School-Based Gatekeeper Training to Prevent Adolescent Suicide

School-BasedSchool-BasedGatekeeper Training toGatekeeper Training to

Prevent Adolescent SuicidePrevent Adolescent Suicide

Materials Originally Developed Thanks to the Sponsorship By:Materials Originally Developed Thanks to the Sponsorship By:

Evanston Northwestern HealthcareEvanston Northwestern HealthcareIllinois Suicide Prevention CoalitionIllinois Suicide Prevention CoalitionMental Health Association in IllinoisMental Health Association in Illinois

John Jochem, Psy.D.John Jochem, Psy.D.Hawthorn Counseling GroupHawthorn Counseling Group

This initiative is an example of a This initiative is an example of a secondary preventionsecondary prevention strategy. The overall goal includes the following:strategy. The overall goal includes the following:

Student at-risk for suicidal behavior is identified by gatekeeper Student at-risk for suicidal behavior is identified by gatekeeper within the school settingwithin the school setting

Student is assessed by in-school trained personnel Student is assessed by in-school trained personnel (social worker or other trained professional)(social worker or other trained professional)

Student is linked with additional community-based evaluation Student is linked with additional community-based evaluation and/or treatment services as indicated, successfully and/or treatment services as indicated, successfully

preventing suicidal behaviorpreventing suicidal behavior

Rational of School-Based Gatekeeper Training to Prevent Adolescent Suicide

Rational of School-Based Gatekeeper Rational of School-Based Gatekeeper Training to Prevent Adolescent SuicideTraining to Prevent Adolescent Suicide

Who and what is a “gatekeeper”?Who and what is a “gatekeeper”?GatekeepersGatekeepers are all adults who work in the school setting who are all adults who work in the school setting who regularly interact and/or observe students.regularly interact and/or observe students.

A Gatekeeper is A Gatekeeper is anyoneanyone who may be the first adult to who may be the first adult to observe signs and symptoms of adolescent depression observe signs and symptoms of adolescent depression and/or suicidal riskand/or suicidal risk

GatekeepersGatekeepers are not expected to function as mental health are not expected to function as mental health providers, but simply keep a watchful eye and are able to “sound providers, but simply keep a watchful eye and are able to “sound the alarm” when an at-risk student is identified.the alarm” when an at-risk student is identified.It is the gatekeeper’s responsibility to refer students of concern to It is the gatekeeper’s responsibility to refer students of concern to the appropriate in-school mental health professional for further the appropriate in-school mental health professional for further evaluation.evaluation.

– TeachersTeachers– AdministratorsAdministrators– Clerical & support staffClerical & support staff– School nurseSchool nurse

– CounselorsCounselors– School librarianSchool librarian– Custodial staffCustodial staff– CoachesCoaches

Research findings have indicated that more than 25% of Research findings have indicated that more than 25% of teachers have been approached by a suicidal adolescent teachers have been approached by a suicidal adolescent but that fewer than 9% felt confident in their abilities to but that fewer than 9% felt confident in their abilities to recognize and manage the suicidal teenager.recognize and manage the suicidal teenager.Gatekeepers benefit from training in the following areas:Gatekeepers benefit from training in the following areas:– Increased awareness of the public health threat posed by Increased awareness of the public health threat posed by

adolescent suicideadolescent suicide– Knowledge of the risk factors and warning signs of adolescent Knowledge of the risk factors and warning signs of adolescent

suicidesuicide– How to intervene with the student deemed as at-risk for suicideHow to intervene with the student deemed as at-risk for suicide– Knowledge of how to access in-school or community-based care Knowledge of how to access in-school or community-based care

for the at-risk studentfor the at-risk student

Rational of School-Based Gatekeeper Rational of School-Based Gatekeeper Training to Prevent Adolescent SuicideTraining to Prevent Adolescent Suicide

Test Your Adolescent Suicide IQTest Your Adolescent Suicide IQTrue or False?True or False?1.1. Adolescent suicide is an increasing problem in the U.S.Adolescent suicide is an increasing problem in the U.S.

TRUETRUE While the rate of suicide in the general population has While the rate of suicide in the general population has been generally stable since the 1950’s, adolescent been generally stable since the 1950’s, adolescent suicide rates have more than tripled.suicide rates have more than tripled.

2.2. Most teenagers will reveal that they are suicidal or if they having Most teenagers will reveal that they are suicidal or if they having problems?problems?TRUETRUE Most teens who are experiencing active suicidal ideation Most teens who are experiencing active suicidal ideation

will admit their plans to someone who is concerned and will admit their plans to someone who is concerned and inquires about their distress.inquires about their distress.

3.3. Adolescents who talk about suicide are not the ones who actually Adolescents who talk about suicide are not the ones who actually make an attempt?make an attempt?FALSEFALSE People usually give some advance indication of suicidal intent; People usually give some advance indication of suicidal intent;

suicidal threats, preoccupation or behavior must always be suicidal threats, preoccupation or behavior must always be taken seriously.taken seriously.

4.4. Talking with someone about suicide may promote suicidal ideas and Talking with someone about suicide may promote suicidal ideas and behavior?behavior?FALSEFALSE It is inner distress, psychiatric illness, serious life stressors and It is inner distress, psychiatric illness, serious life stressors and

irrational thinking that lead to suicidal behavior, irrational thinking that lead to suicidal behavior, notnot expressions of concern by others.expressions of concern by others.

Source:Source: Florida Institute of Mental Health / University of South Florida (2003)Florida Institute of Mental Health / University of South Florida (2003)

Test Your Adolescent Suicide IQTest Your Adolescent Suicide IQ

5.5. Parents are often unaware of their child’s suicidal ideation and Parents are often unaware of their child’s suicidal ideation and behavior?behavior?TRUETRUE Studies have shown that, among parents of children found to Studies have shown that, among parents of children found to

have suicidal ideation, up to 86% of parents were unaware of have suicidal ideation, up to 86% of parents were unaware of their child’s suicidal risk.their child’s suicidal risk.

6.6. The majority of adolescent suicides occur unexpectedly with no The majority of adolescent suicides occur unexpectedly with no warning signs?warning signs?FALSEFALSE Over 90% of suicidal adolescents give clues to others prior to Over 90% of suicidal adolescents give clues to others prior to

their attempt.their attempt.7.7. Most adolescents who attempt suicide fully intend to die?Most adolescents who attempt suicide fully intend to die?

FALSEFALSE As a rule, survivors of suicide attempts are relieved to have lived As a rule, survivors of suicide attempts are relieved to have lived through their suicidal crisis and are grateful for intervention.through their suicidal crisis and are grateful for intervention.

8.8. There are differences between adolescent males & females regarding There are differences between adolescent males & females regarding suicidal behavior?suicidal behavior?TRUETRUE Females attempt suicide more frequently than males (3:1), Females attempt suicide more frequently than males (3:1),

however males complete suicide more frequently than females however males complete suicide more frequently than females (4:1) because boys tend to use more lethal means (e.g., firearms)(4:1) because boys tend to use more lethal means (e.g., firearms)

9.9. Since adolescent females complete suicide less often than males Since adolescent females complete suicide less often than males their attempts should not be taken seriously?their attempts should not be taken seriously?FALSEFALSE A prior attempt is a significant risk factor for later death by A prior attempt is a significant risk factor for later death by

suicide—suicide—everyevery threat or other form of suicidal behavior must be threat or other form of suicidal behavior must be taken seriously.taken seriously.


Test Your Adolescent Suicide IQTest Your Adolescent Suicide IQ

10.10. Adolescent suicide occurs mostly with lower SES (socioeconomic Adolescent suicide occurs mostly with lower SES (socioeconomic status) kids than among wealthier kids who have access to greater status) kids than among wealthier kids who have access to greater resources?resources?FALSEFALSE Adolescent suicide is a threat to kids of every Adolescent suicide is a threat to kids of every

socioeconomic level.socioeconomic level.11.11. The only one who can be of help to a suicidal adolescent is a trained The only one who can be of help to a suicidal adolescent is a trained

mental health professional?mental health professional?FALSEFALSE Most adolescents contemplating suicide are not under the care Most adolescents contemplating suicide are not under the care

of a mental health professional and are more likely to initially of a mental health professional and are more likely to initially come to the attention of non-professional, who then facilitates a come to the attention of non-professional, who then facilitates a referral.referral.

12.12. A teacher who observes distress or warning signs in his/her student A teacher who observes distress or warning signs in his/her student should not betray the student’s trust by referring the student to the should not betray the student’s trust by referring the student to the school social worker?school social worker?FALSEFALSE Adolescent suicide is a serious public health issue and referral Adolescent suicide is a serious public health issue and referral

to in-school mental health resources should always occur to in-school mental health resources should always occur whenever warning signs of suicide are observed.whenever warning signs of suicide are observed.

13.13. If an adolescent wants to commit suicide there is nothing anyone If an adolescent wants to commit suicide there is nothing anyone can do to prevent its occurrence?can do to prevent its occurrence?FALSEFALSE Prompt identification, intervention, means restriction, support Prompt identification, intervention, means restriction, support

and treatment of an underlying condition are all effective means and treatment of an underlying condition are all effective means to prevent suicide.to prevent suicide.


Suicide as Cause of Death:1964 vs 2003, 15-19 year oldsSuicide as Cause of Death:1964 vs 2003, 15-19 year olds

Adolescent Suicide: Scope of the ProblemAdolescent Suicide: Scope of the Problem

19641964

•AccidentsAccidents

•Malignant neoplasmsMalignant neoplasms

•Cardiovascular renal Cardiovascular renal diseasedisease

•HomicideHomicide

•SuicideSuicide

20032003

•Unintentional injuryUnintentional injury

•HomicideHomicide

•SuicideSuicide

•Malignant neoplasmsMalignant neoplasms

•Heart diseaseHeart disease

Source:Source: National Center for Injury Prevention and Control, Centers for Disease Control (2007).National Center for Injury Prevention and Control, Centers for Disease Control (2007).

Leading Causes of Death Among Persons Aged 10 – 24, Leading Causes of Death Among Persons Aged 10 – 24, U.S, 2003U.S, 2003

Suicide11%

Motor Vehicle Crashes

31%

Other Unintentional

Injuries14%

Other Causes29%

Homicide15%



Adolescent Suicide: Scope of the ProblemAdolescent Suicide: Scope of the ProblemWhereas suicide accounted for 1.4% of all deaths in the U.S. Whereas suicide accounted for 1.4% of all deaths in the U.S. annually, they comprised 12.9% of all deaths among 15-24 year annually, they comprised 12.9% of all deaths among 15-24 year olds.olds.Each day there are approximately 12 youth suicides; a person Each day there are approximately 12 youth suicides; a person under the age of 25 dies by suicide every 2 hours, 11 minutes.under the age of 25 dies by suicide every 2 hours, 11 minutes.In 2004, a total of 32,439 people completed suicide. Of these, In 2004, a total of 32,439 people completed suicide. Of these, 4,316 were between the ages of 15-24.4,316 were between the ages of 15-24.For every completed youth suicide it is estimated that 100-200 For every completed youth suicide it is estimated that 100-200 attempts are made.attempts are made.Suicide rates for 15-19 year olds increased 19% between 1980-Suicide rates for 15-19 year olds increased 19% between 1980-1994 and has dropped by approximately 34% since that time.1994 and has dropped by approximately 34% since that time.Firearms remain the most commonly used suicide method Firearms remain the most commonly used suicide method among youth, accounting for 49% of all completed suicides.among youth, accounting for 49% of all completed suicides.

Source:Source: American Association of Suicidology, 2006American Association of Suicidology, 2006

Suicide Rates by Age & Gender, Ages 10-24, 2004Suicide Rates by Age & Gender, Ages 10-24, 2004

0.95

3.52 3.591.71

12.65

20.84

0

5

10

15

20

25

Ages 10-14 Ages 15-19 Ages 20-24

Dea

ths

per

100

,000

Female Male



Suicide Trends by Age & Gender, Ages 10-24, 1981-2004Suicide Trends by Age & Gender, Ages 10-24, 1981-2004

0

5

10

15

20

25

30

Dea

ths

per 1

00,0

00

Males, 10-14 Males, 15-19 Males, 20-24

Females, 10-14 Females, 15-19 Females, 20-24




Note the 34% decline in adolescent suicide rates from Note the 34% decline in adolescent suicide rates from 1994-2003. Theories to explain this decrease in suicide 1994-2003. Theories to explain this decrease in suicide mortality among adolescents include:mortality among adolescents include:– Firearms legislationFirearms legislation– Decreases in divorce ratesDecreases in divorce rates– Suicide awareness & gatekeeper programsSuicide awareness & gatekeeper programs– Crisis hotlinesCrisis hotlines– Perhaps attempts are constant but lethality has declinedPerhaps attempts are constant but lethality has declined– Improved management of mental disorders:Improved management of mental disorders:

Increased prescription of antidepressantsIncreased prescription of antidepressantsImprovements in approaches to psychotherapyImprovements in approaches to psychotherapy

However, 2004 data show some reverse in the pattern of However, 2004 data show some reverse in the pattern of declining youth suicide rates.declining youth suicide rates.


Method of Completed Suicide, Ages 10-24, 2004Method of Completed Suicide, Ages 10-24, 2004

Fall

2%

Firearm

47%

Vehicular

1%

Cutting

1%Other

3%Poisoning

8%

Drowning

1%

Suffocation

37%



Firearms are the most Firearms are the most common method used by common method used by kids who die by suicidekids who die by suicide

Adolescent Suicide: Scope of the ProblemAdolescent Suicide: Scope of the ProblemResearch has shown that most adolescent suicides occur after Research has shown that most adolescent suicides occur after school hours, in the teen’s home.school hours, in the teen’s home.

Although rates vary somewhat by geographic location, it is Although rates vary somewhat by geographic location, it is likely that three students (one boy & two girls) within a typical likely that three students (one boy & two girls) within a typical high school classroom have made a suicide attempt in the past high school classroom have made a suicide attempt in the past year.year.

The typical profile of an adolescent nonfatal suicide attempter is The typical profile of an adolescent nonfatal suicide attempter is a female who ingests pills; the profile of a the typical suicide a female who ingests pills; the profile of a the typical suicide completer is a male who dies from a self-inflicted gunshot completer is a male who dies from a self-inflicted gunshot wound.wound.

Most adolescent suicide attempts are precipitated by Most adolescent suicide attempts are precipitated by interpersonal conflicts. Often, the intent of the suicidal interpersonal conflicts. Often, the intent of the suicidal behavior appears to be to effect change in the behavior appears to be to effect change in the behaviors/attitudes of others.behaviors/attitudes of others.


The Youth Risk Behavior The Youth Risk Behavior Surveillance SystemSurveillance System

School-based survey of teenagers conducted biannually School-based survey of teenagers conducted biannually by the U.S. Department of Health & Human by the U.S. Department of Health & Human Services/Centers for Disease ControlServices/Centers for Disease Control99thth – 12th grade students – 12th grade studentsAnonymousAnonymousSelf-administered, computer-scannable questionnaire or Self-administered, computer-scannable questionnaire or answer sheetanswer sheetRepresentative sample of U.S. high school student Representative sample of U.S. high school student populationpopulation

Total sample size in 2005 = Total sample size in 2005 = 13,91713,917The YRBSS is our The YRBSS is our best sourcebest source of information concerning of information concerning adolescent lifestyle and behavioral factors which adolescent lifestyle and behavioral factors which contribute to risk of illness, accident or injurycontribute to risk of illness, accident or injury

Percentage of High School Students Who Felt Sad or Percentage of High School Students Who Felt Sad or Hopeless,* 1999 – 2005Hopeless,* 1999 – 2005

* Almost every day for > 2 weeks in a row that they stopped doing some usual activities during the 12 months preceding the survey1 No significant change over time

National Youth Risk Behavior Surveys, 1999 – 2005

28.3 28.3 28.5128.6

0

20

40

60

80

100

1999 2001 2003 2005

Perc

en

t

Percentage of High School Students Who Felt Sad or Percentage of High School Students Who Felt Sad or Hopeless,* by Sex** and Race/Ethnicity,*** 2005Hopeless,* by Sex** and Race/Ethnicity,*** 2005

* Almost every day for > 2 weeks in a row that they stopped doing some usual activities during the 12 months preceding the survey** F > M*** H > W, B

National Youth Risk Behavior Survey, 2005

20.425.8 28.4

36.228.5

36.7

0

20

40

60

80

100

Total Female Male White Black Hispanic

Per

cen

t

Percentage of High School Students Who Seriously Percentage of High School Students Who Seriously Considered Attempting Suicide,* 1991 – 2005Considered Attempting Suicide,* 1991 – 2005

* During the 12 months preceding the survey1 Significant linear decrease and quadratic change, P < .05


29.024.1 24.1

20.5 19.3 16.9116.919.0

0

20

40

60

80

100

1991 1993 1995 1997 1999 2001 2003 2005

Perc

en

t

Percentage of High School Students Who Seriously Percentage of High School Students Who Seriously Considered Attempting Suicide,* by Sex** and Considered Attempting Suicide,* by Sex** and

Race/Ethnicity,*** 2005Race/Ethnicity,*** 2005

* During the 12 months preceding the survey** F > M*** W, H > B


12.016.9

12.217.916.9 21.8

0

20

40

60

80

100


Per

cen

t

Percentage of High School Students Who Made a Plan Percentage of High School Students Who Made a Plan about How They Would Attempt Suicide,* 1991 – 2005about How They Would Attempt Suicide,* 1991 – 2005

* During the 12 months preceding the survey1 Significant linear decrease, P < .05


18.6 19.0 17.7 15.7 14.5 13.0116.514.8

0

20

40

60

80

100

1991 1993 1995 1997 1999 2001 2003 2005

Perc

en

t

Percentage of High School Students Who Made a Plan about Percentage of High School Students Who Made a Plan about How They Would Attempt Suicide,* by Sex** and How They Would Attempt Suicide,* by Sex** and

Race/Ethnicity,*** 2005Race/Ethnicity,*** 2005

* During the 12 months preceding the survey** F > M*** H > W > B


9.9 12.59.6

14.513.0 16.2

0

20

40

60

80

100


Per

cen

t

Percentage of High School Students Who Actually Percentage of High School Students Who Actually Attempted Suicide,* 1991 – 2005Attempted Suicide,* 1991 – 2005

* One or more times during the 12 months preceding the survey1 No significant change over time


7.3 8.6 8.7 7.7 8.3 8.418.58.8

0

20

40

60

80

100

1991 1993 1995 1997 1999 2001 2003 2005

Perc

en

t

Percentage of High School Students Who Actually Attempted Percentage of High School Students Who Actually Attempted Suicide,* by Sex** and Race/Ethnicity,*** 2005Suicide,* by Sex** and Race/Ethnicity,*** 2005

* One or more times during the 12 months preceding the survey** F > M*** H > W, B


6.0 7.3 7.611.38.4 10.8

0

20

40

60

80

100


Per

cen

t

Percentage of High School Students Whose Suicide Percentage of High School Students Whose Suicide Attempt Resulted in an Injury, Poisoning, or Overdose That Attempt Resulted in an Injury, Poisoning, or Overdose That

Had To Be Treated by a Doctor or Nurse,* 1991 – 2005Had To Be Treated by a Doctor or Nurse,* 1991 – 2005

* During the 12 months preceding the survey1 No significant change over time


1.7 2.7 2.8 2.6 2.6 2.312.92.6

0

20

40

60

80

100

1991 1993 1995 1997 1999 2001 2003 2005

Perc

en

t

What Conclusions May We Draw What Conclusions May We Draw Concerning Adolescent Suicide?Concerning Adolescent Suicide?

Adolescent suicide is a major public health Adolescent suicide is a major public health problem problem

We know a great deal about the risk factors and We know a great deal about the risk factors and underlying causes of adolescent suicide, which underlying causes of adolescent suicide, which can guide prevention efforts can guide prevention efforts

Prevention efforts should focus upon training in Prevention efforts should focus upon training in the warning signs of adolescent suicide and the warning signs of adolescent suicide and strategies to link at-risk kids with professional strategies to link at-risk kids with professional help, to reduce the incidence of suicidal behaviorhelp, to reduce the incidence of suicidal behavior

Risk Factors for Adolescent SuicideRisk Factors for Adolescent Suicide

Psychiatric illness, especially depressionPsychiatric illness, especially depression

Parental or family problemsParental or family problems

Poor coping skillsPoor coping skills

Impaired reasoning capabilitiesImpaired reasoning capabilities

Social / interpersonal isolationSocial / interpersonal isolation

Low self-esteem, hopelessness, helplessnessLow self-esteem, hopelessness, helplessness

Intense psychic painIntense psychic pain

Exposure to model of suicidal behaviorExposure to model of suicidal behavior

Access to lethal meansAccess to lethal means

Risk Factors for Adolescent SuicideRisk Factors for Adolescent SuicidePsychiatric illnessPsychiatric illness– Findings of psychological autopsy studies:Findings of psychological autopsy studies:

– Among suicide completers, 70% used drugs frequently, 50% Among suicide completers, 70% used drugs frequently, 50% have positive blood alcohol findings at time of death, 75% fit have positive blood alcohol findings at time of death, 75% fit criteria for drug/alcohol abuse criteriacriteria for drug/alcohol abuse criteria

Most Common Psychiatric DiagnosesMost Common Psychiatric Diagnoses

MaleMale FemaleFemale

Mood disorder (depression)Mood disorder (depression) 50%50% 69%69%

Antisocial/conduct disorderAntisocial/conduct disorder 43%43% 24%24%

Substance abuseSubstance abuse 38%38% 17%17%

Anxiety disorderAnxiety disorder 19%19% 48%48%


Risk Factors for Adolescent SuicideRisk Factors for Adolescent SuicideParental or family problemsParental or family problems– Family history of suicidal behaviorFamily history of suicidal behavior– Parental mental health disorderParental mental health disorder– Severe conflicts with parentsSevere conflicts with parents– Parental divorceParental divorce

Poor coping skillsPoor coping skills– ImpulsivityImpulsivity– Aggressive/explosive behavior patternAggressive/explosive behavior pattern– Avoidant coping strategiesAvoidant coping strategies– Poor problem-solvingPoor problem-solving

Risk Factors for Adolescent SuicideRisk Factors for Adolescent SuicidePoor reasoningPoor reasoning– Cognitive inflexibility—tunnel vision where the Cognitive inflexibility—tunnel vision where the

“solution” of suicide seems to be the only way out“solution” of suicide seems to be the only way out– Pervasive hopelessnessPervasive hopelessness– Profound pessimismProfound pessimism– Inability to see transient nature of current problemsInability to see transient nature of current problems

Social/interpersonal isolationSocial/interpersonal isolation– Poor or negative network of supportPoor or negative network of support– Lonely, isolated, insecure attachments with othersLonely, isolated, insecure attachments with others

Low self-esteem, hopelessness, helplessnessLow self-esteem, hopelessness, helplessness– Profound sense of shame, inferiorityProfound sense of shame, inferiority

Risk Factors for Adolescent SuicideRisk Factors for Adolescent SuicideIntense psychic painIntense psychic pain– Often triggered by recent stressful events such as Often triggered by recent stressful events such as

interpersonal losses, disciplinary/legal crisis or other interpersonal losses, disciplinary/legal crisis or other painful life changespainful life changes

Exposure to model of suicidal behaviorExposure to model of suicidal behavior– Experts estimate that approximately 5% of youth Experts estimate that approximately 5% of youth

suicides are linked to media coverage of suicidal suicides are linked to media coverage of suicidal behaviorbehavior

– Suicide clusters within schools are a serious public Suicide clusters within schools are a serious public health threat, triggered by a model of suicidal behaviorhealth threat, triggered by a model of suicidal behavior

Access to lethal meansAccess to lethal means– Controlled studies indicate statistical link between Controlled studies indicate statistical link between

incidence of youth suicide and gun ownership in the incidence of youth suicide and gun ownership in the homehome

Risk Factors for Adolescent SuicideRisk Factors for Adolescent SuicideExamples of precipitating stressful events Examples of precipitating stressful events which may heighten suicidal riskwhich may heighten suicidal risk– Loss of social support (friends, family)Loss of social support (friends, family)– Loss of identity—loss of cherished roles, goalsLoss of identity—loss of cherished roles, goals– Acute psychiatric illness (psychosis, depression, Acute psychiatric illness (psychosis, depression,

anxiety, panic attacks)anxiety, panic attacks)– Loss of hopeLoss of hope– Sense of failureSense of failure– Profound disappointmentsProfound disappointments– Embarrassment, humiliationEmbarrassment, humiliation– Threat of legal/disciplinary actionThreat of legal/disciplinary action– Access to lethal meansAccess to lethal means

Protective Factors Which May Protective Factors Which May ReduceReduce Likelihood of Adolescent Suicidal BehaviorLikelihood of Adolescent Suicidal Behavior

Healthy sense of self-esteemHealthy sense of self-esteem

Sense of self-confidence and ability to cope with Sense of self-confidence and ability to cope with stressful situationsstressful situations

Presence of constraints which inhibit suicidal Presence of constraints which inhibit suicidal behaviorbehavior– Internal constraintsInternal constraints: religious beliefs or other values : religious beliefs or other values

which prohibit suicidewhich prohibit suicide– External constraintsExternal constraints: sense of duty to family: sense of duty to family

Good coping strategiesGood coping strategies

Good social support & openness to helpGood social support & openness to help

Depression in AdolescenceDepression in Adolescence

Depression is a significant risk factor for Depression is a significant risk factor for adolescent suicide.adolescent suicide.

In general terms, what is adolescent In general terms, what is adolescent depression?depression?– Adolescent depression is a disorder occurring Adolescent depression is a disorder occurring

during the teenage years marked by persistent during the teenage years marked by persistent sadness, discouragement , loss of self-worth, sadness, discouragement , loss of self-worth, and loss of interest in usual activities.and loss of interest in usual activities.

Signs & Symptoms of Depression in Signs & Symptoms of Depression in AdolescenceAdolescence

Depressed or irritable mood Depressed or irritable mood Irritability, short temper, agitation Irritability, short temper, agitation Loss of interest in activities, Loss of interest in activities, apathy apathy Reduced pleasure in daily Reduced pleasure in daily activities activities Inability to enjoy activities which Inability to enjoy activities which used to be sources of pleasure used to be sources of pleasure Change in appetite, usually a loss Change in appetite, usually a loss of appetite but sometimes an of appetite but sometimes an increase increase Change in weight (unintentional Change in weight (unintentional weight loss or unintentional weight weight loss or unintentional weight gain) gain) Persistent difficulty falling asleep Persistent difficulty falling asleep or staying asleep ( insomnia ) or staying asleep ( insomnia ) Excessive daytime sleepinessExcessive daytime sleepinessFatigueFatigue

Difficulty concentrating Difficulty concentrating Difficulty making decisions Difficulty making decisions Memory loss (amnesia) episodes Memory loss (amnesia) episodes Preoccupation with self Preoccupation with self Feelings of worthlessness, sadness, Feelings of worthlessness, sadness, or self-hatred or self-hatred Excessive or inappropriate feelings Excessive or inappropriate feelings of guilt of guilt Acting-out behavior (missing Acting-out behavior (missing curfews, unusual defiance) curfews, unusual defiance) Thoughts about suicide or obsessive Thoughts about suicide or obsessive fears or worries about death fears or worries about death Plans to commit suicide or actual Plans to commit suicide or actual suicide attempt suicide attempt School refusalSchool refusalExcessively irresponsible behavior Excessively irresponsible behavior patternpattern

Treatment of Depression in AdolescenceTreatment of Depression in Adolescence

Continuum of Treatment InterventionsContinuum of Treatment Interventions

Self-help: increased Outpatient School-based Self-help: increased Outpatient School-based activity level, sleep psychotherapy interventionsactivity level, sleep psychotherapy interventions hygiene, social supporthygiene, social support

Problem-solving; Antidepressant Partial Problem-solving; Antidepressant Partial stress mgmt efforts medication hospitalizationstress mgmt efforts medication hospitalization

Support group Combined Support group Combined Inpatient Inpatient psychotherapy hospitalization psychotherapy hospitalization

& medication& medication

Less IntensiveLess Intensive More More IntensiveIntensive

What Should A Gatekeeper Do When What Should A Gatekeeper Do When Concerned About A Student?Concerned About A Student?

Role of Gatekeeper is Role of Gatekeeper is notnot to function as a to function as a mental health professionalmental health professionalRole of Gatekeeper is to:Role of Gatekeeper is to:– Observe studentsObserve students– Encourage students who are struggling to Encourage students who are struggling to

access helpaccess help– Serve as conduit to professional help, for Serve as conduit to professional help, for

those students observed to be at riskthose students observed to be at risk

Gatekeepers are Gatekeepers are essentialessential in providing a in providing a safety net for distressed kids & safety net for distressed kids & adolescents!adolescents!

What Should A Gatekeeper Do When What Should A Gatekeeper Do When Concerned About A Student?Concerned About A Student?

A Simple Mnemonic To Provide a A Simple Mnemonic To Provide a Safety N.E.T.Safety N.E.T.

NNoticeotice

EEngagengage

TTalkalk

What Should A Gatekeeper Do What Should A Gatekeeper Do When Concerned About A Student?When Concerned About A Student?

NNoticeotice– Know the warning signs of adolescent suicide & symptoms of Know the warning signs of adolescent suicide & symptoms of

depressiondepression– Be observant for signs of distressBe observant for signs of distress– Be prepared to approach students in distress Be prepared to approach students in distress

Do…Do… Try Not To…Try Not To…View yourself as part of a team View yourself as part of a team working to identify warning signs of working to identify warning signs of depression and/or suicidal riskdepression and/or suicidal riskMaintain a Maintain a watchful eyewatchful eye over students over students to promote safety and early interventionto promote safety and early interventionObserve all students for signs of Observe all students for signs of distress or deterioration in functioningdistress or deterioration in functioningPick up on cues suggestive of inner Pick up on cues suggestive of inner turmoil, pain, hopelessnessturmoil, pain, hopelessness

Be reluctant to acknowledge distress Be reluctant to acknowledge distress or behavioral changes among studentsor behavioral changes among studentsAssume that the student will come to Assume that the student will come to someone else’s attentionsomeone else’s attentionBe reluctant to get involvedBe reluctant to get involvedShrug-off signs of distressShrug-off signs of distressKeep morbid drawings/writings or Keep morbid drawings/writings or other warning signs a “secret”other warning signs a “secret”


EEngagengage– Take the initiative to approach students who show Take the initiative to approach students who show

signs of distresssigns of distress– Engage students in a concerned, friendly, supportive Engage students in a concerned, friendly, supportive

mannermanner

Do…Do… Try Not To…Try Not To…Approach the student of concernApproach the student of concernExpress your concern for the student: Express your concern for the student: “Are you okay? Everything alright?”“Are you okay? Everything alright?”Explain basis for your concernExplain basis for your concernDisplay warmth, encouragementDisplay warmth, encouragementExpress your concerns and Express your concerns and observations in matter-of-fact mannerobservations in matter-of-fact manner

Put the student on the defensivePut the student on the defensiveTake on responsibility for counseling Take on responsibility for counseling the student by giving advice or agreeing the student by giving advice or agreeing to hold information in confidenceto hold information in confidenceView referral of the student to the View referral of the student to the school social worker or other school social worker or other appropriate resource as a “betrayal” of appropriate resource as a “betrayal” of the student’s trustthe student’s trust


TTalkalk– The student may need to talk with someone beyond the initial The student may need to talk with someone beyond the initial

gatekeeper— gatekeeper— be prepared to refer the student an in-school be prepared to refer the student an in-school mental health providermental health provider

– Personally linkPersonally link the student with a school social worker, the student with a school social worker, psychologist or other appropriate resourcepsychologist or other appropriate resource

Do…Do… Try Not To…Try Not To…If you notice signs of distress or If you notice signs of distress or emotional pain, persuade the student to emotional pain, persuade the student to accept additional helpaccept additional helpEnsure that the student is personally Ensure that the student is personally introduced to the receiving mental introduced to the receiving mental health professional within the schoolhealth professional within the schoolShare all pertinent information, Share all pertinent information, observations and concerns with the observations and concerns with the receiving mental health professionalreceiving mental health professional

Simply give the student the name of Simply give the student the name of the in-school mental health professional the in-school mental health professional without personally ensuring linkagewithout personally ensuring linkagePredict the interventions which might Predict the interventions which might follow after evaluation by the mental follow after evaluation by the mental health professionalhealth professionalGive the impression to the student Give the impression to the student that he/she is “in trouble” or that further that he/she is “in trouble” or that further referral is punitive in naturereferral is punitive in nature

Gatekeeper Overview:Gatekeeper Overview:Provide a Safety N.E.T. For StudentsProvide a Safety N.E.T. For Students

NNoticeoticeBe aware that you may be the only adult who Be aware that you may be the only adult who

notices warning signs of possible suicide risknotices warning signs of possible suicide risk

Know warning signs of depression and / or suicidal Know warning signs of depression and / or suicidal riskrisk

Keep a watchful eye over all studentsKeep a watchful eye over all students

EEngagengageEngage students of concern—inquire about their Engage students of concern—inquire about their

well-being, express concernwell-being, express concern

After approaching the student, if you observe After approaching the student, if you observe indications of troubles with mood, outlook on life or indications of troubles with mood, outlook on life or other warning signs, persuade the student to meet other warning signs, persuade the student to meet with an in-school mental health professionalwith an in-school mental health professional

TTalkalkPersuade the student to speak further with a Persuade the student to speak further with a

mental health professional.mental health professional.

Ensure that the linkage of the student of concern Ensure that the linkage of the student of concern with an in-school mental health professional occurswith an in-school mental health professional occurs—personally escort the student or introduce the —personally escort the student or introduce the student to the mental health professional.student to the mental health professional.

For The Receiving Mental Health For The Receiving Mental Health Professional: Suicide Risk AssessmentProfessional: Suicide Risk AssessmentApproaches to the assessment of suicide risk: Approaches to the assessment of suicide risk: The TIME suicide assessment interviewThe TIME suicide assessment interview

TThoughtshoughts– Have you ever thought of hurting or killing yourself? If so, when?Have you ever thought of hurting or killing yourself? If so, when?

IIntentntent– Do you have a suicide plan?Do you have a suicide plan?– Do you plan to make an attempt on your life?Do you plan to make an attempt on your life?

MMethodethod– How would you do it? What preparations have you made?How would you do it? What preparations have you made?– Is there a date or time in mind?Is there a date or time in mind?– Have you told anyone about this plan?Have you told anyone about this plan?– Have you written a note? Do you plan to write a note?Have you written a note? Do you plan to write a note?

EExperiencexperience– Have you previously tried to hurt or kill yourself?Have you previously tried to hurt or kill yourself?– When did this occur? What did you do?When did this occur? What did you do?– Did you see a doctor or nurse for any injuries?Did you see a doctor or nurse for any injuries?

For The Receiving Mental Health For The Receiving Mental Health Professional: Suicide Risk AssessmentProfessional: Suicide Risk Assessment

Risk Assessment Mnemonic:Risk Assessment Mnemonic: IS PATH WARM IS PATH WARM ??II Ideation:Ideation: Suicidal threats or preoccupation Suicidal threats or preoccupation

SS Substance Abuse: Substance Abuse: Increased alcohol or drug useIncreased alcohol or drug use

PP Purposelessness:Purposelessness: No reason for living; no sense of purpose in No reason for living; no sense of purpose in lifelife

AA Anxiety:Anxiety: Fear, agitation, sleep disruption Fear, agitation, sleep disruption

TT Trapped:Trapped: A sense that there is no way out A sense that there is no way out

HH Hopelessness:Hopelessness: Losing hope that things will ever get better Losing hope that things will ever get better

WW Withdrawal:Withdrawal: Pulling away from friends, family and society Pulling away from friends, family and society

AA Anger:Anger: Rage, uncontrolled anger, revenge-seeking behavior Rage, uncontrolled anger, revenge-seeking behavior

RR Recklessness:Recklessness: Engaging in risky behaviors Engaging in risky behaviors

MM Mood Change:Mood Change: Dramatic mood changes, especially depression Dramatic mood changes, especially depressionSource:Source: American Association of Suicidology, 2006American Association of Suicidology, 2006

Management of the Student Who Is Management of the Student Who Is At-Risk for Suicidal BehaviorAt-Risk for Suicidal Behavior

Student comes to attention Student comes to attention of gatekeeperof gatekeeper

•NNoticeotice

•EEngagengage

•TTalkalk

Student seen by in-school Student seen by in-school mental health professionalmental health professional

Preliminary suicide risk assessment Preliminary suicide risk assessment conducted:conducted:

TIMETIME or or IS PATH WARM IS PATH WARM ??

Interventions With Students Who Interventions With Students Who Are At-Risk for Suicidal BehaviorAre At-Risk for Suicidal Behavior

Preliminary suicide risk assessment conducted:Preliminary suicide risk assessment conducted:

TIME or IS PATH WARM ?TIME or IS PATH WARM ?

Are there indications of active suicidal ideation, plans or other risk factors?Are there indications of active suicidal ideation, plans or other risk factors?

Evaluation by Evaluation by school social worker school social worker indicates no suicidal indicates no suicidal

warning signs or warning signs or risk factors risk factors

warranting follow-upwarranting follow-up

Evaluation by Evaluation by school social worker school social worker

indicates no clear indicates no clear risk but areas of risk but areas of concern warrant concern warrant

outpatient referraloutpatient referral


indicates no indicates no immanent threat but immanent threat but further rapid eval is further rapid eval is

indicatedindicated


indicates high indicates high degree of risk for degree of risk for immanent suicidal immanent suicidal

behaviorbehavior

•Parents may be Parents may be notified of concerns notified of concerns prompting eval & prompting eval & outcome of evaloutcome of eval

•Student may be Student may be monitoredmonitored

•Parents are notified Parents are notified

•Outpatient referral Outpatient referral recommendedrecommended

•Student monitoredStudent monitored

•Parents are notified Parents are notified of evalof eval

•Referral for school Referral for school fitness eval at fitness eval at Highland Park Hosp Highland Park Hosp or elsewhereor elsewhere

•Parents are notified Parents are notified of evalof eval

•Referral to Referral to emergency room for emergency room for immediate eval is immediate eval is arrangedarranged

No apparent risk Some concerns Moderate risk No apparent risk Some concerns Moderate risk Immanent risk Immanent risk

SourcesSources

American Association of SuicidologyAmerican Association of Suicidology

National Adolescent Health Information CenterNational Adolescent Health Information Center

National Center for Injury Prevention and Control National Center for Injury Prevention and Control / Centers for Disease Control/ Centers for Disease Control

Youth Risk Behavior Surveillance System / Youth Risk Behavior Surveillance System / Centers for Disease ControlCenters for Disease Control

Youth Suicide Prevention School-Based Guide, Youth Suicide Prevention School-Based Guide, Florida Institute of Mental Health / University of Florida Institute of Mental Health / University of South FloridaSouth Florida

School-Based Gatekeeper Training to Prevent Adolescent Suicide

Documents