Suicidality and Self-Injury in Middle School

1. Suicidality and Self-Injuryin Middle School SOS Signs of Suicide® Program Screening for Mental Health, Inc.

2. Screening for Mental Health, Inc. • 1991: Pioneered the concept of large scale mental health screening with National Depression Screening Day. • SMH Programs include: • SOS Signs of Suicide® High School Program • National Alcohol Screening Day® • CollegeResponse® • WorkplaceResponse® • HealthcareResponse®

3. The Problem: Youth Suicide and Related Risk Factors

4. Prevalence of Suicide in Youth • While child suicide is very uncommon, mortality from suicide increases steadily through the teens. • NIMH, In Harms Way, Suicide in America, 2003 • Suicide is the sixth leading cause of death among 5-14 year olds and the third leading cause of death among those 15-24. • American Foundation for Suicide Prevention

5. Prevalence of Suicide in Youth • In Mississippi, suicide is the 3rd leading cause of death among youth ages 15-24.

6. Prevalence of Suicide in Youth • Suicide also affects youth ages 5-14.

7. Prevalence of Suicide in Youth • Adolescent suicidal behavior is deemed underreported because many deaths of this type are classified as unintentional or accidental. • World Health Organization, 2000 • Over 90% of children and adolescents that die by suicide have a mental health disorder at the time of their death, most often depression.

8. Prevalence of Suicide-Related Phenomena in Middle School Age Group • Seriously thought about killing themselves • 18% of 6th graders • 19% of 7th graders • 24% of 8th graders • Made a plan about how to kill themselves • 11% of 6th graders • 12% of 7th graders • 12% of 8th graders • Made a suicide attempt • 7% of 6th graders • 9% of seventh graders • 11% of eighth graders CDC Middle School Youth Risk Behavior Survey, 2003

9. What Are Risk Factors? • Suicide is a complex behavior that is usually caused by a combination of risk factors in the context of negative life events • A risk factor is anything that increases the likelihood that persons will harm themselves. • Risk factors are not necessarily causes. • The first step in preventing suicide is to identify and understand the risk factors. -Adapted from the National Youth Violence Prevention Resource Center

10. SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric IllnessCo-morbidity Neurobiology Personality Disorder/Traits Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Illness Suicide Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior

11. Depression and Youth • In 2004, 9% of adolescents aged 12 to 17 (an estimated 2.2 million adolescents) experienced at least one major depressive episode in the past year -SAMHSA, 2005 • In children and adolescents, an untreated depressive episode may last between 7 to 9 months (Birmaher et al., 1996a, 1996b) —potentially, an entire academic year! • Depression has been linked to suicide, poor school performance, substance abuse, running away, and feelings of worthlessness and hopelessness -National Institute for Mental Health, 2005

12. Symptoms ofAdolescent Depression • Frequent sadness, tearfulness, crying • Hopelessness • Decreased interest in activities; or inability to enjoy previously favorite activities • Persistent boredom; low energy • Social isolation, poor communication • Low self esteem and guilt • Extreme sensitivity to rejection or failure

13. Symptoms ofAdolescent Depression (cont.) • Increased irritability, anger, or hostility • Difficulty with relationships • Frequent complaints of physical illnesses such as headaches and stomachaches • Frequent absences from school or poor performance in school • Poor concentration • A major change in eating and/or sleeping patterns • Talk of or efforts to run away from home • Thoughts or expressions of suicide or self destructive behavior -AACAP, The Depressed Child

14. Signs of Suicide • Talking, reading, or writing about suicide or death (including online communication) • Talking about feeling worthless or hopeless • Direct verbal cues like “I wish I were dead.” • Indirect verbal cues like “You will be better off without me.” • Visiting or calling people to say goodbye. • Giving things away. • A sudden interest in drinking alcohol. • Purposefully putting oneself in danger. • Obsessed with death, violence, and guns or knives. • Previous suicidal thoughts or attempts. -http://pbskids.org/itsmylife * list is not all inclusive

15. Suicidality and Substance Abuse • Youths aged 12-17 who reported past year alcohol use (19.6%) were more likely than youths who did not use alcohol (8.6%) to be at risk for suicide. • SAMHSA, NHSDA Report, Substance use and the Risk of Suicide Among Youths, 2002 • 1/3 to ½ of teenagers were under the influence of drugs or alcohol shortly before they killed themselves. • National Strategy for Suicide Prevention, DHHS

16. Self-injury in Youth • In the pediatric population, self-injury is defined as deliberate non-lethal harming of oneself • Self-injury is a maladaptive coping skill employed by youth experiencing painful emotions • Is generally NOT an attempt to die by suicide. • Between 150,000 and 360,000 adolescents in the U.S. self-injure • Walsh, Lieberman, 2004.

17. Self-injury Comes in Several Forms • Behaviors include: • Cutting – the most common form • Burning • Hitting • Poking • Picking • Hair pulling • Putting oneself in harms way • Head banging

18. Relationship Between Suicideand Self-injury • Death can occur, even if unintentionally • Those who self-injure may become suicidal in the future. • The student is experiencing a mental health disorder that should be treated professionally and stands the best chance of recovery if caught early. • If handled inappropriately or not at all, there is a potential for contagion.

19. Why Focus on Youth Prevention • Many adult mental disorders have related antecedent problems in childhood • Children who first become depressed before puberty are at risk for some form of mental disorder in adulthood • Suicide rates increase dramatically from early adolescence to young adulthood • A previous suicide attempt is the leading risk factor for adult suicide • Introducing prevention early may help promote prevention throughout the lifecycle • NIMH, 2005

20. Developmental Stages ofYounger Children • Early adolescence is a time of emotional transition when individuals transfer their sense of interpersonal closeness from parents to peers. • Rothbaum et. al., Child Development, 2000 • Due to this transition, addressing the peer group is developmentally appropriate for those youth who have begun to confide in friends. • Since younger students are more apt to share concerns with adults it is also important to encourage help-seeking from adults. • In other words, you have to address both the role of peers and the role of adults.

21. Integrated Prevention Strategies • Integrated prevention strategies that address multiple associated factors are likely to be more effective in reducing suicidal behavior that programs that focus on a single risk factor. • Grunbaum et al., Surveillance Summaries, 2004 • Risk factors for youth include: • Depression • Conduct disorder • Suicidal ideation • Alcohol use • Self-injury

22. Protective Factors

23. Protective Factors • Afford protection against suicidal behavior: • Good relationship with family • Support from family and friends • Good social skills • Seeks help and advice • Participation in positive social activities

24. The SOS Middle School Program

25. Goals of the Program Decrease the incidence of self-injury, suicide attempts, unrecognized depression, and the number of youth who die by suicide Encourage individual help seeking, as well as help seeking on behalf of a friend Increase knowledge and adaptive attitudes about depression, suicidality, and self-injury Reduce stigma associated with mental health problems by communicating that these problems are treatable

26. SOS Middle School Program Components • Video/DVD – “SOS: Get Into the ACT” with Discussion Guide • Posters • Stickers -- “ACT” • Parent newsletter • Student newsletter • Classroom Games • Self-injury packet • Procedure Manual • Screening Forms for staff use

27. SOS Middle School Video/DVDWith Discussion Guide • The SOS: Get Into The Act video is the main teaching tool of the middle school program. • Help students recognize the signs of suicide, depression and self-injury in a friend or within themselves and respond to them as they would in any type of health emergency. • Aim is to create a supportive and responsive atmosphere for those youth who may be at-risk for depression, suicide, or self-injury by empowering them to know how to recognize the warning signs and seek help.

28. Action Message -- ACT • Acknowledge: Acknowledge that your friend has a problem and it is serious • Care: Let the person know you are concerned and want to help • Tell: Tell a trusted adult

29. The ACT Message • The message is primarily directed to peers to encourage them to help a friend but it emphasizes the need to tell a trusted adult • ACT can be generalized to use with any social problem

30. Staff Training Suggestions Show the “Get Into the ACT” video and facilitate a discussion Review the signs of suicide and depression. Answer questions, dispel myths Review the school policy for handling students who disclose suicidal intent Review school and community resources. Distribute protocol for what to do when approached by students asking for help “Feed them and they will come.”

31. Staff Training Training faculty and staff is universally advocated and essential to a suicide prevention program. Research indicates that training faculty and staff can produce positive effects on an educator’s knowledge, attitudes and referral practice. Smith, T & Smith V., Lazear, K, Roggenbaum, S., & Doan, J., 2003.

32. Staff Materials Staff in-service lecture Guidelines for teachers and school clinicians for responding to youth who self-injure (Self-injury Packet) Parent Newsletter for staff who are parents Center for Epidemiological Studies Depression Scale for Children (CES-DC) for school staff to use with individual students seeking help

33. Staff Training (cont.) Schools must prepare staff as students may disclose to any adult. Train to increase school staff’s knowledge about: SOS program: why, when, where, how Warning signs School and community based mental health resources School protocol for providing help for at-risk youth

34. Common Objections “Suicide is not a problem in our school.” “Schools are not appropriate for suicide prevention programs.” “The program may introduce the idea to students.” “I don’t have enough staff or time.” “We have problems making referrals.” “I don’t agree with labeling youth.” “We already have a suicide prevention program.”

35. Responses to Common Objections No school is immune to adolescent suicide. Depression has been linked to poor school performance, substance abuse, running away, and feelings of worthlessness and hopelessness. Integrating the topics of depression and suicide in a health curriculum can reduce stigma associated with these problems and can create a supportive atmosphere. The program can be used flexibly using existing resources and partnering with community providers. Identifying needs can justify funding and/or partnerships. Share resources within school districts. Establish relationship with existing providers. Implementing the SOS program does not result in diagnosis. Decisions about diagnosis and treatment are made between a doctor and a patient, and, in the case of minors, the parent/guardian(s).

36. Student Materials • Student newsletter • ACT stickers promote peer-to-peer communication by making the ACT message popular, personal and powerful. • ACT posters to reinforce the ACT message

37. Interactive Classroom Games • Classroom games serve as a way of increasing both knowledge and skills in students • Games that have learning complexity and are successfully infused into the curriculum are an effective strategy to move the knowledge and skills students receive into long-term memory and result in positive behaviors

38. Parent Materials • Parent materials are provided to actively engage parents in a school’s prevention efforts, to: • Gain their support • Provide information about mental health resources available in the school and community • Encourage parents to discuss the problems of depression, suicide, and self-injury with their children. • By raising awareness, schools can partner with parents to watch for the signs of problems in their children and instill confidence in parents to seek help for their children if necessary.

39. Implementation Overview • School personnel implement the program with materials provided • Can be implemented in one or two classroom periods • Students view and discuss video in classroom. • Students are assigned Student Newsletter to read • Students participate in classroom game

40. Implementation Overview (cont.) • Entire student body or a select portion of student body may participate in the program. • Parent newsletter assists in the identification of depression, self-injury, and suicidality and helps initiate family discussion • Active or passive parental permission • Parent Night • Staff Training

41. Information You Need to Know Prior to Training

42. Info To Know • School policies and procedures associated with youth who may display suicidal behaviors • Community resources

43. National Suicide Prevention Lifeline

44. Talk About It • AnComm's Talk About Itservice allows individuals to communicate anonymously with the MS Department of Mental Health Helpline Staff from this website or from your cell phone via Text Messaging

45. For more information about the SOS Middle School or the SOS High School program, please reach us at:781-239-0071sosinfo@MentalHealthScreening.orgOr visit:www.MentalHealthScreening.org/schools Screening for Mental Health, Inc. One Washington Street, Suite 304 Wellesley Hills, MA 02481 Phone: 781.239.0071 Fax: 781.431.7447 www.mentalhealthscreening.org