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					Suicide Prevention: SOS, Classroom
Activities, and Other Evidence-Based
               Strategies

                 NASP 2010
              3/2/10 12-1:50pm

                  Adam Grieve, MS
              University of Wisconsin-Madison
           John Humphries, MSE, NCSP
  School Psychologist, WI Department of Public Instruction
                                                             1
About this presentation

 Lots of info on a tough topic
 Recognize your own feelings
 Ask questions, share your experiences
 Stigma-free environment




                                          2
Primary Objectives for the day
   Understand suicide as both a public health issue
    and a problem of individual mental health
   Identify risk factors and warning signs
   Learn two evidence based strategies for
    intervention: ACT and QPR
   Contextualize suicide prevention strategies within
    in a three-tiered prevention framework
   Leave with supplemental information about:
       Classroom Instruction
       Gatekeeper Training
       Crisis Response
                                                     3
Language Notes:
Suggestions from Survivors
   Do use:                      Don’t use:

   “Completed Suicide”          “Successful Suicide
   “Died by Suicide”             Attempt”
   “Took his/her own life”      “Committed Suicide”
   “Died of Suicide…”            it’s not illegal




                                                        4
Is suicide very common?
From 1999-2007 (9 yrs.)   Deaths Age 10-19
Motor Vehicle Accidents   1055
Homicide                  301
All Cancers               201
Accidental Drowning       78
Accident/Undet. Firearm   35
Fire/Smoke Inhalation     19
70                                                                                                             10
                         Youth Suicide Numbers and Rate in WI
                                                                                                               9
                    61
60

                                                                                                               8
                                                                             54
                                                         53
                                52
50
                                               49                                                              7
                                                                   47
          44
                                                                                                               6
40                                                                                     40
                                 Number
                                                                                                      35       5
                                 Rate/100,000

30
                                                    3.69                                                       4
               4.17                                                               y = -0.096x + 3.8522
                                                                        3.85           R² = 0.2464
                          3.58
                                          3.41                3.33                                             3
20
     3.02
                                                                                  2.83
                                                                                                2.47
                                                                                                               2

10
                                                                                                               1



0                                                                                                              0
     99        00          01             02        03        04        05        06             07        6
Which gender is most at risk?

 349 males
 85 females


> 4:1 ratio of males to females


                                  7
What is the most common method?
(WI)
   Firearms: 215 deaths (>50% of total)
       191 males, 24 females (8:1)
   Hanging/Suffocation: 167 cases (40%)
       124 males, 43 females (<3:1)
   Poisoning: 22 cases (5%)
       13 males, 9 females
   Falls: 9 cases
       8 Males, 1 Female
   21 Others: Transport, Cut, Drown, Burn
                                             8
Trends in the method
   In WI, suffocation is still most common for
    females and firearms for males
(DHS WISH, 1999-2007)


   National trend is that suffocation has
    become the most common method for all
    groups except males 15-19, where
    firearms still most common
(CDC WISQARS)



                                              9
Firearms and Hanging: most lethal
   Firearm Case Fatality Rate=91%

   Firearms/Hanging= 10% of acts, 67% fatalities

   Poisoning= 74% of acts, 7% of fatalities


   Miller M, Azrael D, Hemenway D. The epidemiology of case fatality rates for suicide in the
    northeast. Ann Emerg Med. 2004 Jun;43(6):723-30.

   All ages, a Northeastern US Hospital, 1996-2000



                                                                                        10
Of all deaths among youth…
In the U.S.                             In Wisconsin
 Suicides are 12%                       Suicides >17%
 Third leading cause of                 Second leading cause
  death                                   of death




 WISQARS, Centers for Disease Control and Prevention, National Center for
 Health Statistics (NCHS), National Vital Statistics System, downloaded
 3/19/08 for years 1999-2005, ages 10-19                                    11
Under-report?
   Nonetheless, youth suicide probably is
    underreported because of social stigma,
    shame, and guilt among family and friends

   “Estimates of official underreporting of
    suicide by medical examiners have ranged
    from 25% to 50%.”

   Jobes, et. al 1991, and Rosenberg et. al., 1988, as cited by King,
    K. A., The Prevention Researcher 13(3), Sept 2006, p. 8-11

                                                                         12
How does WI compare with USA?
   1999-2005
   Ages 10-19, Suicide Rate per 100,000
   Range 2.3 (NJ) to 18.9 (AK)
   US Rate 4.5/100,000
   WI 13th highest rate in nation: 6.41
   WI Rate 42% higher than the national rate
   MN: 18th, IL: 44th
   Others like WI include IA, WV, OK, AZ

    www.cdc.gov/ncipc/wisqars   retrieved 03/19/08

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   15




                       i co
Why Do States Differ? Some Guesses
   Drinking: lower inhibition, alter judgment
        WI: Highest rate of youth binge drinking in US
   Guns
        WI: 12th highest gun ownership rate—43% (2001)
   Mental Health Service Availability
        8.2 Child/Adolescent Psychiatrists/100,000 youth vs.
         recommended 14
   Stigma
   Climate
   Coordinated public health and educational efforts
        Legislation

   2007 YRBS
   as cited in Miller, 2005
   Moreno, C. et. al. (2007) Arch. Gen Psychiatry 64:1032-1039




                                                                  16
It takes:
 Understanding
 Planning
 Commitment
 Resources
 Sustained Effort




                     17
Does depression matter academically?
   Schools with more students who report
    being sad or hopeless make less progress
    in raising test scores than other schools



“Ensuring That No Child Is Left Behind: How Are Student
  Health Risks & Resilience Related to the Academic Progress
  of Schools” 2004
Data Source: California Healthy Kids Survey & STAR data files.
www.wested.org/chks/pdf/p1_stuartreport_ch_final.pdf


                                                            18
Statistics tell a story, and can help us
know when, how and where to intervene

 About one youth each week (WI)
 Suicide is 2nd leading cause of death
 WI rate is >40% higher than US average
 More boys die than girls
       Girls report more attempts (YRBS)
 More girls report depression
 Method: guns, hanging
 Gay/Lesbian kids at high risk

                                            19
Next Steps for this section
   Risk factors
       Direct
       Related
 Warning Signs: Early & Late
 Other related issues
       Medications
       Repetitive Self-Harm (Cutting)
 “The suicide equation”
 Protective Factors


                                         20
Risk Factors
Direct Suicide-Risk Factors are most
  strongly associated with suicidal
  behaviors among youth:
 A prior suicide attempt (strongest
  predictor, 8X rate of no prior attempt)
 Suicide threats & ideation
 Detailed intentions for an attempt


   Eggert, L., 2002. “Best Practices for School-Based Youth Suicide
    Prevention,” WI DPI.
   Lewinsohn et al., 1994, as cited in Langhinrichsen-Rohling, J et al., Suicide
                                                                                21
    and Life Threatening Behavior 38(4), August 2008
Exposure to Suicide is a Risk Factor
   Direct Exposure
       Youth who have family members who attempt
        suicide or die by suicide show high levels of at-
        risk behaviors, especially suicide ideation and
        attempts
       (J. Adol. Health 2005; 36 (4): 352)
   Indirect & Media Exposure
       Extensive coverage of suicide in media leads to
        increases in suicide attempts among
        vulnerable populations (youth, prior attempt)
       Two recent suicides received national attention
       (J. Clinical Psychiatry 2007; 68: 862-866)
                                                        22
Related Suicide Risk Factors
 Serious depression, hopelessness
 Alcohol Use & Drug involvement
 Stressful life events
 Family conflicts
 Risky or impulsive behaviors (police)
 School problems (perceived problems)
 Perceived overweight or underweight
 Cognitive (Problem-Solving) Skills
 Repetitive self-harming behaviors
J. of Adolescence, 29 (2005) 75-87; Arch Pediatr Adolesc Med. 2005;159:513-519;
                                                                                  23
J. School Health, 77, 2, 59-66
Related Risk Factors—Mental Illness
   “Completed Suicide and Psychiatric
    Diagnoses in Young People…”

   89% had a diagnosed mental illness

   40% had substance abuse disorder


Fleischmann, et. al., Amer. J. Orthopsychiatry, 75; 4, 2005


                                                              24
Alcohol/Sedatives and Suicide
   Dis-inhibiting
       Alters judgment
       Can trigger aggression
       Increases impulsivity
 Sedating
 Ataxia (falls, injuries)
 Coma-inducing


    Michael Miller, Meriter, 9/22/08, Eau Claire Suicide Prevention Summit


                                                                             25
Suicide Early Warning Signs
    Withdrawal
    Preoccupation with death
    Marked personality change & serious mood
     changes
    Difficulty concentrating
    Decline in quality of school work
    Change in eating habits
    Change in sleep patterns important marker
Youth Suicide Prevention School-Based Guide, 2003, Louis de la Parte Florida Mental Health Institute
Goldstein, et. al, J Consulting Clinical Psychiatry, 2008 Feb; 76(1): 84-91




                                                                                                       26
Early Warning Signs
 Loss of interest in favorite activities
 Frequent complaints about physical
  symptoms, often related to emotions
  (stomachaches, headaches, fatigue)
 Persistent boredom
Youth Suicide Prevention School-Based Guide, 2003, Louis de la Parte Florida Mental Health Institute




                                                                                                       27
Late Warning Signs
 Talking about suicide—specific plans
 Impulsive or violent actions, rebellious
  behavior, or running away
 Refusing help or feeling beyond help
 Claiming to be a bad person
 Hopelessness, helplessness, or
  worthlessness
Youth Suicide Prevention School-Based Guide, 2003, Louis de la Parte Florida Mental Health Institute




                                                                                                       28
Late Warning Signs
    Being intolerant of praise or rewards
    Making statements that hint at or directly imply
     suicide
    Being suddenly cheerful after a period of
     depression
    Giving away favorite possessions
    Making a last will & testament
Youth Suicide Prevention School-Based Guide, 2003, Louis de la Parte Florida Mental Health Institute




                                                                                                       29
WARNING: IS PATH WARM?
   I       Ideation
   S       Substance Abuse
   P       Purposelessness
   A       Anxiety/Agitation
   T       Trapped
   H       Hopelessness
   W       Withdrawal
   A       Anger
   R       Recklessness
   M       Mood Changes


   See/order Risk Assessment Initial Tips for Counselors
    “FREE Suicide Lifeline Materials Order Form”

                                                                                30
        American Association of Suicidology, 2006, Expert Consensus Statement
Another helpful acronym…FACT
   Feelings
       Hopelessness, fear of losing control, going crazy,
        overwhelmed, shamed, pervasively sad, persistent
        anxiety or anger
   Actions or Events
       Drug/Alcohol abuse, themes of death/destruction in
        spoken or written material, recent loss, agitation,
        aggression, recklessness
   Change
       More withdrawn, tired, apathetic, lack of concentration,
        change in sleep patterns, loss of interest friends,
        hobbies, sudden improvement after a low period
   Threats
       Statements about death, plans, suicidal gestures or
        attempts, putting things in order, giving away prized
        possessions
Impulsivity and Means Restriction

 25% of 153 survivors of near lethal
  suicide attempts acted within 5 minutes of
  the impulse to do so
 71% acted within one hour
   “Factors associated with the medical severity of suicide attempts
    in youths and young adults,” Swahn MH, Potter LB, 2001



   “Suicide Proneness and Adjudicated Adolescents,” Langhinrichsen-
    Rohling, J et al., Suicide and Life Threatening Behavior 38(4),
    August 2008

                                                                        32
Whose gun do kids use?
   85% of youth under 18 who died by
    firearm suicide used a family member’s
    gun, usually a parent’s.
   Harvard Injury Control Research Center, National Violent injury Statistics
    System (NVISS). 2001 suicide data summary.

   We promote 4 safe storage strategies:
        trigger locks/cabinets
        store guns unloaded
        lock ammunition
        lock guns and ammo in separate locations
   (Grossman, JAMA 2/9/05)
                                                                                 33
Precipitating Factors
     Opportunities
          access to a gun (WI Tradition)…
          periods without supervision
     Altered states of mind
          rage
          intoxication--binge drinking high correlate
          (2007 YRBS—WI had highest rate of binge
          drinking of all states)
     Undesirable life events
          loss of an interpersonal relationship
          pregnancy/fear of pregnancy
          physical & sexual abuse
          humiliation (bullying) or reprimand…


                                                        34
              The Suicide “Equation”
   Previous Mental Illness (Depression) +
                   Stressor (Loss, etc.) +
Opportunity (Firearm, Unsupervised Time)
       ________________________________________________________

                     Possible Suicide Attempt?




                                                                  35
Protective Factors
     Important social resources
         strong interpersonal bonds
         social support
         sense of belonging
         dominant attitudes & values prohibit suicide
     Important personal resources
         strong sense of self-worth & self-esteem
         good cognitive skills
         sense of personal control
         self-management skills to deal with stress,
         anger and depression


                                                  36
We add “ACT” as a protective factor

 A is for “Acknowledge” signs and
  symptoms, don’t minimize their feelings
 C is for showing “Care and Concern” for
  the person who is at-risk
 T is for “Tell” a trusted adult who knows
  how to respond, including pupil services,
  heath educators, or administrators in your
  school

                                           37
ACT: Video

   Part of SOS classroom curriculum
       Applicable for students as well as
        staff/parents/community members


   Reactions?
       Video strengths/weaknesses?
Signs of Suicide (SOS)
   Source of ACT
   New Middle School Materials complement HS
   Good evidence base, NASP supported
   DPI Curriculum uses their video
   Materials for students, parents and staff
   Screening forms
   Enough materials for 300 students, $300
   Each CESA has at least one MS and one HS kit

   Step 2: Order SOS using form on the CD
QPR (qprinstitute.com)
   Question
       Ask if the person has had any thoughts, feelings, or
        plans about suicide or self-harm
       Ask clarifying questions
       NOT: “You’re not thinking about suicide, ar you?”
   Persuade
       Persuade the person to get help.
       Listen carefully and say, “Let me help” or “Come with
        me to find help.”
   Refer
       Refer for help.
       Personally escort the person to the resource
       Requires awareness of local help resources
Gatekeeper Training
 Goal: To enhance the probability that
  a potentially suicidal person is
  identified and referred for assessment
  and care before an adverse event
  occurs
 The most likely person to prevent you
  from taking your own life is someone you
  already know.
Gatekeeper Training
   Signal Detection Theory


               Gatekeeper does not   Gatekeeper does
               respond               respond
Warning Sign   Miss                  Hit
Present
Warning Sign   Correct Rejection     False Alarm
Absent
      Increasing “Dose” of Preventive Interventions

Universal              Selected               Targeted
   Target                Target                   Target
  General               High-Risk               High-Risk
 Population              Groups                 Individuals

                                           Suicide-risk
 Solid
                                            Behaviors
  Protective
                                           Related Risk Factors
  Factors
                                           Weak Protective
 Few Risk
                                            Factors
  Factors

                                                              43
Low Risk
  For each intervention level, model strategies are:

 Universal                 Selected                 Targeted
    General                 High-Risk                  High-Risk
   Population                Groups                    Individuals
Public Education        Screening Part 2        Skills Groups
Gatekeepers             Skill-building Groups   Parent Support
Classroom Education     Crisis Teams            Case Management
Means Restriction                               Community Referrals
Media Education                                 Suicide Risk Assessment
Screening


           A comprehensive suicide prevention plan
              includes strategies from each level                    44
On CD:
 All slides of today’s presentation, among
  others
 DPI Middle and High School suicide
  prevention curriculum
 Information regarding suicide crisis
  response
 SOS order form (DPI/UW does not have a
  financial tie to SOS)

				
DOCUMENT INFO
Description: Last Will and Testament Forms for Florida document sample