in office

29. If Screened Yes, move to More In depth Assessments • SAFE-T (Suicide Assessment Five-step Evaluation and Triage) https://www.integration.samhsa.gov/images/res/SAFE_T.pdf • CSSR Risk Assessment (Columbia Suicide SEVERITY Rating Scale Risk Assessment) http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare/#filter=.general-use.english • Combined SAFE-T and CSSR on http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare/#filter=.general-use.english

30. Safety Plans • Individualized • Collaborative with client • Goal is to lower imminent risk • Write out a plan with client, concrete plan for them to reference • Have client share plan, with their consent, with others like emergency contact, caregivers, teachers, school counselor Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64

31. Warning Signs in Crisis

32. Warning Signs • Review what lead up to previous suicidal crisis • thoughts – negative self talk, hopelessness, helplessness, rehearsal of plan, racing thoughts • feelings –anxious, no way out, burden, loneliness and isolation, not worthy of love or connection • behaviors – sleeplessness, agitation, impulsivity • Images- arguments, abuse, rehearsal of plan • mood- irritable, depression, manic • body sensations- chest is heavy, pit in stomach, clinched hands, rocking, pacing • Situations- certain family members, humiliation, shame, sense of failure, sense of burden or isolation • Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64

33. Goal • Enhance protective factors- higher self efficacy of being able to self regulate, better sense of control of emotions and behaviors, increase interpersonal skills • Reduce risk factors- isolation, low interpersonal skills, low emotional regulation, stress level • Have child act out or tell the story of the suicidal event so you can work on what are warning signs that lead up to the event in creating the safety plan- use puppets, sand tray, dress up, doll house

34. Warning signs Thoughts- find a way to explore thoughts that lead up to suicidal ideations Puppets- https://www.easypeasyandfun.com/printable-hedgehog-puppets/

35. Feelings/ Mood- Increase Emotional vocab and Articulationand learn Warning signs • Feeling scale- • Feeling card matching game • Throw ball at chart • Pin the emotion like pin the tail on the donkey game

36. Images- Art • Art

37. Body Sensations • Outline body on butcher block paper

38. Behaviors-Puppets, sand

39. Situations- story telling, doll house

40. Factors that help in Crisis

41. Explore Coping Strategies • what has worked and what has not worked • emotional regulation • physical activities and exercise • guided Imagery • relaxation techniques • music • sensory • Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64

42. Distractions • People- friends, social activities, groups • Places- nature, coffee shop, basketball court • Activities- hiking, walking, choir, yoga, knitting, music, playing • Animals- pets • Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64

43. Safe People • healthy relationships • someone who listens and hears you • someone who does things for you • someone who sits with you or does things with you that make you feel better when stressed • For children at least 3 safe people who are accessible to them immediately- caregiver, parent, teacher • Weigh pros and cons of sharing suicidal thoughts as some people can make crisis situations worse • Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64 • Code word with safe person

44. Professionals • Mental Health • Crisis Centers • Crisis numbers • Psychiatrist (as the counselor notify them of the concern) • Primary Care Physician (as the counselor notify them of concern) • Emergency Department • List #’s and Addresses of these individuals and places

45. Make Environment Safe • firearm safety lock up or removal • medication safety lock up or removal • other means lock up or removal • Supervision of the child needs to increase • Routine, sleep, eating- creates safety • Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64

46. List • Write out the plan • Who collaborated in making the plan • Who was given a copy of the plan • You may want to sign and have the client sign • Help them identify where they want to store the plan to help them easily access it • Be as specific as possible in the plan • Create a tangible reminder of the plan if they do not have it with them they can remember and feel connected

47. Review the Plan • Contingency plans- scared of being hospitalized, fear they may not be able to remember or implement coping strategy (make list and engage others who can help them, remind them in the list to move to a location of help, explore what help looks like) • Explore foreseeable changes (stressors or events that could increase or decrease risk)- for adults this may be loss of a job or changing jobs, for children it could be moving classrooms, moving schools, perpetrator being released from jail

48. Build self-efficacy Around Safety Plan • Collaboration and Individualization of the plan • Role Play • Role modeling • Build self-efficacy- practice using puppets, games • Create concrete tangible plan for younger children -maybe a book with pictures, collages of safe people, places, coping strategies

50. Distractions