Youth Suicide Prevention and Intervention
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Youth Suicide Prevention and Intervention

DRAFT Model Emotional, Behavioral and Suicide Crisis Plan, 2014 - House Bill 1336, passed by the state legislature in April 2013, requires that each Washington school district have a plan for how it will handle emotional and behavioral distress, including suicidal thinking, behavior, and threats of violence. The attached draft, model Plan will help districts and schools develop their own plans to respond quickly and effectively in a crisis.

Preventing Suicide: A Toolkit for High Schools, SAMHSA. The Preventing Suicide: A Toolkit for High Schools was funded by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) to help high schools, school districts, and their partners design and implement strategies to prevent suicide and promote behavioral health among their students.

Model School District Policy on Suicide Prevention: Model Language, Commentary, and Resources: The Trevor Project, in collaboration with the American Foundation for Suicide Prevention, the American School Counselor Association, and the National Association of School Psychologists, created this model policy development document.

Learning Standards in Support of Suicide Prevention Education (PDF)


+ The Role of Teachers

The Role of Teachers in Preventing Suicide

Marianne is a middle school teacher. One of her students, David, began the year as a quiet, subdued, and passive young man. He did his work, but he did not participate in class or interact with the other students. Recently, David has undergone what, to Marianne, seems like a dramatic change in personality: He can barely stay in his seat, is uncooperative, has lost interest in his work, and gets angry easily. Last week, Marianne saw him punch a locker. Marianne decided to speak with some of David’s other teachers. She discovered that they had noticed similar problems, along with a decline in the quality of his school work. Marianne spoke to the school counselor, who suggested that David come in for an appointment. Marianne told David that she was concerned about him and that she thought he might benefit from talking to someone. She walked him to the counseling office while he made an appointment, and she called the counselor later to make sure that he kept it.

Did Marianne prevent a suicide? There is a good possibly that neither she, nor the school counselor, nor her student, David, can ever really be sure. But Marianne noticed a student with problems and took effective action. In doing so, she demonstrated concern and assisted a troubled student in getting help. And she may have saved a life.

Suicide is the third leading cause of death among children, teens, and young adults ages 10 to 24. About 4,000 young people die by suicide each year. But this is only the tip of the iceberg. Every year, approximately 125,000 children—the vast majority of whom are in the 15–24 age group (CDC, 2003a)—are brought to emergency rooms to receive treatment for injuries inflicted while attempting suicide (CDC, 2004). A recent national survey (CDC, 2003b) revealed that in the 12 months preceding the survey:

  • Almost 17 percent of high school students had seriously considered attempting suicide
  • 16.5 percent of high school students had made a plan about how they would attempt suicide 8.5 percent of high school students had attempted suicide one or more times
  • Very few of these suicides, or suicide attempts, take place in schools. But many young people who are at risk of suicide attend school and exhibit warning signs that, if recognized and acted on, could prevent death or injury and reduce emotional suffering.
  • As a teacher, you have day-to-day contact with many young people, some of whom have problems that could result in serious injury or even death by their own hand. You are therefore well-positioned to observe students’ behavior and to act when you suspect that a student may be at risk of self-harm. There are specific steps you can take to identify and help young people at risk, especially if your school has created a structure that can support your personal efforts to safeguard the health and safety of its students.


+ Recognizing the Warning Signs

Recognizing the Warning Signs

Suicide and other self-destructive behaviors rarely occur without some warning signs. You, perhaps even more than parents of teens, can assess what is "normal" adolescent behavior and what may be an indication that something is wrong.

Here are some signs that a young person may be considering suicide:

  • A suddenly deteriorating academic performance. Teens who were typically conscientious about their school work and who are now neglecting assignments, cutting classes, or missing school altogether may be experiencing problems that can affect their academic success, behavior, and health and put them at risk of suicide.
  • Self-mutilation. Some young people resort to cutting their arms or legs with razor blades and other sharp objects to cope with emotional pain. Self-mutilation of this type is an unmistakable sign that something is wrong.
  • A fixation with death or violence. Teens may express this fixation through poetry, essays, doodling, or other artwork. They may be preoccupied with violent movies, video games, and music, or fascinated with weapons.
  • Unhealthy peer relationships. Teens whose circle of friends dramatically changes for no apparent reason, who don’t have friends, or who begin associating with other young people known for substance abuse or other risk behaviors may signal a change in their emotional lives. Their destructive behaviors may discourage more stable friends from associating with them, or they themselves may reject former friends who "don’t understand [them] any more."
  • Volatile mood swings or a sudden change in personality. Students who become sullen, silent, and withdrawn, or angry and acting out, may have problems that can lead to suicide.
  • Indications that the student is in an unhealthy, destructive, or abusive relationship. This can include abusive relationships with peers or family members. Signs of an abusive relationship include unexplained bruises, a swollen face, or other injuries, particularly if the student refuses to discuss them.
  • Risk-taking behaviors. Risk-taking behaviors often co-occur and are symptomatic of underlying emotional or social problems. Such behaviors as unprotected or promiscuous sex, alcohol or other drug use, driving recklessly or without a license, petty theft, or vandalism, especially by young people who formerly did not engage in these activities, can be an indication that something is wrong.
  • Signs of an eating disorder. An eating disorder is an unmistakable sign that a student needs help. A dramatic change in weight that is not associated with a medically supervised diet may also indicate that something is wrong.
  • Difficulty in adjusting to gender identity. Gay, lesbian, bisexual, and transgendered teens have higher suicide attempt rates than their heterosexual peers. While coming to terms with gender identity can be challenging for many young people, gay and lesbian youth face social pressures that can make this adjustment especially difficult.
  • Bullying. Children and adolescents who are bullied, as well as those who bully, are at increased risk of depression and suicidal ideation (Kaltiala-Heino, Rimpela, Marttunen, Rimpela, & Rantanen, 1999).
  • Depression. Although most people who are clinically depressed do not attempt suicide, depression significantly increases the risk of suicide or suicide attempts. Symptoms of depression include the following:
    • A sudden worsening in academic performance
    • Withdrawal from friends and extracurricular activities
    • Expressions of sadness and hopelessness, or anger and rage
    • A sudden decline in enthusiasm and energy
    • Overreaction to criticism
    • Lowered self-esteem, or feelings of guilt
    • Indecision, lack of concentration, and forgetfulness
    • Restlessness and agitation
    • Changes in eating or sleeping patterns
    • Unprovoked episodes of crying
    • Sudden neglect of appearance and hygiene
    • Fatigue
    • The abuse of alcohol or other drugs as young people try to "self-medicate" their emotional pain

    Some warning signs of suicide demand immediate action:

    • Talking or writing about suicide or death
    • Giving direct verbal cues, such as "I wish I were dead" and "I’m going to end it all"
    • Giving less direct verbal cues, such as "You will be better off without me," "What’s the point of living?", "Soon you won’t have to worry about me," and "Who cares if I’m dead, anyway?"
    • Isolating him- or herself from friends and family
    • Expressing the belief that life is meaningless
    • Giving away prized possessions
    • Exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn
    • Neglecting his or her appearance and hygiene
    • Dropping out of school or social, athletic, and/or community activities
    • Obtaining a weapon (such as a firearm) or another means of hurting him- or herself (such as prescription medications)


+ Responding to the Warning Signs

Responding to the Warning Signs

It takes time and courage to reach out to students on a personal level, but your interest can be a lifeline to a child in crisis. Young people—especially those with emotional or family troubles—need support, and school can be a vital part of that support. School may be the last positive social connection for young people from dysfunctional families or who are isolated from their peers.

When you observe behavior that indicates that there is a problem—whether the student is acting out, withdrawing, committing destructive or aggressive acts toward him- or herself or others, or exhibiting a fixation with death or morbid themes—take note and take action. Consult with your school counselor, principal, or nurse to ensure appropriate and quick assessment and treatment.

Many of the same signs that a student is at risk of suicide can also indicate that the student is at risk of (or is already experiencing) other problems, including emotional distress, mental illness (such as depression or bipolar disorder), violence, domestic violence or child abuse, academic failure, running away from home, or the abuse of alcohol or other drugs. You cannot always tell exactly what may be troubling a student and what the outcomes of theses troubles may be. But you can be aware of when something is wrong and take steps to get the student the type of help he or she needs. Below are some of the steps you can take to help students who may be at risk of suicide or of other problems that threaten their well-being.

Ask the Tough Questions Do not be afraid to ask a student if he or she has considered suicide or other self-destructive acts. Research has shown that asking someone if he or she has contemplated self-harm or suicide will not increase that person’s risk. Rather, studies have shown that a person in mental distress is often relieved that someone cares enough to inquire about the person’s well-being. Your concern can counter the person’s sense of hopelessness and helplessness. However, you need to be prepared to ask some very specific and difficult questions in a manner that doesn’t judge or threaten the young person you are attempting to help. For example:

  • I’ve noticed that you are going through some rough times. Do you ever wish you could go to sleep and never wake up?
  • Sometimes when people feel sad, they have thoughts of harming or killing themselves. Have you had such thoughts?
  • Are you thinking about killing yourself?

Be Persistent
A student may feel threatened by your concern. The student may become upset or deny that he or she is having problems. Be consistent and firm, and make sure that the student gets the help that he or she may need.

Be Prepared to Act You need to know what to do if you believe that a student is in danger of harming him- or herself. Many schools have procedures for this situation. If your school has such procedures, explain them to the student.

Do Not Leave a Student at Imminent Risk of Suicide Alone
If you have any reason to suspect that a student may attempt suicide or otherwise engage in self-harm, you need to remain with the student (or see that the student is in a secure environment, supervised by caring adults) until professional help can be obtained. The student’s well-being supersedes any promises of confidentiality you may have made to the student. Let the student know that you care, that he or she is not alone, and that you are there to help.

Get Help When Needed
If you believe that the student is in imminent danger, you, or another member of the school staff, should call 911 or (800) 273-TALK (8255). Tell the dispatcher that you are concerned that the person with you "is a danger to [him- or herself]" or "cannot take care of [him- or herself]." These key phrases will alert the dispatcher to locate immediate care for this person with the help of police. Do not hesitate to make this call if you suspect that someone may be a danger to him- or herself. It could save that person’s life.

Use Your School’s Support System
School districts typically have crisis policies for working with suicidal or violent students, students who are at risk of suicide or violence, or other youngsters who are not in this acute state of crisis but still need support to stay in school and stay healthy. Familiarize yourself with these policies and programs and use them when appropriate. If your school doesn’t have such a policy in place, see "Create a comprehensive school crisis plan," below.

Connect with Parents or Guardians
If a troubled student opens up to you about self-destructive thoughts or actions, contact that student’s parents or legal guardian. Do not promise confidentiality to a child when it comes to issues regarding the child’s safety—but always talk privately with a student before letting others know of your concerns for the student’s safety. If you believe that contacting the parents or guardians may further endanger the child (if, for example, you suspect physical or sexual abuse), contact the proper authorities. In most states, teachers are "mandated reporters" and are required to report suspected child abuse.


+ School-Based Suicide Prevention Programs

School-Based Suicide Prevention Programs

Schools can help prevent suicide by providing teachers and students with the mechanisms necessary to identify and respond to students who are at risk of suicide as well as other risk and self-destructive behaviors. The following are some important steps that schools can take to reduce the risk of suicide among their students:

  • Implement a school-based prevention program. These programs can be especially effective when implemented in the context of a comprehensive risk prevention or health promotion program. Such programs can reduce levels of self-harm and other risk behaviors as well as improve levels of wellness and the academic performance of the school.
  • Implement a gatekeeping program. Suicide prevention gatekeeping programs train those who have regular contact with young people, such as teachers, to do the following:
    • Recognize behavioral patterns and other warning signs that indicate that a young person may be at risk of suicide
    • Actively intervene, usually by talking to the young person in ways that explore the level of risk without increasing it
    • Ensure that young people at risk receive the necessary services
  • Create a comprehensive school crisis plan. A crisis plan helps a school respond to any emergency, from a natural disaster to violence in the school community. Such a plan should include procedures for addressing students who try to harm themselves as well as those who are only contemplating it. It should also provide some guidance for the role of individual teachers in identifying and responding to potential suicidal or violent behavior in students, and how to respond when actual violence takes place.
  • Be prepared to engage in postvention. "Postvention" is a term used to describe prevention measures implemented after a crisis or traumatic event to reduce the risk to those who have witnessed or been affected by the tragedy. The suicide, or violent or unexpected death, of a student, teacher, or even a celebrity can result in an increased risk of suicide for other vulnerable young people. Although rare, a suicide in the community (or even a remote suicide that receives substantial press coverage) can contribute to an increased risk of suicide. Appropriately responding to a tragedy that may put students at risk is an essential part of any crisis or suicide prevention plan.


+ References

References

Centers for Disease Control and Prevention (CDC). (2003a). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved April 14, 2005.

Centers for Disease Control and Prevention (CDC). (2003b). Youth online: Comprehensive results. Retrieved March 23, 2005.

Centers for Disease Control and Prevention (CDC). (2004, June 11). Suicide and attempted suicide. Morbidity and Mortality Weekly Report, 53(22), 471. Retrieved April 14, 2005.

Bullying, depression, and suicidal ideation in Finnish adolescents: School survey. British Medical Journal, 319(7206), 348–351. Retrieved March 23, 2005.


+ School-Based Suicide Prevention Programs and Materials

School-Based Suicide Prevention Programs and Materials

Youth Suicide Prevention Program is an organization whose mission is to reduce youth suicide attempts and deaths in Washington State. Working toward that goal, YSPP builds public awareness, offers trainings, and supports communities taking action.

Columbia University TeenScreen® Program helps schools and communities implement screening programs to identify at-risk teens and pre-teens. It uses simple screening tools that can detect depression, the risk of suicide, and other mental disorders in teens to help schools identify and arrange treatment for youth who are suffering from depression and other undiagnosed mental illness and those who are at risk of suicide.

Jason Foundation, Inc. educates young people, parents, teachers, and others who work with young people about youth suicide. The foundation offers programs, seminars, and support materials on suicide awareness and prevention.

Sources of Strength is a best practice youth suicide prevention project that utilizes the power of peer social networks to change unhealthy norms and culture and ultimately prevent suicide, bullying and substance abuse. The program is designed to prevent suicide by increasing help seeking behaviors and connections between peers and caring adults with a focus on Hope, Help and Strength.

Yellow Ribbon International Suicide Prevention Program® provides training and resources for school- and community-based suicide prevention programs (including gatekeeping). Chapters in a number of states can provide suicide prevention speakers, materials, and training to schools and other organizations.

Youth Suicide Prevention Intervention and Postvention Guidelines: A Resource For School Personnel were developed by the Maine Youth Suicide Prevention Program and designed for schools to use within existing protocols to assist at-risk students and to intervene appropriately in a suicide-related crisis.

The Youth Suicide Prevention School-Based Guide was developed by the Florida Mental Health Institute at the University of South Florida. It provides a framework for schools to assess their existing or proposed suicide prevention efforts (through a series of checklists) and provides resources and information that school administrators can use to enhance or add to their existing program. Information is offered in a series of issue briefs corresponding to a specific checklist. Each brief offers a rationale for the importance of the specific topic together with a brief overview of the key points. The briefs also offer specific strategies that have proven to work in reducing the incidence of suicide, with references that schools can use to explore these issues in greater detail.


+ Suicide Gatekeeping Programs

Suicide Gatekeeping Programs

Livingworks Education, Inc. provides training and support for the Applied Suicide Intervention Skills Training (ASIST) program, a suicide gatekeeping program. Livingworks also offers shorter presentations on suicide awareness and prevention.

Preventing Youth Suicide Through Gatekeeper Training: A Resource Book for Gatekeepers was designed for use in youth suicide prevention gatekeeper trainings and to provide basic information about suicide prevention, crisis intervention, support for survivors of suicide, and suicide prevention resources. The book was created for the Maine Youth Suicide Prevention Program.

QPR Institute offers gatekeeper training programs to the general public and to professionals, including firefighters, clergy, and teachers.


+ General Resources on Suicide and Suicide Prevention

General Resources on Suicide and Suicide Prevention

Sources of Strength is a best practice youth suicide prevention project that utilizes the power of peer social networks to change unhealthy norms and culture and ultimately prevent suicide, bullying and substance abuse. The program is designed to prevent suicide by increasing help seeking behaviors and connections between peers and caring adults with a focus on Hope, Help and Strength.

Model School District Policy on Suicide Prevention - (Model Language, Commentary, and Resources) The Trevor Project, in collaboration with the American Foundation for Suicide Prevention, the American School Counselor Association, and the National Association of School Psychologists, created this model policy development document.

Youth Suicide Prevention Program is an organization whose mission is to reduce youth suicide attempts and deaths in Washington State. Working toward that goal, YSPP builds public awareness, offers trainings, and supports communities taking action.

Suicide Prevention Resource Center provides prevention support, training, and materials to strengthen suicide prevention efforts. Among the resources found on its website is the SPRC Library Catalog, a searchable database containing a wealth of information on suicide and suicide prevention, including publications, peer-reviewed research studies, curricula, and web-based resources. Many of these items are available online.

American Association of Suicidology is a nonprofit organization dedicated to the understanding and prevention of suicide. It promotes research, public awareness programs, public education, and training for professionals and volunteers and serves as a national clearinghouse for information on suicide.

American Foundation for Suicide Prevention is dedicated to advancing our knowledge of suicide and our ability to prevent it. AFSP’s activities include supporting research projects; providing information and education about depression and suicide; promoting professional education for the recognition and treatment of depressed and suicidal individuals; publicizing the magnitude of the problems of depression and suicide and the need for research, prevention, and treatment; and supporting programs for suicide survivor treatment, research, and education.

National Center for Injury Prevention and Control located at the Centers for Disease Control and Prevention, is a valuable source of information and statistics about suicide, suicide risk, and suicide prevention. To locate information on suicide and suicide prevention, scroll down the left-hand navigation bar on the NCIPC website and click on "Suicide" under the "Violence" heading.

National Suicide Prevention Lifeline provides immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: (800) 273-TALK (8255). Technical assistance, training, and other resources are available to the crisis centers and mental health service providers that participate in the network of services linked to the National Suicide Prevention Lifeline.

Suicide Prevention Action Network USA is the nation’s only suicide prevention organization dedicated to leveraging grassroots support among suicide survivors (those who have lost a loved one to suicide) and others to advance public policies that help prevent suicide.



+ Resources for Teachers

Resources for Teachers

Publications

Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (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. A review of the research on youth suicide, its dramatic decrease over the last 10 years, risk factors for suicide, and promising prevention strategies, including school-based skills training, screening, education of primary care physicians, media education, and lethal-means restriction.

Hawton, K., & Heeringen, K. (2000). International handbook of suicide and attempted suicide. New York: John Wiley. Chapters of interest to school staff include Chapter 15: Suicide Behavior in Children, Chapter 16: Adolescent Suicide Behavior, and Chapter 37: Suicide Prevention in Schools.

Jacobs, D. (Ed.). (1999). Harvard Medical School guide to suicide assessment and intervention. San Francisco: Jossey-Bass. A guide to help clinicians in their assessment and care of suicidal patients.

Kalafat, J. (2003). School approaches to youth suicide prevention. American Behavioral Scientist, 46(9), 1211–1223. Literature review, discussion, and recommendations on the types and effectiveness of school-based youth suicide prevention programs.

Leenaars, A. (2001). Suicide prevention in schools: Resources for the millennium. In D.

Lester (Ed.), Suicide prevention: Resources for the millennium (pp. 213–238). Philadelphia: Brunner-Routledge. Overview of school-based prevention and an outline of a comprehensive school-based suicide prevention program.

Maris, R., Berman, A., & Silverman, M. M. (Eds.). (2000). Comprehensive textbook of suicidology. New York: Guilford Press. Chapters of interest to school staff include Suicide, Gender, and Sexuality; Indirect Self-Destructive Behavior; and In the Wake of Suicide: Survivorship and Postvention.

Posner, M. (2000). Preventing school injuries: A comprehensive guide for school administrators, teachers, and staff. New Brunswick, NJ: Rutgers University Press. This book contains information on implementing suicide prevention, postvention, and crisis preparation activities in the context of a comprehensive school injury prevention program.

Velting, D., & Gould, M. (1997). Suicide contagion. In S. Cavetto, R. Maris, and M.

Silverman (Eds.), Review of suicidology (pp. 96–137). New York: Guilford Press. This book chapter reviews the literature on suicide contagion and the influence of media portrayals of suicide.


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