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SCHOOL CRISIS PREVENTION & INTERVENTION: SUICIDE David N. Miller University at Albany, S.U.N.Y. Richard Lieberman Los Angeles Unified School District – PowerPoint PPT presentation

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

The NASP School Crisis Prevention Intervention
Workgroup Suicide
  • Connie Adams
  • Dixon Bryson
  • Wendy Carria
  • Ivan Croft
  • Elliott Davis
  • Kenneth Greff
  • Alan Hilden
  • Jennifer Kitson
  • Jack Martin
  • Scott Poland
  • Susan Ruof

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

No-Suicide or Safety Contracts
  • Widely used and recommended, but there is
    increasing controversy regarding their use
  • In reality, they are neither contractual nor
    ensure genuine safety
  • They tend to emphasize what students wont do
    rather than what they will do
  • May be viewed by students as coercive, since
    failure to sign may force hospitalization
  • May give school psychologists a false sense of
  • Better approach Encourage students to commit to
    treatment rather than merely promising safety

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

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

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

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

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

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

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

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

School-Based Suicide Prevention Programs
  • Curriculum programs for students
  • In-service training for school personnel
  • Student self-report screening procedures

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

School-Based Suicide Prevention Programs
Curriculum Programs
  • Pros
  • May change student knowledge and attitudes
  • May lead students to alert adults about peers
  • Potentially useful component of comprehensive
    suicide prevention program
  • Cons
  • Many erroneously subscribed to stress model
  • Typically dont examine effects on behavior
  • Criticized as inefficient
  • Suicidal youth often have limited peer networks

School-Based Suicide Prevention Programs
In-Service Training
  • Widely used model in schools
  • Typically includes following
  • Discussion of warning signs
  • Discussion of sample cases
  • Referral procedures

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

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

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

School-Based Screening Programs
  • Teen Screen
  • Signs of Suicide (SOS)
  • (781) 239-0071
  • Both have demonstrated effectiveness in
    identifying suicidal youth

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

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

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

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

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

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

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

Web-Based Resources
  • National Association of School Psychologists
  • American Association of Suicidology
  • American Foundation for Suicide Prevention
  • Centers for Disease Control