SPECIAL TOPICS IN SCHOOL CRISIS PREVENTION

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SPECIAL TOPICS IN SCHOOL CRISIS PREVENTION
INTERVENTION SUICIDE

• Richard Lieberman
• Los Angeles Unified School District
• David N. Miller
• University at Albany, S.U.N.Y.
• Co-Chairs, NASP School Crisis Prevention
  Intervention Workgroup - Suicide

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The NASP School Crisis Prevention Intervention
Workgroup Suicide

• Connie Adams
• Dixon Bryson
• Wendy Carria
• Ivan Croft
• Elliott Davis
• Kenneth Greff
• Alan Hilden
• Jennifer Kitson
• Jack Martin
• Scott Poland
• Susan Ruof

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Suicidal Behavior in Children and Youth An
Overview

• Suicidal behavior includes suicidal ideation
  (thoughts), attempts, and completions
• Suicide is the third-leading cause of death among
  children and adolescents in the U.S.
• Suicide rate among children and youth has
  increased over 300 since the 1950s
• A child or adolescent commits suicide in the U.S.
  approximately every 2 hours
• Suicide rates are highest among high school
  students, although there have been recent
  increases among middle school students

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Suicidal Behavior in Children and Youth An
Overview

• More children and adolescents die annually from
  suicide than from cancer, heart disease, AIDS,
  birth defects, and other medical conditions
  combined
• Research suggests approximately 20 of high
  school students experience serious suicidal
  thoughts in a given year, and that about 4-8
  make actual attempts
• Over 2000 children and adolescents commit suicide
  annually
• These statistics likely underestimate actual
  figures, although the degree to which this occurs
  is uncertain

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Suicidal Behavior in Children and Adolescents An
Overview

• In any given year in a typical high school class
  of 30 students
• 6 will seriously consider suicide
• 2 to 3 will attempt suicide
• 1 will make an attempt sufficiently harmful to
  require medical attention

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Suicidal Behavior in Children and Adolescents
Demographics

• Gender
• Adolescent females attempt suicide at a rate of
  21/ 31 compared to adolescent males
• Adolescent males commit suicide at a rate of
  nearly 51 compared to adolescent females
• Age
• Rates of suicidal behavior increase as children
  get older, hitting peak in early 20s

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Suicidal Behavior in Children and Adolescents
Demographics

• Race
• White males currently at highest risk
• Other high risk groups Native-American youth
  African-American males
• Limited data available on other groups
• Geography
• Highest suicide rates in Western states and
  Alaska
• Lowest suicide rates in Northeastern states
• Higher suicide rates in rural than in urban areas

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Suicidal Behavior in Children and Adolescents
Demographics

• When
• Slightly more suicides occur during Spring
• Month with least amount of suicides December
• Suicide rates lower just before and during
  holidays
• Where
• Most adolescent suicides occur at home, where
  primary means for suicide (typically firearms)
  are available

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Suicidal Behavior in Children and Adolescents
Demographics

• How
• Firearms are most popular method among both males
  and females who commit suicide in U.S.
• Worldwide, hanging is the most frequently used
  method of youth suicide, and the second most
  popular method among U.S youth.
• Risk of suicidal behavior is a function of intent
  and lethality students with high level of intent
  who use methods of high lethality (e.g.,
  firearms) present greatest risk

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Suicide Ideation, Attempts, and Completion

• Three different types of suicidal behaviors
  (ideators, attempters, and completers) reflect
  different types of individuals
• Typical youth suicide attempter Adolescent
  female who ingests pills in front of her family
  during an argument
• Typical youth suicide completer Adolescent male
  who is a victim of a gunshot wound

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Common Myths About Youth Suicide

• Students who talk about suicide are just looking
  for attention
• Listening to certain types of music (e.g., heavy
  metal) or engaging in certain activities (e.g.,
  watching particular movies) causes people to
  become suicidal
• Preventing access to lethal means will not
  prevent suicide - students will simply choose
  another method
• Most dangerous myth Talking about suicide will
  encourage suicidal behavior

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Suicidal Behavior and SchoolsLegal Issues

• School districts have been found liable for not
  offering suicide prevention programs, for
  providing inadequate supervision of at-risk
  students, and for failing to notify parents when
  their children were suicidal
• Liability issues are forseeability and negligence
• Schools not responsible ultimately, but must
  demonstrate they made appropriate, good faith
  efforts to prevent suicide from occurring

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Child/Adolescent Risk Factors in Youth Suicide

• Previous suicide attempt
• Current suicidal ideation, intent, and plan
• Psychiatric Disorders and Problems
• Depression
• Hopelessness
• Conduct problems
• Drug and/or alcohol abuse
• Impulse control problems (e.g., shoplifting
  gambling eating disorders self-injury)

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Child/Adolescent Risk Factors in Youth Suicide

• Gay or lesbian sexual orientation
• Unwillingness to seek help because of perceived
  stigma
• Feelings of isolation or being cut off from
  others
• Ineffective coping mechanisms
• Inadequate problem-solving skills
• Cultural and/or religious beliefs (e.g., belief
  that suicide is a noble or acceptable solution to
  a personal dilemma)

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Environmental/Situational/Family Risk Factors in
Youth Suicide

• Access to lethal methods, especially firearms
• Exposure to suicide and/or family history of
  suicide
• Loss (e.g., death divorce relationships)
• Victimization/exposure to violence (e.g.,
  bullying)
• School crisis (e.g., disciplinary academic)
• Family crisis (e.g., abuse domestic violence
  running away child-parental conflict)
• Influence (either through personal contact or
  media representations) of significant people who
  died by suicide
• Barriers to accessing mental health treatment

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Environmental/Situational/Family Risk Factors in
Youth Suicide

• Experiences of disappointment or rejection
• Feelings of stress brought about by perceived
  achievement needs
• Unwanted pregnancy abortion
• Infection with HIV or other sexually transmitted
  diseases
• Serious injury that may change the individuals
  life course (e.g., Traumatic Brain Injury)
• Severe or terminal physical illness
• Death of a loved one
• Separation from family or friends

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Suicide Clusters

• Defined as more suicides or suicide attempts than
  expected, close together in time and location
• Teens most susceptible to contagion
• Appears to represent 1-5 of all suicides
• Centers for Disease Control (CDC) estimates that
  100-200 teens die in clusters annually
• Media reporting may contribute to clusters

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Youth Suicide ClustersCommunity Characteristics

• Lack of integration and belonging
• Rapid community growth and large schools
• High rates of substance abuse
• Emphasis on material possession
• Lack of mental health services and little
  awareness of problem of youth suicide
• No 24-hour crisis hotlines
• Lack of networking and coordination among
  community agencies

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Warning Signs for Youth Suicide

• Suicide threats
• Suicide plan/method/access
• Making final arrangements
• Sudden changes in behavior, friends, or
  personality
• Changes in physical habits and appearance
• Preoccupation with death and suicide themes
• Increased inability to concentrate or think
  clearly
• Loss of interest in previously pleasurable
  activities
• Symptoms of depression
• Increased use and abuse of alcohol and/or drugs

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Suicide Risk Assessment Issues to Cover

• What warning sign(s) initiated the referral?
• Has the youth thought about suicide?
• Has the youth tried to hurt himself/herself
  previously?
• Does the youth have a plan to harm
  himself/herself now?
• Has the youth told anyone about the suicidal
  plan, and what is the possibility of rescue?

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Suicide Risk AssessmentIssues to Cover

• Has the youth imagined the reaction of others to
  his/her death?
• Has the youth made any final arrangements?
• What method is the youth planning to use, and
  does he/she have access to the means?
• What is the youths support system (e.g. parents,
  caregivers, other adults, friends, etc.)
• What does the youth perceive as deterrents to
  suicide?

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Suicide Risk Assessment Interviewing Children
and Youth

• Calmly gather information
• Be direct and unambiguous in asking questions
• Assess lethality of method and identify a course
  of action
• Use effective listening skills by reflecting
  feelings, remaining non-judgmental, and not
  minimizing the problem
• Communicate caring, support, and trust while
  providing encouragement for coping strategies
• Be hopeful emphasize students worth
• Determine if student has a thorough understanding
  of the finality of death

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Suicide Risk AssessmentInterviewing Children
and Youth

• Gather information about youths and familys
  history, with emphasis on suicide and substance
  abuse
• Emphasize alternatives to suicide
• Dont make any deals to keep suicidal thoughts
  or actions a secret
• Do not leave high-risk youth alone
• Get supportive collaboration from colleagues
• Be familiar with community resources
• Outline the steps that will be taken to help the
  student
• Keep detailed notes of procedures

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No-Suicide or Safety Contracts

• Widely used and recommended, but there is
  increasing controversy regarding their use
• In reality, they are neither contractual nor
  ensure genuine safety
• They tend to emphasize what students wont do
  rather than what they will do
• May be viewed by students as coercive, since
  failure to sign may force hospitalization
• May give school psychologists a false sense of
  security
• Better approach Encourage students to commit to
  treatment rather than merely promising safety

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Suicide Risk AssessmentQuestions for Teachers

• Have you noticed any major changes in your
  students schoolwork recently?
• Have you noticed any behavioral, emotional, or
  attitudinal changes?
• Has the student experienced any trouble in
  school? What kind of trouble?
• Does the student appear depressed and/or hostile
  and angry? If so, what clues does the student
  give?
• Has the student either verbally, behaviorally, or
  symbolically (in an essay or story) threatened
  suicide or expressed statements associated with
  self-destruction or death?

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Suicide Risk AssessmentQuestions for
Parents/Caregivers

• Has any serious change occurred in your childs
  or familys life recently?
• (If yes) How did your child respond?
• Has your child had any accidents or illnesses
  without a recognizable physical basis?
• Has your child experienced a loss lately?
• Has your child experienced difficulty in any
  areas of his/her life?
• Has your child been very self-critical, or does
  he/she seem to think that you or teachers have
  been very critical lately?

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Suicide Risk AssessmentQuestions for
Parents/Caregivers

• Has your child made any unusual statements to you
  or others about death or dying? Any unusual
  questions or jokes about death or dying?
• Have there been any changes youve noticed in
  your childs mood or behavior over the last few
  months?
• Has your child ever threatened or attempted
  suicide before, or attempted to harm
  himself/herself?
• Have any of your childs friends or family,
  including yourselves, ever threatened or
  attempted suicide?
• How have these last few months been for you? How
  have you reacted to your child (e.g., with anger,
  despair, empathy)?

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Special Issues in Suicide Risk Assessment
Self-Injury

• Self-injury (also known as self-mutilation)
  involves the intentional self-destruction of body
  tissue without deliberate suicidal intent
• Most typical form of self-injury is cutting
• Self-injury appears to provide rapid but
  temporary relief from stress and tension, a sense
  of security or control, and/or decreases in
  distressing thoughts or feelings
• Although youth who engage in self-injury are at
  increased risk for suicidal behavior, self-injury
  and suicide are two different types of problems
  and are not synonymous

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Special Issues in Suicide Risk Assessment
Self-Injury

• Making accurate distinction between suicidal
  behavior and self-injury is critical, because
  despite some similarities in appearance they
  serve different functions
• An individual attempting suicide is trying to end
  his/her life, whereas the individual engaging in
  self-injury is typically trying to maintain it
• In contrast to suicide completion, self-injury
  appears to be more prevalent in girls than boys
• Self-injury typically begins in early adolescence
  and may persist for years if not adequately
  treated
• The number of children and youth engaging in
  self-injury is likely underestimated and
  increasing

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Suicide Risk AssessmentSelected Self-Report
Scales

• Adolescent Psychopathology Scale (APS)
• Beck Scale for Suicidal Ideation (BSSI)
• Childrens Depression Inventory (CDI)
• Reynolds Adolescent Depression Scale, 2nd
  Edition (RADS-2)
• Reynolds Child Depression Scale (RCDS)
• Suicidal Ideation Questionnaire (SIQ)
• Suicidal Ideation Questionnaire, Junior (SIQ-JR)

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Predicting Probability of Suicidal Behavior

• As with predicting probability of students
  engaging in school violence, this is difficult to
  do with a high degree of accuracy
• As a low base-rate event, reliable and valid
  prediction of suicide at a precise or potential
  future time is virtually impossible
• An added difficulty in accurate prediction is
  that suicidal behaviors are often temporally and
  situationally specific

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Immediate Interventions for Suicidal Students

• Assess severity of suicidal risk
• Remove access to methods
• Notify parents/caregivers and others as needed
• Supervise student at all times
• Suicide-proof the environment
• Seek support and collaboration from colleagues
• Mobilize a support team for student
• Document all actions

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School-Based Suicide Prevention Programs

• Curriculum programs for students
• In-service training for school personnel
• Student self-report screening procedures

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School-Based Suicide Prevention Programs
Curriculum Programs

• Currently most investigated form of school-based
  suicide prevention
• Goals of programs typically include
• Increasing student awareness
• Training students to recognize warning signs
• Providing students with available school and
  community resources

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School-Based Suicide Prevention Programs
Curriculum Programs

• Pros
• May change student knowledge and attitudes
• May lead students to alert adults about peers
• Potentially useful component of comprehensive
  suicide prevention program
• Cons
• Many erroneously subscribed to stress model
  rather than a mental health model
• Typically dont examine effects on behavior
• Criticized as inefficient
• Suicidal youth often have limited peer networks

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School-Based Suicide Prevention Programs
In-Service Training

• Widely used in schools
• Typically includes following
• Discussion of warning signs
• Discussion of sample cases
• Referral procedures

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School-Based Suicide Prevention Programs
In-Service Training

• Pros
• Can lead to increased awareness among staff
• May involve less risk and be less intrusive than
  other approaches
• Found to produce positive effects on staff
  knowledge, attitudes, and referral practices
• Cons
• Assumes staff can and will correctly identify
  suicidal students
• Lacks efficiency and is a passive approach
• One-shot in-service training often ineffective

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School-Based Suicide Prevention Programs Student
Screening

• Many researchers contend that direct assessment
  of students is an essential component of
  effective prevention
• Reynolds 2-stage model
• 1. Initial self-report screening
• 2. Follow-up individual interviews for those
  identified as at-risk

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School-Based Suicide Prevention Programs Student
Screening

• Pros
• Initial research promising
• Uses more direct approach
• Reliable and valid screening instruments
  available
• Cons
• Will often over-identify students
• More labor intensive than other procedures
• May be less acceptable than other methods
• Issue of timing of screening When? How often?

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School-Based Screening Programs

• Teen Screen
• www.teenscreen.org
• Signs of Suicide (SOS)
• www.mentalhealthscreening.org
• [phone]
• Both have demonstrated effectiveness in
  identifying suicidal youth

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Screening ProgramsSigns of Suicide (SOS)

• Two key components educational video and
  questionnaire
• Video is designed to teach teens warning signs of
  depression and suicide and the importance of
  getting help
• Questionnaire designed to screen teens, with both
  subtle and direct questions about depression and
  suicide
• Potentially at-risk teens flagged for further
  assessment and intervention as needed
• Designated as an effective program by SAMHSA and
  has many sponsors, including NASP
• Implemented in over 1500 schools nationwide

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School-Based Suicide PreventionSome Conclusions

• A combination of primary and secondary prevention
  programs is recommended
• Programs may be most effective when they involve
  multiple levels of influence and address multiple
  risk factors
• Need to shift focus from prevention of separate
  disorders/problems to emphasis on healthy living
  and competency-based models

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Suicide Postvention

• Schools frequently not prepared for suicide, yet
  few events have greater impact on students,
  parents, and staff
• Primary goal of postvention is to prevent further
  suicidal behavior and possible contagion effects

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Suicide PostventionRecommended Dos and
Donts

• Do plan in advance of any crisis
• Do select and train a crisis team
• Do verify that a suicide occurred
• Do disseminate information to faculty, students,
  and parents be truthful but avoid unnecessary
  detail
• Do report information to students in small groups
  (classrooms) using fact sheets and uniform
  statements
• Do not release information about the suicide in a
  mass assembly or over a loud speaker
• Do have extra counselors available on site for
  students and staff

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Suicide PostventionRecommended Dos and
Donts

• Do not dismiss school or stop classes
• Do not dedicate a memorial, fly flag at
  half-mast, or have a moment of silence for
  diseased develop living memorials instead (e.g.,
  student assistance programs)
• Do allow students, with parental permission, to
  attend the funeral
• Do not make special arrangements to send all
  students from a class or school to the funeral
• Do contact the family and offer any assistance
• Do collaborate with media, law enforcement, and
  community agencies

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Suicide PostventionMedia Guidelines

• Do not sensationalize with front page coverage
  and/or details of suicide method
• Do not print pictures of deceased
• Do not report the suicide as simplistic or
  romantic
• Do emphasize that no one person or thing is to
  blame
• Do provide information on suicide prevention
• Do provide information about where students can
  go for help, including both school and community
  resources
• Do emphasize that suicide is a preventable
  problem, and that we all have a role in it

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References

• Berman, A.L., Jobes, D.A., Silverman, M.M.
  (2006). Adolescent suicide Assessment and
  intervention, 2nd edition. Washington, DC APA.
• Brock, S.E. (2002). School suicide postvention.
  In S.E. Brock, P.J. Lazarus, and S.R. Jimerson
  (Eds.), Best practices in school crisis
  prevention and intervention (pp. 553-576).
  Bethesda, MD NASP
• Kalafat, J., Lazarus, P.J. (2002). Suicide
  prevention in schools. In S.E. Brock, P.J.
  Lazarus, S.R. Jimerson (Eds.), Best practices
  in school crisis prevention and intervention (pp.
  211-223). Bethesda, MD NASP.
• Lieberman, R., Davis, J. (2002). Suicide
  intervention. In S.E. Brock, P.J. Lazarus, S.R.
  Jimerson (Eds.), Best practices in school crisis
  prevention and intervention (pp. 531-551).
  Bethesda, MD NASP.
• Lieberman, R., Poland, S. (2006).
  Self-mutilation. In G. Bear K. Minke (Eds.),
  Childrens needs III. (pp. 965-975). Bethesda,
  MD NASP.
• Miller, D.N., McConaughy, S.H. (2005).
  Assessing risk for suicide. In S.H. McConaughy
  Clinical interviews for children and adolescents
  (pp. 184-199). New York Guilford.

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Web-Based Resources

• National Association of School Psychologists
• www.nasponline.org
• American Association of Suicidology
• www.suicidology.org
• American Foundation for Suicide Prevention
• www.afsp.org
• Centers for Disease Control
• www.cdc.gov