The Impact of Suicide on
Children and Families
The Ones We Miss
Developed by NEW Partnership for Children and Families
January 2010  Revised August 2014
NEW Partnership for Children and Families
University of Wisconsin - Green Bay
2420 Nicolet Dr – Rose Hall 310
Green Bay, WI 54311-7001
Phone: (920) 465-2724
Fax: (920) 465-2961
newpart@uwgb.edu
www.uwgb.edu/newpart
ACKNOWLEDGEMENTS
The “Impact of Suicide on Children and Families: The Ones We Miss” curriculum and training
materials were developed by the NEW Partnership for Children and Families with federal Title
IV-E funds.
Curriculum and training materials were primarily developed by Candy Conard, MSSW, LCSW.
2014 revisions completed by Stephanie Reilly, MSW, and Tammy Snortum, MSSW.
The References page in the curriculum cites resources consulted and utilized in the
development of the curriculum and training materials.
A special thanks to Samantha Surowiec, Ph.D.C, for her creative development of the visual
components of this curriculum.
A special thanks to Kevin Breel for “The Depressed Comic” and TED.com. TED.com videos may
be freely shared and reposted: On TED.com, we make the best talks and performances from
TED and partners available to the world, for free. More than 1400 TED Talks are now available,
with more added each week. All of the talks are subtitled in English, and many are subtitled in
various languages. These videos are released under a Creative Commons BY-NC-ND license, so
they can be freely shared and reposted.
A special thanks to Jonah Mowry and his father, Kevin Mowry for permission to utilize the video
clip “What’s Goin’ On…” Jonah and Kevin provided permission to utilize this clip as part of this
training. YouTube is the only “authorized” video site to host and play the video and only on
Jonah’s BlahBlahBlah2145 channel. This video clip must be accessed by linking to YouTube as
noted above. Both music and video are copyrighted. Sia has graciously allowed Jonah to use
her song with his video as long as it is together on YouTube.
Video ‐‐ "What’s goin on..." US copyright ©2011 Jonah Mowry.
All rights reserved. Duplication without express permission of the author is prohibited.
Music ‐‐ "Breathe Me" by Sia. ℗ 2004, 2005 Systemtactic Limited t/a Go! Beat under exclusive
license to Astralwerks. Used with permission from the artist. Thank you Sia!!
A special thanks to Brady and Christina Shaver for permission to utilize the blog posting “No
More”. Brady and Christina provided permission to utilize this blog as part of this training.
A special thanks to Shane Koyczan for his poem “To This Day”….for the bullied and beautiful
and TED.com. TED.com videos may be freely shared and reposted: On TED.com, we make the
best talks and performances from TED and partners available to the world, for free. More
than 1400 TED Talks are now available, with more added each week. All of the talks are
subtitled in English, and many are subtitled in various languages. These videos are released
under a Creative Commons BY-NC-ND license, so they can be freely shared and reposted.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
2
The Impact of Suicide on Youth and Families: The Ones We Miss
Course Description:
Why do the numbers in Wisconsin continue to either rise, or stay the same, when most of the
country is seeing a decline in child/adolescent suicide? Who are we missing? The “Ones We
Miss” are most often children in out-of-home care and youth who are bullied. We certainly
have a basic understanding of suicide, and what to do about it, but yet it continues to be a
challenge. This training will address these questions and also provide you with ideas for case
planning when working with families where suicidal behaviors and ideations continue to be
challenging. This 6-hour training will include lecture, handouts, small group discussions, and
development of a system of care and crisis plan as part of case planning.
Course Objectives:
Participants will:

Understand the phenomenology of suicide and its impact on children and adolescents.

Understand the warning signs, risk factors, and protective factors of suicide when
assessing children and families.

Gain an understanding of the scope of the problem facing Wisconsin and thus Child
Protective Services and Juvenile Justice Professionals.

Awareness and understanding of who are the “Ones We Miss”, including children in outof-home care and youth who are bullied.

Have an opportunity to discuss several strategies currently utilized in Wisconsin to
address the problem of child/adolescent suicide to use in case planning.

Develop a system of care and crisis plan for a child/adolescent in the system to use in
case planning.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
3
Notes
Notes to the Training Organization and Trainers
Training Time: 1 day
Target Audience: This training is intended for child protective services staff and other child
welfare professionals. This training is appropriate for child protective services and juvenile
justice social work professionals and supervisors who want to increase their knowledge about
the impact of suicide on children and adolescents. There are no prerequisite requirements for
this training.
Focus of the Curriculum: This training is designed to help professionals understand the risk
factors, warning signs and protective factors related to suicide in children and youth. In
addition, participants will learn about increased risk of suicide for particular groups, including
boys, Native American, African American, LGBTQ, bullies, and the bullied, and the impact of
children and youth in out-of-home care. Information on some of the prevention and
intervention models is presented. The training addresses the impact of suicide on social
workers. Participants have an opportunity to use care scenarios to practice assessing potential
risks and warning signs, and develop a system of care and support plan (crisis plan).
Transfer of Learning: An Idea Catcher worksheet is provided for participants to list ideas that
may be relevant to their work. The Action Plan is designed to help participants identify a
specific plan to integrate important concepts into their practice. Post-training, supervisors of
the participants will receive a copy of the Action Plan along with a memo that will provide tips
for enhancing transfer of learning.
Learning Objectives:
Participants will:
 Understand the phenomenology of suicide and its impact on children and adolescents.
 Understand the warning signs, risk factors, and protective factors of suicide when
assessing children and families.
 Gain an understanding of the scope of the problem facing Wisconsin and thus Child
Protective Services and Juvenile Justice Professionals.
 Awareness and understanding of who are the “Ones We Miss”, including children in outof-home care and youth who are bullied.
 Have an opportunity to discuss several strategies currently utilized in Wisconsin to
address the problem of child/adolescent suicide to use in case planning.
 Develop a system of care and crisis plan for a child/adolescent in the system to use in
case planning.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
4
Notes
Trainers:
This curriculum is designed to be presented by one trainer. The trainer should have expertise in
child welfare work and experience or knowledge in working with child and adolescent suicide.
This material is quite difficult to train; consequently it is recommended that trainers have
experience and skill in the following:
1.
2.
3.
4.
5.
6.
7.
8.
Extensive training experience.
Understand group management skills
Understand adult learning and learning styles
Understand secondary traumatic stress and be able to effectively manage its
manifestation in the learning environment
Understand the basics of suicide, suicide risk and protective factors
Have a comprehensive understanding of the various cultures involved in the training,
relevant to suicidality
Understand and demonstrate professional boundaries in the training environment
Recommended, but not required, professional experience with suicide
Trainers should be aware that talking about suicide can be emotional and difficult. Some
participants will likely have experience with a person who attempted or completed suicide,
either professionally or personally.
Training Logistics:
Timing
The curriculum is planned for a training day that begins at 9:00 AM and ends at 4:00 PM, with a
one hour lunch and two 15-minute breaks. See the Daily Timing section for more details.
Participant Numbers
The curriculum is appropriate for a maximum of 24 participants.
Participant Seating
Participants should be seated in half-moon round tables in teams of four or five to allow small
group work.
Room Requirements
Room should be large enough to comfortably accommodate participants and allow room in
front for the trainer, equipment, and flip chart stand. Some wall space is needed for displaying
flip charts.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
5
Notes
Materials and Equipment Requirements
 Laptop
 LCD projector and screen
 Speakers
 Wi-Fi/internet connection for the videos
 Flip chart stand
 Flip chart paper and markers
 Tape
 Video: Richard Cardinal: Cry from a Diary of a Métis Child (1986) produced by the
National Film Board of Canada. Available via website: www.nfb.ca or 1-800-542-2164
 Video Clip: Jonah Mowry: ‘Whats going on..’ made August 2011 accessible via you-tube
at http://www.youtube.com/watch?feature=player_embedded&v=TdkNn3Ei-Lg
 Video Clip: Confessions of a Depressed Comic” accessible via Ted.com at
http://www.ted.com/talks/kevin_breel_confessions_of_a_depressed_comic
 Video Clip: Shane Koyczan: "To This Day" ... for the bullied and beautiful accessible via
TED.com at
http://www.ted.com/talks/shane_koyczan_to_this_day_for_the_bullied_and_beautif
ul.html
Handouts and Slides
Participants should be given a folder with handouts. A printout of the slides (3 per page with
lines for notes, double-sided, stapled) should be included, along with the Idea Catcher, two
Notes sheets, and the carbon-copy Action Plan.
Master Lists of Handouts and Flip Charts
See the Handouts Master List at the conclusion of these notes.
There are no flip charts that require advance preparation, as they are utilized during group
discussion or can be completed quickly.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
6
TOC
Impact of Suicide on Youth and Families: The Ones We Miss
TABLE OF CONTENTS
Training Time: 1 day
DAILY TIMING........................................................................................................................ 9
TRAINING OUTLINE.............................................................................................................. 10
MODULE 1 – INTRODUCTION TO TRAINING ......................................................................... 14
A. Welcome and Trainer Introductions (5 minutes) ................................................................ 15
B. Training Introduction (10 minutes) ...................................................................................... 15
C. Scope of the Problem in Wisconsin (10 minutes) ................................................................ 16
D. Participant Introductions (15 minutes) ............................................................................... 17
E. Agenda and Learning Objectives (5 minutes) ...................................................................... 17
MODULE 2- THE PHENOMENOLOGY OF SUICIDE .................................................................. 18
A. The Burden of Suicide in Wisconsin (10 minutes) ............................................................... 19
B. Risk Factors, Protective Factors and Warning Signs (10 minutes)...................................... 23
C. Suicidal Behaviors (10 minutes) ........................................................................................... 24
D. Self-Injurious Behaviors (SIB) (10 minutes) ........................................................................ 27
E. Children and Adolescents (20 minutes) ............................................................................... 30
MODULE 3 – SUICIDE - “THE ONES WE MISS” ....................................................................... 35
A. Children & Adolescents (10 minutes) ................................................................................. 36
B. Native American Children and Adolescents (25 minutes) .................................................. 37
C. African American Men and Youth (10 minutes) .................................................................. 41
D. Lesbian, Gay, Bisexual, Transgender and Questioning Youth (15 minutes) ........................ 43
E. The Bullies and the Bullied (45 minutes) ............................................................................. 46
F. Summary and Application ..................................................................................................... 55
MODULE 4- PREVENTION AND INTERVENTION MODELS....................................................... 57
A. Familial Pathways to Suicidal Behavior Model (10 minutes) .............................................. 58
B. The Question Model (35 minutes) ....................................................................................... 59
C. Additional Approaches (Optional) ........................................................................................ 62
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
7
TOC
MODULE 5- SURVIVING THE SUICIDAL CLIENT ...................................................................... 66
A. Introduction (5 minutes) ..................................................................................................... 67
B. Impact of Suicide on the Social Worker (20 minutes) ......................................................... 67
MODULE 6- YOU ARE NOT AN ISLAND- THE SYSTEM OF CARE............................................... 71
A. Summary (5 minutes) .......................................................................................................... 72
B. System of Care (40 minutes) ................................................................................................ 72
MODULE 7- CLOSING ........................................................................................................... 76
A. Closing ................................................................................................................................... 77
RESOURCES ......................................................................................................................... 78
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
8
Daily Timing
Impact of Suicide on Youth and Families: The Ones We Miss
DAILY TIMING
This is based on a 9:00 AM - 4:00 PM training day with one hour break for lunch and two 15
minute breaks. Timing is approximate.
9:00 – 9:45
Introduction to Training (Module 1)
9:45 – 10:25
The Phenomenology of Suicide (Module 2)
10:25 – 10:40
Break
10:40 – 11:00
The Phenomenology of Suicide (Module 2) continued
11:00 – 12:00
Suicide - “The Ones We Miss” (Module 3)
12:00 – 1:00
Lunch
1:00 – 1:45
Suicide - “The Ones We Miss” (Module 3) continued
1:45 – 2:30
Prevention and Intervention Models (Module 4)
2:30 – 2:45
Break
2:45 – 3:10
Surviving the Suicidal Client (Module 5)
3:10 – 3:55
You Are Not an Island- The System of Care (Module 6)
3:55 – 4:00
Closing (Module 7)
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
9
Outline
IMPACT OF SUICIDE ON YOUTH AND FAMILIES: THE ONES WE MISS
TRAINING OUTLINE
MODULE 1: INTRODUCTION TRAINING
I. Introduction to Training
A. Welcome and Trainer Introductions
B. Trainer Introduction
- Video Clip/Discussion
C. Scope of the Problem in Wisconsin
D. Participant Introductions
- Small Group Activity
E. Agenda and Learning Objectives
MODULE 2: THE PHENOMENOLOGY OF SUICIDE
II. The Phenomenology of Suicide
A. The Burden of Suicide in Wisconsin
B. Risk Factors, Protective Factors and Warning Signs
- Small Group Activity
C. Suicidal Behaviors
D. Self-Injurious Behaviors
E. Children and Adolescents
MODULE 3 – SUICIDE - “THE ONES WE MISS”
III. Suicide – “The Ones We Miss”
A. Children and Adolescents
B. Native American Children and Adolescents
- Video Clip/Discussion
C. African American Men and Youth
D. Lesbian, Gay, Bi- Sexual, Transgender, and Questioning Youth
- Video Clip/Discussion
E. The Bullies and the Bullied
F. Summary and Application
- Small Group Activity
MODULE 4- PREVENTION AND INTERVENTION MODELS
IV. Prevention and Intervention Models
A. Familial Pathways to Suicidal Behavior Model
B. The Question Model
- Pairs/Small Group Activity
C. Additional Approaches (Optional)
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
10
Outline
MODULE 5- SURVIVING THE SUICIDAL CLIENT
V. Surviving the Suicidal Client
A. Introduction
B. Impact of Suicide on Social Workers
- Small Group Activity
MODULE 6- YOU ARE NOT AN ISLAND- THE SYSTEM OF CARE
VI. You Are Not an Island- The System of Care
A. Summary
B. System of Care
- Small Group Activity Part 1
- Small Group Activity Part 2
MODULE 7- CLOSING
VII. Closing
A. Closing
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
11
Handout List
HANDOUT LIST
HO# HO Title
Mod #
1.
Agenda
1
2.
Learning Objectives
1
Suicides, Inpatient Hospitalizations and Emergency Department
Visits by Wisconsin Counties of Residence 2007-2011 (Aggregate)
Suicides, Inpatient Hospitalizations and Emergency Department
Visits by Age 2007-2011 (Aggregate)
2
5.
Lifetime Risk of Suicide by Diagnosis
2
6.
Definitions
2
7.
Self-Injurious Behavior SIB
2
8.
Risk and Protective Factors
2
9.
Warning Signs and Risk Factors in Children
2
10.
Risk and Protective Factors for Native Youth
3
11.
Risk and Protective Factors for African American Youth
3
12.
Risk and Protective Factors for LGTQ Youth
3
13.
The Bullied and the Bullies
3
14.
Risk and Protective Factors for Those Involved in Bullying
3
15.
Warning Signs: All Children & Adolescents
3
16.
Familial Pathways to Early-Onset Suicidal Behavior
4
17.
Please Listen to Me
4
18.
Kicked out of Foster Home #7
4
19.
Suicide Prevention Strategies
4
20.
Jared- Juvenile Justice Part 1
6
21.
Jared- CPS Part 1
6
22.
Jared – Juvenile Justice Part 2
6
23.
Jared –CPS Part 2
6
3.
4.
2
PowerPoint – 3 to a page
Out of Folder
24.
No More
4
25.
A System of Care
6
26.
A System of Care – 2 part form
6
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
12
Handout List
27.
Support Plan - System of Care
6
28.
Foster Care Providers: Helping Youth at Risk for Suicide
6
29.
Preventing Suicide Behavior Among Youth in Foster Care
6
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
13
Module One
MODULE 1 – INTRODUCTION TO TRAINING
Timing: Approximately 45 minutes
A. Welcome and Trainer Introductions
5 minutes
B. Trainer Introduction
15 minutes
C. Scope of the Problem in Wisconsin
10 minutes
D. Participant Introductions
10 minutes
E. Agenda and Learning Objectives
5 minutes
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
14
Module One
MODULE 1- INTRODUCTION TO TRAINING
TRAINING CONTENT
I. Introduction to Training
(45 minutes)
A. Welcome and Trainer Introductions (5 minutes)
SLIDES
Title Slide (Slide 1)
Welcome participants to training.
Introduce yourself, providing applicable background experience.
B. Training Introduction (15 minutes)
SLIDES
Confessions of a Depressed Comic Video Link (Slide 2)
Video (Slide 3)
Trainer note: Be sure to have internet access in order to play the video. It links directly from
Slide 2.
Show the video clip “Confessions of a Depressed Comic” using link (Slide 2). Following the
video, display “We need to stop the ignorance…” (Slide 3) and briefly discuss the impact of the
video clip.
Trainer note: You may use “We’re All Hiding Something…” video as an alternative to the video
in slide 2, depending on the audience (be sure to tie the information in the video into the
opening remarks below :
http://www.ted.com/talks/ash_beckham_we_re_all_hiding_something_let_s_find_the_courage_to_
open_up
Suicide can happen in any family. This is a very difficult topic to talk about, hear about, and one
that is difficult to research.
As professionals, it may be difficult to ask the questions that get to the heart of the matter,
which is whether the person in front of you wants to end their life. They know that telling you
means you will do something. Suicide to the social worker/professional is like heart failure to a
cardiologist.
It is difficult for the parent, the spouse, the caregiver, or other family members. Difficult
because it is scary, and when they know, what do they do with that information? Sometimes it
feels better to just not know, or to believe it is temporary or attention-seeking. After all, how
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
15
Module One
could that person want to die when they have so much going for them? Perhaps it is paralyzing
just thinking about the possibility that someone they love wants to die.
The purpose of this training is to talk about suicide, the warning signs, the risk factors, the
protective factors, questions to ask, and what to do when you “know what you know”. We will
look at specific groups of people that we are missing, the burden of suicide in Wisconsin, the
scope of the problem, and how this information will impact your work. We will provide a few
tools to take into your work.
C. Scope of the Problem in Wisconsin (10 minutes)
SLIDES
What do we know? United States (Slide 4)
What do we know? Wisconsin (Slide 5)
Display What do we know? United States (Slide 4) and share the following information:
Nationally, more men of all ages complete suicide behavior. The most common means of
suicide for men in all categories (age and ethnicity) is firearms. There are 3.6 male deaths by
suicide for each female death by suicide. Females, however, attempt suicide 3 times as often
as men. Females are hospitalized more frequently than men due to their methodology, which
is by overdose of medication/drugs and cutting. Men’s lethal means prohibit the intervention
of hospitalization. So, logically one could say that one of the “groups we miss” is men and boys
of all ages because of the lethal means they choose.
Suicide is the 10th ranking cause of death in the U.S. for all ages. It is the second ranking cause
of death for 15-24 year olds in the U.S. On average, one young person ages 10-24, kills
themselves every one hour and 43 minutes. There are an estimated 25 attempts for every
death by suicide in the U.S.
Display What do we know? Wisconsin (Slide 5) and continue with the following:
In Wisconsin, the picture of suicide mirrors that of the nation. Suicide is the 10 th leading cause
of death in Wisconsin for all age groups, with the rate of suicide holding steady between 2007
and 2011. Wisconsin’s 2011 suicide rate was 13.1, which was higher than the national average
(12.7). For every suicide in 2011, there were 11 hospitalizations or emergency room visits for
self-inflicted injuries (WISH, 2014).
We also know that 51% of decedents had a mental health problem and 43% were receiving
mental health treatment at the time of suicide. Additionally, 24% of decedents had a history of
suicide attempts and 34% disclosed their intent to die by suicide to at least one person.
These statistics, however, fail to capture the number of people with suicide ideation and
attempts who do not present to the emergency room, are hospitalized, or complete suicide.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
16
Module One
D. Participant Introductions (10 minutes)
SLIDES
Why are YOU here today? (Slide 6)
Display Why are YOU here today? (Slide 6) and provide instructions.
Small Group Activity:
Take a few minutes to introduce yourself to your small group. Share where you work, what you
do, and for how long. Then share why you are here today-what is your compelling story?
Let them know you will ask them to share with the large group if they are willing.
Trainer can share compelling story about what brought you to this training topic or the impact
of suicide in your professional work.
Facilitate large group introductions and compelling stories. Note that some may choose to
share stories that are tragic and perhaps personal. Be prepared for emotional responses. Guide
the large group to be respectful as needed.
E. Agenda and Learning Objectives (5 minutes)
SLIDES
Learning Objectives (Slides 7 & 8)
HANDOUTS
Agenda (HO 1)
Learning Objectives (HO 2)
Review agenda and learning objectives briefly, utilizing Handout 1- Agenda and Handout 2Learning Objectives and Learning Objectives (Slides 7 & 8).
Cover any additional “housekeeping” such as training/lunch times or self-care.
This may also be a good time to refer participants to the Action Plan and explain briefly.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
17
Module Two
MODULE 2- THE PHENOMENOLOGY OF SUICIDE
Timing: Approximately 60 minutes, excluding break
A. The Burden of Suicide in Wisconsin
10 minutes
B. Risk Factors, Protective Factors and Warning Signs
10 minutes
C. Suicidal Behaviors
10 minutes
D. Self-Injurious Behaviors
10 minutes
BREAK
15 minutes
E. Children and Adolescents
20 minutes
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
18
Module Two
MODULE 2 – THE PHENOMENOLOGY OF SUICIDE
TRAINING CONTENT
II. The Phenomenology of Suicide
(60 minutes)
This module will describe the issue of suicide in Wisconsin, as well as discuss risk factors and
suicidal behaviors.
A. The Burden of Suicide in Wisconsin (10 minutes)
SLIDES
The Burden of Suicide in WI (Slides 9 & 10)
Method (Slide 11)
Interesting Data on Wisconsin (Slide 12)
Who are we missing? (Slide 13)
HANDOUTS
Suicides, Inpatient Hospitalizations and Emergency Department Visits by Wisconsin Counties of
Residence 2007-2011 (HO 3)
Suicides, Inpatient Hospitalizations and Emergency Department Visits by Age 2007-2011 (HO 4)
Lifetime Risk of Suicide by Diagnosis (HO 5)
Display The Burden of Suicide in Wisconsin (Slide 9). Review the statistics to create a picture of
the phenomenology of suicide in WI. Promote discussion where possible, but keep this section
moving quickly. Point out how this is relevant to their practice and caseloads.
“Suicide affects an entire community and,
because it is a complex issue,
it will take a community to work on it.”
(Pat Derer, President, HOPES from The Burden of Suicide in WI, 2008)
Suicide rates remained relatively constant from 2007-2011 averaging 724 suicides per year. This
adds up to 20,000 years of potential life lost each year. The greatest number of suicides falls
between the ages of 45-54 years old. Hospitalizations and emergency room visits for selfinflicted injuries are greatest for ages 15-24 years. The cost of impatient hospitalizations and ER
visits averaged over $78 million each year from 2007-2011. In terms of demographics, Whites
had highest rate, followed by American Indian groups, Asian, Black, and then Hispanics.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
19
Module Two
Display The Burden of Suicide in Wisconsin (Slide 10) and present the following:






Firearms were the most frequently used method in Wisconsin (45.4%), followed by
hanging/strangulation (24.9%), and poisoning (includes drugs and carbon monoxide)
(19.5%)
Of those with known mental health issues, 59% had current depressed mood
1 out of 4 suicide victims had a history of previous attempts
Over 1/3 disclosed their intent to die by suicide to at least one person
Over 1/3 had alcohol present in their system
About 1/3 had antidepressants present in their system
Is any of this information new to you? Surprising?
There are also differences in males and females. Males are 4 times more likely to die from
suicide than females. Men use more lethal methods, thus fewer visits to the hospital. Females
have three times the number of suicide attempts.
Why is it important to pay attention to suicidal behavior? Here are some facts:
For every one suicide death, there are nearly 8 inpatient hospitalizations. Keeping track of
suicide attempts provides an opportunity for prevention. Increased prevention may reduce the
need for medical treatment, therefore reducing cost.
Remember, the greatest rate of ER visits due to self-inflicted injuries is with the younger
population, which impacts the youth and families with whom you work.
Refer participants to Handout 3- Suicides, Inpatient Hospitalizations and Emergency
Department Visits by Wisconsin Counties of Residence 2007-2011 and Handout 4 – Suicides,
Inpatient Hospitalizations and Emergency Department Visits by Age 2007-2011.
Trainer note: You can briefly go over these handouts, but they are more for a reference for
participants see what the statistics are in their county.
We have talked about some of the costs related to hospitalizations and emergency room visits
for suicide attempts, but there is another cost in years lost to society, community, and family.
When we consider other causes of death, suicide has a higher rate than homicide, diabetes,
and HIV combined.
Let’s talk about the methods and circumstances in which suicides are occurring.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
20
Module Two
Display Method (Slide 11).
Methods:
In Wisconsin, the top 3 methods are: use of a firearm (45.4%), hanging / strangulation /
suffocation methods (24.9%), and poisoning (19.5%).
Location:
Most suicides occur in the home. The second highest location is a natural area, such as a field,
river, beach, or woods, followed by locations in a motor vehicle, street, sidewalk, or alley. The
lowest percentage occurs in jail or detention facility. These locations match the national trends.
Circumstances:
Refer participants to Handout 5 – Lifetime Risk of Suicide by Diagnosis. Review the relevant
statistics. You will discuss mental illness as a factor later in this module.
1.
2.
3.
4.
5.
6.
59% had current depressed mood
50% mental health problems
43% currently in treatment
52% never had treatment
26% had an alcohol problem
13% with other substance abuse
Interpersonal circumstances:
1. 1 out of 3 had relational problems
2. Other relational problems such a death of a friend/family member, recent
suicide of friend/family member
Life Stressor Circumstances
1. Crisis in the past two weeks
2. Physical health problem
3. Financial problem
4. Job problem
5. School problem
6. Recent criminal or non-criminal legal problem
Suicide event
1. 40% left a note or disclosed intent
2. 25% had history of attempts
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
21
Module Two
Toxicology Testing: (available for 65% of the cases)
1. 37% alcohol
2. 32% antidepressants
3. 3% amphetamines
4. 5% cocaine
5. 8% pot
6. 19% opiates
7. 50% other drugs
Note: Alcohol and drug abuse are second only to depression and other mental health
disorders as the most common risk factors for suicide (The Burden of Suicide in
Wisconsin, 2007-2011).
Transition to a discussion of youth suicide rates in Wisconsin. Display Interesting Data on WI
Slide (Slide 12), reference Handout 4, and discuss the following information:

Firearms and hanging/strangulation (in relatively even numbers) accounted for over
80% of completed youth suicides.

Medication overdoses and cutting accounted for 90% of self-inflicted injury
hospitalizations.

Binge drinking and underage drinking (highest rate in WI) is highly correlated with
suicide attempts.

6% of Wisconsin high school students report an attempted suicide in 2013, while the
rate for Milwaukee high school students was 14.8% according to the “Youth Risk
Behavior Surveillance” summary.

13.2% of Wisconsin high school students report seriously considering attempting suicide
and 12.1% reported having a plan

24.6% of Wisconsin high school students reported feeling sad or hopeless almost every
day for at least 2 weeks
Conclusion:
Rates of suicide mortality, attempts and self-reported risk behaviors among youth in
Wisconsin continue to be unacceptably high. Those who are using the most lethal methods are
not the population that are being seen in hospitals or in-patient settings first. So who are they?
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
22
Module Two
Display Who are we missing? (Slide 13).
Females are hospitalized twice as many times as males, however male deaths outnumber
female deaths by almost a 4:1 ratio. We are missing these men. Hospitalization rates and
mortality rates are greater than 50% higher in rural counties. The population of American
Indians has the highest hospitalization and mortality rates. This tells us of the seriousness of the
issue.
B. Risk Factors, Protective Factors and Warning Signs (10 minutes)
SLIDE
Risk Factors, Protective Factors and Warning Signs (Slide 14)
There is nothing simple about trying to anticipate human behavior, especially when they are in
a crisis. Tools such as safety contracts may feel helpful but they do not always work and
sometimes are detrimental.
We cannot predict suicide with 100% accuracy, but we have a great deal of information about
risk factors, warning signs and protective factors.
Suicide can be prevented - Do you believe that?
Small Group Activity:
Introduce the small group activity by acknowledging that participants already have knowledge
about the warning signs, risk factors and protective factors of suicide. Display Risk Factors,
Warning Signs and Protective Factors (Slide 14). Hand out flip chart paper/markers.
Ask participants to talk with their team about what they know about suicide, such as warning
signs and risk factors. Put the list on flip chart paper and hang on the wall. Give them 5-8
minutes.
Trainer note: You do not need to spend much time, if any, processing the accuracy of the
answers. The point here is to get the group to begin thinking about these as separate categories
and reinforce the fact that they do already know some things about the topic. The Resource
Suicide Prevention Resource Center, & Rodgers, P. (2011). Understanding risk and protective
factors for suicide: A primer for preventing suicide. Newton, MA: Education Development
Center, Inc. provides comprehensive information for trainers. You may also want to refer to
Handouts 8 -15.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
23
Module Two
Wrap up this section by providing the following information:
Risk factors:
Risk factors affect the likelihood of suicidal behavior. They are characteristics that make it more
likely that individuals will consider, attempt or die by suicide. Risk factors indicate that
someone is at heighted risk for suicide, but indicate little or nothing about immediate risk.
Protective factors:
Protective factors are characteristics that make it less likely that individuals will consider,
attempt or die by suicide. Protective factors are not just the opposite or lack of risk factors.
Rather, they are conditions that promote strength and resilience and ensure that vulnerable
individuals are supported and connected with others during difficult times, thereby making
suicidal behaviors less likely.
Risk and protective factors are found in individuals, families and communities – they may be
fixed or modifiable.
Warning Signs:
Warning signs indicate an immediate risk of suicide and require immediate intervention. In
contrast to risk and protective factors, warning signs are only applicable to individuals.
“Thinking about heart disease helps to make this clear. Risk factors for heart disease include
smoking, obesity, and high cholesterol. Having these factors does not mean that someone is
having a heart attack right now, but rather that there is an increased chance that they will have
heart attack at some time. Warning signs of a heart attack are chest pain, shortness of breath,
and nausea. These signs mean that the person may be having a heart attack right now and
needs immediate help”.
Source: American Foundation for Suicide Prevention; “Risk Factors and Warning Signs” retrieved from website July
2014
During this training, we will focus specifically on risk and protective factors to identify and
target prevention efforts for high risk groups (or “the one’s we miss”).
C. Suicidal Behaviors (10 minutes)
SLIDES
Suicidal Behaviors (Slide 15)
Ones we miss (Slide 16)
Specific Risk for Males (Slide 17)
HANDOUT
Definitions (HO 6)
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
24
Module Two
Introduction: Before we go any further, let us be certain that we share the same understanding
of the terminology. Please refer to Handout 6- Definitions.
Display Suicidal Behaviors (Slide 15). Review each of the definitions, providing additional
information. Share examples as they are relevant.
Suicide:
A deliberate act of self-harm with at least some intent to die that results in death.
Suicide Attempt:
A deliberate act of self-harm with at least some intent to die that does not result in death. Such
acts have a wide range of medical seriousness. The risk of completion increases with each
attempt. Suicide attempts are a long-term risk factor that represents a chronic situation risk
and needs to be taken seriously.
Suicidal Ideation:
Thoughts of attempting suicide. Such thoughts have a wide range of specificity, intensity, and
frequency. Suicidal ideation is relatively common. About 34% of those with suicidal ideation go
on to make a plan, and 36% make an unplanned attempt. Of those who have experienced
suicidal ideation, only 0.05% completes suicide.
It is important to note that suicidal ideation is an unreliable marker for safety. It may be a longterm risk indicator. Substantial numbers of people who make a severe attempt deny having
suicidal ideation. An assessment must be made to distinguish suicidal ideation and suicidal
intention.
Suicide Planning:
A severe form of suicidal ideation that includes identifying a method or scenario to attempt
suicide.
Display Ones we miss (Slide 16) and review the following:
There is a 72% chance that a person who makes a suicide plan will make an attempt. Keep in
mind that, based upon 2007-2011 Wisconsin statistics, 34% disclosed their intent to die by
suicide to at least one person, however this means that 66% did not.
It is estimated that 73% who died did not mention intent or ideation during their last contact
with a professional. For those that did talk about it, there is indication that they mentioned it
at least 3 times, generally to spouses (60%), relatives (50%), or caregivers (18%).
Note the 18% who mentioned intent or ideation to a caregiver - these include the children and
youth in out-of-home care. Any thoughts on why that number might be so low? One of the
goals of this training is to increase the number of those in out of home care who disclose
suicidal intent or ideation by providing their case managers and caregivers information.
Transition to discussion of suicide risks for men. Display Specific Risks for Males (Slide 17).
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
25
Module Two
Discuss the risk factors for men in general:
Men have higher rates of suicide if they were never married. They are more likely to use
firearms (youth use hands guns found at home). The murder-suicide rate is higher for men,
especially when sexual jealousy is involved.
Men are more socially isolated - this is actually a protective factor for women, who are more
social, less impulsive, use less lethal means, and are more likely to seek out people to talk to
about these issues. However, women are more depressed, which is linked to suicide attempts.
Let’s talk about some of the other circumstances and risk factors that may have an impact on
what you see on your caseloads.
Family history plays a role, therefore it important to consider in the assessment process.
Suicide is 3.5 times more likely to occur if a first degree relative has been suicidal.
We briefly discussed the role of mental illness in suicides earlier. Refer back to Handout 5 –
Lifetime Risk of Suicide by Diagnosis. Briefly review the handout as relevant to the following:
 95% who die of suicide have an Axis I diagnosis
 40-50% have a diagnosis of mood disorder
 50% are not in treatment at the time of the suicide
 25-50% have an alcohol related diagnosis
EARLY in the course of treatment, before learning to cope successfully can be a high risk time.
They remain at risk even as they have begun treatment.
Think of how this applies to kids in care. How many have a diagnosis? How does this impact
their lifetime risk? How does this apply to parents who have recently been diagnosed and have
children in out-of-home care?
There are patterns in suicidal behavior based on the time of year. For example, the peak time
for young people and college-aged adults is March and April. August is the peak month for the
elderly. The rate of suicide drops in December and January for all age groups.
The impact of the media can contribute by providing information and creating drama.
Share example of a local or national story. One example is the 11/1/09 story of the teen suicide
in Palo Alto “Anguish Over California Teen Suicides Spurs Actions”, which was published after a
four teens committed suicide by stepping in front of a commuter train during a six month
period of time (Leff, 2009).
Source: http://www.deseretnews.com/article/705341292/Anguish-over-California-teen-suicides-spurs-action.html
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
26
Module Two
Marital status has a correlation to the suicide rates as well. Suicide doubles for men who are
not married, so it seems marriage would be a protective for men. For men, the rate is 4-5 times
higher if they are divorced, widowed or separated.
LGBTQ (Lesbian, Gay, Bisexual, Transgendered and Questioning) persons have more suicide
attempts.
D. Self-Injurious Behaviors (SIB) (10 minutes)
SLIDE
Self-Injurious Behavior (SIB) (Slide 18)
HANDOUTS
Self-Injurious Behavior (HO 7)
Risk and Protective Factors (HO 8)
No More (OOF)
Transition to a discussion of self-injurious behavior.
There are often questions about self-injurious behavior. What is it? Is it a risk factor or is it a
warning sign? This question is most frequently asked by social workers on this topic.
Self-injurious behaviors are great cause for concern, confusion, and anxiety for the social
worker. The question has been asked many times; how do I know the difference between a
suicide attempt and self-mutilation, or cutting? Acknowledge that it is confusing and scary.
Refer to the definition on Handout 6- Definitions.
Self-injurious behavior (SIB) is “a deliberate alternation or destruction of body tissue without
conscious suicidal intent”. They are self-directed acts of self-harm without intent to die.
Broadly, these acts tend to have intrapersonal (e.g., manage emotion) or interpersonal (e.g.
communicate distress) motivations and include a variety of behaviors (cutting, piercing,
burning) and a have wide range of medical seriousness.
According to Dr. David Mays (2000), self-injurious behavior was originally thought to be
associated with only serious mental illness or trauma. Recent findings are different and include
that this occurs in high functioning populations and with those who do not have a psychiatric
diagnosis.
Here are 4 main types that may help you understand these phenomena.
Display Self-Injurious Behavior (Slide 18) and refer participants to Handout 7- Self-Injurious
Behavior.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
27
Module Two
1. Severe SIB
These are infrequent acts in which significant amounts of body tissue is destroyed. Severe SIB
usually occurs suddenly but with a great deal of damage. It is associated with psychotic states,
acute intoxication, encephalitis, schizophrenia, etc. Some examples include enucleation
(removing eyeball), castration, and limb amputation. For those who complete severe SIB, some
seem indifferent to the act, some have no explanation, or the explanation does not make sense,
and most are very calm afterwards. The high risk population includes those who have psychosis
and are preoccupied with religion and sexuality and suddenly change their behavior (i.e.
shaving their head, plucking out eyebrows).
2. Stereotype SIB
This type occurs in a fixed pattern, often rhythmic, such as head banging or finger biting. There
is no symbolism to the behavior. It is most common in populations that are institutionalized,
developmentally disabled, autistic, or in acute psychotic states. This is an Axis I
stereotypic/habit disorder. The purposes of the behavior could be done to gain attention, as a
response due to under-stimulation, out of frustration, or aggression turned towards self.
3. Socially Accepted/Emblematic SIB
This type includes tattooing, piercing, scarification, etc.
4. Superficial/Moderate SIB
This type of self-injurious behavior has low lethality and little tissue damage. The behavior
occurs sporadically or repetitively, and is often a time-limited experimentation among peers.
Examples of this SIB include cutting, burning, scab picking, needle sticking, self-punching,
excoriations, or scratching. The SIB may be compulsive (nail biting, skin picking, hair pulling),
episodic (quick, effective release from stress, often impulsive, often in response to anger and
anxiety), repetitive (little resistance to the act, rumination, identifications as a cutter/burner,
qualities of addiction), counter-dissociative (the purpose is to reconnect with reality), or parasuicidal (ambivalent suicide attempt, attempt to communicate).
This type of SIB has been reported with PTSD, or after rape, combat, and during
depersonalization. It may be exacerbated by a dissociative identity disorder, borderline
personality disorder, or histrionic personality disorder. It is often seen in prisoners with
antisocial personality disorder and persons with Addison’s (adrenal disease) or eating disorders.
Self-Injurious Behavior is a common clinical phenomenon. Poisoning and cutting account for
90% of ER visits.
It is more common in adolescent females (worldwide) by nearly a 4:1 ratio. Depression, anxiety,
and impulsivity are associated with self-harm in girls (not boys). Self-harm in adolescents
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
28
Module Two
increases proportionately with the consumption of cigarettes, alcohol, or drugs, or having
family members who recently self-harmed. Childhood abuse, substance abuse, PTSD, and
Intermittent explosive disorder are also associated with SIB. Girls explain their actions by saying
they want to punish themselves or they are trying to get relief from an unbearable state of
mind.
Information is widely accessible over the internet. For example, a Google search of self-injury
has over a million hits. A person can watch videos on you-tube of people hurting themselves.
So, ask your clients about their internet usage, especially around this subject matter. It may
give you some needed insight into the behavior.
Again, all of the information above is about the assessment, and asking the questions to gain
awareness or understanding of how the individual may be impacted or may be at risk.
Provide Out-of-folder (OOF) Handout “No More”. Explain that this is a blog written by a
mother who found her son’s bloody t-shirt while looking for something underneath his bed.
Read this out loud for participants for full effect (or as an alternative, ask participants to read
the handout themselves).
Ask participants to take out Handout 8 – Risk and Protective Factors which lists these factors
for all individuals. Review the handout with participants. Note that those factors with an
asterisk * are consistently indicated across the most up to date literature. It is a review of the
material covered, reiterating the protective factors. Try to acknowledge key concepts that they
were able to identify on their flip charts, if possible.
BREAK
15 minutes
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
29
Module Two
E. Children and Adolescents (20 minutes)
SLIDES
Children (Slide 19)
Children- Risk Factors (Slide 20)
Children in Care (Slide 21)
Adolescents (Slide 22)
General Risk Factors for Adolescents (Slide 23)
Protective Factors (Slide 24)
HANDOUTS
Warning Signs and Risk Factors – Children (HO 9)
An article published in Science Daily (Nov. 28, 2011) concluded that thoughts about killing
oneself and engaging in suicidal behavior begin much younger than previously thought. New
findings reveal that a significant proportion of youth make their first attempt in elementary or
middle school.
The Journal of Adolescent Health cited a study of young people who had attempted suicide.
Almost 40% of those studied indicated that they had tried or made their first attempt before
entering high school, some as young as 9 years old. There is a sharp increase at 6th grade (age
12), which continues to rise peaking at 8th or 9th grades.
Source: http://www.hhs.gov/news/healthbeat/2012/01/20120117a.html
With young adults who end up having chronic mental health problems, their struggles begin
early in life. This is a good place to begin intervention and prevention.
Suicide rates have not increased in last 20 years internationally, but they have in the US.
Hanging and use of fire arms were the most common methods by all youth in Wisconsin in
2007-2011.
Trainer note: Examples: Refer to articles such as “Dallas School Staff finds 9-year old Boy
Hanging in Bathroom” (1/22/10). Blogs from students and parents after the event commented
that the boy was depressed and bullied. He had just returned from an alternative school.
Jasmine McClain from North Carolina who hung herself at age 10 reports suggest she was
bullied. (11/16/11)
Other factors that influence suicide in children:
 Children with access to guns
 Children with a history of impulsive and aggressive behavior
 Children who are in the 90th percentile of their age group in height – looking more
similar to adolescents, but differ from adolescents
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
30
Module Two
Display the Children (Slide 19) and refer to Handout 9- Warning Signs and Risk Factors in
Children.
It is important to note that children younger than 15 years who commit suicide do not often
show signs of depression and do not express suicidal intent.
Children are less exposed to some types of stressors (no romantic disappointments) and are not
as likely to be intoxicated.
There are fewer warning signs for child suicide, but it is often marked by having conflicts with
parents and precipitated by disciplinary crisis. The parent/child relationship is important and
must be assessed.
Display the Children- Risk Factors Slide (Slide 20). As you complete your assessments and in
your ongoing work with children and youth, pay particular attention to how some of the
following risk factors or warning signs may be manifesting for the child:






















Past suicide attempts or threats
Depression (risk factor for EVERY group)
Past violent or aggressive behavior
Mental illness (bipolar disorder - chronic anxiety and/or alcohol use)
Eating disorders
Family history
Use of certain medications
Homosexuality/bisexuality
Cognitive immaturity and impulsivity
Bringing weapons to school
Recent experience of humiliation, shame loss
Bullying
Victim of abuse or neglect
Witnessing violence in the home
Themes of death or depression in reading, conversation or artwork
Preoccupation with violence on TV, comics video games, internet
Disciplinary problems
Vandalism, cruelty to animals, setting fires
Poor peer relationships
Involvement with cults or gangs
Little or no supervision.
Stressful psychosocial events:
 Parental divorce
 Separation from family
 Death in the family
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
31
Module Two
Reiterate the risk factor of being separated from parents and how this may play out in foster
care placements.
There was a very interesting 2006 study done in Stockholm, Sweden, National Board of Health
and Welfare (Vinnerljung, Hern, & Lindblad, 2006) that looked at suicide attempts and severe
psychiatric morbidity among former child welfare clients and found that “former child welfare
clients were 4-5 times more likely than peers in the general population to have been hospitalized
for suicide attempts. They were 5-8 times more likely to have been hospitalized for serious
psychiatric disorders in their teens and 4-6 times more likely in young adulthood. High excess
risks were also found for psychoses and depression among this population. Individuals who had
been in long term foster care tended to have the most dismal outcome.”
Conclusions: “Former child welfare/protection clients should be considered a high risk group for
suicide attempts and severe psychiatric morbidity.”
Source: Vinnerljung, B., Hjern, A. and Lindblad, F. (2006), Suicide attempts and severe psychiatric morbidity among
former child welfare clients – a national cohort study. Journal of Child Psychology and Psychiatry, 47: 723–733.
Display Children in Care (Slide 21)
There was a more recent study conducted in the United States in 2014 that examined the rates
of suicidal thoughts and behaviors among preadolescent children (aged 9-11) who experienced
maltreatment and subsequent placement into foster care. The results of this study indicate
that despite the young age of participants, suicidality was high with an overall prevalence of
26% (the highest type being suicidal ideation). This rate is nearly 5 times the rate of suicidality
of the general population at this age. The most common methods that children in this study
planned or attempted suicide included cutting/stabbing and choking/hanging. This provides
important information about reducing risk by restricting access to these potential methods.
Further findings indicate that those who have been physically, sexually or emotionally abused
are at greater risk of suicidality than those exposed to neglect only. Children who had
experienced physical abuse were 4 times more likely to have made suicidal plans than nonphysically abused children. Those who attempted suicide had been in out of home care longer
and more lifetime household transitions were associated with almost every index of suicidality.
In addition, the number of prior referrals to social services also predicted caregiver reports of
suicidality. These findings speak to the importance of screening for all children entering foster
care, especially when we consider that children entering foster care are 3-10 times more likely
to receive a mental health diagnosis.
These results have substantial practice implications for mental health and social agencies
serving this group, especially when considering placement in foster care or other treatment
facilities.
Source: Taussig, Harpin & Maguire; “Suicidality Among Preadolescent Maltreated Children in Foster Care”; Child
Maltreatment 2014, Vol. 19(1) 17-26, Sage Publishing
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
32
Module Two
RISK FACTORS FOR ADOLESCENTS
Display Adolescents (Slide 22).
What separates those teens who attempt suicide from those who think about it?
Substance abuse is a factor, as youth are 12.8 times more likely to commit suicide when under
the influence. Teens who attempt suicide feel more severe or enduring hopelessness and
isolation. They are generally reluctant to discuss suicidal thoughts.
There are some general risk factors for adolescents. Below are the most commonly accepted:
Display General Risk Factors for Adolescents Slide (Slide 23).
Previous suicide attempt
The first and greatest risk is within 3 months immediately following the first attempt and
continues for at least 2 years.
Mental illness
About 90% have a diagnosis of depression, substance abuse or anxiety a year before the
suicide. It is estimated that 1 million youths suffer from depression, and 60-80% do not receive
help. Substance abuse/use is a risk in teens over age 16 years.
Many parents do not recognize the signs of suicidal behavior. The stressors can be misleading
as it could be mental illness causing the stress. The profile of a special risk is a person with
depression and impulsive aggression as a reaction to stress, particularly when an additional
stressor is introduced.
Imitation
This is referred to as a cluster phenomenon. Often the suicide of a peer influences other youth
in the community or school to commit suicide.
Family history of suicide
Family dysfunction does not seem to influence suicide, but family history of suicide does, which
is key to your assessment work with families.
Sexual orientation
Gay and lesbian youth have more ideation, attempts, and psychopathology, but not necessarily
more suicide death.
Sexual abuse
A history of sexual abuse contributes to psychopathology but does not specifically affect suicide
rates. Note: Physical abuse does increase the risk of suicide in boys.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
33
Module Two
Incarceration
For youth placed in juvenile detention, the rate of suicide is 57 to 100,00. In comparison, the
rate of suicide in adult facilities is 2,041 to 100,000.
Other stressors
 Interpersonal loss
 Disciplinary crises
 Bullying (either being a perpetrator or a victim)
 Failure to communicate with fathers
 Youngsters who are not affiliated with school, work or any institution, could be after a
period of absence from school (suspension)
 Males – romantic breakup (which may be their only intimate relationship)
 Being a minority in a upwardly mobile family
All of these stressors may increase isolation. Think particularly about how these stressors
impact youth in out-of-home care.
Move into a discussion of protective factors in children and adolescents.
Display Protective Factors Slide (Slide 24).
There are three very important factors:
1. Having friends (most important protective factor)
2. Having a supportive parent
3. Having school relationships (being connected)
All of these act as buffers to stress. Think of the youth you serve in your work- do they have
these protective factors?
What can you do to strengthen their protective factors?
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
34
Module Three
MODULE 3 – SUICIDE - “THE ONES WE MISS”
Timing: Approximately 105 minutes, excluding lunch
A. Children and Adolescents
10 minutes
B. Native American Youth
25 minutes
C. African American Youth
10 minutes
D. Lesbian, Gay, Bi- Sexual, Transgender, and Questioning Youth
15 minutes
LUNCH
60 minutes
E. The Bullies and the Bullied
25 minutes
F. Summary and Application
20 minutes
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
35
Module Three
MODULE 3 – SUICIDE- “ THE ONES WE MISS”
TRAINING CONTENT
III. Suicide- “The Ones We Miss”
We have discussed what suicide is and what it looks like in Wisconsin. We have identified
warning signs, risk factors and protective factors.
We are now going to be more specific and look at possible explanations of why the numbers
continue to increase, or at best stay the same.
A. Children & Adolescents (10 minutes)
SLIDES
Are these… “Ones We Miss”? (Slide 25)
Girls (Slide 26)
Boys (Slide 27)
Start by showing the Are these… “Ones We Miss” Slide (Slide 25). Note the animation- the slide
will end with the Boys graphic displayed. This is the first group we miss.
Suicide becomes a public health problem around the age of 12 years. The rate increases by age,
with ages 20-24 seeing the greatest rate (per 100,000).
Frequency of suicidal ideation increases with risky behaviors, such as alcohol use and
aggression.
In Wisconsin, suicide is the leading cause of violent death in the state. The counties clustered in
the Northern and Western regions of the state experienced the highest suicide rates between
2007 and 2011. Firearms are involved in 45% of those completed suicides.
Discuss and compare the facts about suicide in boys and girls.
Display Girls (Slide 26) and discuss the following:
With girls, the ratio of attempts to completions is 4,000:1. A suicide attempt is NOT a statistical
risk factor for eventual suicide for girls, but a depressive episode is a factor. Girls often do not
have a precipitating event and may kill themselves while recovering from depression. Panic
attacks are a risk factor (intense fear, impending doom). Panic attacks escalate rapidly (10
minutes) and can include cognitive and somatic symptoms.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
36
Module Three
Display Boys Slide (Slide 27) and emphasize the differences in risk factors and suicide
completions.
With boys, the ratio of attempts to completion is 500:1. This is significant when compared to
girls. Suicide attempts ARE a statistical risk factor for boys.
Boys often kill themselves within a few hours of a precipitating event, while anxiety is at its
peak and before thinking through the consequences. Remember, impulsivity is a risk factor. The
precipitating events can be legal problems, relationships, or humiliating experiences.
Aggressiveness is a risk factor, too, and a history of physical abuse increases the risk of suicide.
Remember that we talked about the relationship component. A romantic break up, especially
when this may be their only intimate relationship, can increase risk or be a precipitating event.
Think of this issue with youth in placement.
B. Native American Youth (25 minutes)
SLIDES
Are these some of the “Ones We Miss”? (Slide 28)
Richard Cardinal Video (Slide 29) Link to video clip
Risk Factors for Native Youth (Slide 30)
Protective Factors for Native Youth (Slide 31)
Richard Cardinal (Slide 32)
HANDOUT
Risk and Protective Factors for Native Youth (HO 10)
OTHER
Video: Richard Cardinal: Cry from the Diary of a Metis Child – play the first 7 minutes
Display Are these some of the “Ones We Miss”? Slide (Slide 28). Note the animation- the slide
will end with the Native Americans graphic displayed.
Display Richard Cardinal Slide (Slide 29) and transition to video clip from Richard Cardinal: Cry
from the Diary of a Métis Child (this links directly from slide 29). Introduce the video. Richard
was placed in out-of-home care at the age of 4, and had 28 placements up until the age of 17,
when he committed suicide. The Métis (MAY-tee) people are an Indian tribe in Canada. Richard
left behind a diary that served as the basis for this movie. His death in 1984 spurred legislation
to improve the foster care system in Canada for Native children. Participants will only watch the
beginning clip of the video (7 minutes).
Prepare participants that the video contains actual pictures of Richard’s suicide by hanging.
Encourage them to take care of themselves as needed given the sensitive nature of the video.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
37
Module Three
Play video clip. Stop after interview with the last foster parents and the court process begins
(approx. 7 minutes).
According to the Center for Disease Control and Prevention, suicide was the second leading
cause of death among American Indian / Alaska Native youth ages 10-24 in 2010, and the eight
leading cause of death for American Indians / Alaska Natives of all ages.
American Indian / Alaska Native high school students report higher rates of suicidal behaviors
than the general population of high school students.
Reservation reared American Indian/Alaskan Native youth experience higher rates of suicidal
ideation (33%) than urban-reared youth (21%), although rates of attempted suicide were not
significantly different. (American Association of Suicidality 2010).
In addition to the general risk factors already discussed (prior attempts, alcohol and drug abuse,
mood disorders, access to lethal means), there are specific factors that contribute to the
alarming rate of suicide among Native American youth.
Refer participants to Handout 10 – Risk and Protective Factors for Native Youth and provide
the following information:
There are significant risk factors for American Indian/Alaskan Native populations in general that
include:
 Historical trauma - attempts to eliminate culture such as forced relocation, removal of
children who were sent to boarding schools, prohibition of the practice of native
language and cultural traditions, and outlawing of traditional religious practices have
affected multiple generations of AI/AN people and contribute to high rates of suicide
among them.
 Acculturation - greater adaptation to the mainstream culture reportedly increased
psychosocial stress, less happiness, and greater use of drugs or alcohol to cope with the
stress of navigating the differences between two cultures.
 Lack of access to and use of mental health services – lack of Native American mental
health professionals, rural isolation, self- reliance and embarrassment.
 Alienation - In an analysis of suicide notes to determine motivation, alienation among
Native Americans was double that of Whites
 Alcohol and drug use - According to the National Violent Death Reporting System 2003–
2009, of AI/AN suicide decedents tested for alcohol, 36% were legally intoxicated at the
time of death. There were proportionally more positive test results for alcohol among
AI/AN decedents than
there were for any other racial or ethnic group.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
38
Module Three
Display Risk Factors for Native Youth (Slide 30)
In addition to the risk factors above, here are risk factors specific to AI/AN Youth:











Loss of culture
Loss of language
Loss of cultural identity
Family disruption
Community Violence - AI/AN youth are 2.5 times more likely to experience trauma than
non-AI/AN youth
Contagion - Many suicide deaths occur on reservations where AI/AN youth have
considerable exposure to suicide
Low perceived social support
Coming from a home without both biological parents
Family history of substance abuse
Alcohol and drug use - In 2011, AI/AN had the highest rate of current illicit drug use
(13.4%) among those ages 12 or older compared to any other single racial/ethnic group.
The overall rate for all racial/ethnic groups was 8.7%.
Discrimination - Studies of American Indian youth found that discrimination was as
important a predictor of suicidal ideation as poor self-esteem and depression.
Depending on the cultural beliefs of a particular tribe and/or how connected to the reservation,
being lesbian, gay, bisexual, questioning or “two-spirited” can be a risk factor or a protective
factor. .
Explain that in many tribes, the elders speak of people who were gifted among all beings
because they carried two spirits, that of male and female. They were honored and revered. Two
spirited people were often the visionaries, the healers, the medicine people, the nannies of
orphans, and care givers.
Trainer note: Research this topic to add to the above description if you are less familiar with the
concept of two spirited people.
Display Protective Factors for Native Youth (Slide 31) and continue to refer to Handout 10 –
Risk and Protective Factors for Native Youth
Culture, tradition, spirituality and family appear to be the most influential protective factors for
Native American youth. Prevention efforts should include the family, the youth, and the
community.
Healing is continuous, and is not limited to an artificial environment for 50 minutes per week
(i.e. counseling). If a teen is really part of his/her community and family and believes that they
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
39
Module Three
are loved, then their “thinking” changes and they have the internal message of “I could never
hurt my family or community like that.”
How many of you felt that way when you were a teen? Do you remember actually thinking that
way?
Think about the children and youth that are in foster care. I wonder who they think really loves
them and who they would not want to hurt by taking themselves from them permanently.
Display Richard Cardinal (Slide 32) in preparation for large group discussion. Process with the
following questions based on the video at the beginning of this section:
1. What were some of the risk factors in Richard’s life (keep in mind the risk factors for
boys, youth in care and native youth)?
Examples: multiple placements, loss of cultural identity, family disruption (loss of
sibling connections), loss of romantic connection, rural, lack of supervision,
physical abuse, etc.
2. What were some protective factors? *key focus
Examples: connection to family (brother), contact with caregivers (good
relationship with foster dad), emotional health (journaling), etc.
3. How could they have been utilized to help Richard?
4. What does this make you think about today – your case load? Today’s system? Youth in
the system?
5. Are there some commonalities with Richard’s life, even though we have come so far?
Bring this topic to a close. Transition to the next “missed” group.
Sources:
National Indian Child Welfare Association (NICWA). (n.d.). Ensuring the seventh generation: A youth suicide
prevention toolkit for tribal child welfare programs. NICWA- National Indian Child Welfare Association. Retrieved
from http://www.nicwa.org/resources/documents/YSPToolkit.pdf
Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: American
Indians/Alaska Natives. Waltham, MA: Education Development Center, Inc.
American Association of Suicidology, Washington D.C.; www.suicidology.org; 2012 (based on 2010 data)
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
40
Module Three
C. African American Men and Youth (10 minutes)
SLIDES
Are these some of the “Ones We Miss”? (Slide 33)
Risk Factors for African American Youth (Slide 34)
Protective Factors for African American Youth (Slide 35)
HANDOUT
Risk and Protective Factors for African American Youth (HO 11)
Display Are these some of the “Ones We Miss”? (Slide 33). Note the animation- the slide will
end with the African American graphic displayed.
Suicide in African American men is 2.5 times less than the rate of Caucasian men. It is the third
leading cause of death between ages 15 and 24 years. Although African American suicide rates
are lower than the overall U.S. rates, suicide affects African American youth at a much higher
rate than adults and there has been an increase in this rate.
Why the increase?
Perhaps we are paying more attention to suicide and identifying suicide as a cause of death
more frequently. It could be that more are attempting and committing than in the past. We are
seeing the same reasons as white counterparts, including depression, social isolation and
hopelessness, relationship conflicts, and sexual identity issues.
2009 data suggests an association of anxiety with suicide attempts in black adolescents,
especially social anxiety (social phobia).
The lethal combination of substance abuse and depression may be related to the increase.
Those with the highest number of co-occurring disorders are adolescents between 15 and 24
years. We also consider the structural barriers to mental health care, including the lack of
health care coverage (25% lack coverage) and disparities in diagnosis and treatment of black
adolescents.
There may be attitudinal barriers to seeking help due to a cultural tendency to overcome
hardship by trying harder and there is a stigma to seeking help. The preference for community,
religious and spiritual forms of support versus use of the formal mental health system can be a
risk factor and a protective factor.
The combination of those factors with easy access to guns can contribute to the higher rates.
Access to firearms is critical, as there is a higher rate than for whites. Gun-related suicide
accounts for 96% of the increase in black youth aged 10-19 years.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
41
Module Three
One counselor in Atlanta, told the Washington Post that young black men she counsels said
they feel isolated from social institutions, such as family, church, and school that could help
them. Remember that lacking a sense of culture and community is a risk factor. On the flip side,
having these qualities is a protective factor.
Display Risk Factors for African American Youth (Slide 34)
Refer participants to Handout 11 – Risk and Protective Factors for African American Youth and
provide the following information:
Risk factors include:
 Age: younger than 35 – although this factor isn’t specific to “youth only”, it is a
significant factor in the African American community
 Marital status – being divorced or widowed has been significantly associated with
increased odds of suicidal ideation (again, not specific to “youth only”)
 Family conflict
 Acculturation – increased acculturation into White society can include loss of family
cohesion and support
 Hopelessness, racism and discrimination – perceived racism and discrimination along
with social and economic disadvantage
 Access to and use of mental health services – African American youth were
substantially less likely than White youth to have used a mental health service in the
year during which they seriously thought about or attempted suicide
 Access to firearms (firearms are the predominant method of suicide among African
Americans regardless of gender and age)
 Gender and cultural role expectations – this includes the stigma of suicide as the
“unforgiveable sin”, African American men as “macho” and not taking their own
lives, and African American women as always strong and resilient
Display Protective Factors for African American Youth (Slide 35)
Protective factors for African American Youth include:
 Religion – Orthodox religious beliefs and personal devotion have been identified as
protective against suicide among African Americans
 Social and economic support
 Black identity – 2 small studies of African American women found that having a
strong sense of African American identity, heritage and history was protective
against suicide
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
42
Module Three


Geographic location - There is a diminished risk of suicide for black adolescents who
live in the south, perhaps due to the protective factors of cultural and religious
beliefs. This is relevant given where we live.
Connection to family, community and social institutions - Family support, peer
support and community connectedness
Sources:
Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: Blacks.
Waltham, MA: Education Development Center, Inc.
American Association of Suicidology, African American Suicide Fact Sheet, Washington D.C.; www.suicidology.org;
2012 (based on 2010 data)
D. Lesbian, Gay, Bisexual, Transgender and Questioning Youth (15 minutes)
SLIDES
Are these some of the “Ones We Miss”? (Slide 36)
LGBTQ Youth (Slide 37)
Risk Factors for LGBTQ Youth (Slide 38)
Risk Factors for LGBTQ Youth, cont. (Slide 39)
Protective Factors for LGBTQ Youth (Slide 40)
Hi! I’m Jonah! (Slide 41) Link to video clip
HANDOUT
Risk and Protective Factors for LGBTQ Youth (HO 12)
Introduce the section. Display Are these some of the “Ones We Miss”? (Slide 36). Note the
animation- the slide will end with LGBTQ displayed.
Display LGBTQ Youth (Slide 37).
The lesbian, gay, bisexual and questioning (LGBTQ) population has an extremely high rate of
depression, suicidal thoughts, and suicide attempts.
Feelings and experiences are often created by their environment, such as:
 Social isolation
 Anger
 Depression
 Repeated stress
 Feelings of inadequacy
 Sexual identity difficulties
 Homelessness (being thrown out or running away)
 Family problems
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
43
Module Three


Lack of support
School (high dropout rate)
According to the 2013 Wisconsin Youth Risk Behavior Survey data, compared to high school
students who identified as heterosexual, a larger percentage of students who identified as gay,
lesbian or bisexual (LGBTQ) reported poor mental health, feelings of severe sadness or
hopelessness, suicidal thoughts and behaviors, non-suicidal self-harming behaviors, subjection
to bullying, disconnection from their school, and lack of relationships to adults at school.
 Approximately 49% of LGB students reported seriously considering suicide in the past 12
months compared to 11% of heterosexual students.
 28% of LGB students reported attempting suicide in the past 12 months compared to 4%
of heterosexual students
 14% of LGB students reported suffering injuries related to suicide attempts that
required medical treatment compared to 2% of heterosexual students (from The Burden
of Suicide in Wisconsin 2007-2011)
Let’s let this sink in for a few seconds. Emphasize the following:
These youth are 2-4 times more likely to attempt suicide (SPRC, 2008).
They must cope with developing a sexual minority identity, negative comments and jokes, and
often the threat of violence because of their sexual orientation. This is true especially for young
people with “cross-gender” appearances, traits, or behaviors. Those behaviors often go
unnoticed by school personnel. Many LGBTQ students report that school personnel are
perpetrators of homophobic remarks in school. In fact, many LGBTQ students surveyed
reported hearing homophobic remarks from school staff (63% in GLSEN’s National School
Climate Survey). When remarks are made, teachers are less likely to intervene compared to
when they intervene for remarks that are racist and sexist in nature. (Espelage, n.d.)
The primary causes (as reported by LGBTQ teens) are negative family interactions, rejection,
and being “kicked out”. Nothing is “unconditional” for these youth.
Display Risk Factors for LGBTQ Youth (Slide 38)
Refer participants to Handout 12 – Risk and Protective Factors for LGBTQ Youth and provide
the following information:
Being LGBT is not in itself a risk factor, but social stigma, discrimination, unsafe schools,
ineffective providers are all associated with mood, anxiety and substance abuse disorders and
suicidal behavior.
What is different for LGB youth is that they tend to have more risk factors and/or more severe
risk factors.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
44
Module Three
Risk factors for LGBTQ Youth include:
 Homophobia
 LGBT Youth’s perception of homophobia (whether accurate or not – internalizing
negative assumptions about being gay can lead to risky behavior)
 High rates of bullying and violence in schools
 High rates of alcohol/drug use
 High rates of sexually transmitted infections
 High rates of homelessness/”couch surfing”
 Gender nonconformity
 Internal conflict about sexual orientation
Display Risk Factors for LGBTQ Youth, cont. (Slide 39)
 Time of coming out/early coming out
 Low family connectedness
 Lack of adult caring
 Unsafe school
 Family rejection
 Victimization
 Stigma and discrimination
 Ethnicity – some ethnic and cultural groups (such as first-generation immigrants) are
less accepting of children who do not conform to standard gender roles
Display Protective Factors for LGBTQ Youth (Slide 40)
The protective factors that apply to all youth are also applicable to LGBTQ youth, regardless of
sexual orientation:
 Family support and acceptance
 Family connectedness
 Caring adults
 Positive role models
 Positive peer groups
 Strong sense of self and self esteem
 Engagement in school and community activities
 Safe schools
Sources:
LGB Youth: Challenges, Risks and Protective Factors: A Tip Sheet for Grantees of the Office of Adolescent Health and
the Family and Youth Services Bureau, May 1, 2014
Suicide Prevention Resource Center. (2011). Suicide prevention among LGBT youth: A workshop for professionals
who serve youth. Newton, MA: Education Development Center, Inc.
Suicide Risk and Prevention for Lesbian, Gay, Bisexual and Transgender Youth; Prepared by the Suicide Prevention
Resource Center for the Center for Mental Health Services Substance Abuse and Mental Health Services
Administration U.S. Department of Health and Human Services 2008
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
45
Module Three
What about the LGBTQ youth that might be in foster care?
Solicit discussion about how youth in care have often changed communities and schools when
placed in care, or have moved from placement to placement. They might have been reunified
with a family who relocated in their absence. These youth are at a disadvantage. Youth in outof-home care all have these challenges, but for youth who are LGBTQ, it is compounded.
The role of the child welfare worker is instrumental and critical. Why?
Ask participants whether they ask the question (LGBTQ) of youth on their caseload. Do you
discuss this with foster parents, biological parents, or caregivers?
Prepare for video clip. Display Hi! I’m Jonah! Slide (Slide 41). The link for the video clip from
you-tube is embedded on the slide.
Show video and open the discussion with the group.
Trainer note: You may not have much discussion from the group- that is to be expected. It has
been my experience with this material, that there is little feedback. It often impacts
participants because these conversations with youth are difficult and often avoided.
You may supplement with a story of an “a-ha” moment working with this population of youth.
Example from a participant in a prior training: The participant’s client – who had a history of at
least 4 suicide attempts – had told his mother that he was gay, and the social worker did not
follow up with a conversation with the youth about what it was like for him to be gay.
Also consider adding an example of being successful at having this conversation with a youth,
or discuss questions that can be used to open this dialogue. This is a good opportunity to model
how these conversations, while awkward for some, can be successful (what worked, how
engagement was accomplished, etc.)
LUNCH
60 minutes
E. The Bullies and the Bullied (45 minutes)
SLIDES
Are these some of the “Ones We Miss”? (Slide 42)
Definition of Bullying (Slide 43)
Profile of a Bullied Child/Adolescent (Slide 44)
LGBTQ Youth and Bullying (Slide 45)
Myths (Slide 46)
Risk Factors for Those Involved in Bullying (Slide 47)
Protective Factors for Those Involved in Bullying (Slide 48)
Small Group Discussion (Slide 49)
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
46
Module Three
HANDOUTS
The Bullied and the Bullies (HO 13)
Warning Signs: All Children & Adolescents (HO 14)
Display the Are these some of the “Ones We Miss”? (Slide 42). Note the animation- the slide
will end with the Bullies and Bullied graphic displayed.
Begin the discussion by talking about a current suicide case that would be relevant to this
section.
Example: Phoebe Prince, the Irish teen who was bullied by a group of students who were later
charged and convicted for bullying behavior. Talk about how bullying experiences led her to
take her own life, how so many people knew she was suffering, and how teachers and
administrators and fellow students who witnessed the bullying attacks daily did not intervene.
The students continued to “harass” her after her death via Facebook and at school functions.
Trainer note: There are many articles about this case on the web. Research prior to training.
Let’s talk about bullying, as those who bully and those who get bullied are among the ones we
miss.
Display Definition of Bullying (Slide 43). Discuss the definition on the slide:
Definition: Unwanted aggressive behavior that is intentional and that involves a real or
perceived imbalance of power or strength. The behavior is repeated, or has the potential to be
repeated, over time
There are three main types of bullying, including verbal, social or relational, and physical
bullying.
 Physical bullying against a person’s body or possessions includes hitting, pinching,
shoving, tripping, making mean or rude hand gestures (and similar behaviors), as well as
taking or breaking possessions, extorting money, etc.
 Verbal (and written) bullying includes name calling, teasing, taunting, threatening harm,
making inappropriate sexual comments, etc.
 Social/Relational involves hurting relationships or reputation, such as shunning,
spreading rumors or gossip, mocking, public embarrassment, cyber-bullying, etc.
Source: stopbullying.gov; Bullying Definition, n.d.
According to a recent studies teens report that the top two reasons for bullying are
1. Appearance
2. Actual or perceived sexual orientation or gender expression
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
47
Module Three
Additional reasons include looks, body shape and race.
Source: Gay Bullying Statistics, 2009; (Davis and Nixon, 2010) http://www.pacer.org/bullying/about/mediakit/stats.asp;
Discuss the information regarding the prevalence of bullying for children and adolescents.
Approximately 20% of high school students (2009 national study) reported being bullied on
school property.
About 10% of children are bullied on regular basis. Bullying impacts some children and youth on
a daily basis. According to one study for the 2007-2008 school year, 32% of the nation’s
students ages 12-18 reported being bullied. For those students who were bullied, frequency of
bullying was reported as:





21% once or twice a month
10% once or twice a week
7% daily
9% report being physically injured
4% report being cyber bullied
Source: http://www.sprc.org/sites/sprc.org/files/library/Suicide_Bullying_Issue_Brief.pdf
The nature of cyber-bullying allows it to occur on a 24/7 basis. Between 30-60% of teens report
being cyber-bullied, but 85-90% have never told their parents.
LGBTQ youth are bullied 26 times per day, that is 1 time every 14 minutes. They hear anti-gay
slurs (homo/faggot/sissy). About 31% were threatened or injured in the last school year. About
90% report being verbally or physically harassed or assaulted due to one or more reasons,
including their perceived or actual appearance, gender, sexual orientation, gender expression,
race/ethnicity, disability, or religion. (This compares to compare to 65% of other students, ages
13-18.)
Research suggests that many bullying incidents are unreported. Students are more likely to
report physical abuse, damage to property, and physical threats than bullying that is
social/relational. Why do you think that might be? Why is this important to think about?
Display Profile of a Bullied Child/Adolescent (Slide 44). There are two main groups of
children/youth who are bullied. Discuss the differences between passive and provocative
victims.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
48
Module Three
Passive Victim
Most victims of bullying are passive victims. They present as anxious and unsure of themselves.
They are generally passive, submissive, usually quiet, careful, and sensitive. These children may
start crying easily. They have poor self-confidence and negative self-images. They have few or
no friends. Boys who are passive victims do not fight and are physically weaker.
Provocative Victim
This type of victim is less common. It is more common that a group of students or whole class
will be involved in bullying the provocative victim. Provocative victims may try to bully weaker
students. These children tend to be quick tempered and try to retaliate, often without success.
They are often restless, clumsy, immature, unable to concentrate, and generally considered
difficult. They may be hyperactive. As students, they have reading and writing difficulties. They
may be disliked by adults or their teachers because of their irritating behaviors.
Ask: Does any of this remind you of children or youth on your caseload? Share examples.
Let’s talk about the potential impact that bullying has on children and youth.
Bullying contributes to short and long-term negative outcomes for poor health and mental
health, such as depression. These children experience real suffering that can interfere with
social and emotional development. Being a victim of bullying interferes with school
performance.
Trainer note: Revisiting the information on the LGBTQ population is purposeful here. It is
important for participants to think about the impact of bullying on LGBTQ youth.
Display LGBTQ Youth and Bullying (Slide 45).
In the last section, we spoke about the higher risk of suicide for LGBTQ youth, and we heard
from Jonah, a youth who was bullied throughout his school years. Remember the top two
reasons for bullying? The second reason was the actual or perceived sexual orientation or
gender expression.
LGBTQ youth feel they have nowhere to turn. Four out of five say they do not know even ONE
supportive adult at school. Their mental health and education and physical well-being are at
constant risk. Remember that these youth 2-4 times more likely to attempt suicide than
heterosexual youth. Often the bullying is so intense that they are unable to receive an adequate
education. They are 5 times more likely not to attend school because of feeling unsafe. They
are afraid, embarrassed, and ashamed – of being targeted and do not ask for help. These youth
are apt to skip school due to fear, threats, and property vandalism, and 28% drop out of school.
This is more than 3 times the national average. They are also more likely to smoke, use alcohol
and drugs, and engage in other risky behaviors.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
49
Module Three


Use the example of Alliance School in Milwaukee to illustrate the experiences of LGBTQ
youth in the school system. An article was published in Time Magazine (10/11) about
this school. Alliance is a publically funded charter school that accepts gay students and
shields kids from bullies.
Some are critical about the school and whether separating students will resolve the
problem. But the fact remains that there is no reason LGBTQ students, or others who
are bullied, should be forced to endure hardship until society gets to the point where all
schools are safe for all students. It is not happening enough or quick enough. Would you
sacrifice your child if you had an option?
Source: http://www.time.com/time/specials/packages/article/0,28804,2095385_2096859_2096805,00.html
We often hear the stories of how being bullied leads to suicide for youth. It is important for us
to realize that both victims and perpetrators are at a higher risk for suicide.
Children who are both victims and perpetrators are at the highest risk (SPRC, 2011). A study
completed with middle school students in 2011 indicated that these children are 6.6 times
more likely to report seriously considering suicide.
Source: http://www.socialworktoday.com/archive/092011p10.shtml
All three groups are more liked to be depressed – which is a major risk factor. Victims of cyber
bullying are at a higher risk for depression than face to face bullying. We know that those who
commit suicide (attempts) have other serious risk factors, so assessment is imperative.
Media coverage often exaggerates the connection between suicide and bullying.
From a 6th grade girl: “When I saw the cover of my mom’s magazine, there was a picture of a
pretty girl with words like “bullied to death” or something. I’ve been bullied too but haven’t
told anyone. That girl was so much cooler and prettier than I am, and I thought if she had to die
maybe I’d have to die too.”
Source: http://www.socialworktoday.com/archive/092011p10.shtml
Although bullying behavior and suicide-related behavior are closely related (those involved in
bullying are more likely to report suicide related behavior than those who do not report
involvement with bullying), suicide is not a “natural response” to being bullied. It is unknown if
bullying directly causes suicide-related behavior (as most youth involved in bullying do not
engage in suicide-related behavior).
Source: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of
Violence Prevention, “The Relationship Between Bullying and Suicide: What we Know and What it Means for
Schools” 2014; www.cdc.gov/violenceprevention
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
50
Module Three
Transition to a discussion about the warning signs of bullying and how this impacts children and
youth on their caseload. Begin by discussing the children who have been bullied.
Refer participants to Handout 13- The Bullied and the Bullies.
Review the factors that increase a child’s risk of being bullied. These include a child who
internalizes problems (including withdrawal, anxiety/depression), a child with low self-esteem
or lack of assertiveness. Aggressiveness in early childhood can lead to rejection by peers and
social isolation. (SPRC, 2011)
Think about this- children who have the highest risk for suicide tend to be bullied, which in
turn further raises their risk of suicide, as well as depression/anxiety and other problems
associated with suicidal behavior.
In addition to personal factors, we want to consider family factors, such as the presence of
maltreatment, domestic violence, or parental depression. We also consider the dynamics of the
school environment, which may include lack of adequate adult supervision and lack of
consistent effective discipline (SPRC, 2011).
The handout provides a list of red flags for all victims of bullying. These are signs to watch for
in children and youth. Being alert to these signs and asking questions as part of assessment can
help identify early warning signs.
These include emotional and behavioral changes, such as a child who is acting depressed (not
eating, not sleeping, having nightmares, displaying anxiety, or not doing things they usually
enjoy). They may display mood swings, including frequent crying. Children who are being
bullied may withdraw socially. They may frequently complain of illness or express not wanting
to go to school or avoid certain classes. Parents or caregivers may notice that the child is
bringing home damaged possessions, or reporting possessions as lost. The child may state that
he/she feels picked on or persecuted. They may talk about running away. Parents or school
staff may catch bullied children attempting to take or taking something to protect themselves
to school (stick, rock, knife, etc.). Bullied children may start to take a different route home from
school or refuse to take the bus.
Tips for if you suspect the child is being bullied:





Ask the child what they think should be done
Find out what has already been tried and what worked and what did not work
Seek help from teacher/guidance counselors/ school administration
Be aware that bullying usually happens in lunchroom, bathroom, school buses, and
unsupervised halls. Pay particular attention to these areas.
Children need help from school staff. Do not encourage them to fight back, but get help
instead/tell someone.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
51
Module Three


Use role- playing to practice what the child will say to the bully the next time and
practice being assertive
Encourage child to be with friends when traveling in and out of school.
Source: American Academy of Child and Adolescent Psychiatry, Bullying: Facts for Families
http://aacap.org/page.ww?name=Bullying&section=Facts+for+Families
Let’s talk next about the children who engaging in bullying behavior, including commons myths,
characteristics, and family risk factors. It is important to remember that both kids who are
bullied and kids who bully others may have serious and lasting problems.
Display Myths (Slide 46) and review the myths about children and youth who bully.
Myths about bullies:
1. They are usually “loners”
 The opposite is true, even though the friend group may be small
2. Have low self-esteem
 Children who bully often have above average self esteem
 Interventions to build their self-esteem are ineffective
3. Bullying is the same thing as conflict
 Bullying is aggressive behavior that involves imbalance of power
4. Most bullying is physical
 Some is physical, however the most common is verbal (for boys and girls)
5. Bullying isn’t serious
 It is extremely serious
6. Most likely to happen in urban school
 Bullying happens everywhere, every race, every income level, every
geographic region
7. Most likely to happen on the bus
 More likely on school grounds
8. Most kids who are bullied tell an adult
 Estimates indicate that only 25-50% tell an adult
9. Bullied kids learn to deal with it on their own
 They cannot learn to deal with this on their own, and it can impact their
lives
Refer participants back to Handout 13. Children and youth who are engaging in bullying
behavior tend to thrive on control and dominating others. These children have often been
victims of physical abuse of have been bullied. Bullying behavior may be linked to the child
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
52
Module Three
being depressed, angry, or upset about events at home or school. Children who bully
experience suicidal ideation.
Bullies chose targets that fit the profile described above (passive, easily intimidated, have few
friends). Children who bully lack empathy and have difficulty following rules. They tend to view
violence in a positive way. They can be impulsive, hot- headed, and dominant. Boys who bully
tend to be physically stronger than other children. They engage in fighting behaviors, criminal
misconduct, and academic misconduct. This is often an attempt to fit in to a peer group.
There are several family risk factors that are more likely for children who bully than nonbullying peers. These include a lack of warmth and involvement on part of parents, overly
permissive parenting, a lack of supervision, and use of harsh, physical discipline. The family
serves as a model for bullying behavior.
In addition, if school personnel ignore bullying, the intimidating behaviors are reinforced.
Those who are bully/victims (both) often display higher levels of social isolation, depression,
and anxiety, especially among girls.
Then there are the bully/bystanders who are a new category in this dynamic. These are
children who see it and do nothing, or feel that have no power to do anything. They feel
helpless or even guilty for not doing anything to stop it.
Let’s review the risk and protective factors for those involved in bullying behavior.
A Minnesota Student Survey conducted in 2010 assessed risk and protective factors for three
groups of youth involved in bullying: victims, perpetrators and youth reporting involvement as
both a victim and perpetrator.
Many of the risk and protective factors for suicidality identified in this study among youth
involved in bullying mirror factors found to predict and protect against suicidal ideation and
behavior in general populations of adolescents. Because bullying victimization and
perpetration are potent risk factors for suicidality among youth, the presence of other known
suicide risk factors among youth involved in bullying dangerously elevates the risk for suicidal
behavior.
Refer participants to Handout 14- Risk and Protective Factors for Those Involved in Bullying
Display Risk Factors for Those Involved in Bullying (Slide 47)
Relate risk factors as outlined in Handout 14:

All three groups:
History of self-harm, greater emotional distress, involvement in bullying in any way,
especially both bullying others and being bullied (highest risk for suicide related
behavior of any groups involved with bullying)
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
53
Module Three




Bully:
Physical abuse, sexual abuse, mental health problem, running away from home, carrying
a weapon and perceiving oneself as overweight
Victim:
Additional risk factors include physical abuse, sexual abuse, mental health problem,
running away from home, perceiving oneself as overweight, participation in religious
activities, higher levels of distractibility, disabilities or learning differences, LGBTQ
Victims and Bully-Victims:
History of sexual abuse, mental health problem, running away from home
Bully-victims:
Additional risk factors include witnessing family violence, history of physical abuse,
cigarette smoking, marijuana use, skipping school due to safety concerns, perceived
school and neighborhood safety concerns.
Display Protective Factors for Those Involved in Bullying (Slide 48)
Relate Protective Factors as outlined in Handout 14:
 All three groups:
Higher levels of parent connectedness, stronger perceived caring by friends
 Bullies:
Stronger connections to non-parental adults was an additional protective factor
 Victims:
Stronger connections to non-parental adults, liking school, feeling safe at school
General Protective Factors:





School connection
Family Outreach
Healthy problem coping skills
Identification of students in need of mental and behavioral health services
Implementation of effective and inclusive anti-bullying policies, rather than conflict
resolution methods
Sources:
Borowsky, Taliaferro & McMorris; Journal of Adolescent Health 53 (2013) S4-S12; Suicidal Thinking and Behavior
Among Youth Involved in Verbal and Social Bullying: Risk and Protective Factors; October 22, 2012
Suicide and Bullying: Issue Brief; SPRC Suicide Prevention Resource Center; retrieved from website July 2014
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence
Prevention, “The Relationship Between Bullying and Suicide: What we Know and What it Means for Schools” 2014;
www.cdc.gov/violenceprevention
How is this relevant in your work with children and families? If a child presents with mental
health problems, explore their peer relationships and health/ illness (bullying can make you ill,
especially if it is chronic and severe).
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
54
Module Three
An informal survey of former foster youth found that half had been bullied because they were
in foster care. They reported feeling afraid, angry, sad, and depressed. Children enter out-ofhome care due to abuse or neglect, which is often associated with one or more of the
parent/child difficulties described for those who either bully or are bullied.
Child welfare professionals have a role in helping to identify and intervene on behalf of child
who are bullied and those who engage in bullying behavior. Understanding the risk and
protective factors can assist in assessment and intervention.
Refer participants to Handout 15- Warning Signs: All Children & Adolescents. Review briefly
with participants.
As discussed at the beginning of training, risk factors increase the likelihood of suicide and
warning signs can be strong indications of need for immediate intervention. These are specific
behaviors and cues that move beyond risk factors.
F. Summary and Application
SLIDE
Small Group Discussion (Slide 49)
Trainer note: Provide a brief summary, using the following points below and other key concepts
and “take-aways” from your previous discussions.
Summary:
Now what do we know? We are missing some young people who are at higher risk for suicide.
Review the categories and some facts to support why we need to pay particular attention.
Boys are more successful in completions (4:1 boys to girls in Wisconsin). They are not
hospitalized at the rate of girls (who are at least twice the number), therefore may not receive
intervention. They use more lethal means (fire arms). We can see signs in school failure and
impulse control problems. Boys are triggered by an event, usually around a relationship that is
significant to them. Think about the loss of significant relationships for kids who are removed
from their homes, or moving to different foster homes. Girls have more protective factors in
their relationships with others and are more likely to ask for help or reach out to friends. Boys
act impulsively within a very short time after the event.
Native American youth are 5 times more at risk. Discuss other risk factors from the earlier
discussion.
Suicides among African American youth are increasing.
LGBTQ youth have additional risk factors, and have an extremely high rate of depression,
suicidal thoughts, and suicide attempts.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
55
Module Three
In addition, think back about the characteristics of children who are bullied. How do those fit
the children and youth you have placed in out-of-home care? Think of the risk of being bullied
for children with disabilities (emotional, physical, intellectual, developmental, and sensory) and
think about how risk is increased when you add foster home placement to the mix. How many
children and youth on your case load include children with “special needs” of some type?
LGBTQ? All of these combined?
Remember how few tell you, or anyone about the bullying. How will you find out?
Large Group Discussion:
1. Discuss the bullying component - Do you think that the youth in these at risk groups
may also be greater targets for bullying? What does that do to their risk for suicide?
2. Can you see a pattern of cumulative risk factors?
3. Did anything else catch your attention from discussions so far?
4. What about girls? Anything specific about their risk factors?
5. Think now of your caseload. How common are some of these risk/protective factors?
Small Group Activity:
Display Small Group Discussion (Slide 49).
We introduced six groups: Boys, Native American, African American, LGBTQ, Bullies, and
Bullied.
At your table, take a few minutes to discuss:
 Youth you may have on your caseload that you now may be able to identify as “at risk”
of suicide
 Talk about specific risk factors
 What protective factors can you utilize in your case planning?
Give them 10 minutes. Discuss with large group. Try to get them to be specific with risk factors,
and protective factors, plus the impact of the identified six groups for their consideration.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
56
Module Four
MODULE 4- PREVENTION AND INTERVENTION MODELS
Timing: Approximately 40 minutes, excluding break following the module
A. Familial Pathways to Suicidal Behavior Model
10 minutes
B. The Question Model
30 minutes
C. Additional Approaches (Optional)
BREAK (15 minutes)
Trainer note: There is no additional time allocated for the optional content. Consider using only
in the event that the training is ahead of schedule, otherwise material will need to be cut in
order to complete the final modules. Even if the training is running ahead of schedule, you can
easily use any spare time to extend the activities in Module 5, as timing is very tight.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
57
Module Four
MODULE 4 – PREVENTION AND INTERVENTION MODELS
TRAINING CONTENT
Introduction: We will look at prevention and intervention. Both tie back to the need for
assessment. Accurate assessment will both prevent and intervene.
In an effort to prevent suicide, we have to understand risk. We cannot predict suicide, but we
can assess factors that increase risk.
A. Familial Pathways to Suicidal Behavior Model (10 minutes)
SLIDE
Familial Pathways to Early-Onset Suicidal Behavior (Slide 50)
HANDOUT
Familial Pathways to Early-Onset Suicidal Behavior (HO 16)
Trainer note: The information for this section can be found at the following source: Brent, D.A.,
and Mann, J.J. (2006). Familial pathways to suicidal behavior – Understanding and preventing
suicide among adolescents. Perspective. Retrieved from
http://www.nejm.org/doi/full/10.1056/NEJMp068195#t=article
Introduce the section by explaining that you will be sharing a model that may help us
understand youth who may be more predisposed to suicidal tendencies.
Display the Familial Pathways to Early Onset Suicidal Behavior (Slide 50). Direct participants to
Handout 16- Familial Pathways to Early-Onset Suicidal Behavior.
Ask participants to listen to the example (read aloud):
A 16 year old boy was seen in the emergency room after slashing his wrists. He says that his
brother recently committed suicide, and since then he has been extremely depressed and felt
hopeless. He has been drinking a lot more. He has been depressed since the age of 12 years old
and attributes it to when his father died. He does not feel like it ever got better. He says that he
had gotten into trouble at school, usually because he was fighting with other students who
picked on him for being effeminate. He just had a big fight with his girlfriend before he slashed
his wrists. He felt so bad that he thought he might as well be dead. His mother reports that the
boy’s father died of “accidental carbon monoxide poisoning”. The father had had problems with
depression, alcohol and aggression and most likely also committed suicide.
Adapted from Brent & Mann, 2006 from http://www.nejm.org/doi/full/10.1056/NEJMp068195
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
58
Module Four
This young man has many known risk factors for suicide. What are they?
Mood disorder, substance abuse, bullied, recent loss of loved one, family history, and an
event (fight with girlfriend)
Even though these risks exist, the vast majority of people do not attempt or commit suicide.
Let’s take a look at this model to see if we can identify a pathway that may be an explanation
and a predictor. This may be helpful in your work.
Use the slide and handout to discuss the following points:
The life stressors are outside the family system. They could be the event (loss of the
relationship) creating despair in this case and impacting the child’s suicide attempt.
Note the direction of the arrows in the chart. The parent’s genetics and behaviors impact the
child.
From this diagram we can see that early child abuse/neglect appear to contribute to familial
transmission of suicidal behavior by compounding genetic vulnerability. Again, the impulsive
aggression is not only genetic but affects the parent’s ability to provide optimal environment
for child rearing.
Parents who have a mood disorder and attempt suicide are more than six times as likely to
have child who attempts. It is the suicide attempt that creates the risk factor. Suicidal behavior
that begins before age 25 is highly familial. Key word here is suicidal behavior.
This pathway helps us identify familial transmission and identify vulnerability factors with
greater precision, impacting treatment and prevention efforts.
B. The Question Model (30 minutes)
SLIDES
The Question Model (Slide 51)
Let’s Practice! (Slide 52)
Now, what do you do with what you know? (Slide 53)
HANDOUTS
Please Listen to Me (HO 17)
Kicked out of Foster Home #7 (HO 18)
Trainer note: You will need approximately 20 minutes for the last two activities so move
through the lecture piece quickly. It is important for participants to have an opportunity to
practice asking the questions so make this the priority if time is short.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
59
Module Four
As a social worker, what is your role in identifying and assessing risk of the young people in
your care, whether voluntary or involuntary?
Display The Question Model (Slide 51).
Your role is about asking the questions. This can be difficult, but understanding the risks will
guide what questions you ask. One approach that is simple and effective includes three simple
steps:
1. Ask the Question(s)
2. Listen and Respond
3. Act or Refer
I am going to spend a little time talking about this approach because it is a good place to start
thinking about the questions you might want to ask, and then what to do when and if you do
get a positive response to suicidal thinking, ideation, or behavior.
1. ASK THE QUESTION(S)
Asking a person about having suicidal thoughts is often awkward. It is a difficult subject. We
really do not want the person to be suicidal, and what do we do if they tell us they are?
The truth is that you are probably the best person to ask these questions because you know the
warning signs, the risk factors, and the protective factors. You can do this indirectly or directly.
Examples of an indirect approach:
 “Do you ever wish you could go to sleep and never wake up?”
 “You know, when people are as upset as you seem to be, they sometimes wish they
were dead. I’m wondering if you’re feeling that way too.”
Examples of a direct approach
 “Have you ever wanted to stop living?”
 “You look pretty miserable. Are you thinking of killing yourself?”
 “Are you thinking about suicide?”
Use questions that are comfortable to you. It takes some practice and some risk-taking.
If you get a “yes” answer to the question, then what? You have to do something.
Research shows that once a person is asked about suicidal thoughts and they disclose them,
they feel relief, not distress. Usually, people want to talk about it. There is a myth that exists
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
60
Module Four
that asking the question will plant ideas. Asking the suicide question does not increase risk of
suicide.
2. LISTEN AND RESPOND
Help begins with the simple act of listening. It can be life-saving. Being a good listener involves
giving the person your full attention without interrupting. You can speak when the person is
finished. Listening means that you are not rushing to judgment. Listening to someone talk
about suicide can evoke personal emotions. You need to tame your own fear so that you can
focus on the other person. Listening gives you time for this. Listen first, and then respond.
The goal is simple – to move the person to say “yes” they want some help. Put yourself in the
situation for a moment. What if it was you and you were so miserable and not thinking clearly?
Or think about being a child who is not able to think it through it at all? Would you want those
who care about you to stand by and let you kill yourself?
3. ACT OR REFER
The best way to act is to personally see that the individual is connected (face-to-face) to a
mental health professional, crisis worker, or police officer. You want to make sure there is no
access to firearms or other methods for harm.
We will now spend some time practicing what we have discussed up to this point in the training.
Pairs/Small Group Activity:
Display Let’s Practice! (Slide 52) and ask participants to take out Handout 17- Please Listen to
Me and Handout 18- Kicked Out of Foster Home #7
Give instructions for participants to get into pairs. The handouts contain two case scenarios.
Pairs will choose one participant to be Justin and the other to be Grant. They will practice using
the model with their partner for 5 minutes. When the time is up, the trainer will instruct them
to switch roles and interview again for 5 minutes. They can provide feedback to the
interviewer at the end of the interview.
Let them know that we will process together afterwards, paying particular attention to the
questions you used, and what it was like to ask and be asked those questions.
Give them 1-2 minutes to read one of the scenarios before beginning the skills practice. Be sure
to track the time and call out a one minute warning to give them time to wrap up their
interviews. Ask them to provide feedback to the interviewer about the interview for a few
minutes, particularly what went well. Then give them 1-2 minutes to read the other scenario
and begin the interviewing and feedback process.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
61
Module Four
After the interviews, process together. Ask the participants what was challenging about this
particular client. Ask them if what they knew about this particular client was helpful. Perhaps
they can identify what they had learned about this particular population that helped them.
Next, display the Now, what do you do with what you know? Slide (Slide 46) and complete the
small group activity together with the participants at their table. Provide instructions:
1. Choose Grant or Justin. In your small group/table discuss:
 Who will you refer this client to in your community?
 Who will you have on your team to help you with this case?
 Who makes the decision regarding the “act/refer”?
2. Put your responses on flip chart paper and post when finished
3. Each group will share their responses with the larger group
Process their responses and bring the activity to a close.
C. Additional Approaches (Optional)
Trainer note: The following section on additional approaches is optional. Use this material only
if you have time to fill. There has not generally been time for this section, therefore there is no
time built into the curriculum. You may try to weave suggestions into the rest of the training,
or into the previous activity.
SLIDE
Additional Approaches (Slide 54)
HANDOUT
Suicide Prevention Strategies (HO 19)
FLIP CHART
www.teenscreen.org
Display Additional Approaches (Slide 54).
What are others doing? There are many interventions available for you to study, and I would
recommend that you do your research; however, there are a couple of initiatives that have been
around for quite some time, and have shown positive outcomes.
The Department of Education mandates all staff and students to have ongoing
training/education on suicide. Students receive education in Health classes. The faculty is
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
62
Module Four
trained in SOS (Signs of Suicide) and ACT (Acknowledge, Care, and Tell). The Telling component
includes telling a member of the in-house crisis team.
ASK: Do you have a crisis team, or plan within your unit/department to help any of you that
may have a client (child or adult) who is suicidal?
Some other interventions include addressing bullying, improving school and classroom climate,
and develop life skills such as problem-solving and decision-making. Interventions also include
having counseling and mental health services that are responsive. It is not advised to provide
training to students in large groups or assembly formats. A smaller setting is recommended.
Use of a screening tool is another effective intervention. The Teen Screen consists of screening
tools that can help identify and refer youth (ages 11-18) that are presenting with mental health
or AODA concerns or are at risk for suicide. Fond du Lac School System has implemented the
Teen Screen since 2003.
There are 3 types of screening:
 Columbia Health Screen – 14 item self-report measure of risk (paper and pencil)
 Diagnostic Predictive Scale – multi-disorder screen (computerized)
 Columbia Depression scale – 22 item depression screen (paper and pencil)
Parental consent is required prior to the teen taking the screening and the youth must agree to
complete it. Students who screen positive are interviewed by a clinician to determine if further
evaluation is necessary, and appropriate referrals are made.
NOTE: This program has been successfully implemented in foster care, shelter care, and
residential treatment facilities. This may be an alternative for your case planning.
The purpose of these screens is to identify students at the greatest risk for suicide. Remember
90% of all teens who die by suicide suffer from a treatable mental illness. There is no cost for
the screening, assessment instruments, or training and technical assistance and consultation
are all free. Agencies must provide the mental health professional for the clinical interview.
The Teen Screen has been implemented in 41 states, including Wisconsin. It is supported by 23
national organizations, including the American Academy of Child & Adolescent Psychiatry, the
American Federation of Teachers, and the President’s New Freedom Commission on Mental
Health.
What do we know about the results of the screening? The screening identifies youth at risk of
suicide and teens experiencing depression and other mental health conditions. Almost 2/3 of
suicidal teenagers were not known to school professionals. One-half of suicidal teens were not
known to either school or mental health professionals. One-third of the highest risk teens were
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
63
Module Four
not known to either school or mental health professionals. Only 1.6% of the highest risk teens
were known to a mental health professional.
Screening participants do not have higher distress levels than non-participants. Screening
participants do not have higher rates of depressive feelings than non-participants. Screening
participants are not more likely to report suicidal ideation after completing the screening.
Depressed teens and previous suicide attempters who are screened are less distressed and
suicidal than depressed teens and previous suicide attempters who are not screened.
You can find more information on this website (display flip chart with web address):
www.teenscreen.org
Suicide Prevention Strategies
Refer participants to Handout 19 – Suicide Prevention Strategies. These are additional suicide
prevention strategies taken from Dr. David May’s book, “Suicide: Risk Assessment and Risk
Management”. Explain each strategy.
1. Assembly Type Group Suicide Awareness
This strategy is popular with “normal” teens but does not seem to increase selfreferrals, help seeking, or help giving in adolescents. It may activate suicidal ideation in
disturbed adolescents and may contribute to clustering. This strategy tends to minimize
the role of mental illness. Suicide training as part of curriculum may be helpful.
2. Screening
As discussed earlier, screening can help identify depression, alcohol or substance abuse,
recent or frequent suicidal ideation or past suicide attempts. If a screening program
does NOT include evaluate/refer, then it should not be used. Recommend using
teenscreen.org
3. Gatekeeper Training
This training educates teachers, counselors, and youth workers on ways to recognize
risk. There is no clear research on the efficacy of this strategy.
4. Crisis Center and Hotlines
It is important to understand that few teenagers use crisis centers and hot-lines, and
those that do are NOT the highest risk (boys).
5. Restrictions of lethal means/alcohol
There is a modest but statistically significant reduction in firearm suicides in 14-17 year
old age group associated with child access prevention laws. Caregivers are three times
more likely to remove guns from the home if they are educated about the dangers.
Youth are more likely to use firearms when intoxicated. States that have increased the
minimum drinking age have seen a 7% increase in suicide reduction in teens.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
64
Module Four
6. Skills Training
Skills training involves using a high school curriculum to further the development of
problem-solving and coping skills. There is some evidence that this may help reduce the
risk.
7. Emergency Room (ER)
There are a number of people who come into the ER who do not follow up with
appointments (17%). Over half who attend their post-ER appointments will quit after 2
sessions (52%). Nighttime phone contact and the next day follow up have been shown
to assure that 90% will stay in treatment. Missed sessions, sudden wellness, or sudden
desire to stop treatment are RED FLAGS that suicidality may be present.
8. Antidepressants
There is controversy regarding the appearance of suicidal ideation. When using
antidepressants as a strategy, look for the following side effects; decreasing inhibition,
increase in irritability, change in sleep patterns, or increase in agitation/restlessness.
Source: David Mays, MD, PhD, Suicide: Risk Assessment and Risk Management (2009), 9th edition
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
65
Module Four
MODULE 5- SURVIVING THE SUICIDAL CLIENT
Timing: Approximately 25 minutes
A. Introduction
5 minutes
B. Impact of Suicide on Social Workers
20 minutes
Trainer note: This section is important for encouraging the self-care and help-seeking of
workers who have experienced a client who committed suicide or who are suicidal.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
66
Module Five
MODULE 5 – SURVIVING THE SUICIDAL CLIENT
TRAINING CONTENT
V. Surviving the Suicidal Client
Trainer note: This module is for the social worker who past or current experience with a
suicidal client or one who has committed suicide. Trainer should always include this module in
the training.
A. Introduction (5 minutes)
For every person who commits suicide, there are approximately 6-10 survivors. Those survivors
are close in relationship to the victim or close to the suicide survivors. This is one of life’s most
stressful events, and it is important to understand that bereavement in suicide situations is
different than other types of death.
Bereavement of a person who completed suicide can create depression, anxiety, complicated
grief, PTSD symptoms, or guilt and shame in the survivor. Only 25% who suffer these symptoms
seek help. Complicated grief and depressive symptoms independently heighten the risk for
suicidal ideation, which may pose a risk for subsequent suicide in survivors. Some research
indicates that survivors are more likely to have suicidal ideation. Link this back to the discussion
about the familial pathways diagram in the previous module.
This indicates the strong need for us to assess the suicide risk of the family and those close to
the victim. In addition, it is important to identify protective factors for family members and
other survivors.
B. Impact of Suicide on the Social Worker (20 minutes)
SLIDES
What about YOU? (Slide 55)
What about YOU? (Slide 56)
Small Group Discussion (Slide 57)
Trainer should transition to a discussion about the impact of suicide on the social worker. What
about you, the social worker? How are you impacted by clients who commit, attempt, or
threaten suicide?
The research is limited in terms to the impact of client suicide on social workers. Most of the
research is relates to the fields of psychiatry and psychology. However, one study looked at the
impact of suicide on mental health social workers, and can be used to inform our practice.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
67
Module Five
Source: http://sw.oxfordjournals.org/content/51/4/329.full.pdf+html?sid=701aa999-d1f6-49f8-b087de4f24839927
Ting, L. S. (2006). Dealing with the aftermath: A qualitative analysis of mental health social workers' reactions after
a client suicide. Social Work, 51(4), 329-341.
The research indicated that social workers are at as great of risk as others to experience the
suicide of a client. Note to participants that although they may not be labeled as “mental health
social workers”, their work with clients with mental illness makes this information relevant and
applicable.
Display What about YOU? Slide (Slide 55) and discuss each of the points.
The research revealed 12 major themes associated with the experiences of social workers who
had dealt with the suicide of a client.
Denial and Disbelief
Social workers indicated that they were “unprepared”, “didn’t see it coming”, and “I had no
warning about this.” They felt shocked, shook up, and surprised. Some statements indicated
that the social worker believed that the suicide must have been an accident, implying that the
client did not really mean to kill themselves.
Grief and Loss
Social workers reported such things as “I could not control my crying” and “I was griefstricken.” They experienced feelings of devastation and depression. Social workers expressed
having wept for their clients, some did not sleep well, and one thought they were having a
heart attack. The suicide brought up feelings of personal loss, especially memories and grief
issues around other losses.
Anger
Anger was a common feeling, including anger at the client, the agency, and at society.
Self-Blame and Guilt
Social workers experienced a sense of personal blame and guilt, making statements such as “I
felt the whole would’ve, could’ve, should’ve thing” and felt they should have seen it coming.
Some questioned themselves for not taking it more seriously and experienced a sense of guilt
that they had not done enough to help the client.
Professional Failure and Incompetence
There was indication that social workers felt doubtful of their abilities and experienced fear of
being judged by colleagues and the family of the client. They questioned, “Did the family think I
did the right thing or that I’m stupid?” and wondered what others would think.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
68
Module Five
Responsibility
Workers often felt personally responsible and liable for the suicide. This stemmed from feeling
like they were working all alone and were not part of a team making decisions, which created a
helpless feeling. They had invested a great deal of emotional energy with the client and now
afterwards in dealing with the suicide.
Display What about YOU? (Slide 56).
Isolation
Social workers experienced feelings of alienation, social isolation, lack of support and being
blamed after the suicide. They felt isolated in their work, indicating that they were not getting
the level of supervision they needed and wished they had asked for more. Workers expressed
feeling they were on their own.
Avoidant Behaviors
The suicide of one client impacted their lack of desire to work with other clients who were
potentially suicidal, or talk about the suicide. Workers also reported that this impacted their
personal decisions, such as to leave the job.
Intrusion
It was common for social workers to have intrusive reactions and feelings of anxiety. They
would fear for the well-being of other clients, fear another suicide occurring while on their
watch, and found they were becoming “fearful” of clients. One stated it was “A lot of pressure –
I was feeling helpless because there is only so much one can do; I had a lot of anxiety, waiting
for something to happen again.” Social workers reported that this spilled over and intruded into
their personal lives, where the memories continued to intrude and they had lingering thoughts
about the suicide.
Changes in Professional Behavior
Social workers reported that the experience spurred positive changes in practice, such as
“increased awareness of suicidal ideations, not making assumptions of what suicidal people are
like, and conducting more detailed screening and lethality assessments.” There were also policy
changes in the professional environment that were beneficial.
Justification
Another common theme included social workers justifying their actions and thus absolving
themselves of blame. This reflected on the clients making the choice to commit suicide
regardless of what help was offered. Social workers stated; “He just didn’t listen”, “Committing
suicide was a choice he made”, and “I make my best call given all the information I have, and
then I have to say it’s not my responsibility because if they’re going to kill themselves they’re
going to kill themselves. I have absolutely no control over that.” Some reported no guilt or
unresolved feelings over their actions, indicating, “I wouldn’t change anything; I’ve not done
anything wrong so I didn’t make any changes in practice.”
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
69
Module Five
Acceptance
Social workers also reflected feelings of forgiveness and absolution. This was most evident
where the social worker received support from others regarding responsibility.
Conclude the discussion by summarizing that there is quite a range of emotional and
psychological reactions. So, what do you do?
Small Group Activity:
Display Small Group Discussion (Slide 57).
Ask participants to spend a few minutes talking about your reaction to these themes. If you
have experienced a completed or attempted suicide client situation, discuss with your small
group some things that were helpful, and some things that were not helpful. Be ready to
share with large group your list of things that helped and those that did not help.
Give participants 5-8 minutes, depending on their need and timing.
Process their responses quickly, paying particular attention to drawing out strategies that were
successful. Draw out personal coping strategies and support provided by colleagues and the
agency. Encourage them to seek help and support.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
70
Module Six
MODULE 6- YOU ARE NOT AN ISLAND- THE SYSTEM OF CARE
Timing: Approximately 40 minutes
A. Summary
5 minutes
B. System of Care
35 minutes
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
71
Module Six
MODULE 6 – YOU ARE NOT AN ISLAND – THE SYSTEM OF CARE
TRAINING CONTENT
VI. You Are Not an Island- The System of Care
A. Summary (5 minutes)
SLIDES
Whew! (Slide 58)
Display Whew! (Slide 58). Provide a summary of key information that was discussed during the
training, such as:
We have covered a great deal of information today, and you will now have an opportunity to
put it all together. We talked about suicide in Wisconsin. We spent some time review the “ones
we miss”, including the boys, Native American youth, African American youth, LGBTQ youth,
and the bullies and the bullied.
We talked about how each of these is exacerbated for youth in care, whether foster care,
juvenile detention, or relative care. We reviewed the warning signs of suicide, the risk factors,
and protective factors.
ASK: What are the key protective factors for youth in all categories? (friendships, supportive
adults, and good relationships with parents, culture, of the family and community)
ASK: If you know all of the above, and are aware of the ones we miss, are you a protective
factor? Especially to kids in care? Refer back to Handout 8- Risk and Protective Factors.
You also practiced asking the difficult questions.
Now it is time to think about what you are going to do when and if you hear from your client
that they indeed do want to end their lives. You can also use this tool in general case planning.
B. System of Care (35 minutes)
SLIDES
System of Care Application (Slide 59)
Support Plan (Crisis Plan) Application (Slide 60)
HANDOUTS
A System of Care (OOF)
Jared- Juvenile Justice Part 1 (HO 20)
Jared- CPS Part 1 (HO 21)
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
72
Module Six
Support Plan- System of Care (OOF)
Jared- Juvenile Justice Part 2 (HO 22)
Jared- CPS Part 2 (HO 23)
Foster Care Providers: Helping Youth at Risk for Suicide (OOF)
Preventing Suicide Behavior Among Youth in Foster Care (OOF)
Provide Out-of Folder Handout- A System of Care. Introduce the system of care and review the
intent of each part.
 Name of client
 Challenge – What is the general problem/challenge?
 Goal – List the specific or priority goal
 Completion Date is filled in at completion
The system includes key people who may be able to help meet the specific goal. As yourself,
who are you going to engage to help you with this case?






Formal/informal – Encourage the worker to consider both in the plan. They do not need
to identify whether it is formal or informal, but can list the name of the agency or
program (formal) or relationship (informal)
Contact Person – List the name of the specific person you will contact
Purpose – List the purpose for this person to in the system and what they bring to the
table (Examples: social worker, counselor, best friend)
Date – Set the date to be contact each individual
Strategic care planning date – List when are you going to meet
Attending: List who will attend the meeting. Not all on your system list need to attend
the planning meeting. You may not need to have a meeting, at all, but this could be the
beginning of the creation and implementation of a collaborative team.
Small Group Activity:
Trainer note: This activity has two separate parts. Provide clear instructions to keep the group
together and avoid confusion.
Part 1
Display the System of Care Application Slide (Slide 59).
Each team will use a case scenario about Jared, either from the CPS or JJ perspective. The
scenarios are similar. Teams may choose the scenario that is more relevant to their work.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
73
Module Six
After choosing their perspective, teams should read Part 1 of the applicable case scenario. For
the JJ perspective, use Handout 20- Jared- Juvenile Justice Part 1. For the CPS perspective, use
Handout 21- Jared- CPS Part 1.
Teams will them develop the System of Care for Jared. Use the OOF Handout- A System of Care
to record responses. Determine the specific goal for Jared, and choose potential members of
the system of care that can help you reach this goal with Jared.
Give 10 minutes to complete the System of Care.
Process the activity. Ask several teams to quickly share their system of care. Ask whether they
think this might be a helpful model and why.
Next, provide the Out-of-Folder Handout Support Plan- System of Care and discuss the
purpose of this document.
The Support Plan can be thought of as an “if-then” crisis plan. If this happens, then we will do
that. This crisis plan is a composite of the plans utilized by crisis agencies, and counties in the
Northeast region. In developing this training, we requested samples from at least 10 agencies,
and put this example together from what is currently being used.
Review the components of the Support Plan. Briefly discuss why each component is important
and useful in the event of a crisis. Some of the components help identify protective factors.
This plan is always completed alongside the client with their input.
Part 2
Display the Support Plan (Crisis Plan) Slide (Slide 60).
Teams should read the corresponding Part 2 of the scenario. For the JJ perspective, use
Handout 22 – Jared- Juvenile Justice Part 2. For the CPS perspective, use Handout 23 – JaredCPS Part 2.
Jared comes back to his residence after his suicide intervention. You will use the Support Plan
to help prepare everyone for a crisis. Although ideally the entire tool would be completed, in
training, we are going to focus on Question 6 “Strategy/Intervention for client during crisis”.
As a team, think about some behaviors or indications that Jared may be in crisis. Think about
the warning signs. Develop specific strategies or interventions to use to maintain safety (When
Jared….then we will…). Utilize your system of care providers.
Give 10 minutes to complete.
Process the activity by asking participants to share some of their strategies.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
74
Module Six
Provide positive feedback. Be sure to pay attention to their use of informal providers, clarity
and effectiveness of strategies, and recognition of warning signs that Jared is in crisis.
As you developed your systems of care, foster parents and other placement resources were
noted as providers. In order to support foster parents and other placement resources with
information about helping youth at risk for suicide and preventing suicidal behavior among
youth in foster care, we have two handouts that you can provide to foster parents and other
placement resources: Out-of Folder Handout - Foster Care Providers: Helping Youth at Risk for
Suicide and Out-of Folder Handout - Preventing Suicide Behavior Among Youth in Foster Care.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
75
Resources
MODULE 7- CLOSING
Timing: Approximately 5 minutes, or use time remaining until the end of the training day
A. Closing
5 minutes
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
76
Resources
MODULE 7- CLOSING
TRAINING CONTENT
VII. Closing
A. Closing
SLIDES
For the Bullied and Beautiful (Slide 61) Link to video clip
Resources (Slide 62)
The One thing (Slide 63)
HANDOUTS
Evaluation
Action Plan
Prepare for video clip. Display For the Bullied and Beautiful Slide (Slide 61). The link for this
video is embedded on the slide. Show video.
Display Resources Slide (Slide 62) and encourage participants to utilize these sites for current
information.
Close with the following summary, or develop your own:
You are not an island. This work is difficult, but you do not have to do it alone. Actually, it is
better not to be the “Lone Ranger”, especially with this subject matter. I wonder whether this
just might be a barrier to asking those difficult questions. Maybe we feel this is just too scary to
do alone, and perhaps it is “easier” not to know.
Refer back to the very first small group where they identified warning signs or symptoms of
suicide. Point out that we really do know a lot about suicide.
Display The One Thing slide (slide 63).
Ask participants to share “1 Thing” that they will take with them today or something they have
learned or an “a-ha” moment. Saying it out loud assists with transfer of learning.
Action Plans and Evaluations
Refer participants to the Evaluation form and Action Plan in their folder. Ask them to complete
both prior to leaving training. Instruct them to leave the yellow copy of the Action Plan and the
Evaluation in the envelope on the registration table. This copy will be sent to their supervisors
along with a memo that provides transfer of learning questions and tips. Remind them to sign
out.
Thank participants for attending the training.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
77
Resources
RESOURCES
American Academy of Child and Adolescent Psychiatry. (2011). Bullying. Facts for Families.
American Academy of Child and Adolescent Psychiatry, 80. Retrieved from
http://aacap.org/page.ww?name=Bullying&section=Facts+for+Families
American Association of Suicidology. (2014). U.S.A. Suicide: 2011 Official Final Data. Retrieved
from
http://www.suicidology.org/c/document_library/get_file?folderId=248&name=DLFE941.pdf
American Association of Suicidology. (n.d.). African American suicide fact sheet. Retrieved from
http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE241.pdf
American Association of Suicidology. (n.d.). Lesbian, gay, bisexual and transgendered resource
sheet. Retrieved from
http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE167.pdf
American Association of Suicidology. (n.d.). National suicide statistics. Retrieved from
http://www.suicidology.org/stats-and-tools/suicide-statistics
American Association of Suicidology. (n.d.). Youth suicide fact sheet. Retrieved from
http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE245.pdf
American Foundation for Suicide Prevention. (2014). Risk factors and warning signs. Retrieved
from http://www.afsp.org/understanding-suicide/risk-factors-and-warning-signsJuly
2014
American Foundation for Suicide Prevention. (2013). Facts and figures. Retrieved from
http://www.afsp.org/index.cfm?page_id=04EA1254-BD31-1FA3-C549D77E6CA6AA37
Associated Press. (2010). Dallas school staff finds 9-year-old hanging in bathroom. Fox News.
Retrieved from http://www.foxnews.com/story/0,2933,583654,00.html
Associated Press. (2010, May 13). Bullying partly blamed for 15-year-old-girl's suicide jump
from overpass. Fox News. Retrieved from
http://www.foxnews.com/us/2010/05/13/bullying-partly-blamed-year-old-girls-suicidejump-overpass/
Baldessarini, R.J. (2003). Reducing suicide risk in psychiatric disorders. Current Psychiatry, 2(9).
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
78
Resources
Bender, E. (2003). Study identifies suicide risk factors in Native-American youth. Psychiatric
News, 38(11), 29-33. Retrieved from
http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=106305
Blackwell, S., Gromoske, A., Guerrieri, M., and Schlotthauer, A. (2014). The burden of suicide in
Wisconsin: 2007-2011. Wisconsin Department of Health Services, Injury Research Center
at the Medical College of Wisconsin, and Mental Health America of Wisconsin. Retrieved
from http://www.dhs.wisconsin.gov/publications/P0/p00648-2014.pdf
Borowsky, Taliaferro & McMorris. (2013). Suicidal thinking and behavior among youth involved
in verbal and social bullying: risk and protective factors. Journal of Adolescent Health 53
(2013) S4-S12.
Brent, D., & Mann, J. (2006). Familial pathways to suicidal behavior - Understanding and
preventing suicide among adolescents. The New England Journal of Medicine. DOI:
10.1056/NEJMp068195. Retrieved from
http://www.nejm.org/doi/full/10.1056/NEJMp068195
Bullying Statistics . (2009). Gay Bullying Statistics. Retrieved from
http://www.bullyingstatistics.org/content/gay-bullying-statistics.html
Centers for Disease Control and Prevention. (2010). Suicide: Risk and protective factors.
Retrieved from
http://www.cdc.gov/ViolencePrevention/suicide/riskprotectivefactors.html
Centers for Disease Control and Prevention. (2014). Youth Risk Behavior Surveillance – United
States, 2013. Surveillance Summaries, June 13, 2014. MMWR 2014; 63 (4).
Centers for Disease Control and Prevention. (2010). Suicide: Risk and protective factors.
Retrieved from
http://www.cdc.gov/ViolencePrevention/suicide/riskprotectivefactors.html
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control,
Division of Violence Prevention. (2014). The relationship between bullying and suicide:
what we know and what it means for schools. Retrieved from:
www.cdc.gov/violenceprevention.
Davis, S., & Nixon, C. (2010). The youth voice research project: Victimization and strategies.
Retrieved from: http://www.pacer.org/bullying/about/media-kit/stats.asp
Espelage, D. (n.d.). Bullying & the lesbian, gay, bisexual, transgender, questioning (LGBTQ)
community. White House Conference on Bullying. Retrieved from
http://www.stopbullying.gov/atrisk/groups/lgbt/white_house_conference_materials.pdf
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
79
Resources
Evers, T. (n.d.). Facts about youth suicide in Wisconsin. Wisconsin Department of Public
Instruction. Retrieved from http://dpi.wi.gov/sspw/pdf/spythsuicidefacts.pdf
Hisgens, J. (2011). Issues in mental health: Suicide prevention grades 6-8. Wisconsin
Department of Public Instruction. Retrieved from
http://dpi.wi.gov/sspw/pdf/spcurriculum6-8.pdf
Hisgens, J. (2011). Issues in mental health: Suicide prevention grades 8-10. Wisconsin
Department of Public Instruction. Retrieved from
http://dpi.wi.gov/sspw/pdf/spcurriculum8-10.pdf
HOPES. (n.d.). Wisconsin suicide prevention facts. HOPES Suicide Education & Prevention.
Retrieved from http://www.hopes-wi.org/Resources/prevfactsheet.pdf
HOPES. (n.d.). Wisconsin suicide prevention strategies. HOPES Suicide Education & Prevention.
Retrieved from http://www.hopes-wi.org/Strategy/index.htm
HOPES. (n.d.). Wisconsin suicide statistics. HOPES Suicide Education & Prevention. Retrieved
from http://www.hopes-wi.org/Resources/facts.htm
Irvine, M. (2010). Teen's suicide prompts schools to take on bullying. Associated Press.
Retrieved from http://www.foxnews.com/us/2010/04/26/teens-suicide-promptsschools-bullying/
Jared Story. (2003). Plaintiffs' trial brief. Jared Story. Retrieved from
http://www.jaredstory.com/trial_brief.html
Kristin Brooks Hope Center. (2012). Suicide. Hopeline. Retrieved from
http://www.hopeline.com/edu-suicide.html
Laframboise, M., & Anhorn, M. (2008). The way of the two-spirited people: Native American
concepts of gender and sexual orientation. Dancing to Eagle Spirit Society. Retrieved
from http://www.dancingtoeaglespiritsociety.org/twospirit.php
Leff, L. (2009). Anguish over California teen suicide spurs action. Deseret News. Retrieved from
http://www.deseretnews.com/article/705341292/Anguish-over-California-teensuicides-spurs-action.html
LGB Youth: Challenges, Risks and Protective Factors: A Tip Sheet for Grantees of the Office of
Adolescent Health and the Family and Youth Services Bureau. JBS International, Inc.
under contract with the U.S. Department of Health and Human Services; Office of
Adolescent Health; Family and Youth Services Bureau. Vision Solutions LLC. (2014).
Mallon, M. (2011). The Road to Resilience. Social Work Today, 11(5). Retrieved from
http://www.socialworktoday.com/archive/092011p4.shtml
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
80
Resources
Mays, D. (2000). Self-Injurious Behavior.
Mays, D. (2010). Suicide: Risk assessment and management. Safe Communities of MadisonDane County. Retrieved from
http://www.safercommunity.net/documents/suicide_prevention/DrMaysbooklet.pdf
Mental Health America of Wisconsin. (n.d.) Bullying in schools: Harassment puts gay youth at
risk. Retrieved from http://www.mhawisconsin.org/Data/Sites/1/media/factsheets/bullyingandgayyouth.pdf
Mental Health America. (2013). Bullying and gay youth. Retrieved from
http://www.nmha.org/index.cfm?objectid=CA866DCF-1372-4D20-C8EB26EEB30B9982
Mental Health American of Wisconsin. (2013). School based model: the Wisconsin components
of school-based suicide prevention, intervention, postvention model. Retrieved from
http://www.mhawisconsin.org/schoolbasedmodel.aspx
Mental Health America of Wisconsin. (2014). The Burden of Suicide in Wisconsin 2007-2001
(released 2014). A Joint Report from the Wisconsin Department of Health Services, the
Injury Research Center at the Medical College of Wisconsin, and Mental Health America
of Wisconsin. Retrieved from:
http://www.mhawisconsin.org/Data/Sites/1/media/suicide-prevention/burden-ofsuicide-2014-final-electronic-version.pdf
Mims, B., Joyner, M., & Burns, M. (2011). Bullied 10-year-old girl commits suicide. WRAL/
Capital Broadcasting Company. Retrieved from
http://www.wral.com/news/local/story/10390079/
National Indian Child Welfare Association (NICWA). (n.d.). Ensuring the seventh generation: A
youth suicide prevention toolkit for tribal child welfare programs. Retrieved from
http://www.nicwa.org/resources/documents/YSPToolkit.pdf
National Resource Center for Permanency and Family Connections. (2013). Bullying and
children in the child welfare system.
New York University Child Study Center. (2004). Gay, lesbian, and bisexual youth: Facing
challenges, building resilience. Child Study Center Letter, 9(2). Retrieved from
http://www.aboutourkids.org/files/articles/nov_dec_0.pdf
Petrosino, A. G. (2010). What characteristics of bullying, bullying victims, and schools are
associated with increased reporting of bullying to school officials? (Issues & Answers
Report, REL 2010-No. 092). U.S. Department of Education, Institute of Educational
Sciences, National Center for Education Evaluation and Regional Assistance, Regional
Educational Laboratory Northeast and Islands. Retrieved from
http://ies.ed.gov/ncee/edlabs.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
81
Resources
Pumphrey, S. C. (2011). Suicide- personally and professionally. Social Work Today. Retrieved
from http://www.socialworktoday.com/archive/092011p6.shtml
Reitz, S. (2010). Nine charged with bullying Mass. teen who killed self. ABC News. Retrieved
from http://abclocal.go.com/wpvi/story?section=news/national_world&id=7356350
Robinson Reynolds, M. (Writer). (n.d.). Acknowledgement movie [Motion Picture]. Make a
Difference. Retrieved from http://www.acknowledgmentmovie.com/
Sassu, K., Elinoff, M., Bray, M., & Kehle, T. (2004). Behavior problems bullies and victims:
Information for parents. National Association of School Psychologists. Retrieved from
http://www.nasponline.org/resources/handouts/revisedPDFs/bulliesvictims.pdf
Seeley, K., Tombari, M., & Dunkie, J. B. (2011). Bullying in schools: an overview. US Department
of Justice. Retrieved from http://www.ojjdp.gov/pubs/234205.pdf
SPAN USA. (n.d.). Suicide among American Indians/Alaskan Natives. Suicide Prevention Resource
Center. Retrieved from http://www.sprc.org/library/ai.an.facts.pdf
Substance Abuse and Mental Health Services Administration. (2010). Suicide prevention in
Native populations: Helping youth "live to see the great day that dawns". Retrieved
from
http://www.samhsa.gov/samhsanewsletter/Volume_18_Number_3/SuicidePrevention
NativePopulations.aspx
Substance Abuse and Mental Health Services Administration. (2010). The DAWN report:
Emergency department visits for drug-related suicide attempts by adolescents: 2008.
Substance Abuse and Mental Health Services Administration. Retrieved from
http://www.oas.samhsa.gov/2k10/DAWN001/SuicideAttempts.htm
Substance Abuse and Mental Health Services Administration. (2012). Mental health statistics.
SAMSHA. Retrieved from http://www.samhsa.gov/dataoutcomes/urs/
Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.:
American Indians/Alaska Natives. Education Development Center, Inc.
Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the
U.S.: Blacks. Education Development Center, Inc.
Suicide Prevention Resource Center. (2011). Suicide and bullying issue brief. Education
Development Center, Inc. Retrieved from
http://www.sprc.org/sites/sprc.org/files/library/Suicide_Bullying_Issue_Brief.pdf
Suicide Prevention Resource Center. (2011). Suicide prevention among LGBT youth: A workshop
for professionals who serve youth. Education Development Center, Inc.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
82
Resources
Suicide Prevention Resource Center, & Rodgers, P. (2011). Understanding risk and protective
factors for suicide: A primer for preventing suicide. Education Development Center, Inc.
Suicide Prevention Resource Center. (n.d.). Wisconsin suicide prevention fact sheet: suicides,
1999-2005. Suicide Prevention Resource Center.
Suicide Prevention Resource Center for the Center for Mental Health Services Substance Abuse
& Mental Health Services Administration U.S. Department of Health and Human
Services. (2008). Suicide Risk and Prevention for Lesbian, Gay, Bisexual and Transgender
Youth.
Teen Screen- National Center for Mental Health Checkups at Columbia University. (2003).
Checking in on Teen Mental Health. TeenScreen. Retrieved from
http://www.teenscreen.org/
The JED Foundation. (2012). Learn more about suicide prevention. The JED Foundation.
Retrieved from http://www.jedfoundation.org/learn-more/about-suicide-prevention
Ting, L. S. (2006). Dealing with the aftermath: A qualitative analysis of mental health social
workers' reactions after a client suicide. Social Work, 51(4), 329-341.
Taussig, Harpin & Maguire (2014). Suicidality among preadolescent maltreated children in
foster care. Child Maltreatment, 19(1), 17-26.
U.S. Department of Health & Human Services. (2013). Bullying of LGBT youth and those
perceived to have difference sexual orientations tipsheet. Retrieved from
http://www.stopbullying.gov/at-risk/groups/lgbt/lgbtyouthtipsheet.pdf
U.S. Department of Health & Human Services. (n.d.). Bullying definition. Retrieved from
http://www.stopbullying.gov/what-is-bullying/definition/index.html
Underwood, M. M., Rish-Scott, M., & Springer, J. (2001). Bullying and suicide risk. Social Work
Today. Retrieved from http://www.socialworktoday.com/archive/092011p10.shtml
University of Washington. (2011). 40 percent of youths attempting suicide make first attempt
before high school, study finds. Science Daily. Retrieved from
http://www.sciencedaily.com/releases/2011/11/111128120146.htm
US Department of Health & Human Services. (2012). Children attempting suicide. HHS
HealthBeat. Retrieved from
http://www.hhs.gov/news/healthbeat/2012/01/20120117a.html
U.S. Department of Health, Human Services (HHS) Office of the Surgeon General, & National
Action Alliance for Suicide Prevention. (2012). National strategy for suicide prevention:
goals and objectives for action. Washington, DC: HHS, September 2012.
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
83
Resources
Vinnerljung, B., Hjern, A., & Lindblad, F. (2006). Suicide attempts and severe psychiatric
morbidity among former child welfare clients - a national cohort study. Journal of Child
Psychology and Psychiatry, 47, 723-733. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2005.01530.x/full
Webley, K. (2011). A separate peace? Time Magazine. Retrieved from
http://www.time.com/time/specials/packages/article/0,28804,2095385_2096859_2096
805,00.html
NEW Partnership for Children and Families • University of Wisconsin - Green Bay
Impact of Suicide on Youth and Families: The Ones We Miss (Revised: August 2014)
May be reproduced with permission from original source for training purposes.
84