Suicide Screening in Play Therapy Setting

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. Suicide • There is not one cause • Suicide is complex and has many factors

4. Concerning • The number of children and teens who visited emergency rooms for suicidal thoughts and suicide attempts has doubled • The average age of a child evaluated for SA/ SI was 13 • 43% of children evaluated were ages 5-11 years of age • https://www.cnn.com/2019/04/08/health/child-teen-suicide-er-study/index.html • 1 in 5 kids have seriously considered suicide • More people die by suicide than traffic accidents -CDC

5. In the year before their death, 83 % of those who die by suicide have seen a health care provider • 40-50 percent of individuals who died by suicide had a primary care visit within a month of their death • Compliance Standards Pave the Way for Reducing Suicide in Health Care Systems. Julie Goldstein Grumet / Michael F. Hogan / Adam Chu / David W. Covington / Karen E. Johnson • Journal of Health Care Compliance — January–February 2019

6. 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

7. 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

8. 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

9. 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 • Often had relational problems with family or friends , arguments • Most likely present with somatic complaints

10. Media Programs and Series 13 reasons why- a teenager who takes her life and leaves 13 audio tapes of painful experiences she experienced before dying by suicide National Association of School Psychologist- Does not recommend that vulnerable youth, who have any degree of suicidal ideation May identify with the character, intense emotions, and sense of no way out https://www.nasponline.org/resources-and-publications/resources/school-safety-and-crisis/preventing-youth-suicide/13-reasons-why-netflix-series/13-reasons-why-netflix-series-considerations-for-families https://www.nasponline.org/resources-and-publications/resources/school-safety-and-crisis/preventing-youth-suicide/13-reasons-why-netflix-series

11. Goals to discuss today • Standardized and routine screening and assessment • Collaborative safety planning • Reducing access to lethal means • Treatment that targets suicidal thoughts and feelings directly • Follow-up during acute care transitions to reduce suicide • https://theactionalliance.org/sites/default/files/hccj_0102_19_grumet_0.pdf

12. Henry Ford Health System (HFHS) • Perfect Depression Care implemented “suicide assessment for all behavioral health patients, means restriction for patients at acute risk for suicide, provider education, follow-up via phone calls, and peer support services.” • Reduced suicide rate by about 75% • Avera Health, implemented Zero Suicide in five states in 2016 and approximately a year later observed a 97-percent decrease in suicide attempts among patients who had previously been hospitalized in the behavioral health inpatient units • Compliance Standards Pave the Way for Reducing Suicide in Health Care Systems. Julie Goldstein Grumet / Michael F. Hogan / Adam Chu / David W. Covington / Karen E. Johnson • Journal of Health Care Compliance — January–February 2019

13. 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

14. 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

15. When Should Screening occur • Every client at first visit (30% mental health professionals are not doing this) • https://theactionalliance.org/sites/default/files/hccj_0102_19_grumet_0.pdf • Existing clients • Also, 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

16. Where -Clinical Setting • Outpatient • Hospital • Agency • Private Practice • School

17. 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 and Depression higher risk • LGBTQ are at higher risk

18. Impulsive thought • * not all people who attempt or die by suicide are depressed, some have an impulsive thought and acting within 5-20 minutes https://www.hsph.harvard.edu/means-matter/means-matter/duration/

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

20. Who to screen • All ages including children

21. Historically • 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 thinking not allowing them to conceptualize a plan and understand lethality of their actions and not understanding 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 engaged in 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

22. 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

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

24. 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 • SI/HI (duty to warn), HI ^ • Suicide Plan ^ • Previous attempts ^ • Do they fall within my scope • Psychoeducation/ referrals

25. 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

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

27. 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/

28. 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

29. 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

30. 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. • 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 • Use clinical judgement at each visit • Notice mood or behavior change in office

31. 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

32. 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

33. Safety Planning We have Tornado and fire drills, have a individualized safety plan for suicide crisis

34. Warning Signs in Crisis

35. Safety Planning-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

36. 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

37. Using Play Therapy to Assist in Safety Planning

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

39. 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

40. Images- Art • Art

41. Body Sensations • Outline body on butcher block paper

42. Behaviors-Puppets, sand

43. Situations- story telling, doll house

44. Factors that help in Crisis

45. Explore Coping Strategies • Start and stop games increase impulse control(Simon says, red light green light) • emotional regulation (breathing, breaks, mindfulness, yoga) • physical activities and exercise • guided Imagery • Muscle relaxation techniques • music • Sensory (soothing objects, wrapping in weighted blanket) • Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64

46. Distractions • People- friends, social activities, groups (also give a sense of connection and belonging and need different groups in case something is not working in one area) • Places- nature, coffee shop, basketball court • Activities- hiking, walking, choir, yoga, knitting, music, playing • Animals- pets (dogs have lower resting heart rate helps child regulate) • Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64

47. Safe People • healthy relationships (healthy caregiver interaction helps children learn to regulate) • someone who listens and hears you • someone who does things for you • someone who sits with you or provides you comfort that makes 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

48. Professionals (connection with mental health resources reduces risk) • 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

49. 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 and regulation • Stanley B & Brown GK, A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19:2, May 2012, 256-64

50. List • Write out the safety 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