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+ Some Secrets SHOULD be Shared… It Takes a Village: Involving School Staff and + 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 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 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 What we will cover today: Youth suicide 1. a. b. Signs & symptoms Risk factors & other definitions 2. What can schools do? Implementing an evidence 3. 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 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/School. Crisis. Guide. pdf

Prevalence of Suicide Among Youth • 3 rd leading cause of death among youth Prevalence of Suicide Among Youth • 3 rd 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% 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/Healthy. Youth/yrbs/index. htm

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based 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 Risk Factors • A risk factor is any personal trait or environmental quality that is associated with suicide. • Risk factors ≠ causes. • Examples: 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 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 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 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 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 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 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 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 Suicide: A Multi-Factorial Event

What Can Schools Do? “School systems are not responsible for meeting every need of 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 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 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 ACT

SOS Program Components What comes in the program? Implementation Guide Educational DVD & Discussion 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 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 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 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 Training Trusted Adults SOS Gatekeeper Video

Sample Q’s from the Discussion Guide What are some of the risk factors and 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 1. Review your school’s crisis response protocol 2. Preparing for Your Staff Meeting/Parent Night 1. Review your school’s crisis response protocol 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 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 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 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 & 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 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 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 with Response Card

Brief Screen for Adolescent Depression (BSAD) Brief Screen for Adolescent Depression (BSAD)

Student Response Card BASED ON THE VIDEO AND/OR SCREENING, I FEEL THAT: □ I 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 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 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 Start small and On the Day of the Program Identify & train your team Start small and pilot-test 3. Facilitate discussion 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. Prepare for follow-up Show video 4. Engage your gatekeepers Introduce program 2. Decide on format 1. 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 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 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 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 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 Best Practices Prompt disclosure of a suicide threat to a parent is both legal and prudent Document steps taken by the school, including parental foll 0 w-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. k 12. va. us/student-services/suicideintervention/suicide-guidelines. pdf

Common Objections & Talking Points • Suicide is not a problem in our school 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 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 For more information contact: Screening for Mental Health Rebecca Davis, LICSW [email protected] org 781 -591 -5230 Or visit: www. Mental. Health. Screening. org Screening for Mental Health, Inc. One Washington Street, Suite 304 Wellesley Hills, MA 02481 Phone: 781. 239. 0071 Fax: 781. 431. 7447 www. Mental. Health. Screening. org

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4 th References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4 th 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. & De. Martino, 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 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/Content. Display. cfm&Content. ID=17623

References Schilling, E. A. , Aseltine, R. H. , Glanovsky, J. K. , James, 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/30 publications/10 policies/a 9/index. html. pdf? printmedia-type&footer-right=[page]/[to. Page]