Youth Suicide Prevention in Wisconsin Schools

1. Gatekeeper Training Brenda Jennings And Kathryn Bush Wisconsin Department of Public Instruction Revised February 2012 Youth Suicide Prevention in Wisconsin Schools 1

2. Goals for this workshop 2 Present useful data Discuss risk factors Identify warning signs for suicide Suggest an easy way to help suicidal students: A.C.T. End youth suicide in Wisconsin!

3. 3 Wisconsin Law See bold sections on the handout,  “WI Youth Suicide Prevention Laws…” Help you meet your legal requirements Educate youth in suicide prevention Curriculum must be part of Health Instruction Model notice: suicide prevention resources Meet DPI’s legal requirements Training and TA for school-based prevention For more information see DPI website at www.dpi.wi.gov

4. 4 “Survivors” Suggest Use: “Completed Suicide” “Died by Suicide” “Took his/her own life” “Died of Suicide…” Avoid: “Successful Suicide Attempt” “Committed Suicide” it’s not illegal

5. 5 Among causes of death in WI, and how many youth dieby suicide every year? Except where noted, data on the next 10 slides are from  the DHS WISH data system—for 2000-2009, Ages 5-19 Wisconsin Dept. of Health Services, Division of Public Health, Bureau of Health Information and Policy. Wisconsin Interactive Statistics on Health (WISH) data query system, http://dhs.wisconsin.gov/wish/ Mortality Module, accessed 01/2012 Is Suicide A Problem?

6. Is Suicide A Problem? 6

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8. 8 CDC finds that the suicide rates tend to rise and fall with the economy. SPRC 4/2011CDC finds that the suicide rates tend to rise and fall with the economy. SPRC 4/2011

9. Let’s look at those youth suicides 9 379 Males, 88 Females (greater than a 4:1 ratio) Firearms consists of about half of the deaths (215) Of those 215, more than 89% (192) were males Suffocation resulted in 192 deaths Of those 192, more than 76% (147) were males Suffocation is the highest for both males and females in 2009 Other methods include poisoning, falls, drowning, vehicles DHS WISH Injury Mortality 2000-2009 (age 5-19)(accessed 01/12)

10. Let’s look at those youth suicides 10 Trends in the method over the 10-year span: Firearms drop by 50% in last 10 years Hanging/Suffocation rose by 66% in the last four years and almost doubled in last year Nationally and in Wisconsin, hanging/suffocation is becoming most common method DHS WISH Injury Mortality 2000-2009 (age 5-19 )(accessed 01/12)

11. Lethal Means 11 Firearm Case Fatality Rate = 89-91% Suffocation (hanging) Case Fatality Rate = 69% Poisoning Case Fatality Rate = 2% “Case fatality rate": of those who attempt suicide using a given method, the percent who die in that attempt. A suicide depends not only on intent but availability and accessability of the lethal means.“Case fatality rate": of those who attempt suicide using a given method, the percent who die in that attempt. A suicide depends not only on intent but availability and accessability of the lethal means.

12. Race and Ethnicity in those youth 12 7 were American Indian, for a rate of 4.39 414 were White, for a rate of 4.17 36 were Black, for a rate of 3.44 10 were Asian, for a rate of 2.85 450 Non-Hispanic, for a rate of 4.18 17 Hispanic, for a rate of 2.37 Rates per 100,000 youth age 5-19 DHS WISH Injury Mortality 2000-2009 (age 5-19) (accessed 01/12)

13. Top 10 causes of death in youth: 13 In the U.S Suicide is #4 Causes 10% of all deaths In Wisconsin Suicide is #2 Causes about 14% of all deaths

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15. Why Wisconsin? Some Hypotheses… 15 Drinking: lower inhibition, alter judgment Highest rate of youth binge drinking in US Availability of Lethal Means 12th highest gun ownership rate—43% Mental Health Service Availability 8.2 Child/Adolescent Psychiatrists/100,000 youth vs. recommended 14 Stigma…

16. Stigma 16 Stigma is dangerous because it prevents people from seeking help and meeting their own needs Stigma causes these barriers: Lack of awareness—we can’t even talk about it Reluctance to seek treatment—confirms problem Ignorance of how to seek services—who treats depression

17. Consider Youth Risk Behavior Survey (YRBS) data Other local surveys Anecdotal data Those seeking services Attempts Completions in students Consider students, staff, families, community Get your county data Local/County Data 17

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24. Online YRBS 24 Gather student self-reported data on health behaviors, attitudes and perceptions. Raise awareness of important health issues. Monitor the impact of prevention programs. Over 200 WI school districts have successfully used the OYRBS. Contact Emily Holder (608) 267-9170 or emily.holder@dpi.wi.gov

25. Reviewing YRBS Gender Data 25

26. LGBTQ Students at High Risk 26 Of students who had sexual contact with someone of the same gender: 44.6% Sad/Hopeless 39.7% Considered Suicide 32.2% Made a Plan 24.8% Made an Attempt (compared to 5.7% heterosexual youth) 10% Required Treatment due to Attempt (compared to 1.6% of heterosexual youth) 2009 YRBS comparison data for LGBTQ Youth 2009 YRBS is the last comparison data with LGBT youth2009 YRBS is the last comparison data with LGBT youth

27. Risk & Protective Factors 27 Being LGBT is not itself a risk factor for suicidal behavior BUT social stigma and discrimination unsafe schools ineffective providers are associated with mood, anxiety, and substance use disorders, and suicidal behavior. SPRC Jan. 2011

28. Family Rejection Can Predict Suicide 28 LGBT youth with higher levels of family rejection were more than eight times as likely to report suicide attempts than those with more family acceptance

29. Trevor Helpline: 866.4.U.TREVOR 29 The Trevor Project is a national organization focused on crisis and suicide prevention efforts among lesbian, gay, bisexual, transgender and questioning (LGBTQ) youth. The Trevor Project operates an AAS-accredited, nationwide, around-the-clock crisis and suicide prevention helpline for LGBTQ youth.

30. Other ways to help LGBTQ students 30 Start a Gay-Straight Alliance Get a “Safe Space” kit from the Gay, Lesbian and Straight Education Network (GLSEN). “Assure that each member of every school community is valued and respected regardless of sexual orientation or gender identity/expression.” Get a poster from GLSEN and put it on your office or classroom door at www.glsen.org www.gsaforsafeschools.org – GSA for Safe Schools

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32. 32 Risk Factors Direct Suicide-Risk Factors are most strongly associated with suicidal behaviors among youth: A prior suicide attempt (strongest predictor, 8X rate of no prior attempt) Suicide threats & ideation Detailed intentions for an attempt

33. 33 Exposure to Suicide is a Risk Factor Direct Exposure Youth who have family members who attempt suicide or die by suicide show high levels of at-risk behaviors, especially suicide ideation and attempts by a parent Indirect & Media Exposure Extensive coverage of suicide in media leads to increases in suicide attempts among vulnerable populations (youth, prior attempt)

34. 34 Related Suicide Risk Factors Serious depression, hopelessness Alcohol Use & Drug involvement Stressful life events (economy) Family conflicts/abuse (foster kids) Risky or impulsive behaviors (police)(bully/victim) School problems (perceived)(alternative school) Perceived overweight or underweight Cognitive (Problem-Solving) Skills (brain injury) Associations of Body Mass Index and Perceived Weight With Suicide Ideation and Suicide Attempts Among US High School Students Danice K. Eaton, PhD; Richard Lowry, MD; Nancy D. Brener, PhD; Deborah A. Galuska, PhD; Alex E. Crosby, MD  Arch Pediatr Adolesc Med. 2005;159:513-519 Regardless of body mass index, extreme perceptions of weight appear to be significant risk factors for suicidal behavior; important racial/ethnic differences exist. Those people who have experienced a concussion or brain injury may be at higher risk for suicide. Medscape 2011 Rates of nonfatal attempts and ideation have been found to be higher among youth who are in alternative schools. CDC 1999 Bullies and victims are at higher risk for depression and suicide. SPRC 2011Associations of Body Mass Index and Perceived Weight With Suicide Ideation and Suicide Attempts Among US High School Students Danice K. Eaton, PhD; Richard Lowry, MD; Nancy D. Brener, PhD; Deborah A. Galuska, PhD; Alex E. Crosby, MD Arch Pediatr Adolesc Med. 2005;159:513-519 Regardless of body mass index, extreme perceptions of weight appear to be significant risk factors for suicidal behavior; important racial/ethnic differences exist. Those people who have experienced a concussion or brain injury may be at higher risk for suicide. Medscape 2011 Rates of nonfatal attempts and ideation have been found to be higher among youth who are in alternative schools. CDC 1999 Bullies and victims are at higher risk for depression and suicide. SPRC 2011

35. 35 Related Risk Factors—Mental Illness “Completed Suicide and Psychiatric Diagnoses in Young People…” 89% had a diagnosed mental illness 40% had substance abuse disorder

36. 2011 YRBS2011 YRBS

37. 37 Alcohol/Sedatives and Suicide Dis-inhibiting Alters judgment Can trigger aggression Increases impulsivity Sedating Ataxia (falls, injuries) Coma-inducing

38. 38 Addiction can Trigger Mental Illness Addiction or abuse can trigger mental illness, and secondary or situational depression: Loss of relationships Loss of job Failure in school Legal, parental, school, or other disciplinary problems

39. 2011 YRBS Results for AODA 1st drink before 13 yrs. old = 18.6% At least one drink in the past 30 days = 39.2% 5 or more drinks in a row in past 30 days = 23.8% Got drunk in the past 30 days = 26.4% Used marijuana one or more times in past 30 days = 21.6% Ever used prescription drugs w/o prescription = 18.1% Ever used over the counter drugs to get high = 10.4% 39

40. 2011 YRBS Results Students thought parents would feel it is wrong for them to drink alcohol more than two times a month = 67.8% Students felt that there is at least one teacher/adult in school that they can talk to if they have a problem = 73.0% 40

41. 41 Repetitive Self-Harm: Related Risk Mostly females Onset at age 13 or 14 (anecdotally changing) Most report self-loathing Many report physical/sexual abuse Most report no pain-endorphins Usually have depression Need risk assessment & monitoring

43. 43 Repetitive Self-Harm: Related Risk Risk of suicidality increases with frequency Lack of coping skills Problem-Solving Deficits (Coping Skills) A cry for help, not manipulation Injury externalizes pain & isolation Episodic (response to conflict)

44. 44 Repetitive Self-Harm Teachers Identify these students Refer to crisis team Pupil Services Use cognitive-behavioral interventions Best role is to support clinical intervention You can have a group for depression, but not focused on self-harm Never discuss methods with the group For more information, go to www.sprc.org, look for NSSI – Non-suicidal Self-Injury

45. 45 Warning Signs Withdrawal Preoccupation with death Marked personality change & serious mood changes Difficulty concentrating/anxiety Decline in quality of school work AODA issues

46. 46 Warning Signs Change in eating habits (eating disorders) Change in sleep patterns—insomnia and hypersomnia (when combined, risk is even higher) Loss of interest in favorite activities Frequent complaints about physical symptoms, often related to emotions (stomachaches, headaches, fatigue) Persistent boredom Claiming to be a bad person Teens w/eating disorders are more likely to suffer from anxiety disorders, substance abuse, and suicide ideation. It’s easier to approach topic of sleep and physical health and then lead into suicide questions.Teens w/eating disorders are more likely to suffer from anxiety disorders, substance abuse, and suicide ideation. It’s easier to approach topic of sleep and physical health and then lead into suicide questions.

47. 47 Warning Signs Talking about suicide—specific plans, seeking means Impulsive (urgency/premeditation) Violent actions, rebellious/risky behavior, anger, or running away (trouble w/law – 3x) Refusing help or feeling beyond help (trapped) Hopelessness, helplessness, or worthlessness Worsening of sleep disturbance (last week of life) Urgency and premeditation was present, there was a high risk for suicide ideation and attempts Youth involved with the juvenile justice system are at 3 time the risk of attempting suicide (adults - 9 times) – General Psychiatry and Science Daily 2011Urgency and premeditation was present, there was a high risk for suicide ideation and attempts Youth involved with the juvenile justice system are at 3 time the risk of attempting suicide (adults - 9 times) – General Psychiatry and Science Daily 2011

48. 48 Warning Signs Being intolerant of praise or rewards Making statements that hint at or directly imply suicide Suddenly cheerful after a period of depression Giving away favorite possessions Making a last will & testament Having no purpose/reason to live

49. I Ideation S Substance Abuse P Purposelessness A Anxiety/Agitation T Trapped H Hopelessness W Withdrawal A Anger R Recklessness M Mood Changes “FREE Suicide Lifeline Materials” www.suicidepreventionlifeline.org 49 WARNING: IS PATH WARM?

50. Warning Signs of Acute Risk: 50 Threatening to hurt or kill him or herself, or talking of wanting to hurt or kill him/herself; and/or, Looking for ways to kill him/herself by seeking access to firearms, available pills, or other means; and/or, Talking or writing about death, dying or suicide, when these actions are out of the ordinary. SAMHSA 1/11

51. Impulsive Acts 51

52. 52 Suicide is not a “destiny” 90% of survivors of near-lethal suicide attempts do not complete suicide thereafter. That’s why we limit access to lethal suicide methods. NVISS Several 6.De Moore GM, Plew JD, Bray KM, Snars JN. Survivors of self-inflicted firearm injury. A liaison psychiatry perspective. Med J Aust 1994;160(7):421-5. Peterson LG, Peterson M, O'Shanick GJ, Swann A. Self-inflicted gunshot 9. Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a reexamination. Am J Psychiatry 2000;157(12):1925-32. 10. O'Donnell I, Arthur AJ, Farmer RD. A follow-up study of attempted railway suicides. Soc Sci Med 1994;38(3):437-42. 11. Seiden RH. Where are they now? A follow-up study of suicide attempters from the Golden Gate Bridge. Suicide Life Threat Behavior 1978;8(4):203-16. 12. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 2003;182:537-42. NVISS Several 6.De Moore GM, Plew JD, Bray KM, Snars JN. Survivors of self-inflicted firearm injury. A liaison psychiatry perspective. Med J Aust 1994;160(7):421-5. Peterson LG, Peterson M, O'Shanick GJ, Swann A. Self-inflicted gunshot 9. Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a reexamination. Am J Psychiatry 2000;157(12):1925-32. 10. O'Donnell I, Arthur AJ, Farmer RD. A follow-up study of attempted railway suicides. Soc Sci Med 1994;38(3):437-42. 11. Seiden RH. Where are they now? A follow-up study of suicide attempters from the Golden Gate Bridge. Suicide Life Threat Behavior 1978;8(4):203-16. 12. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 2003;182:537-42.

53. 53 Means Restriction is THE BEST! Firearms play a major role in suicide We promote safe storage 4 strategies each protect trigger locks/cabinets store unloaded lock ammo separate location

54. 54 Precipitating Factors Opportunities access to a gun periods without supervision Altered states of mind Rage intoxication--binge drinking high correlate Undesirable life events loss of an interpersonal relationship pregnancy/fear of pregnancy physical & sexual abuse humiliation (bullying) severe reprimand/punishment

55. 55 “Psychological Autopsy” 90% had some form of mental illness &/or AODA Old model: anyone stressed would attempt Our new model…

56. Many Factors to Suicide 56 Previous Mental Illness (Depression) + Stressor (Loss, etc.) + Opportunity (Firearm, Unsupervised Time)+ + Possible Suicide Attempt?

57. Internet and Suicide Negatives: Online bullying Spreading news of suicide inappropriately Online forums - anonymous and limited support Positives: +prevention strategies +can learn about what motivates people +networking +social support Live Science – SPRC 12/10/10 57

58. Bullying “Students who report being bullied, as well as those who admit to bullying others, have been found to have significantly higher rates of depression, suicidal ideation and suicidal behaviors than students who do not report experiences with bullying.” AFSP 2009 58

59. Facebook Launched a new suicide prevention tool A direct link to an online chat with counselors who can help Friends can report suicidal behavior anonymously National Suicide Prevention Lifeline provides link and online chat Help – Report a Problem SPRC 2011 59

60. 60 Protective Factors Important social resources strong interpersonal bonds social support sense of belonging dominant attitudes & values prohibit suicide Important personal resources strong sense of self-worth & self-esteem good cognitive skills sense of personal control self-management skills to deal with stress, anger and depression

61. 61 We add “ACT” as a protective factor A is for “Acknowledge” signs and symptoms, don’t minimize their feelings C is for showing “Care and Concern” for the person who is at-risk T is for “Tell” a trusted adult who knows how to respond, including pupil services, heath educators, or administrators in your school

62. Acknowledge 62 “That sounds really tough, I’m sorry to hear it.” “You have some major challenges on your plate.” Don’t minimize their feelings by saying: “You’ll get over it.” “Time heals all wounds.” “Stop worrying about it.” You don’t even have to ask questions!

63. Care and Concern 63 “I would hate for any harm to come to you.” “I don’t want this to get any worse. I’d really like to see you get some help.” “You’re an important part of my class and I want to be sure you stay safe.”

64. Tell 64 “I know Ms. Jennings in the Student Services office, and she works with many students who are facing challenges like this. Let’s go see her together.” Know your School Counselor, School Psychologist, School Social Worker, School Nurse, and other members of your Crisis Response Team. Take the student to see one of them right away, even if you’re not sure if it’s a crisis. If you can’t take them, notify someone on the crisis team immediately.

65. WI State Law Protects You 65 WI 118.295 Suicide intervention; civil liability exemption. “…any (school) officer, employee or volunteer, who in good faith attempts to prevent suicide by a pupil is immune from civil liability for his or her acts or omissions in respect to the suicide or attempted suicide.” You are safe in trying to help students. For private and public schools.

66. Scenario 66 17 year-old boy Girlfriend breaks up with him, starts feeling depressed Loses motivation, grades drop, social isolation Sleep disturbance, problem-solving and emotional regulation skills falter Gets poor score on tests Impulsive violent reaction gets him suspended Parents out of town for weekend Makes plan to use firearm in home when alone

67. What can schools do? 67 All staff and volunteers should be trained in identifying and helping suicidal students (gatekeeper training) Train all students (suicide prevention curriculum) Collaborate with Student Services/Health Teachers Develop prevention/intervention programs Student Services/Crisis Team should be skilled at suicide risk assessment or have access to someone who is skilled in this area (crisis plan) Don’t do it alone. Consult/Refer/Support

68. Remember 68 All you need to do to stop youth suicide is: ACT Acknowledge Care Tell The National Suicide Prevention Lifeline is always available at (800) 273-TALK or www.suicidepreventionlifeline.org

69. When you see urgent warning signs: 69 Don’t shame: “You’re too sensitive. Grow up!” Don’t delay: get help right away, don’t wait. Don’t blame: “If you wanted a better grade, you would have worked harder.” Don’t give up: suicide is NOT a destiny

70. Resources 70 Suicide Prevention Resource Center www.sprc.org Mental Health America of Wisconsin www.mhawisconsin.org HOPES www.hopes-wi.org AAS – American Association of Suicidology www.suicidology.org

71. Resources Prevent Suicide Wisconsin www.preventsuicidewi.org National Suicide Prevention Lifeline www.suicidepreventionlifeline.org Department of Public Instruction www.dpi.wi.gov search: YRBS, LGBT, or Suicide Prevention 71

72. DPI Contacts 72 Brenda Jennings Education Consultant, Suicide Prevention (608)266-7051 brenda.jennings@dpi.wi.gov Kathryn Bush School Psychology Consultant (608)266-1999 kathryn.bush@dpi.wi.gov