Depression Suicide in Children and Adolescents by MikeJenny


									The Face of Depression
 and Warning Signs of
 Suicide in Our Youth

     Ariel Mindel, MC, LPC
 Mental Health America of Illinois
               About MHAI…
Mental Health America of Illinois (MHAI)
*Formerly Mental Health Association in Illinois

• Statewide, non-profit organization founded in 1909 –
  Celebrating 100-Years of Service in 2009!

• Mission is to promote mental health, work for the
  prevention of mental illnesses, advocate for fair care
  and treatment of those suffering from mental and
  emotional problems.

• Engage in public education, prevention, advocacy.
        Presentation Topics
1.   The Impact of Suicide
2.   Suicide vs. Self-Injury
3.   Mental Illnesses & Suicide
4.   Risk & Protective Factors of Suicide
5.   Symptom Management Strategies
    Suicide is a Serious
   Public Health Problem

• In 1999, former Surgeon General Dr.
  David Satcher declared suicide a
  national public health problem

• In 2001, the National Strategy for
  Suicide Prevention was completed
         Suicide in Illinois
Illinois Suicide Prevention Alliance (ISPA)
 Dedicated to reducing suicide in Illinois by raising
    public awareness, lessening the stigma
    surrounding it and making treatment accessible.

In 2004, passed the Suicide Prevention, Education &
  Treatment Act in Illinois to develop and
  implement the Illinois Suicide Prevention
  Strategic Plan.
*The Illinois Plan can be downloaded from the Illinois
  Department of Public Health website.
   Illinois Suicide Prevention
   Strategic Plan’s Ten Goals:
1. Ask about Suicide – Encourage screenings for
   suicidal ideations and intentions.
2. Know Your Neighbor – Develop support networks
   to help decrease isolation for those at-risk.
3. Treatment Works – Create a continuum of care for
   those at the highest risk of suicide.
4. Ensure Safety to Live and Love – Promote support
   and outreach to victims of harassment and
5. Knowledge is Power – Establish suicide education
   curriculum requirements for public service
     Illinois Suicide Prevention
     Strategic Plan’s Ten Goals:
6. Everyone Deserves Care – Increase access to mental
   health care services.
7. Data Counts – Improve data collection of suicide-
   related data.
8. Suicide is Everyone’s Business – Increase the public’s
   awareness of the benefits to restricting access to
9. Help Break the Stigma – Reduce stigma and increase
   public awareness.
10. Bank on Saving Lives – Develop funding sources
   for suicide prevention, intervention and
   post-vention programs in IL.
                Suicide in Illinois
                 by the numbers
 12 – Rank as leading cause of death in Illinois
 3 – Rank as leading cause of death for ages 10-24 in
   Caucasian, African- and Latino-American populations
 15 – 19 - Age with the highest attempt rate
  in IL
 70 – Age with the highest suicide rate in IL
 30,000 – Number of people who die by suicide every year
   in the U.S.
 18,000- Number of people who die by homicide in the U.S.
 1,086 - Number of people who died by suicide in Illinois
   in 2005, vs. 953 died by homicide

Suicide Prevention Resource Center (SPRC), American Association of Suicidology (AAS)
           Who is Most
        At-Risk for Suicide?
• More men than women die by suicide, BUT
  attempts are higher in women
  – 73% of all suicide deaths are white males

• Young people ages 10 – 19
  In 2003 – 2004
   9% increase in boys aged 15 – 19 years old
   32% increase in girls aged 15 – 19 years old
   75.9% increase in 10 – 14 year old girls
          Caucasian                    African-                    Latino-
                                       American                    American
Data from the 2009 Youth         Data from the 2009 Youth          Data from the 2009 Youth Risk Behavior
Risk Behavior Survey             Risk Behavior Survey              Survey indicates that 14% of Latino-American
indicates that 14.5% of          indicates that 16.1% of           high-school aged youth seriously considered
Caucasian high-school aged       African-American high-            suicide in the last 12 months, and 9.8%
youth seriously considered       school aged youth seriously       attempted.
suicide in the last 12 months,   considered suicide in the last
and 6.1% attempted.              12 months, and 11.8%
Nationally, suicide rate is      Nationally, suicide rate is 5.8   Nationally, suicide rate is individuals 5.42 per
12.2 individuals per 100,000     individuals per 100,000           100,000

Firearms and suffocation         Firearms were the                 The use of firearms and suffocation were the
were the two predominant         predominant method of             two most common methods in Latino
methods at 50% and 34%           suicide among African             populations (37.8% and 40% respectively for
respectively.                    Americans regardless of           Latinos of all ages). This compares to 51.1%
                                 gender and age, accounting        and 22.3% use by the non-Latino populations.
                                 for roughly 52% of all
              Key Definitions
• Suicide – self-inflicted death with evidence that
  the person intended to die
• Suicide attempt – self-injurious behavior with a
  non-fatal outcome & evidence the person
  intended to die
• Suicidal ideation – thoughts of serving as the agent
  of one’s own death
• Suicidal intent – subjective expectation and desire
  for a self-destructive act to end in death
• Deliberate self-harm – willful self-inflicting of
  painful, injurious acts without intent to die
                    Self Injury
                      – vs -
• Typical onset of self-injury is puberty
• Self-injurious behaviors often last 5 – 10 years, but
  can persist longer without treatment
• Self injurious behavior is a way for people to cope
  with or relieve painful or hard-to-express feelings
  – self-destructive cycle begins
• Generally not a suicide attempt, BUT if goes
  untreated, can lead to suicide attemtps
    and Mental Illnesses

    Research has shown that
more than 90% of people who kill
 themselves have depression or
   another diagnosable mental
  or substance abuse disorder
   at the time of their death.
• Clinical depression is one of the most
  common mental illnesses and affects
  nearly 19 million Americans each year
  (1 in 5 Americans)
• Most people who have depression do
  not die by suicide; HOWEVER…
• Having major depression increases
  suicide risk
• Depression is HIGHLY treatable
            Youth Depression
 Recent surveys indicate that as many as one in five
  teens suffers from clinical depression. Mental Health

 Children under stress, who experience loss, or who
  have attention, conduct or anxiety disorders are at
  higher risk for depression. American Academy of Child
  & Adolescent Psychiatry

 Children whose parents have been diagnosed with
  affective disorders are far more likely to be
  diagnosed with a mental illness- especially an
  affective disorder – than their peers whose parents
  do not have mood disorders. Psychiatric Times, 1999
          What is Depression?
 Depression is a treatable medical illness, not a
  weakness or a moral failure, that often runs in

 Between 80% to 90% of cases of depression can be
  treated successfully.

 Clinical depression is a common and serious disorder
  of mood, that is pervasive, intense and attacks the
  mind and body simultaneously

 Depression can be triggered by health conditions
  and/or environmental stressors
                Depression is a
             Biopsychosocial illness
Physiology                             Psycho:
Chemistry                              Psyche
Genetics                               Emotions

               Environment - Others
        Symptoms of Depression
       in Children & Adolescents
 Irritability and/or depressed mood
 Loss of interest in usual activities
 Low energy and/or restlessness
 Poor concentration
 Sleeping too much or too little
 Weight loss or weight gain
 Feeling hopeless and helpless
 Feeling worthless and guilty
 Persistent physical symptoms that
  don’t respond to treatment such as
  headache, stomachache, chronic
  pain, constipation, etc.
 Thoughts of death or suicide
           Typical Adolescence
 Struggle for independence, limit testing
 Identity struggle
 Less affectionate toward parents, “occasional” rudeness
 “Occasional” moodiness
 Increased responsibility
 Limited thoughts of the future

   Typical vs. Depressed Adolescence
 Symptoms of depression are more persistent and interfere
  with daily living, particularly when they last for more
  than two weeks.
 Adolescent depression interferes with acquisition of
  necessary life long skills developed during adolescence.
Depression in the Classroom
 Frequent absences
 Excessive tardiness
 Inability to screen out stimuli
 Inability to concentrate
 Difficulty with time pressures & multiple tasks
 Difficulty handling negative feedback
 Sudden drop in grades
 Difficulty responding to change
 Refusal to participate in school activities
 Difficulty interacting with others
Depression in the Classroom
 Peer group change
 Defiant
 Social anxiety
 Fatigue
 Irritability
 Fidgety
 Restless
 Isolating
 Disruptive
 Quiet
      Classroom Management
Ask parents what would be helpful to motivate
 and decrease pressure for student
Consult regularly with parents, school support
 staff, etc. ~ Don’t be the only person dealing
 with the student’s issues
Designate a “safe” person in school
Give advanced warning of major changes to
 students, if possible
Shorten assignments or allow more time to
Break tasks into smaller parts
      Classroom Management
Provide refocusing assistance and prompts
Preferential seating by a teacher or positive peer
Word banks or alternative testing methods to
 accommodate for retrieval problems
Provide assistance to see assignments recorded
 accurately and all materials are packed
2nd set of books to be left at home
Keep a record of their accomplishments and
 show them occasionally
Put corrections in the context of a lot of praise
 and support
      Classroom Management
Reassure student they can catch up, be flexible
 and realistic about your expectations
Avoid situations that might socially isolate or
 ostracize (allowing students to choose team
Encourage gradual social interaction
Let them know you care without getting too
Be alert to suicidal thoughts and behaviors; take
 threats seriously
      Classroom Management
Find student’s strengths and focus on them
Don’t ignore depressed student, it invites them
 to give up
Help students focus on positives
Give adolescents a “feeling vocabulary”
Create a classroom environment where kids
 aren't mean
        Depression & Suicide
 Each year, around 5,000 young people, ages 15-24,
  lose their lives to suicide.

 The rate of suicide for this age group has nearly
  tripled since 1960, making it the third leading cause
  of death in adolescents and the second leading
  cause of death among college-age youth.

 4 out of 5 teens give CLEAR warning signs before a
  suicide attempt.

                                 -Mental Health America
More teenagers and young
  adults die from suicide
  than cancer, heart
  disease, AIDS, birth
  defect, stroke,
  pneumonia and
  influenza, and chronic
  lung disease
  The Surgeon General Report on Mental
  Health, 1999
 What to look for in a child
who might be thinking about
   committing suicide…
               SIGNS                       RISK FACTORS
   Talking about wanting to         Access to weapons (guns,
    die                               knives, etc.)
   Unusual neglect of personal      Substance abuse
   Saying things like               History of impulsive
    “Everyone would be better         and/or aggressive
    off if I weren’t around,”         behaviors
    “There’s no point in living      Signs of psychosis, bizarre
    anymore,” etc.                    thoughts, hallucinations,
   Giving away personal              etc.
    possessions                      Family history of suicide
   A sudden dramatic
    improvement in mood              Previous suicide attempts
                               The Many Paths to Suicide
     Fundamental Risk                               Proximal Risk Factors                                     Cause of
         Factors                                    “Triggers or Final Straws”                                 Death
Biological                                                   Crisis in
                                                             Relation                                           Poison

                         Sex                                  Loss of
                                                             Freedom                                             Gun

                                                                                         WALL OF RESISTANCE
                                                              Fired/       Increasing
                                                             Expelled     Hopelessness                         Hanging
                           Culture     Values      Drugs                 Contemplation
  Child       Loss of                  Religion      or
  Abuse       Parent        Shift       Beliefs    Alcohol                 of Suicide
                                                              Illness      as Solution                         Autocide
Environmental                        Urban     for
                                      vs.    Suicide
                         Geo-                                 Major                                            Jumping
                        graphy       Rural                    Loss
          of year

                                                                ?                                                ?
• All “Causes” are real.
• Hopelessness is the common pathway.
• Break the chain anywhere = prevention.
         Risk Factor: Violence
• Domestic Violence Victims, Perpetrators and their
  – Women exposed to acute or prior domestic violence
    are more likely than unexposed women to have made
    suicide attempts
  – Approximately half of U.S. homicides are followed by
    a suicide
  – Violent family interactions is a significant variable in
    youth suicide and completions
  – Violent people have a history of self-destructive
                         Risk Factor:
                      Sexual Orientation
• Gay youth are 2 to 3 times more likely to
  attempt suicide than other young people

• Survey questions related to sexual orientation
  found elevated risk of suicide attempts

• Youth Risk Behavior Survey (YRBS - for
  Illinois statistics:

(Gibson, 1989) and (Remafedi et al, 1998)
                         Risk Factor:
                      Sexual Orientation
It has been found that suicide attempts among
   youth identifying as GLBT are significantly
   associated with:
Gender non-conformity         Stress
Other psychiatric symptoms Lack of support
Dropping out of school        Family problems
Homelessness                  Substance abuse
Acquaintances’ suicide attempts      Violence
Early awareness of homosexuality

(Remafedi, Farrow, & Deisher, 1991; Schneider, Farberow & Kruks, 1989; D’Augelli & Hershberger, 1993;
    Hershberger, Pilkington & D’Augelli, 1997; Remafedi, et al, 1998; Schneider, Farberow & Kruks, 1989;
    Nicholas & Howard, 1998)
    Wall of Resistance to Suicide
Counselor or therapist   Duty to others    Others?

 Good health     Medication Compliance         Fear

Job Security or Responsibility Support of significant
   Job Skills        for children         other(s)
   Difficult Access        A sense of      Positive
      to means               HOPE         Self-esteem
              Religious          Calm        AA or NA
             Prohibition      Environment     Sponsor
     Best                 Safety          Treatment
   Friend(s)            Agreement         Availability

                  -- Sobriety --
               Protective Factors
                         Cultural Factors to Consider related
                           to African-American Populations
Help remove the stigma and myths that suicide contradicts gender and cultural role
     •Religious stigma of suicide as the unforgivable sin
     •African American men are macho and do not take their own lives;
     •African American women are always strong and resilient and never crack under
     •Remove barriers to treatment.
     •Improve access to mental health treatment.
     •Remove stigma associated with mental health treatment.
Increase awareness in cultural differences in the expression of suicidal behaviors:
     •African American are less likely to use drugs during a suicide crisis;
     •Behavioral component of depression in African Americans is more pronounced;
     •Some African Americans express little suicide intent or depressive symptoms during
     suicidal crises
     •Develop liaisons with the faith community
     •Recognize warning signs and help a friend or family member get professional help
     American Association of Suicidology
                       Cultural Factors to Consider related
                                   to Latino-Americans
The following hypotheses have been presented regarding suicidal behavior among Latinos:
•Family needs are placed above individual needs and respect to the parents and elders is of
major importance
•Suicidal behavior among Latino females may be related to the stress caused by the expectation
of obligation to the family.
•Family closeness and good relations with parents have been found to be a resiliency factor for
suicidality among Latino males and females
•Latino adolescents may also experience stress with the conflict between placing family needs
above individuals needs and what is taught in the mainstream culture about the importance of
•Recently immigrated Latino families may not fully understand the health care system and may
be reluctant to seek help in the fear of being reported as undocumented
•Latino families may avoid seeking mental health help because they feel that suicide should be
dealt with by the family or faith community first
•Language differences are a barrier to seeking mental health help
• Although most suicidal Latino youth are born in the United States and know English, many
times they prefer for their parents to be involved in their treatment, and often their parents
cannot speak English, thus are placed at a disadvantage because they need bilingual clinicians or
trained interpreters                                         American Association of Suicidology
        Cultural Factors to Consider related
           to Latino-Americans, continued…
Treatment and Prevention:

•Involving the family in treatment is very important since the
Hispanic culture places grave importance on the well-being of the
family; with adolescents the involvement of the parents is essential
to treatment
•Professionals who are in position to identity people and
adolescents at risk for suicidal behavior should take into
consideration that distress is not always expressed the same way
by all people of different backgrounds
•Immigration, acculturation, collectivism, and interdependence
should be considered in treatment
•It is essential to eliminate language barriers and have trained
interpreters available for the families who need them
American Association of Suicidology
    Crisis Intervention
for those who are Suicidal
Create a safety plan
Seek professional help
Remember a crisis is temporary and an
 opportunity to impact change

     Suicidal Behavior and Adolescence
The 1st suicide attempt usually occurs before the
 age of 17
Family cohesiveness and religiosity serve as
 protective factors for suicidal youth
       What Can You Do to
        Prevent Suicides?
• Know the warning signs and risk factors
• Ask the “Suicide” question
• Know referral resources in your community
• Consult with other colleagues and/or a
• Express concerns to parents and provide
  education about seriousness of a situation
• Be clear about your level of urgency/concern
• Visit to learn more
Reasons for Hospitalization
Suicidal thoughts or plans -or-
Homicidal thoughts or plans -or-
Psychotic thinking is present -AND-
Unable to create/implement a safety plan.

Hospitalization can be a helpful intervention or
 can begin a life long pattern of using the
 hospital to avoid dealing with life challenges.
What works…a combination
 Counseling:
 Cognitive-Behavioral Therapy (CBT) and Interpersonal Therapy
 have shown to be very effective

 Medication:
 Antidepressant medication acts on chemical pathways of the
 brain related to mood

 Support & Education:
 Groups, educational literature, support system
   Cognitive Behavioral            Interpersonal Therapy
                              It is also brief
 CBT focuses on the child’s
  persistent cognitive
                              It focuses on current
  distortions                  relationships

 It is a brief approach          It uses the therapy
                                   relationship to repair other
 Other components include:
       Affective Education          Change happens through
       Activity Planning             insight and new interactions
       Problem Solving
       Social Skills training
       Self-instructional Training
       Relaxation Training
       Cognitive Restructuring
 Psychotherapeutic medications may make other
  kinds of treatment more effective

 How long someone must take a psychotherapeutic
  medication depends of the individual and the

 Psychotherapeutic medications are divided into 4
  groups- antipsychotic, antimanic, antidepressant, and

 Be sure to discuss potential benefits and side effects
  with your doctor and to report accurately the effect
  of the medication in follow up appointments.
 Choosing the Right Provider
        Types of Health Care Providers
Provide Medication              Provide Counseling

                              Licensed Clinical Psychologist
Primary Care Physician               (Ph.D or Psy.D)
        (MD)             Licensed Clinical Professional Counselor
     Psychiatrist            Licensed Clinical Social Worker
        (MD)                             (LCSW)
                         Licensed Marriage and Family Therapist
Enhancing Mental Health
 Connectedness to school
 Positive adult role models/relationships
 Social Interest
 Modeling Stress Management
 Setting Limits
Enhancing Mental Health
 Teach children feelings vocabulary
 Be accurate with your feedback
 Provide constructive experiences
 Teach them to take pride in themselves and
  their accomplishments
 Use Positive and Kind Humor
           What Can MHAI Offer
 Classroom/Community Seminars (for teens, children, faculty,
  parents, and other adult caregivers)

 Educational Activities

 Treatment Resources and Referrals

 Mental Health Screenings

 Educational Materials/Pamphlets

 Assistance in implementing Illinois’ mandated Social and
  Emotional Learning standards

**Please refer to the full list of MHAI’s scope of services to schools
   and communities.
          Student Education
EXAMPLE - Student Program Schedule:
  Day 1:
     -Depression and Suicide
    -Bipolar Disorder
    -How to Ask for Help
    -Where to Go for Help (Resources)
 Day 2:
    -Anxiety Disorders
    -Taking Care of Your Mental Health
       QuickTime™ and a
are needed to see this picture.
                                  It Only Takes One
  •Addresses Illinois’ Strategic Plan by reducing the
  stigma and increasing the public’s awareness of suicide
  •Envisions an Illinois where no one is touched by
  •Provides information on suicide warning signs,
  actions to take when one witnesses these signs, Illinois
  statistics, stories of loved ones lost to suicide, and the
  Violet Registry - a place to post in support of a
  survivor, in memory of a loved one lost to suicide, or in
  support of the campaign
         Additional Resources
•Mental Health America of Illinois:
•National Mental Health America:
•Erika’s Lighthouse:
•Suicide Prevention Resource Center:
•American Association of Suicidology:
•American Foundation for Suicide Prevention:
Undiagnosed & Untreated Mental Illnesses Affect
          but, the Good News is…

                For further information, contact:
            Mental Health America of Illinois (MHAI)

 Carol Gall, MA, MSW
 Executive Director
 312-368-9070 ext. 24

 Ariel Mindel, MC, LPC
 Program Director, Public Education & Disaster Mental Health
 312-368-9070 ext. 22

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