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Some Secrets SHOULD be Shared…
It Takes a Village: Involving School
Staff and Parents in Suicide Prevention
Rebecca Davis, LICSW
Youth Programs Manager
Screening for Mental Health, Inc.
What is Screening for Mental Health, Inc.
SMH is…
a national non-profit organization whose mission is to
provide innovative mental health and substance abuse
resources, linking those in need to quality treatment
options.
The SOS Signs of Suicide® Prevention
Program is…
an award-winning, evidence-based educational and
screening tool used in middle and high schools across the
country.
Youth Programs at SMH
 SOS Signs of Suicide Prevention Program
 High School Program
 Middle School Program
 SOS Signs of Suicide Booster Program
 Signs of Self-Injury Prevention Program
What we will cover today:
Youth suicide
1.
a.
b.
Signs & symptoms
Risk factors & other definitions
2. What can schools do? Implementing an evidence3.
4.
5.
6.
based, universal prevention program
Reaching out to trusted adults in your community
Suicide prevention and risk management
Talking points
Question and answer
Crisis Management
Part 1: Being Prepared — Before a Crisis
Part 2: Being Responsive — During a Crisis
Part 3: Being Thorough — After a Crisis
http://crisisguide.neahin.org/crisisguide/images/SchoolCrisisGuide.pdf
Prevalence of Suicide Among Youth
• 3rd leading cause of death among youth ages 15-24 (CDC, 2011)
• In 2011, 4,630 people between the ages of 15 and 24
completed suicide.
• 12.5% of total suicides that year.
• But STILL….adolescent suicidal behavior is deemed
underreported
By the Numbers…
• 2011 Youth Risk Behavior Survey found that:
•
28.5% felt so sad or hopeless for 2+ weeks that they stopped doing
some usual activity.
•
15.8% seriously considered attempting suicide.
•
12.8% made a suicide plan.
•
7.8% attempted suicide.
•
2.4% of those who made an attempt required medical attention
• Find the data for your city/state:
http://www.cdc.gov/HealthyYouth/yrbs/index.htm
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics
Query and Reporting System (WISQARS) [online]. (2005) [cited 2011 Feb.16]. Available from URL:
www.cdc.gov/ncipc/wisqars
Risk Factors
• A risk factor is any personal trait or environmental
quality that is associated with suicide.
• Risk factors
≠ causes.
• Examples:
o
o
o
o
o
Behavioral Health (depressive disorders, NSSI, substance abuse)
Personal Characteristics (hopelessness, ↓ self-esteem, social isolation, poor
problem-solving)
Adverse Life Circumstances (interpersonal difficulties, bullying, hx abuse,
exposure to peer suicide)
Family Characteristics (family hx suicide, parental divorce, family hx mental
health disorders)
Environmental (exposure to stigma (including discrimination based on sexual
orientation), access to lethal means, limited access to mental health care, lack of
acceptance)
Risk Factors for Suicide
• Mental illness
• The strongest risk factors for suicide in youth
• depression
• substance abuse
• previous attempts (NAMI, 2003)
• Over 90%...
of people who die by suicide have a least one major psychiatric disorder
(Gould et al., 2003)
• Alarmingly, 80%...
of youth with mental illness are not receiving services (Kataoka, et al 2002).
Depression & Youth
Major Depressive Episode is defined as:
a period of at least 2 weeks when a person experienced a depressed
mood or loss of interest or pleasure in daily activities and had at least four
of seven additional symptoms.
(DSM-IV-TR; APA, 2000)
 In 2010, 8% of the population age 12-17 had MDE.

Youth with MDE were more than twice as likely to use illicit drugs
compared to youths who did not have MDE.
SAMHSA, 2012
Alcohol and Suicidal Behavior in Teens
 Alcohol use, drinking while down, and heavy episodic drinking are
strongly associated with suicide among adolescents.
 Relationship of drinking to unplanned suicides:



↑ disinhibition and impulsivity
↑ aggression and negative affectivity
↑ cognitive constriction → restricted production of alternative coping
strategies
 Drinking alcohol while down: more than a 75% increase in risk
 Alternative avenue for identification and early intervention.
(Schilling, et al. 2009)
Suicide Warning Signs
 A warning sign is an indication that an individual may
be experiencing depression or thoughts of suicide.
 Most individuals give warning signs or signals of their intentions.
 Seek Immediate Help
•
Threat to kill themselves, actively seeking means, talking/writing about death
 Other Warning Signs to Take Seriously

Risky behavior, recklessness
↑ substance use
↓ interest in usual activities

Withdrawal


***Stay aware of changes in your students –
in their affect, behavior, appearance, attendance, etc.***
What do you see?
In your role, how do you see warning signs
and risk factors presented by your students?
How are they presented in a school setting?
Protective Factors
 Protective factors are personal traits or environmental
qualities that can reduce the risk of suicidal behavior.
 Protective factors don’t provide immunity,
but help reduce risk.
 Examples:





Individual Characteristics (adaptable temperament,
coping skills, self-esteem, spiritual faith)
Family/Other Support (connectedness, social support)
School (positive experience, connectedness, sense of respect)
Mental Health and Healthcare (access to care, support through medical and
mental health relationships)
Access to Means (restricted access to firearms/medications/alcohol, safety barriers
for bridges)
Precipitating Event
 A precipitating event is a recent life event that serves as
a trigger, moving an individual from thinking about suicide
to attempting to take his or her own life.
 NOT causes

No single event causes suicidality; other risk factors are typically present.
 Examples:




breakup
bullying incident
sudden death of a loved one
trouble at school
Suicide: A Multi-Factorial Event
What Can Schools Do?
“School systems are not responsible for meeting every need of their students. But
when the need directly affects learning, the school must meet the challenge.”
(Carnegie Task Force on Education)
 Barriers to the mission of education
 Take responsibility:
minimize student alienation & despair
 Promote healthy development & protective buffers
Center for Mental Health in Schools at UCLA (http://smhp.psych.ucla.edu)
SOS Signs of Suicide Program Goals
• Decrease suicide and attempts by increasing
knowledge and adaptive attitudes about depression
• Encourage individual help-seeking and help-seeking on
behalf of a friend
• Reduce stigma: mental illness, like physical illness,
requires treatment
• Engage parents and school staff as partners in
prevention through education
• Encourage schools to develop community-based
partnerships
SOS Signs of Suicide Student Goals
 Help youth understand that depression is a treatable illness
 Educate youth that suicide is not a normal response to stress, but a
preventable tragedy that is often a result of untreated depression
 Inform youth of the risk associated with alcohol use to cope with
feelings
 Increase help-seeking by providing students with specific
action steps: ACT
 Encourage students and their parents to engage in discussion
about these issues
ACT
SOS Program Components
What comes in the program?









Implementation Guide
Educational DVD & Discussion Guide
Screening Tools and Student Response
Cards
High School Student Newsletter / Middle
School Student & Parent Newsletters
Customizable Wallet Cards/ ACT stickers
/ Posters
Educational Materials for Staff, Students,
and Parents
Postvention Guide
Gatekeeper Training Tools: Training
Trusted Adults DVD and Plan, Prepare,
Prevent online training module
“Life Teammates” Packet for Coaches
Universal Prevention
Universal prevention strategies are designed to reach the
entire population, without regard to individual risk factors and are
intended to reach a very large audience. The program is provided to
everyone in the population, such as a school or grade, with a focus
on risk reduction and health promotion.

Reach a broad range of adolescents




At-risk/sub-clinical/clinical symptoms
Reduces stigmatization
Promotes learning and resiliency in all students
Overrides implementer assumptions
Gatekeeper Training
Gatekeeper training involves educating adults who
regularly interact with youth to recognize warning
signs for suicide and know how to respond
appropriately to at-risk youth.
A gatekeeper should ultimately be able to provide a
link, or open the gate, between a young person and a
mental health professional.
Why Gatekeeper Training?
 Teaches additional skills, including how to:



reduce a person’s suicide risk by talking with them
keep someone safe until additional help can be found
facilitate referrals
 Creates more community members prepared to help
 Trains adults to effectively respond if approached for help by a youth
 Increases participation and investment of community in youth suicide
prevention
 Clarifies myths and facts about youth mental health and suicide
Training Trusted
Adults
SOS Gatekeeper Video
Sample Q’s from the Discussion Guide
 What are some of the risk factors and warning signs
in the video that stuck out for you?
 What are some protective factors you might find in
your students?
 The professionals discussed confidentiality and
Melissa in Elyssa’s story said, “It’s ok to tell.” What
are some steps to take if a student discloses the need
for help?
 What qualities do you think make you a trusted
adult?
Preparing for Your Staff Meeting/Parent Night
Review your school’s crisis response protocol
1.
2. Take SOS online gatekeeper training module


Familiarize yourself with youth depression and suicidality
Plan for specific program implementation
3. Work with your administration


Establish whether your school will be implementing the program
If so, establish date and time so that you may communicate the information
to your staff during the training
Preparing for Your Staff Meeting/Parent Night
4.
Preview the Training Trusted Adults DVD
 Make sure the DVD is in working order
 Think about your own reactions to this video
5.
Consult the discussion guide, plan your talkback
 Personalize the discussion to your audience
6.
Review definitions (risk factors, etc.)
 Be prepared to communicate these terms to your staff
7.
Understand myths/facts about depression and suicide
 Refer to examples in your Implementation Guide
Staff Meeting: Step by Step
1. Distribute disclosure guidelines for staff.


Review your district’s crisis response protocol.
Review how staff should proceed if approached by a student for
help.
2. Show the Training Trusted Adults DVD.
3. Facilitate a follow-up conversation using the
discussion guide (including definitions,
myths/facts).
4. Allow extra time for q & a with your staff.
Parent/Community Night: Step by Step
1. Review your district’s crisis response protocol.
2. Show the Training Trusted Adults DVD.
3. Facilitate a follow-up conversation using the discussion guide
(including definitions, myths/facts).
4. Review school policy for following up with at-risk students, including
how and when parents/guardians will be contacted if their child needs
further help.
5. Encourage parents to talk to their children about depression, suicide,
and mental health!
6. Provide parents/guardians with school and community-based mental
health resources in your area.
Implementation Overview
Start small
and pilot-test
Prepare for
follow-up
Engage your
gatekeepers
Identify &
train your
team
Decide on
format
1. Identify and Train Your Team
Identify &
train your
team
Decide on
format
Review program goals and assign roles/responsibilities
Familiarize yourselves with kit materials, student video,
and discussion guide
Take 90-minute online module, preview gatekeeper video
Engage your
gatekeepers
Prepare for
follow-up
Start small and
pilot-test
Review screening form and scoring
Designate time and date for program implementation
Review school policies for handling suicide disclosure,
parental consent, record keeping, etc.
2. Decide On Format
Identify & train
your team
Decide on
format
Select your audience (school-wide, specific grade, etc.)
Select setting
Choose screening option:
Engage your
gatekeepers
Prepare for
follow-up
Start small and
pilot-test
Eliminate (do not screen)
Non-anonymous (recommended)
Anonymous with number ID
Anonymous
Anonymous with Response Card
Brief Screen for Adolescent Depression (BSAD)
Student Response Card
BASED ON THE VIDEO AND/OR SCREENING,
I FEEL THAT:
□ I need to talk to someone …
□ I do not need to talk to someone …
ABOUT MYSELF OR A FRIEND.
NAME(PRINT):_________________________________
HOMEROOM SECTION:_________________________
TEACHER:_____________________________________
IF YOU WISH TO SPEAK WITH SOMEONE, YOU WILL BE
CONTACTED WITHIN 24 HOURS. IF YOU WISH TO SPEAK WITH
SOMEONE SOONER, PLEASE APPROACH STAFF IMMEDIATELY.
3. Engage Your Gatekeepers
Identify & train
your team
Decide on
format
Engage your
gatekeepers
Prepare for
follow-up
Start small and
pilot-test
Involve your administration. Demonstrate the
program and obtain buy-in.
Bring staff, parents, and community members
on board by providing gatekeeper training
(staff meeting, parent night, etc.).
Make sure your school community is aware of
this program and when implementation will
take place.
4. Prepare for Follow-Up
Identify & train
your team
Decide on
format
Use SAMHSA’s Find Treatment Locator to identify
additional referral resources.
Contact local mental health facilities and verify their
referral procedures, wait lists, insurance details, etc.
Create a referral resource list to send with parent letter.
Engage your
gatekeepers
Have copies of the student follow-up form available.
Review school’s emergency procedures and parental
notification.
Prepare for
follow-up
Start small and
pilot-test
Identify in advance who will be handling emergencies.
Notify the nearest crisis response center about the
program in advance in order to facilitate referrals.
On the Day of the Program
Identify & train
your team
Decide on
format
Engage your
gatekeepers
Prepare for
follow-up
Start small
and pilot-test
1.
Introduce program
2.
Show video
3.
Facilitate discussion
4.
Students complete screening forms and Student
Response Card
5.
Set expectation about when follow-up can be
expected; provide referral information
6.
Follow up with students requesting help
7.
Respond to requests for help; track students
seeking help using the Student Follow-Up form
Evaluation of the SOS Program
• SOS is the only universal school-based suicide prevention program for
which a reduction in self-reported suicide attempts has been
documented with a randomized experimental design. In a randomized
controlled study, the SOS Program showed a reduction in self-reported
suicide attempts by 40%.
• Based on evidence from the first year of a 2-year study involving over
2,100 students in 5 schools (Aseltine, 2004), the SOS program was
added to SAMHSA’s National Registry of Evidence-Based Programs
and Practices
• Study published in BMC Public Health, 2007 found SOS to be
associated with significantly greater knowledge, more adaptive
attitudes about depression and suicide, and most importantly,
significantly fewer suicide attempts among intervention youths
relative to untreated controls (Aseltine, 2007)
Prevention Programs – Reducing Liability
Common Themes in Lawsuits
 The institution ignored warning signs of suicide.
 The institution provided the tools that the students
used for suicide.
 The institution took insufficient steps to address
warning signs.
 The institution failed to notify the family about the
student’s condition.
-United Educators, “The Suicidal Student: Issues in Prevention,
Treatment, and Institutional Liability” Roundtable Discussion,
2003
Student Mental Health Screening:
A Risk Management Perspective
 A record of prevention programs is important. Many causes of serious
student injury and death relate to mental health concerns.
 Screening efforts and counseling services help show that the school takes
student mental health issues seriously.
 United Educators actively encourages schools to provide a safe
environment for students and reduce the institution’s liability. They
believe that the SOS Suicide Prevention Program can serve as an
important risk management tool for schools.
Constance Neary, Vice President for Risk Management, United Educators Insurance
Student Mental Health Screening
 It is important to convey to students and parents that the
mental health screenings being conducted in your school
are for educational purposes
 Screenings are informational,
not diagnostic -
Diagnoses, treatment recommendations and opinions
should not be given
 The goal of the screening is to identify students with
symptoms consistent with depression and/or suicidality
and to advise a complete professional evaluation
Best Practices
 Prompt disclosure of a suicide threat to a parent is both




legal and prudent
Document steps taken by the school, including parental
foll0w-up and clinical care status
Joint decision making and good documentation help justify
decisions should they later be challenged
Confidential materials should be stored under lock and key
Always consult with the school legal department for
questions regarding policies
http://www.acps.k12.va.us/student-services/suicideintervention/suicide-guidelines.pdf
Common Objections & Talking Points
• Suicide is not a problem in our school
• No school is immune to adolescent suicide
• Schools are not appropriate for suicide prevention
programs
• Student problems with academics, peers, and others are more
apt to be evident in school. The majority of parents are
unaware of their child’s suicidality.
• The program may introduce the idea to students
• There has been no harm seen in screening teens for suicide
risk (Gould, M., et al, 2007)
• I don’t agree with labeling youth
• The screenings are not diagnostic
Common Objections & Talking Points
• I don’t have enough staff/time
• The program can be implemented in one class period using
existing resources and partnerships with community
providers.
• There are no referral resources in my area
• Identifying the need for resources can help justify the need
for funding.
• We cannot conduct mental health screenings
• Screenings can be done confidentially or not at all
• We already have a suicide prevention program
• SOS is the only evidence-based that addresses suicide risk and
depression, while reducing attempts.
• It can also compliment other programs
For more information contact:
Screening for Mental Health
Rebecca Davis, LICSW
rdavis@mentalhealthscreening.org
781-591-5230
Or visit:
www.MentalHealthScreening.org
Screening for Mental Health, Inc.
One Washington Street, Suite 304 Wellesley Hills, MA 02481
Phone: 781.239.0071 Fax: 781.431.7447
www.MentalHealthScreening.org
References
 American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC.
 Aseltine, R., et al. (2007). Evaluating the SOS suicide prevention program: A
replication and extension. BMC Public Health 7(161).
 Aseltine Jr., R.H. & DeMartino, R. (2004). An Outcome Evaluation of the SOS
Suicide Prevention Program. American Journal of Public Health, 94 (03), 446451.
 Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control. Web-based Injury Statistics Query and Reporting
System (WISQARS) [online]. (2005) [cited 2011 Feb.16]. Available from URL:
www.cdc.gov/ncipc/wisqars
References
 Gould, M., et al. (2003). Youth suicide risk and preventive interventions: A
review of the past 10 years. Journal of the American Academy of Child and
Adolescent Psychiatry, 42 (4), 386-405.
 Gould, et al. (2007). Evaluating Iatrogenic Risk of Youth Suicide Screening
Programs. American Medical Association, 293(13), 1635-1643.
 Kataoka, S.; Zhang, L.; & Wells, K. (2002). Unmet need for mental health care
among U.S. children: Variation by ethnicity and insurance status. American
Journal of Psychiatry, 159 (9), pp. 1548-1555.
 National Alliance of Mental Illness (NAMI). (2003). Depression in Children
and Adolescents. Retrieved on June 16, 2009 from
http://www.nami.org/Template.cfm?Section=By_Illness&template=/Content
Management/ContentDisplay. cfm&ContentID=17623
References
 Schilling, E. A., Aseltine, R. H., Glanovsky, J. K., James, A., & Jacobs, D.
(2009). Adolescent alcohol use, suicidal ideation, and suicide attempts. Journal
of Adolescent Health, 44,335-341.
 Substance Abuse and Mental Health Services Administration. (2012). Results
from the 2010 National Survey on Drug Use and Health: Mental Health
Findings, NSDUH Series H-42, HHS Publication No. (SMA) 11-4667. Rockville,
MD: Substance Abuse and Mental Health Services Administration.
 UCLA Center for Mental Health in Schools. School community partnerships: a
guide. Retrieved from
http://smhp.psych.ucla.edu/pdfdocs/guides/schoolcomm.pdf
 World Health Organization. (2006). WMO Statement on Adolescent Suicide.
http://www.wma.net/en/30publications/10policies/a9/index.html.pdf?printmedia-type&footer-right=[page]/[toPage]