Culturally Responsive Youth Suicide Prevention and Intervention

1. Culturally Responsive Youth Suicide Prevention and Intervention October 2013 CSSW Conference Ellen Kelty, MA, NCSP Nationally Accredited School Suicide Prevention Specialist Mental Health and Assessment Services Denver Public Schools Ellen_kelty@dpsk12.org 720-423-8164

2. Is Suicide a Problem in Colorado? In 2011, there were: 195 Homicides 482 Motor vehicle deaths 610 Influenza and pneumonia deaths 790 Diabetes deaths 910 deaths by Suicide According to Colorado Health Info Dataset (COHID) http://www.cdphe.state.co.us/cohid

3. 2011 Healthy Kids Colorado Survey HSCompleted by 9th through 12th graders in public high schools in Colorado 22 percent reported feeling so sad or hopeless almost every day for two weeks or more in a row that they stopped doing some usual activities during the past 12 months 11.4% percent reported making a plan during the past 12 months 6 % reported an actual suicide attempt in the past 12 months http://www.cdphe.state.co.us/hs/yrbs/yrbs.html

4. 2011 Healthy Kids Colorado Survey MSCompleted by 9th through 12th graders in public high schools in Colorado 17.4 percent reported feeling so sad or hopeless almost every day for two weeks or more in a row that they stopped doing some usual activities during the past 12 months 10.4% percent reported making a plan during the past 12 months 5.7 % reported an actual suicide attempt in the past 12 months http://www.cdphe.state.co.us/hs/yrbs/yrbs.html

5. More Suicide Facts • Statewide, suicide is the 2nd leading cause of death for people 10 - 24 years old • In 2008 Colorado had the seventh highest rate of suicide in the country • http://webappa.cdc.gov/sasweb/ncipc/mortrate.html Ellen Kelty, MA, NCSP October 2013

6. Suicide and Other Violent Behavior • Given the strong correlation between suicidal and violent behavior, addressing suicidal behaviors may help address other violent behaviors. • 78% of school attackers exhibited a history of suicide attempts or suicidal thoughts at some point prior to their attack. • `(US Secret Service Report Safe School Initiative) Ellen Kelty, MA, NCSP October 2013

7. Who is at Risk? • Any youth can become suicidal • Suicide deaths in Colorado • 76% are male • 84% are white Non-Hispanic (2006) • Hospitalizations • 59% of hospitalizations for suicide attempts are female • 75% are white Non-Hispanic (2004) • Psychological autopsy studies have found that 90% of teen suicides could be retrospectively diagnosed with one or more mental disorders • (American Association of Suicidology Resource Guide 2008) Ellen Kelty, MA, NCSP October 2013

8. Special Populations at Greater Risk • LGBTQQ students • Students involved with juvenile justice system and foster care • Latino students • Students with disabilities Ellen Kelty, MA, NCSP October 2013

9. Suicide among LGBTQQ Youth LGBTQQ youth have a significantly higher rate of attempting suicide Most attempts among LGBTQ populations occur during adolescence and young adulthood 2005 MA YRBS – Students who self-reported as LGB were 4x as likely to report attempting suicide in the last year as compared to non-LGB counterparts LGBTQQ youth are more likely to be bullied, homeless, and ostracized by family because of their sexual preference or gender identity Suicide Risk and Prevention for Lesbian, Gay, Bisexual, and Transgender Youth, Suicide Prevention Resource Center

10. The Trevor Project • Operates the nation’s only 24-hour toll-free suicide prevention helpline for LGBTQQ youth • 1.866.4.U.TREVOR • www.thetrevorproject.org Ellen Kelty, MA, NCSP October 2013

11. Youth in Juvenile Justice and Child Welfare • 10% of CO youth are involved in either or both the juvenile justice and child welfare systems • Risk of suicide among adolescents involved with either the juvenile justice or child welfare systems was 5 x as high as those in the general adolescent population • (Farand, Chagnon, Renaud, Rivard, 2004) Ellen Kelty, MA, NCSP October 2013

12. Youth Detained in Juvenile Justice System • Chicago research project of 1829 youth • More than 1/3 of the youth and nearly 50% of females had felt hopeless or thought about death in the 6 months prior to detention • 10% had thoughts about committing suicide in the past 6 months • 10% had ever attempted suicide • Recent suicide attempts were most prevalent in females and youth with major depression and generalized anxiety disorder • Fewer than 50% with recent thoughts of suicide had told anyone about their ideation • Abram, Choe, Washburn, Teplin, King, and Dulcan(2008) Ellen Kelty, MA, NCSP October 2013

13. Juvenile Probation and Youth Suicide • Probation offenders with 8+ offenses are 5 x at risk • 90% of probation officers stated they are completely or somewhat responsible for mental health information about youth they supervise • 40% of probation officers indicated that it is acceptable for youth to pass through intake, adjudication & disposition without receiving a full assessment • 75% of probation officers indicated no one in their setting is responsible for mental health assessment • Wasserman, McReynolds, 2002 Ellen Kelty, MA, NCSP October 2013

14. Youth in Foster Care • 2 ½ x more likely to seriously consider suicide • 4x more likely to have attempted suicide • (Pilowsky & Wu, 2006). • 8-year-olds who were maltreated or at risk for maltreatment, nearly 10% reported wanting to kill themselves • (Thompson, 2005). • Experiencing childhood abuse or trauma increased the risk of attempted suicide 2 to 5x (Dube et al., 2001) • 2/3 of suicide attempts may be attributable to abusive or traumatic childhood experiences • (Dube et al., 2001) Ellen Kelty, MA, NCSP October 2013

15. Denver Health Kids Colorado Survey Data on Alternative Schools 11-12 Ellen Kelty, MA, NCSP October 2013

16. Students with Disabilities • Students in special education have higher rates of suicidal ideation and suicide attempts • These students have higher depression scores • A relationship exists between students having SIED and suicidal ideation and attempts • Adolescent females in special education think more about suicide and attempt more often than adolescent females in general education • (Wachter and Bouck, Teaching Exceptional Children, 2008) Ellen Kelty, MA, NCSP October 2013

17. Hispanic High School Students • Hispanic students considered suicide 2x more often than white students • Among females, over 32% of Hispanic girls considered suicide. • This number is more than 2x the percentage of white girls (15%) (Center for Disease Control and Prevention National Study, 2007) Ellen Kelty, MA, NCSP October 2013

18. Protective Factors What factors might be protective and help student to avoid suicide? Ellen Kelty, MA, NCSP October 2013

19. Protective Factors • Self-esteem • Involvement in community • Religious belief system • Coping strategies • good problem solving skills • Strong support system • Optimism Ellen Kelty, MA, NCSP October 2013

20. Chance of suicide • Increase when these factors occur at same time • Biological Factors • Risk Factors • Warning Signs • Immediate Trigger or Crisis • Model from American Association of Suicidology Ellen Kelty, MA, NCSP October 2013

21. Risk Factors for Teens • Psychopathology • Prior attempts • People who have attempted suicide are more likely to succeed in the future • Family Problems • Poor Coping Skills • Cognitive Inflexibility • Having alcohol or drug problem • 50% of teens who die by suicide have a high blood alcohol content at time of death Ellen Kelty, MA, NCSP October 2013

22. Genetic/Biological Risk Factors • Suicidal behavior runs in families • Identical twins higher rates then fraternal twins • Biological parents of teen suicides are more likely to have suicidal histories then do adoptive parents Ellen Kelty, MA, NCSP October 2013

23. Warning Signs • Acute Risk Factor Red Flag • Suicidal ideation • Looking for ways to kill self, practice • Increasing alcohol, drug use • Withdrawing from friends, family • Dramatic mood changes • Anxiety, agitation, sleep disturbance • Rage, uncontrolled anger • Hopelessness Ellen Kelty, MA, NCSP October 2013

24. Immediate Trigger or Crisis • Legal or disciplinary crisis most common • Break up with girlfriend/boyfriend • Public Humiliation/Shame • Major Loss • Sense of Failure Ellen Kelty, MA, NCSP October 2013

25. Suicidal Teens • Think their problems are unsolvable • Thinking narrows until they can’t see other solutions • Are dangerous to themselves for 24 - 78 hours • (Nelson and Galas) Ellen Kelty, MA, NCSP October 2013

26. Ellen Kelty, MA, NCSP October 2013

27. Cultural Factors in Suicide Preventions Ellen Kelty, MA, NCSP October 2013

28. Latino Youth • Among females may be related to the stress caused by the expectation of obligation to the family • May experience stress with the conflict between placing family needs above individuals needs and what is taught in the mainstream culture about the importance of individuality • Recently immigrated families may not understand the health care system and may be reluctant to seek help in the fear of being reported as undocumented • Families may avoid seeking mental health help because they feel that suicide should be dealt with by the family or faith community • First Language differences are a barrier to seeking help • Family closeness and good relations with parents are resiliency factor Ellen Kelty, MA, NCSP October 2013

29. Latinas caught between two cultures • Girls struggle to reconcile two cultures • The greater the level of emotional attunement and understanding between the daughter and her parents, the less likelihood of a suicide attempt • Typical Latina teen who attempts suicide • 14 or 15 • the daughter of immigrant parents • lives in a low-income setting • is caught in an intense battle with her mother over Latino and American cultures. • Zayas, Latinas Attempting Suicide: When Cultures, Families and Daughters Collide Ellen Kelty, MA, NCSP October 2013

30. Connection between Familism and Latina suicide attempts • Values • Family has a governing role • Family cohesion, obligation • Intense attachment to relatives • Deference to parents’ and the family’s needs • Interdependence • Cultural traditions socialize women to be passive, demure, and responsible for family obligations, unity, and harmony • A girl’s perception of causing a breach in family integrity may be a precondition for her suicide attempt • (Zayas, et all 2005, retrieved on 4-7-2012 at http://www.cathexa.com/uploads/Latina_Suicide.pdf) Ellen Kelty, MA, NCSP October 2013

31. Myths regarding Suicide in the African American Community • African Americans don’t die by suicide • Myth within the culture and in dominate culture • Women are strong, resilient and never take their own lives • Men are macho and never take their lives • African Americans don’t have depression • Faith based culture therefore suicide does not occur • Every 4.5 hr, one African American dies by suicide • Suicide in this population is responsible for 73,065 years of potential life lost • (Crosby & Molock, 2006). Ellen Kelty, MA, NCSP October 2013

32. African Americans youth • Rates were low until the beginning of the 1980’s when rates started to increase radically • Between 1981 and 1994, the rate increased 78% • Since then, the rate has decreased significantly • White youth are almost 2x as likely to die by suicide • Firearms are the predominant method of suicide regardless of gender and age, accounting for roughly 50.4% of all suicides • National Center for Injury Prevention and Control www.cdc.gov/ncipc/wisqars, 2009 Ellen Kelty, MA, NCSP October 2013

33. African Americans youth • Adolescents have both the highest number and the highest percentage of suicides in all of the African American population, and cohort studies have shown them to be more at risk than older generations • (Crosby & Molock, 2006; Joe, 2006) • Resource: http://www.nopcas.com/index.html Ellen Kelty, MA, NCSP October 2013

34. Suicide risk with Asian American Females • Asian-American women ages 15-24 have the highest suicide rate of women in any race or ethnic group in that age group • Suicide is the second-leading cause of death for Asian-American women in that age range Ellen Kelty, MA, NCSP October 2013

35. Suicide risk with Asian American youth • Higher rates among teens with • lower acculturation • parent-child conflict • collectivist/family-harmony values 72. • Lau AS, Jernewall NM, Zane N, Myers, 2008 • Protective factors • Religiosity • Family cohesion are protective against suicidal thoughts • Zang 1996 Ellen Kelty, MA, NCSP October 2013

36. Factors for Asian American youth • Stress related to being model minority • Expected to excel academically • Problems should be dealt with in the family • Value of privacy regarding family matters • Females • The cultural expectations may conflict with expectations of dominate culture • May not have freedom to socialize outside of school as much as white students Ellen Kelty, MA, NCSP October 2013

37. Native American /Alaskan Natives youth • Native youth have an average suicide rate 2.2x higher than the national average (CDC, 2005) • On certain reservations, the incidence of youth suicide has been documented at 10 times the national average • North Dakota 2004 there was an average of 6suicide attempts and 1 completion for every 5 days • Senator Byron L. 2010 Dorganhttp://www.apa.org/pubs/journals/features/ser-7-3-213.pdf • Significantly fewer (21%) urban-reared AI/AN youth were found to have suicide ideation versus 33% among reservation-reared youth • Cultural spiritual orientation is a protective factor • Freedenthal, S. & Stiffman, A. R. (2004) Ellen Kelty, MA, NCSP October 2013

38. Case Study • Jose is a Latino boy in fostercare. He attends a small school and is involved in art at the school • He recently was taken to the detention center for stealing a car. On the way there he kept saying he was suicidal. • Table top Discussion • What are Jose’s risk factors? • What are resiliency factors for Jose? • How will his cultural background impact his situation and need for treatment Ellen Kelty, MA, NCSP October 2013

39. Barriers to treatment • Cultural views of mental illness • Cultural views about mental health treatment • Mistrust of mental health system • Lack of culturally responsive treatment • Access to treatment • Concern about undocumented status • Stigma regarding seeking help • Language differences • Disconnect between faith and counseling services Ellen Kelty, MA, NCSP October 2013

40. Ideas for successful counseling for children of color • Include parents and extended family • Value and incorporate religious belief system • Be aware that depression or suicidal ideation maybe expressed differently than in white culture Ellen Kelty, MA, NCSP October 2013

41. Spiritual beliefs • Spiritual beliefs may be extremely relevant • There are many religions which denounce suicide • Child’s understanding of death may not be developed, may not understand death is permanent • Younger youth may want to die to be with family member • A fantasy may be that post suicide, a person is able to witness the impact on others, gaining revenge for a hurt. • Lack of spiritual belief or naïve concepts of death may predict lethality • (Zadah and Sandoval 2008) Ellen Kelty, MA, NCSP October 2013

42. Table Activity Individual- Think of the most difficult case that you have had with a suicidal youth What was the situation? Who was involved- what were the cultural differences between yourself and youth involved? Was the treatment successful? What if anything could have been done differently? Ellen Kelty, MA, NCSP October 2013

43. Talking to Students about Suicide • Talking about suicide will not give students the idea to complete suicide • Discussing the subject openly and showing that you care is one of the most helpful things that you can do • Ask directly, “Are you thinking of killing yourself?” • Ask even when they do not bring it up • Always ask about prior attempts Ellen Kelty, MA, NCSP October 2013

44. What to do • ASK— “Are you having thoughts of suicide?” Have you tried to kill yourself before? How did you try/would you do it? • LISTEN— “Tell me what’s been going on for you.” • TAKE ACTION. DO a suicide risk assessment- Connect to supportive services Ellen Kelty, MA, NCSP October 2013

45. Why do a Suicide Risk Review (SRR) ? • Research has shown that suicide risk assessments are effective in preventing suicide in middle and high school students • Identifying and assessing students who are considering suicide are clearly effective means of preventing it (Crepeau-hobson 2011) • To date, DPS has not lost a student to suicide when an SRR was completed. Ellen Kelty, MA, NCSP October 2013

46. Magic of 3,443 • 3 School Districts • Research- Based Suicide Prevention and district wide Suicide Risk Assessment • Of 3443 students assessed over a three year period, none went on to commit suicide • Conversely the small number of students who committed suicide during that time were not previously assessed by school personnel • Crepeau-Hobson, UCD 2012 • Assessment + Prevention = Saving Lives • Slide used with permission from Ron Lee, CCSD Ellen Kelty, MA, NCSP October 2013

47. When to Do a Suicide Risk Review • Should occur whenever a student conveys an intent to harm themselves • Intent can be conveyed a numbers of ways – verbal and written statements, drawings, song lyrics etc. • Intent is appearing on Facebook, Ims, and text messages • Need to consult? Contact: • Mental Health & Assessment at 720-423-8034 Ellen Kelty, MA, NCSP October 2013

48. SRR Step 1 to 3 • Make sure the student is safe • Do not leave them alone • Notify the building leader immediately that you have a suicidal student and are doing an assessment • Document the incident in detailIt is recommended that this process include two staff members with mental health training Ellen Kelty, MA, NCSP October 2013

49. SRR Step 4 Parent Notification Emergency Contract for Parents is completed • Available in English and Spanish • Needs to be signed by the parent or guardian • Parents receives a copy • If unable to reach parent or guardian • Document attempts • May need to do home visit • Can request police to do welfare check Ellen Kelty, MA, NCSP October 2013

50. SRR Step 5 • Talk to others involved with the student to get more background information Ellen Kelty, MA, NCSP October 2013