Welcome Attendees

1. Welcome Attendees

2. Housekeeping Notes • Please turn cell phones and pagers off or to vibrate mode during sessions. Ringing, beeping or electronic music going off during the workshops is extremely distracting to everyone in the room. • Evaluations: These will be given out during each session. Completed evaluations should be turned in after each session to the registration desk. • CEUs: To receive a CEU certificate attendees must sign out at the registration desk AND turn in their evaluation form(s).

3. Youth Suicide, Self Injury and the Choking Game: Critical Issues for Prevention and Intervention Dr. Scott Poland NOVA Southeastern University National Emergency Assistance Team spoland@nova.edu

4. Suicide Prevention: What Works? • Survey of research in 35 countries from 1960 to 2005 • Most effective prevention involves restricting lethal means and educating everyone on warning signs especially physicians

5. 2007 YRBSS RESULTS • Surveyed 15,000 H.S students and in the last year • 28.5 % reported being sad or hopeless • 11.3% made a suicide plan • 6.9% made an attempt

6. Recommendations • Create a task force and develop school policies • Train staff on warning signs • Form a partnership with community resources • Train staff in assessment • Parent notification is essential • Provide referral and follow-up when a student is suicidal

7. Secret Service Study of School Shooters; Conclusions There is no profile of school shooters Revenge was the motive Most were the victims of bullying Two thirds were suicidal.

8. Bullying • Repetitive • Humiliating • Physical and/or verbal • Involves power • New term ‘Bullicide”

9. Reduce Bullying…. Turn the “silent majority” into a “caring majority”.

10. WARNING SIGNS OF YOUTH SUICIDE • Suicide notes • Threats • Symptomatic clues • Giving away prized possessions/making a will • Fascination with death

11. PROTECTIVE FACTORS • Family cohesion and stability • Coping and problem solving skills • Positive self worth and impulse control • Positive connections to school and extracurricular participation • Successful academically

12. PROTECTIVE FACTORS • Good relationships with other youth • Seeks adult help when needed • Lack of access to suicidal means • Access to mental health care • Religiosity

13. Childhood Adversities • Childhood maltreatment • Problematic family relations • Socioeconomic hardship • Difficult relations with peers • Juvenile/police arrests/incarcerations • Numerous childhood adversity dramatically raises risk

14. Postvention Situation • Newburyport, MA • Student suicide on steps of high school • Should you allow large scale memorial on steps? Parents say their children feel like they are walking over victim’s body and why isn’t school responding the way they did for accident victim?

15. Mares vs. Shawnee Mission Schools • Two brothers who attended same school died by suicide • Case involved questions of postvention and mental health responsibilities of school after first death and could second death have been prevented? • Case settled in mediation

16. Other LEGAL CASES • Wyke Vs. Polk County • Eisel Vs. Montgomery County • Szostek Vs. Cy-Fair • Brooks Vs. Logan • Jasperson Vs. Anoka Hennepin • Corales Vs. Montclair

17. Suicide/Legal Case • An 8th grade boy who was disciplined for truancy goes home and kills himself • He leaves behind a note saying the AP is a blank and he had to many problems • The parents sue claming their child was denied his constitutional right to participate in an Immigration Rally. How would you defend the school district?

18. Choking Game The object is to cut off blood flow to carotid artery causing the player to nearly or completely pass out, then releasing the pressure allowing the rush of blood back into the brain causing a lightheaded feeling resembling a quick high.

19. Warning Signs: • Frequent headaches. • Bruises or abrasions on neck. • Blood shot eyes or flushed face • Agitated or aggressive moods • Presence of strap, rope or belt without reason www.gaspinfo.com

20. Factors are impulsivity and thrill seeking Contagious often done in pairs Debate as to whether it results in suicidal or accidental deaths Prevention involves protective factors and increased supervision Choking or Blackout Game

21. Choking Game • Estimate is that several hundred adolescents die each year www.gaspinfo.org • Hanging deaths are on increase • Many adolescents who do not use drugs see the choking game as acceptable • Adolescents often seek thrills and communities need to provide recreational/adventure programs

22. Self Mutilation/Self Injury Definition Issues • Multitude of terms • Major type infrequent/severe associated with psychotic population • Stereotypic such as head banging/biting associated with developmentally disabled • Moderate/superficial such as cutting found in non-hospitalized and “normal population”

23. Scenario for Teacher • You have noticed one of your students who has never worn a short sleeve shirt has a bandaged wrist on several occasions • What should you do?

24. Case Situation • A teacher has referred a 13 year old girl to you for self mutilation concerns • The girl readily admits to you that following an argument at home she cut her arm last night to feel better and shows you the bandages. • You are the counselor-- what do you do as she begs you not to tell her parents?

25. Another Scenario • Another student has been referred to the counselor for depression and anxiety. • The 13 year old admits to cutting in the past and shows you an old scar and states that she doesn’t do it anymore. • What do you do?

26. Repetitive Self Injury/Mutilation Syndrome • Recurrent failure to resist impulses to harm one’s body physically without suicidal intent—Favazza • New Axis I has been proposed RSM • Compulsive-- hair pulling and skin picking • Impulsive– cutting and burning

27. Understanding and Responding to Students who Self-Injure • Very complex behavior that fulfills a multitude of needs • Contagious: often runs in peer groups • Respond individually • Assess for suicide risk as estimates are 20 to 50% are suicidal

28. Contagion • Rite of togetherness • Popularized by movies such as “Thirteen” • Separate the dominant female • Individual counseling preferred over group • My body expresses what words can not (Lori from Oklahoma)!

29. New Breed • Less body image emphasis • More related to stress • Younger onset • More amenable to treatment • One method of SI only • Less psychiatric history

30. Understanding and Responding • Warn and involve parents • Increase circle of care • Utilize school/community resources • Do not discourage self harm or get into power struggles----focus on underlying behavior • Do teach substitute behaviors that focus on help-seeking/communication skills, reduction of tension and isolation

31. Suicide----want to end all feelings Precipitating event Give advance warning Less frequent Assess for suicide risk Use No Harm contract Notification of parent essential Referral Self Mutilation---want to feel better Precipitating event Rarely give warning Repeat behavior Assess for suicide risk Use No Harm contract Controversy over parent notification Referral Suicide Vs. Self Injury

32. THEORIES • Releases Endorphins • Helps Regulate Emotions • Anger Directed Inward for Catharsis • Trauma History • Provided Poor Role Models for Coping

33. Want to feel concrete pain when psychological pain is overwhelming Reduces numbness Keeps trauma from intruding I cut so I will not kill myself Gets attention of others Discharges tension, anger and despair Gain a sense of control Punish myself Cutting is better than going out and getting drunk What Do Kids Report?

34. Excerpts from Cutter’s Poem • “Turn up the music and set the mood • Once is never enough • Quivering with anticipation • Watch it the drop spills over and runs down my arm • Crimson orgasm---you seduce me every time Mr. Knife” • Sight of blood flow is central to experience

35. Helping Those Who Self Injure • Care about the person and the pain behind the injury • Respect their efforts to cope • Emphasis it is important to talk about it and SI can be understood • Recognize it takes a long time for individuals to give up SI

36. Strategies Students Suggest • Carry safe stuff---stress relievers • Find something to do –keep brain & hands busy • Journaling • Collage work • Call friend----suck on hot candy • Snap a rubber band

37. More Suggestions • Get sensory input---aromatherapy, lip balm or lotions • Scribble with red crayon on arm or paper • Brush skin with toothbrush • Get exercise---carry skates with me • Make a list of surroundings and details for reality check

38. Additional Suggestions • Tear paper • Use play-dough • Brush teeth and hair • Squeeze stress balls • Scribble on paper • Take hot shower • Scratch clothes

39. No single treatment identified in the literature as most effectiveCombination of medication and therapy most effectiveMedications most used are Prozac, Paxil and ZoloftNaltrexone-opiate blocker

40. Promising Therapies—progress is slow • Dialectical Behavior Therapy---skill training for mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance • Manual Assisted Cognitive Behavior Therapy---reduces anxiety as manuals are used at home • Intensive/ lengthy require frequent contact and record keeping such as diaries to help manage emotions and understand triggers for RSM-educated family as allies in assessment and intervention

41. PREVENTION: Screening Programs • Rationale is research found adolescents will answer questionnaires honestly • Screening does not create suicidal ideation • Screening programs may identify as much as 10% of school population • Parent consent is required and examples provided of active or passive consent

42. PREVENTION: Screening Programs • Referral system and services for suicidal teens must be in place prior to screening • School reluctance to implement screening is combination of denial of youth suicide and academic time pressures • Drawback to screening is that suicidal thoughts of adolescents fluctuate and they may not have been suicidal on screening date

43. PREVENTION: Screening Programs • Signs of Suicide SOS www.mentalhealthscreening.org SOS research found fewer suicide attempts and increased adult help seeking behavior

44. Signs of Suicide (ACT) • Two key components: educational video and questionnaires that emphasize acknowledge, care and tell! • Video is designed to teach teens the warning signs of depression and suicide and the importance of getting adult help • Student and/or parent questionnaires screen for depression and take 5 to 10 minutes with subtle and direct questions about depression and suicide

45. Signs of Suicide (SOS) • Potential at-risk youth are flagged for further screening and intervention • Designated as an effective program by SAMHSA and has many sponsors including NASP, NASSP, NASN and ASCA • Program has been implemented in approximately 2500 schools • Nonprofit organization and cost for starter kit and 500 questionnaires is $200

46. RISK ASSESSMENT: Key Questions • Are you thinking about suicide now? • Have you ever attempted before? • How would you end your life?

47. SUICIDE INTERVENTION:Intervention strategies • No-Harm Contracts/Safety Plans • Increase connectedness with adults • Increase help–seeking behaviors • Improve communication skills • Increase linkages with community and school resources

48. Criticisms of Contracts • May be more for therapist’s benefit • Have not been proven effective • Should not be used in place of treatment • Should be only one aspect of assessment and intervention

49. Midwestern Suicide Cluster • Six Suicides Between August and December • Two deaths of students from each of three high schools • Students did not know each other • Small Group Activity Report on Postvention Strategies

50. Postvention Strategies • Follow recommended guidelines • Reach out to family of the victim • Acknowledge the death without glorifying it • Focus on traumatized and suicidal students • Emphasize prevention: no one thing/person is to blame and help is available • Avoid sensational media coverage