Suicidality and Self-Injury in Middle School SOS Signs of Suicide ® Program Screening for Mental Health, Inc.

Suicidality and Self-InjurySuicidality and Self-Injuryin Middle Schoolin Middle School

SOS Signs of SuicideSOS Signs of Suicide®® ProgramProgram

Screening for Mental Screening for Mental Health, Inc.Health, Inc.

Screening for Mental Screening for Mental Health, Inc.Health, Inc.

1991: Pioneered the concept of large 1991: Pioneered the concept of large scale mental health screening with scale mental health screening with National Depression Screening Day.National Depression Screening Day.

SMH Programs include:SMH Programs include: SOS Signs of Suicide® High School SOS Signs of Suicide® High School

ProgramProgram National Alcohol Screening Day®National Alcohol Screening Day® CollegeCollegeResponseResponse®®

WorkplaceWorkplaceResponseResponse®®

HealthcareHealthcareResponseResponse®®

The Problem: The Problem: Youth Suicide and Youth Suicide and

Related Risk FactorsRelated Risk Factors

Prevalence of Suicide in Prevalence of Suicide in YouthYouth

While child suicide is very uncommon, While child suicide is very uncommon, mortality from suicide increases mortality from suicide increases steadily through the teens.steadily through the teens.

NIMH, In Harms Way, Suicide in America, NIMH, In Harms Way, Suicide in America, 20032003

Suicide is the Suicide is the sixth leading cause of sixth leading cause of death among 5-14 year oldsdeath among 5-14 year olds and the and the third leading cause of death among third leading cause of death among those 15-24those 15-24. .

American Foundation for Suicide PreventionAmerican Foundation for Suicide Prevention

Prevalence of Suicide in Prevalence of Suicide in YouthYouth

In Mississippi, suicide is the 3In Mississippi, suicide is the 3rdrd leading leading cause of death among youth ages 15-24.cause of death among youth ages 15-24.

52 5056

40

4954

37

5053

0

10

20

30

40

50

60

2000 2002 2004 2006 2008

# of Suicides

Prevalence of Suicide in Prevalence of Suicide in YouthYouth

Suicide also affects youth ages 5-14Suicide also affects youth ages 5-14.

2

3

5

1

3 3

1 1

3

0

1

2

3

4

5

2000 2002 2004 2006 2008

# of Suicides

Prevalence of Suicide in Prevalence of Suicide in YouthYouth

Adolescent suicidal behavior is Adolescent suicidal behavior is deemed deemed underreportedunderreported because because many deaths of this type are classified many deaths of this type are classified as unintentional or accidental.as unintentional or accidental.

World Health Organization, 2000World Health Organization, 2000

Over 90% of children and adolescents Over 90% of children and adolescents that die by suicide have a that die by suicide have a mental mental health disorderhealth disorder at the time of their at the time of their death, most often depression.death, most often depression.

Prevalence of Suicide-Related Prevalence of Suicide-Related Phenomena in Middle School Phenomena in Middle School

Age GroupAge Group Seriously thought about killing themselvesSeriously thought about killing themselves

18% of 618% of 6thth graders graders 19% of 719% of 7thth graders graders 24% of 824% of 8thth graders graders

Made a plan about how to kill themselvesMade a plan about how to kill themselves 11% of 611% of 6thth graders graders 12% of 712% of 7thth graders graders 12% of 812% of 8thth graders graders

Made a suicide attemptMade a suicide attempt 7% of 67% of 6thth graders graders 9% of seventh graders9% of seventh graders 11% of eighth graders11% of eighth graders CDC Middle School CDC Middle School

Youth Risk Behavior Youth Risk Behavior Survey, 2003Survey, 2003

What Are Risk Factors?What Are Risk Factors?• Suicide is a complex behavior that is Suicide is a complex behavior that is

usually caused by a usually caused by a combination of risk combination of risk factorsfactors in the context of negative life in the context of negative life eventsevents

• A A risk factor is anything that risk factor is anything that increases the likelihoodincreases the likelihood that persons that persons will harm themselves. will harm themselves.

• Risk factors are Risk factors are not necessarily causesnot necessarily causes. . • The first step in preventing suicide is The first step in preventing suicide is

to identify and understand the risk to identify and understand the risk factorsfactors. .

-Adapted from the National Youth Violence Prevention

Resource Center

SUICIDE: A MULTI-FACTORIAL EVENT

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

Depression and YouthDepression and Youth In 2004, 9% of adolescents aged 12 to 17 (an In 2004, 9% of adolescents aged 12 to 17 (an

estimated 2.2 million adolescents) experienced at estimated 2.2 million adolescents) experienced at least one major depressive episode in the past yearleast one major depressive episode in the past year

-SAMHSA, 2005-SAMHSA, 2005

In children and adolescents, an untreated In children and adolescents, an untreated depressive episode may last between 7 to 9 months depressive episode may last between 7 to 9 months ((Birmaher et al., 1996a, 1996bBirmaher et al., 1996a, 1996b) ) ——potentially, an potentially, an entire academic year!entire academic year!

Depression has been linked to suicide, poor school Depression has been linked to suicide, poor school performance, substance abuse, running away, and performance, substance abuse, running away, and feelings of worthlessness and hopelessnessfeelings of worthlessness and hopelessness

-National Institute for Mental Health, 2005-National Institute for Mental Health, 2005

Symptoms ofSymptoms ofAdolescent DepressionAdolescent Depression

Frequent sadness, tearfulness, crying Frequent sadness, tearfulness, crying Hopelessness Hopelessness Decreased interest in activities; or Decreased interest in activities; or

inability to enjoy previously favorite inability to enjoy previously favorite activities activities

Persistent boredom; low energy Persistent boredom; low energy Social isolation, poor communication Social isolation, poor communication Low self esteem and guilt Low self esteem and guilt Extreme sensitivity to rejection or Extreme sensitivity to rejection or

failure failure

Symptoms ofSymptoms ofAdolescent Depression Adolescent Depression

(cont.)(cont.) Increased irritability, anger, or hostility Increased irritability, anger, or hostility Difficulty with relationships Difficulty with relationships Frequent complaints of physical illnesses Frequent complaints of physical illnesses

such as headaches and stomachaches such as headaches and stomachaches Frequent absences from school or poor Frequent absences from school or poor

performance in school performance in school Poor concentration Poor concentration A major change in eating and/or sleeping A major change in eating and/or sleeping

patterns patterns Talk of or efforts to run away from home Talk of or efforts to run away from home Thoughts or expressions of suicide or self Thoughts or expressions of suicide or self

destructive behavior destructive behavior --AACAP, The Depressed ChildAACAP, The Depressed Child

Signs of SuicideSigns of Suicide Talking, reading, or writing about suicide or Talking, reading, or writing about suicide or

death (including online communication)death (including online communication) Talking about feeling worthless or hopelessTalking about feeling worthless or hopeless Direct verbal cues like “I wish I were dead.”Direct verbal cues like “I wish I were dead.” Indirect verbal cues like “You will be better off Indirect verbal cues like “You will be better off

without me.”without me.” Visiting or calling people to say goodbye.Visiting or calling people to say goodbye. Giving things away.Giving things away. A sudden interest in drinking alcohol.A sudden interest in drinking alcohol. Purposefully putting oneself in danger.Purposefully putting oneself in danger. Obsessed with death, violence, and guns or Obsessed with death, violence, and guns or

knives.knives. Previous suicidal thoughts or attempts.Previous suicidal thoughts or attempts.

-http://pbskids.org/itsmylife * list is -http://pbskids.org/itsmylife * list is not all inclusivenot all inclusive

Suicidality and Suicidality and Substance AbuseSubstance Abuse

Youths aged 12-17 who reported past Youths aged 12-17 who reported past year alcohol use (19.6%) were more year alcohol use (19.6%) were more likely than youths who did not use likely than youths who did not use alcohol (8.6%) to be at risk for suicide.alcohol (8.6%) to be at risk for suicide.

SAMHSA, NHSDA Report, Substance use and the SAMHSA, NHSDA Report, Substance use and the Risk of Suicide Among Youths, 2002Risk of Suicide Among Youths, 2002

1/3 to ½ of teenagers were under the 1/3 to ½ of teenagers were under the influence of drugs or alcohol shortly influence of drugs or alcohol shortly before they killed themselves.before they killed themselves.

National Strategy for Suicide Prevention, DHHSNational Strategy for Suicide Prevention, DHHS

Self-injury in YouthSelf-injury in Youth In the pediatric population, self-injury is In the pediatric population, self-injury is

defined as deliberate non-lethal harming defined as deliberate non-lethal harming of oneself of oneself

Self-injury is a maladaptive coping skill Self-injury is a maladaptive coping skill employed by youth experiencing painful employed by youth experiencing painful emotionsemotions

Is generally Is generally NOTNOT an attempt to die by an attempt to die by suicide.suicide.

Between 150,000 and 360,000 Between 150,000 and 360,000 adolescents in the U.S. self-injureadolescents in the U.S. self-injure

Walsh, Lieberman, 2004.Walsh, Lieberman, 2004.

Self-injury Comes in Self-injury Comes in Several FormsSeveral Forms

Behaviors include:Behaviors include: Cutting – the most common formCutting – the most common form BurningBurning HittingHitting PokingPoking PickingPicking Hair pullingHair pulling Putting oneself in harms wayPutting oneself in harms way Head bangingHead banging

Relationship Between Relationship Between SuicideSuicide

and Self-injuryand Self-injury Death can occur, even if Death can occur, even if

unintentionallyunintentionally Those who self-injure may become Those who self-injure may become

suicidal in the future.suicidal in the future. The student is experiencing a mental The student is experiencing a mental

health disorder that should be treated health disorder that should be treated professionally and stands the best professionally and stands the best chance of recovery if caught early.chance of recovery if caught early.

If handled inappropriately or not at If handled inappropriately or not at all, there is a potential for contagion.all, there is a potential for contagion.

Why Focus on Youth Why Focus on Youth PreventionPrevention

Many adult mental disorders have related Many adult mental disorders have related antecedent problems in childhood antecedent problems in childhood

Children who first become depressed before Children who first become depressed before puberty are at risk for some form of mental puberty are at risk for some form of mental disorder in adulthooddisorder in adulthood

Suicide rates increase dramatically from early Suicide rates increase dramatically from early adolescence to young adulthood adolescence to young adulthood

A previous suicide attempt is the leading risk A previous suicide attempt is the leading risk factor for adult suicidefactor for adult suicide

Introducing prevention early may help promote Introducing prevention early may help promote prevention throughout the lifecycleprevention throughout the lifecycle

NIMH, 2005NIMH, 2005

Developmental Stages ofDevelopmental Stages ofYounger ChildrenYounger Children

Early adolescence is a time of emotional Early adolescence is a time of emotional transition when individuals transfer their transition when individuals transfer their sense of interpersonal closeness from parents sense of interpersonal closeness from parents to peers.to peers.

Rothbaum et. al., Child Development, 2000Rothbaum et. al., Child Development, 2000 Due to this transition, addressing the peer Due to this transition, addressing the peer

group is developmentally appropriate for group is developmentally appropriate for those youth who have begun to confide in those youth who have begun to confide in friends.friends.

Since younger students are more apt to share Since younger students are more apt to share concerns with adults it is also important to concerns with adults it is also important to encourage help-seeking from adults.encourage help-seeking from adults.

In other words, you have to address both In other words, you have to address both the role of peers and the role of adults.the role of peers and the role of adults.

Integrated Prevention Integrated Prevention StrategiesStrategies

Integrated prevention strategies that Integrated prevention strategies that address multiple associated factors are address multiple associated factors are likely to be more effective in reducing likely to be more effective in reducing suicidal behavior that programs that focus suicidal behavior that programs that focus on a single risk factor.on a single risk factor.

Grunbaum et al., Surveillance Summaries, 2004Grunbaum et al., Surveillance Summaries, 2004

Risk factors for youth include:Risk factors for youth include: DepressionDepression Conduct disorderConduct disorder Suicidal ideationSuicidal ideation Alcohol useAlcohol use Self-injurySelf-injury

Protective FactorsProtective Factors

Protective FactorsProtective Factors

Afford protection against suicidal Afford protection against suicidal behavior:behavior: Good relationship with familyGood relationship with family Support from family and friendsSupport from family and friends Good social skillsGood social skills Seeks help and adviceSeeks help and advice Participation in positive social activitiesParticipation in positive social activities

The SOS Middle School The SOS Middle School ProgramProgram

Goals of the ProgramGoals of the Program

Decrease the incidence of self-injury, Decrease the incidence of self-injury, suicide attempts, unrecognized depression, suicide attempts, unrecognized depression, and the number of youth who die by suicideand the number of youth who die by suicide

Encourage individual help seeking, as well Encourage individual help seeking, as well as help seeking on behalf of a friendas help seeking on behalf of a friend

Increase knowledge and adaptive attitudes Increase knowledge and adaptive attitudes about depression, suicidality, and self-injuryabout depression, suicidality, and self-injury

Reduce stigma associated with mental Reduce stigma associated with mental health problems by communicating that health problems by communicating that these problems are treatablethese problems are treatable

SOS Middle School SOS Middle School Program ComponentsProgram Components

Video/DVD – Video/DVD – ““SOS: Get Into the ACTSOS: Get Into the ACT”” with with Discussion GuideDiscussion Guide

PostersPosters Stickers -- “Stickers -- “ACTACT”” Parent newsletterParent newsletter Student newsletterStudent newsletter Classroom GamesClassroom Games Self-injury packetSelf-injury packet Procedure ManualProcedure Manual Screening Forms for staff useScreening Forms for staff use

SOS Middle School SOS Middle School Video/DVDVideo/DVD

With Discussion GuideWith Discussion Guide The The SOS: Get Into The ActSOS: Get Into The Act video is the main video is the main

teaching tool of the middle school program.teaching tool of the middle school program. Help students recognize the signs of suicide, Help students recognize the signs of suicide,

depression and self-injury in a friend or depression and self-injury in a friend or within themselves and respond to them as within themselves and respond to them as they would in any type of health emergency.they would in any type of health emergency.

Aim is to create a supportive and responsive Aim is to create a supportive and responsive atmosphere for those youth who may be at-atmosphere for those youth who may be at-risk for depression, suicide, or self-injury by risk for depression, suicide, or self-injury by empowering them to know how to recognize empowering them to know how to recognize the warning signs and seek help.the warning signs and seek help.

Action Message -- Action Message -- ACTACT

AAcknowledge: Acknowledge that cknowledge: Acknowledge that your friend has a problem and it is your friend has a problem and it is seriousserious

CCare: Let the person know you are are: Let the person know you are concerned and want to helpconcerned and want to help

TTell: Tell a trusted adultell: Tell a trusted adult

The The ACTACT Message Message

The message is primarily directed to The message is primarily directed to peers to encourage them to help a friend peers to encourage them to help a friend but it emphasizes the need to tell a but it emphasizes the need to tell a trusted adulttrusted adult

ACTACT can be generalized to use with any can be generalized to use with any social problemsocial problem

Staff Training Staff Training SuggestionsSuggestions

Show the Show the ““Get Into the ACT”Get Into the ACT” video and video and facilitate a discussionfacilitate a discussion

Review the signs of suicide and depression.Review the signs of suicide and depression. Answer questions, dispel mythsAnswer questions, dispel myths Review the school policy for handling Review the school policy for handling

students who disclose suicidal intentstudents who disclose suicidal intent Review school and community resources.Review school and community resources. Distribute protocol for what to do when Distribute protocol for what to do when

approached by students asking for helpapproached by students asking for help ““Feed them and they will come.”Feed them and they will come.”

Staff TrainingStaff Training Training faculty and staff is universally Training faculty and staff is universally

advocated and essential to a suicide advocated and essential to a suicide prevention program.prevention program.

Research indicates that training faculty Research indicates that training faculty and staff can produce positive effects on and staff can produce positive effects on an educator’s knowledge, attitudes and an educator’s knowledge, attitudes and referral practice.referral practice.

Smith, T & Smith V., Lazear, K, Roggenbaum, S., & Doan, Smith, T & Smith V., Lazear, K, Roggenbaum, S., & Doan, J., 2003.J., 2003.

Staff MaterialsStaff Materials

Staff in-service lectureStaff in-service lecture Guidelines for teachers and school Guidelines for teachers and school

clinicians for responding to youth who clinicians for responding to youth who self-injure (Self-injury Packet)self-injure (Self-injury Packet)

Parent Newsletter for staff who are Parent Newsletter for staff who are parentsparents

Center for Epidemiological Studies Center for Epidemiological Studies Depression Scale for Children (CES-DC) Depression Scale for Children (CES-DC) for school staff to use with individual for school staff to use with individual students seeking helpstudents seeking help

Staff Training (cont.)Staff Training (cont.)

Schools must prepare staff as students Schools must prepare staff as students may disclose to any adult.may disclose to any adult.

Train to increase school staff’s Train to increase school staff’s knowledge about:knowledge about: SOS program: why, when, where, howSOS program: why, when, where, how Warning signsWarning signs School and community based mental health School and community based mental health

resourcesresources School protocol for providing help for at-School protocol for providing help for at-

risk youthrisk youth

Common ObjectionsCommon Objections

““Suicide is not a problem in our school.”Suicide is not a problem in our school.” ““Schools are not appropriate for suicide Schools are not appropriate for suicide

prevention programs.”prevention programs.” ““The program may introduce the idea to The program may introduce the idea to

students.”students.” ““I don’t have enough staff or time.”I don’t have enough staff or time.” ““We have problems making referrals.”We have problems making referrals.” ““I don’t agree with labeling youth.”I don’t agree with labeling youth.” ““We already have a suicide prevention We already have a suicide prevention

program.”program.”

Responses to Common Responses to Common ObjectionsObjections

No school is immune to adolescent suicide.No school is immune to adolescent suicide. Depression has been linked to poor school performance, substance Depression has been linked to poor school performance, substance

abuse, running away, and feelings of worthlessness and abuse, running away, and feelings of worthlessness and hopelessness. hopelessness.

Integrating the topics of depression and suicide in a health Integrating the topics of depression and suicide in a health curriculum can reduce stigma associated with these problems and curriculum can reduce stigma associated with these problems and can create a supportive atmosphere.can create a supportive atmosphere.

The program can be used flexibly using existing resources and The program can be used flexibly using existing resources and partnering with community providers.partnering with community providers.

Identifying needs can justify funding and/or partnerships. Share Identifying needs can justify funding and/or partnerships. Share resources within school districts. Establish relationship with resources within school districts. Establish relationship with existing providers.existing providers.

Implementing the SOS program does not result in diagnosis. Implementing the SOS program does not result in diagnosis. Decisions about diagnosis and treatment are made between a doctor Decisions about diagnosis and treatment are made between a doctor and a patient, and, in the case of minors, the parent/guardian(s). and a patient, and, in the case of minors, the parent/guardian(s).

Student MaterialsStudent Materials

Student newsletterStudent newsletter

ACT ACT stickers promote peer-to-peer stickers promote peer-to-peer communication by making the communication by making the ACT ACT message popular, personal and message popular, personal and powerful.powerful.

ACTACT posters to reinforce the posters to reinforce the ACTACT messagemessage

Interactive Classroom Interactive Classroom GamesGames

Classroom games serve as a way of Classroom games serve as a way of increasing both knowledge and skills in increasing both knowledge and skills in studentsstudents

Games that have learning complexity and Games that have learning complexity and are successfully infused into the are successfully infused into the curriculum are an effective strategy to curriculum are an effective strategy to move the knowledge and skills students move the knowledge and skills students receive into long-term memory and result receive into long-term memory and result in positive behaviorsin positive behaviors

Parent MaterialsParent Materials Parent materials are provided to actively Parent materials are provided to actively

engage parents in a school’s prevention efforts, engage parents in a school’s prevention efforts, to:to: Gain their supportGain their support Provide information about mental health resources Provide information about mental health resources

available in the school and communityavailable in the school and community Encourage parents to discuss the problems of Encourage parents to discuss the problems of

depression, suicide, and self-injury with their depression, suicide, and self-injury with their children.children.

By raising awareness, schools can partner with By raising awareness, schools can partner with parents to watch for the signs of problems in parents to watch for the signs of problems in their children and instill confidence in parents their children and instill confidence in parents to seek help for their children if necessary.to seek help for their children if necessary.

Implementation Implementation OverviewOverview

School personnel implement the School personnel implement the program with materials provided program with materials provided

Can be implemented in one or two Can be implemented in one or two classroom periodsclassroom periods Students view and discuss video in Students view and discuss video in

classroom.classroom. Students are assigned Student Students are assigned Student

Newsletter to readNewsletter to read Students participate in classroom gameStudents participate in classroom game

Implementation Implementation Overview (cont.)Overview (cont.)

Entire student body or a select portion of Entire student body or a select portion of student body may participate in the student body may participate in the program.program.

Parent newsletter assists in the Parent newsletter assists in the identification of depression, self-injury, and identification of depression, self-injury, and suicidality and helps initiate family suicidality and helps initiate family discussiondiscussion

Active or passive parental permissionActive or passive parental permission Parent NightParent Night Staff TrainingStaff Training

Information You Need Information You Need to Know Prior to to Know Prior to

TrainingTraining

Info To KnowInfo To Know

School policies and procedures School policies and procedures associated with youth who may associated with youth who may display suicidal behaviorsdisplay suicidal behaviors

Community resourcesCommunity resources

National Suicide Prevention National Suicide Prevention LifelineLifeline

Talk About ItTalk About It

AnComm's Talk About ItAnComm's Talk About It service allows individuals service allows individuals to communicate to communicate anonymouslyanonymously with the MS with the MS Department of Mental Health Helpline Staff from this Department of Mental Health Helpline Staff from this website or from your cell phone via Text Messaging website or from your cell phone via Text Messaging

For more information about the SOS For more information about the SOS Middle School or the SOS High School Middle School or the SOS High School

program, please reach us at:program, please reach us at:

[email protected]

Or visit:Or visit:www.MentalHealthScreening.org/schoolswww.MentalHealthScreening.org/schools

Screening for Mental Health, Inc.One Washington Street, Suite 304 Wellesley Hills, MA 02481

Phone: 781.239.0071 Fax: 781.431.7447www.mentalhealthscreening.org