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1 RecommendationsforSuicidePreventionandRelatedRiskBehaviors by MaryMargaretKerr ProfessorofChildPsychiatry,PsychologyinEducation,andAdministrativeandPolicy Studies FoundingCoDirector,ServicesforTeensatRiskforSuicide(STARCenter) UniversityofPittsburgh [email protected] www.sbbh.pitt.edu www.starcenter.pitt.edu www.projectreassure.pitt.edu 1
2 TableofContents Introduction..................................................................................................................................3 HowTheseGuidelinesAreOrganized.....................................................................................3 KeyTerms.....................................................................................................................................4 BackgroundInformationonYouthSuicide.............................................................................4 1.PoliciesandProcedures..........................................................................................................9 2.DataCollection........................................................................................................................9 3.ProfessionalDevelopment...................................................................................................10 NeedsAssessment..................................................................................................................10 FocusofProfessionalDevelopment.....................................................................................10 4.MentalHealthPromotion/SuicidePreventionEfforts.....................................................11 HealthCurriculumandClassroomInstruction.................................................................14 Libraries...................................................................................................................................14 SchoolbasedSupportServices.............................................................................................14 DrugandAlcoholServices....................................................................................................15 ParentEducation.....................................................................................................................15 ActionstoAvoid.....................................................................................................................16 5.InteragencyandCommunityCollaboration......................................................................16 InteragencyCouncil...............................................................................................................16 EmergencyDepartmentMeansRestrictionProtocol........................................................17 SubstanceAbuseintheCommunity....................................................................................17 6.PublicAwareness...................................................................................................................18 YellowRibbonProgram........................................................................................................18 OtherGatekeeperPrograms.................................................................................................19 7.Postvention.............................................................................................................................19 2
3 1 Introduction 2 3 AccordingtotheColoradoDepartmentofPublicHealthandEnvironment,suicideisthe 4 secondleadingcauseofdeathforyouth(ages1024)inColorado. 5 6 Considerthesefindingsfromthe2011YouthRiskBehaviorSurveyResults(YRBS):Colorado 7 HighSchoolSurvey: 8 Percentageofstudentswhofeltsosadorhopelessalmosteverydayfortwoweeksor 9 moreinarowthattheystoppeddoingsomeusualactivitiesduringthepast12months: 10 21.9 11 12 Percentageofstudentswhoseriouslyconsideredattemptingsuicideduringthepast12 13 months:14.8 14 15 Percentageofstudentswhomadeaplanabouthowtheywouldattemptsuicideduring 16 thepast12months:11.4 17 18 Percentageofstudentswhoactuallyattemptedsuicideoneormoretimesduringthe 19 past12months:6.1 20 21 Percentageofstudentswhomadeasuicideattemptduringthepast12monthsthat 22 resultedinaninjury,poisoning,oroverdosethathadtobetreatedbyadoctorornurse 23 2.2(Source:http://www.chd.dphe.state.co.us/topics.aspx?q=Adolescent_Health_Data) 24 25 HowTheseGuidelinesAreOrganized 26 27 Currentresearchhighlightssevencriticalelementsinasuccessfulschoolbasedsuicideandrisk 28 preventionmodel.Thesecomponentsinclude: 29 1. Boardpolicyandimplementingprocedures 30 2. Datacollection 31 3. Staffdevelopment 32 4. Mentalhealthpromotion/suicidepreventionforstudents 33 5. Interagencycollaborationforprevention/intervention 34 6. Publicawareness 35 7. Postvention 36 37 Accordingly,thisreportisorganizedbythesecomponents.Withineachsection,weofferour 38 impressions,recommendations,andresources(whereappropriate).Recommendationsare 39 underlined.Theentirereportislinenumberedtofacilitatediscussion. 40 3
4 41 KeyTerms1 42 Becausethisreportdiscusseshighlyspecializedtopicsandnecessarilyrequirestheuseof 43 specificterms,wereviewthesetermsforthereaderhere. 44 45 SuicidethreatAsuicidethreatisaverbalornonverbalcommunicationthattheindividual 46 intendstoharmhim/herselfwiththeintentiontodiebuthasnotactedonthebehavior. 47 48 Suicidalact(alsoreferredtoassuicideattempt)apotentiallyselfinjuriousbehaviorfor 49 whichthereisevidencethatthepersonprobablyintendedtokillhimselforherself;asuicidal 50 actmayresultindeath,injuries,ornoinjuries. 51 52 Suspectedsuicide(alsoreferredtoassuicidecompletionordeathbysuicide)deathfrom 53 injury,poisoning,orsuffocationwherethereisinitialindicationorevidencethataselfinflicted 54 actmayhaveledtothepersonsdeath.Note:Onlyacoronerormedicalexaminercanconfirm 55 thatadeathwascausedbysuicide.2 56 57 BackgroundInformationonYouthSuicide 58 59 Toaidthereaderinunderstandingthecontextfortherecommendationsthatfollow,thissection 60 firstoffersabriefreviewofresearchonyouthsuicide,includingriskfactorsthatcontributeto 61 suicidalbehavior.3 62 63 Suicideisthethirdleadingcauseofdeathforyoungpeopleaged10to14and15to19 64 years,killing1,600teenagerseachyearintheUnitedStates.Therapidincreaseofsuicide 65 deathsfromthe1950stothemid1980sledtoanationalclarioncallformoreeffective 66 prevention.Thereafter,thegeneralrateofyouthsuicidedeclineddramatically. 67 Nevertheless,5%to8%ofteenagersattemptsuicide,andoneinfiveteenagersseriously 68 considerssuicideeachyear(Gould,2003).4Inthissection,weprovideageneral 1Becausesuchtermscanbehurtfultolovedonesandalsoimplythattheindividualwasmakinga rationaldecision,werecommendthatthefollowingtermsnotbeusedinpoliciesandother communications: Theindividualcommittedsuicide,killedhim/herself,tookhis/herownlife.Seealso:SuicidePrevention ResourceCenter.(2004).Afterasuicide:Recommendationsforreligiousservicesandotherpublicmemorial observances.Newton,MA:EducationDevelopmentCenter,Inc. 2DefinitionsfromNationalStrategyforSuicidePrevention:GoalsandObjectivesforAction.Rockville,MD: U.S.DepartmentofHealthandHumanServices,PublicHealthService,2001. 3ThissectionisexcerptedfromKerr,M.M.(2009).Schoolcrisispreventionandintervention.UpperSaddle River,NJ,PearsonEducation,Inc.andisbasedinpartonKerr,M.M.(2009),Kerr,M.M.&Traupman,E. (2003).Youthsuicideprevention:Risks,implications,andstrategies.PublicationSeries.Harrisburg,PA:PA CASSPTrainingandTechnicalAssistanceInstitute. 4Gould,M.S.,Jamieson,P.&Romer,D.(2003).Mediacontagionandsuicideamongtheyoung.American BehavioralScientist,46(9),12691284 4
5 69 understandingoftheriskfactorsforyouthsuicidecompletionandattempts,andwe 70 highlighttheimplicationsoftheseriskfactorsforpreventionefforts. 71 72 Age 73 Theratesofcompletedyouthsuicidesarelow(1.5per100,000among10to14yearolds 74 and8.2per100,000among15to19yearolds).However,theYouthRiskBehavior 75 Surveyreportedthat19%ofhighschoolersseriouslyconsideredasuicideattempt 76 duringthepastyear;15%madeaspecificsuicideplan,8.8%reportedasuicideattempt, 77 and2.6%madeanattemptthatrequiredmedicaltreatment(Grunbaumetal.,2002)5. 78 Completedsuicideisrareinchildrenundertheageof10becausechildreninthisage 79 grouplacktheaccessto,orinformationabout,lethalmethods.Accordingly,most 80 preventionstrategiesfocusonadolescents. 81 82 Gender,Race,andSexualOrientation 83 Femalesexperiencesuicidalideation(thoughtsaboutsuicide)andmakemoresuicide 84 attemptsthanmales,althoughcompletedsuicideismorecommonamongmales 85 (Grunbaumetal.,2002).IntheUnitedStates,youthsuicidesaremorecommonamong 86 whitesthanAfricanAmericans,highestamongNativeAmericans,andlowestamong 87 Asian/PacificIslanders(Anderson,2002)6.Areviewofresearchonsexualorientation 88 andyouthsuicidefoundhigherratesofattemptedsuicideamonghomosexualyouths 89 comparedtotheirheterosexualcounterparts(Remafedi,1999)7.Studiesthataremore 90 recenthaveidentifiedatwotosixfoldincreasedriskofnonlethalsuicidalbehavior 91 forhomosexualandbisexualyouths(Gould,Greenberg,Velting,&Shaffer,2003,p. 92 390)8. 93 94 Method 95 Firearms,theleadingcauseofsuicidecompletionintheUnitedStates,accountfor 96 almost60%ofallsuicidesinbothmalesandfemales.Forthoseaged15to19,suicideby 97 firearmsaccountedfor63%oftheincreaseintheoverallratefrom1980to1996(U.S. 98 PublicHealthService,1999)9.Othermethodsincludehangingandoverdose.Some 5Grunbaum,J.A.,Kann,L.,Kinchen,S.A.,etal.(2002).YouthriskbehaviorsurveillanceUnitedStates, 2001.MMWRCDCSurveillanceSummary51(SS4),164. 6Anderson,T.(2002)Commentary:Owlpelletsandcrisismanagement.Legacy:TheJournalofthe NationalAssociationforInterpretation,vol.13,number2,pp.2224. 7Remafedi,G.(1999)Sexualorientationandyouthsuicide.JournaloftheAmericanMedicalAssociation, 282(13):1291. 8Gould,M.,Greenberg,T.,Velting,D.M.,andShaffer,D.(2003).Youthsuicideriskandpreventive interventions:Areviewofthepast10years.AmericanAcademyofChild&AdolescentPsychiatry, 42(4),April. 9U.S.DepartmentofHealthandHumanServices,HealthResourcesandServicesAdministration, MaternalandChildHealthBureau.ChildHealthUSA2005.Rockville,Maryland:U.S.Departmentof HealthandHumanServices,2005. 5
6 99 preventionapproacheshaveastheirgoalthereductionofaccesstolethalmeanssuchas 100 firearms. 101 102 103 RiskFactorsandPrecipitants10AssociatedWithYouthSuicide 104 105 MentalIllness 106 Withoutadoubt,mentalillnessisthemostsignificantriskfactorforsuicidalbehavior. 107 Psychiatricdiagnoses,oftenincombination,arepresentinabout90%ofteensuicide 108 completions.Thisdramaticlinkbetweenmentalillnessandsuicidalbehaviorexplains 109 whymanypreventionapproacheshavescreeningasapartoftheirprogram.For 110 example,theColumbiaTeenScreenProgramusesamultistagescreeningprogramthat(1) 111 teachesteensaboutdepressionandtreatment,toencouragethemtoidentifyandrefer 112 themselves,and(2)systematicallyscreenseachteenforanxiety,depression,substance 113 abuse,andsuicidality.TheSOS:SignsofSuicideProgramcombinesacurriculumforhigh 114 schoolstudentswithabriefscreening.Helpseekingisagoalofbothprograms. 115 Teenswhodoaccesspsychiatrictreatmentusuallyfinditeffective.Acombinationof 116 psychotherapy(e.g.,cognitivebehaviortherapy)andmedicationtreatmentoftenworks 117 best.Sadly,however,inthemonthbeforesuicidalbehavior,manyyoungpeopleseek 118 somemedicalcare,buttheirneedforpsychiatrictreatmentgoesunrecognizedbytheir 119 primarycareproviders. 120 121 Depression.Depression,withitsaccompanyinghopelessness,anxiety,andcognitive 122 distortions,isamajorriskfactorforsuicideandsuicideattempts.Considerthisexample: 123 124 Ateenagerhasexperiencedrepeatedepisodesofdepressionandfeelshopeless,despite 125 somesessionswithaschoolcounselor.Afterencounteringaformerromanticpartneron 126 thestreet,shebreaksdownandisolatesherselffordays.Ultimately,sheconcludesthat 127 shehasnothingtolivefor,andwouldbebetteroffdead.Shethenoverdoses. 128 129 AnxietyDisorders.Coexistingwithamooddisorder,theseconditionscaninterferewith 130 apersonstreatmentandrecovery.Ifnotidentifiedandtreated,thesedisorderscan 131 increasetheriskforsuicidalthoughtsand/orbehaviorsindepressedindividuals. 132 Considerthisillustration: 133 134 Agiftedteenagerexperiencedanxietyforseveralyears.Despitehelpfromhisfamilyand 135 schoolcounselors,hecontinuedtobeselfcriticalandoverlyconcernedabouthis 136 performanceandothersapprovalofhim.Whenhewascaughtparkinghiscaronschool Riskfactorsareconditionsthatincreasetheriskofagivendisorder,illness,orinthiscasesuicidal 10 behaviororsuicide.Thoughtheyarenotconsideredtocausesuicidalbehavior,precipitantsareevents thathavebeenshowntooccurwithsomefrequencypriortosuicideattemptsordeaths. 6
7 137 campuswithoutastudentpermit,hefacedasuspension.Panicked,hedrovethecartoa 138 bridgeandjumped. 139 140 Asillustratedinthiscase,asignificantnumberofsuicidecompletersfacedapending 141 disciplinarycrisis.Disciplineshouldoccurassoonaspossibleaftermisbehaviorto 142 decreasethefeelingsofanticipatoryanxiety.Ifthestudentintroubleishighlyanxious, 143 schoolorlawenforcementofficialsshouldtakestepstoreduceanxietyandget 144 immediateassistance. 145 SubstanceAbuse 146 Anincreasedprevalenceofdrugsoralcoholisafactoraccountingforwhyolder 147 adolescentsaremorelikelytoattemptandcompletesuicidecomparedwithyounger 148 adolescents.Someadolescentsusedrugsandalcoholtocopewithdepressivefeelings. 149 Alcoholactsasadisinhibitortosuicidalbehavior.Adolescentswhoaredepressedand 150 usealcoholaremorethanfivetimesmorelikelytouseafirearm.Considerthis 151 illustration: 152 153 Diagnosedatage8withconductdisorderandattentiondeficit/hyperactivitydisorder, 154 this16yearoldstruggledacademically.Hecompensatedforhispooracademicstatusby 155 beingtheclassclownandtakingriskstogaintheattentionofhisfriends.Onenightata 156 friendshouse,hedrankwiththeotherkidsandthenplayedafatalgameofRussian 157 roulette. 158 Becausesuicidalindividualsareoftenimpulsive,restrictingaccessduringcriticaltimes 159 mayreducesuicides.Inaddition,evenifmeanssubstitutiondoesoccur,thechanceof 160 survivalmaybegreaterwithlesslethalmethods.Educatingparentsofhighriskyouth 161 aboutinjurypreventionmayalsoaidinreducingaccesstolethalmeans.Weexamine 162 nextfamilycharacteristicsthatplacestudentsatriskforsuicide. 163 164 FamilyMentalIllness 165 Afamilyhistoryofsuicidalitysignificantlyincreasesthelikelihoodthatateenagerwill 166 takehisownlife(Gouldetal.,2003).Childrenofdepressedparentsappeartobeat 167 substantiallyincreasedriskforcompletedsuicide,asdochildrenofparentswith 168 substanceabuseproblems(Brentetal.,1993)11. 169 170 Consider,forexample,howaparentsownstrugglesmighthinderattemptstohelpher 171 child.Adepressedparentmightbeoverwhelmedbysuggestionsofferedby 172 professionals,feelanxiousandguilty,lackconfidenceinparenting,havetroublesetting 173 limitsforateensuseofalcoholorotherdrugs,orlacktheenergytofollowthrough 174 withtreatmentsuggestions.Outreachtoparentsstrugglingwiththeirownmental Brent,D.A.,Perper,J.A.,Moritz,G.,Allman,C.,Roth,C.,Schweers,J.,Balach,L.,&Baugher,M.(1993). 11 Psychiatricriskforsuicide:Acasecontrolstudy.JournaloftheAmericanAcademyofChildand AdolescentPsychiatry,32,521529. 7
8 175 healthchallenges,includingdepressionandsubstanceabuse,isanimportantelementof 176 thepreventionofyouthsuicide. 177 178 FamilyDiscord 179 Childsexualorphysicalabuseisasignificantriskfactorforyouthsuicide.Onestudy 180 revealedthatdiscordant,hostilefamilyinteractionspredisposed[youth]tosuicidal 181 thoughts(Kosky,Silburn,&Zubrick,1986,p.527).12Gould,Fisher,Parides,Flory,and 182 Shaffer(1996)13reportedthatsuicidevictimshadlessfrequentandlesssatisfying 183 communicationswiththeirparents.Thesefindingssupporttheneedtoincorporatethe 184 familyintreatmenteffortsforayoungpersonwhoisatriskforsuicide. 185 186 ExposuretotheSuicidalityofOthers 187 Researchsupportsacontagionfactorassociatedwithsuicidalbehaviorinadolescents. 188 ExposuretoTVprogramsandnewsstoriesonsuicidemaypromptsuicidalbehaviorin 189 vulnerableadolescents.Preventioninvolveseducatingreporters,editors,andproducers 190 aboutcontagiontominimizeharmandemphasizethemediaspositiveroleineducating 191 andshapingattitudesaboutsuicide. 192 193 Exposuretoaclassmatessuicideattemptmaypromptsuicidalbehaviorinother 194 students.Youngpeoplemostvulnerabletocontagionimmediatelyfollowingasuicide 195 generallyarecharacterizedasmoreisolated,notclosetothesuicidevictims,and 196 exhibitingtheriskfactorsidentifiedearlier. 197 198 BehavioralIndicators 199 Suicidalteensmaybeginwritingortalkingaboutdeathandsuicide.Cluesmayalso 200 appearinartandmusicprojects,diaries,orjournals.Occasionally,suicidalteensbegin 201 givingawayprizedpossessions,writingwillsorsuicidenotesorsayinggoodbyein 202 anuntimelyway.Youthconsideringsuicidealsomay: 203 204 Beginlisteningtomusicaboutdeathorsuicide. 205 Complaintheyarefeelinghopelessortrappedinabadsituation. 206 Becomemoreaggressive,ortextingorwritingaboutwantingtohurtothers. 207 Visitingorcreatingwebsites/profilesglorifyingsuicideanddeath. 208 Beginusingorincreasetheiruseofdrugsoralcohol. 209 Suddenlybecomecheerfulfornoapparentreasonafteraperiodofdepression. 210 Havejusthadabadfightwiththeirparents,boyfriend,orgirlfriend. 211 Haverecentlylostsomeonetheycaredabout. 212 12Kosky,R.,Silburn,S.,&Zubrick,S.(1986).Symptomaticdepressionandsuicidalideation:A comparativestudywith628children.JournalofNervousandMentalDisease,174,523528. 13Gould,M.S.,Fisher,P.,Parides,M.,Flory,M.,&Shaffer,D.(1996).Psychosocialriskfactorsofchild andadolescentcompletedsuicide.ArchivesofGeneralPsychiatry,53,11551162. 8
9 213 Tragically,thestigmaassociatedwithmentalhealthproblemsandsubstanceabuseproblems 214 andtheirtreatmentpreventsmanyyouth(andtheirparents)fromseekinghelp(Kerr,2009,pp. 215 9093). 216 217 1.PoliciesandProcedures 218 Werecommendthatdistrictsadoptacomprehensivesetofproceduresandabriefauthorizing 219 policy.TheSTARCenteroffersanexampleat 220 http://www.starcenter.pitt.edu/SchoolDistrictSuicidePolicy/47/Default.aspx. 221 222 ProgramPolicies.Toreducetheriskofthewelldocumentedphenomenonofsuicide 223 contagion14,werecommendthatdistrictsalsoadoptapolicythatindicatesthatonlyresearch 224 validatedsuiciderelatedprogramswillbeimplementedinschools. 225 226 MemorialPolicies.Weurgedistrictstoadoptapolicyregardingallmemorials,regardlessof 227 causeofdeath.Memorials(includingcommemorationofanniversariesofdeaths)oftencreate 228 tensionbetweenfamiliesandschoolsandcanincreasetheriskofsuicidecontagion.[Specific 229 guidelinesformemorialsandanniversariescanbefoundinKerr,M.M.(2009).Schoolcrisis 230 preventionandintervention.UpperSaddleRiver,NJ,PearsonEducation,Inc.] 231 232 MediaPolicies.Unfortunately,localmediaoftenprovideextensivecoverageofsuicides.Such 233 coveragecanincreasetheriskofsuicideinvulnerableaudiences.Werecommendthatdistricts 234 and/orcommunityleadersmeetwithregionalmediarepresentativestoreviewacceptable 235 mediaguidelinesforreportingonsuchdeaths.Forinformationregardingmediaguidelines,see 236 http://mentalhealth.samhsa.gov/suicideprevention/newsroom.asp. 237 238 239 2.DataCollection 240 ManydistrictsacrosstheUSmaintainlittleornoformalinformaldataonstudentriskbehaviors 241 oroutcomesassociatedwithclassroompreventionprograms.Districtscannotrelyonreferrals 242 asdataaboutprevalence,becausesuicidalindividualsmayneverseektreatmentorsharetheir 243 planswithothers.Therefore,wesuggestthatdistrictsuseanestablishedanonymoussurveyto 244 gatherinformationthatcan: 245 informdistrictsandcommunityagenciessuchaslawenforcementandtreatment 246 providersregardingtherisktakingbehaviorsofyouth. 247 aiddistrictsinsuccessfulgrantapplicationsforadditionalfundingforpreventionand 248 intervention. 249 assistdistrictsinstrategicplanningandstaffingofitspreventionandintervention 250 efforts. 14Studieshaveshownthatsuicidalbehavioriscontagious(SeeGould,M.S.,Greenberg,T.,Velting,D. M.,&Shaffer,D.(2003).Youthsuicideriskandpreventiveinterventions:Areviewofthepast10years. JournaloftheAmericanAcademyofChild&AdolescentPsychiatry,42(4),386405.)Thatis,following exposuretoasuicideattemptordeathbysuicide,vulnerableindividualsareathigherriskforsuicidal behaviors.Becauseofcontagion,suicidalbehaviordiffersfromothercrises. 9
10 251 OnesuchexampleistheYouthRiskBehaviorSurveillanceSystem(YRBSS)availableatnocost 252 fromtheCentersforDiseaseControlandPreventionat 253 http://www.cdc.gov/healthyyouth/yrbs/index.htm.Districtsmaymodifythequestionnaire 254 dependingoncommunityneedsandinterests.ThestandardYRBSSquestionnairetakesabout 255 35minutestocomplete.AccordingtotheUtahDepartmentofHealth,theYRBSShasbeenused 256 since1991(http://health.utah.gov/opha/publications/hsu/09Dec_YRBS.pdfYRBSS).UtahYRBSS 257 dataareavailableathttp://ibis.health.utah.gov/query/ 258 selection/yrbs/YRBSSelection.html 259 260 3.ProfessionalDevelopment 261 NeedsAssessment. 262 Staffinvolvedindailyinteractionwithstudentsatriskforsuicidearevitalinpreventionefforts. 263 Ifschoolgatekeepersareunderinformedabouttheindicatorsofsuiciderisk(asstudieshave 264 shown),thentheymaynotrecognizestudentswhoneedhelp15.Toimprovethispractice, 265 schoolsmustfirstassesswhatschoolemployeesknow. 266 267 Asisoftenseen,communitymembersmayholddifferentviewsofwhatleadstosuicide 268 attempts,withsomeendorsingastressmodelthatmaynotbesupportedbycurrentresearch. 269 Sothateveryonecanworkconsistentlytosafeguardstudents,werecommendthatdistricts 270 undertakeasurveyofemployeesknowledgeaboutsuicideriskandsuicidebehaviors,using 271 theScoullerandSmith(2003)orcomparableinstrument.Basedonthesedata,districtscould 272 planprofessionaldevelopmentthataddressesanygapsininformation. 273 274 FocusofProfessionalDevelopment 275 Trainingmaterialsshouldexplainspecificsuiciderelatedconceptssuchascontagion,restriction 276 oflethalmeans,memorials,orriskassessmentandmanagement.Allemployees, 277 whethercertifiedornot,shouldknowhowtoidentifywarningsignsforsuicidal 278 behaviorandotherhighriskbehaviorandhowtoreferstudentsfornon 279 emergencyfollowup.Employeesshouldalsolearnhowtorespondtocrisis 280 situations.The1800273TALKNationalSuicidePreventionLifelinehasfree 281 walletcards,posters,andothermaterialsforsuchdissemination. 282 283 Werecommendthatdistrictsprovidesuicidepreventionorientationforallnewstaff.All 284 employeesmustbealertedtothoseathighestrisk(e.g.,males1619,teenswithmentalhealthor 285 substanceabuseproblems,GLBTteens,thosewhohaveattemptedsuicide,and/orthosewitha 286 pendingdisciplinaryincidentwhohaveotherriskfactors). 287 288 289 15Scouller,K.M.,&Smith,D.I.(2002).Preventionofyouthsuicide:Howwellinformedarethepotential gatekeepersofadolescentsindistress?SuicideandLifeThreateningBehavior,32,6779. 10
11 290 4.MentalHealthPromotion/SuicidePreventionEfforts 291 Preventionmodelsstressverydifferentapproaches,makingitdifficultforschoolstodetermine 292 themosteffectivewaystopreventyouthsuicide.Someapproaches(seeworkbyKalafatand 293 Lazarus)emphasizeprotectivefactorsandsupportnetworks.Otherstrategiesderivefrommental 294 healthresearchonriskfactorsandprecipitatingeventsinsuicide(seeworkbyBrent,Shaffer,and 295 Gould).Finally,athirdcategoryofsuicidepreventionmethodsstemfromthedirectpersonal 296 experiencesofthosewhohavelostalovedonetosuicide(seeJasonFoundation,YellowRibbon 297 Campaign). 298 299 Werecommendamodelthatteachesadultshowtoidentifystudentsatriskandtomake 300 expedientandeffectivereferralstocompetentmentalhealthspecialists.Wesupportvalidated 301 mentalhealthscreeninginschoolandmentalhealthpromotioncurricula.Wecontinuetobe 302 cautiousaboutsuicidefocusedclassroominstruction,giventheAmericanAcademyofChildand 303 AdolescentPsychiatryswarning: 304 305 Becausecurriculumbasedsuicideawarenessprogramsdisturbsomehighriskstudents, 306 asaferapproachmightbetofocusontheclinicalcharacteristicsofdepressionorother 307 mentalillnessesthatpredisposetosuicidality.Intheabsenceofevidencetothecontrary, 308 talksandlecturesaboutsuicidetogroupsofchildrenandadolescentsdrawnfrom 309 regularclassesshouldbediscouraged.Thisisbecauseoftheirpropensitytoactivate 310 suicidalideationindisturbedadolescentswhoseidentityisnotusuallyknowntothe 311 instructor(AmericanAcademyofChildandAdolescentPsychiatry,2000,pp.2728)16. 312 313 PreventionCurricula 314 WesuggestthatdistrictsadoptEvidencebasedProgramsandPractices(NREPP)17,because 315 theseprogramshavebeenshowntoreduceriskbehaviorswhenimplementedasdesigned.A 316 commonconcernaboutanydistrictspreventionprogramsisthewhethertheyarebeing 317 implementedwithfidelity18.WesuggestthatDistrictsformallymonitorimplementationof 318 thesepreventioncurricula.Moreover,newteachersshouldreceivetrainingeachyearinthe 319 curricula.NREPPvalidatedprogramsinclude: 320 321 TeenScreen 322 TheColumbiaUniversityTeenScreenProgramidentifiesmiddleschoolandhighschoolaged 16AmericanAcademyofChildandAdolescentPsychiatry,2000.PracticeParameterfortheAssessment andTreatmentofChildrenandAdolescentswithSuicidalBehavior.Availableat http://www.aacap.org/galleries/PracticeParameters/Suicide.pdf 17NationalRegistryofEvidencebasedProgramsandPractices(NREPP),aserviceoftheSubstanceAbuse andMentalHealthServicesAdministration(SAMHSA).NREPPisasearchabledatabaseof interventionsforthepreventionandtreatmentofmentalandsubstanceusedisorders.SAMHSAhas developedthisresourcetohelppeople,agencies,andorganizationsimplementprogramsandpracticesin theircommunities(descriptiontakenfromwebsite). 18Implementationfidelityisimportant,becauseitassuresdistrictsthattheprogramisbeingimplemented inthemannerinwhichthereportedpositiveoutcomeswereachievedinstudies. 11
12 323 youthinneedofmentalhealthservicesduetoriskforsuicideandundetectedmentalillness.The 324 programsmainobjectiveistoassistintheearlyidentificationofproblemsthatmightnot 325 otherwisecometotheattentionofprofessionals.TeenScreencanbeimplementedinschools, 326 clinics,doctorsoffices,juvenilejusticesettings,shelters,oranyotheryouthservingsetting. 327 Typically,allyouthinthetargetagegroup(s)atasettingareinvitedtoparticipate. 328 329 Thescreeninginvolvesthefollowingstages: 330 1. Beforeanyscreeningisconducted,parentsactivewrittenconsentisrequiredfor 331 schoolbasedscreeningsitesandstronglyrecommendedfornonschoolbasedsites. 332 Teensmustalsoagreetothescreening.Boththeteensandtheirparentsreceive 333 informationabouttheprocessofthescreening,confidentialityrights,andtheteens 334 rightstorefusetoansweranyquestionstheydonotwanttoanswer. 335 2. Eachteencompletesa10minutepaperandpencilorcomputerizedquestionnaire 336 coveringanxiety,depression,substanceandalcoholabuse,andsuicidalthoughtsand 337 behavior. 338 3. Teenswhoseresponsesindicateriskforsuicideorothermentalhealthneedsparticipate 339 inabriefclinicalinterviewwithanonsitementalhealthprofessional.Iftheclinician 340 determinesthesymptomswarrantareferralforanindepthmentalhealthevaluation, 341 parentsarenotifiedandofferedassistancewithfindingappropriateservicesinthe 342 community.Teenswhoseresponsesdonotindicateneedforclinicalservicesreceivean 343 individualizeddebriefing.Thedebriefingreducesthestigmaassociatedwithscores 344 indicatingriskandprovidesanopportunityfortheyouthtoexpressanyconcernsnot 345 reflectedintheirquestionnaireresponses(descriptionfromNREPPWebsite). 346 347 SOSSignsofSuicide 348 SOSSignsofSuicideisa2daysecondaryschoolbasedinterventionthatincludesscreeningand 349 education.Studentsarescreenedfordepressionandsuicideriskandreferredforprofessionalhelp 350 asindicated.Studentsalsoviewavideothatteachesthemtorecognizesignsofdepressionand 351 suicideinothers.Theyaretaughtthattheappropriateresponsetothesesignsistoacknowledge 352 them,letthepersonknowyoucare,andtellaresponsibleadult(eitherwiththepersonoronthat 353 personsbehalf).Studentsalsoparticipateinguidedclassroomdiscussionsaboutsuicideand 354 depression.Theinterventionattemptstopreventsuicideattempts,increaseknowledgeabout 355 suicideanddepression,developdesirableattitudestowardsuicideanddepression,andincrease 356 helpseekingbehavior(descriptionfromNREPPWebsite). 357 358 CARE(Care,Assess,Respond,Empower)formerlycalledCounselorsCARE(CCARE)and 359 MeasureofAdolescentPotentialforSuicide(MAPS)isahighschoolbasedsuicideprevention 360 programtargetinghighriskyouth.CAREincludesa2hour,oneononecomputerassisted 361 suicideassessmentinterviewfollowedbya2hourmotivationalcounselingandsocialsupport 362 intervention. 363 364 Thecounselingsessionisdesignedtodeliverempathyandsupport,provideasafecontextfor 365 sharingpersonalinformation,andreinforcepositivecopingskillsandhelpseekingbehaviors. 12
13 366 CAREexpeditesaccesstohelpbyconnectingeachhighriskyouthtoaschoolbasedcaseworkeror 367 afavoriteteacherandestablishingcontactwithaparentorguardianchosenbytheyouth.The 368 programalsoincludesafollowupreassessmentofbroadsuicideriskandprotectivefactorsanda 369 boostermotivationalcounselingsession9weeksaftertheinitialcounselingsession. 370 371 ThegoalsofCAREarethreefold:todecreasesuicidalbehaviors,todecreaserelatedriskfactors, 372 andtoincreasepersonalandsocialassets.CAREassessestheadolescentsneeds,provides 373 immediatesupport,andthenservesastheadolescentscrucialcommunicationbridgewithschool 374 personnelandtheparentorguardianofchoice.TheCAREprogramistypicallydeliveredby 375 schooloradvancedpracticenurses,counselors,psychologists,orsocialworkerswhohave 376 completedtheCAREimplementationtrainingprogramandcertificationprocess. 377 378 AlthoughCAREwasoriginallydevelopedtotargethighriskyouthinhighschoolparticularly 379 thoseatriskofschooldropoutorabusingsubstancesitsscopehasbeenexpandedtoinclude 380 youngadults(ages20to24)insettingsoutsideofschools,suchashealthcareclinics 381 (descriptionfromNREPPWebsite). 382 383 Ifadistrictengagesinapartnershipwithanoutsidementalhealthprovidertoprovidemental 384 healthservicesatthehighschools,thefollowinggrouppreventionprogramforstudentsatrisk 385 mightbeappropriate. 386 387 CAST 388 CAST(CopingandSupportTraining)isahighschoolbasedsuicidepreventionprogram 389 targetingyouth14to19yearsold.CASTdeliverslifeskillstrainingandsocialsupportina 390 smallgroupformat(68studentspergroup).Theprogramconsistsof1255minutegroup 391 sessionsadministeredover6weeksbytrained,masterslevelhighschoolteachers,counselors,or 392 nurseswithconsiderableschoolbasedexperience.CASTservesasafollowupprogramforyouth 393 whohavebeenidentifiedthroughscreeningasbeingatsignificantriskforsuicide.Intheoriginal 394 trials,identificationofyouthwasdonethroughaprogramknownasCARE(Care,Assess, 395 Respond,Empower),butotherevidencebasedsuicideriskscreeninginstrumentscanbeused. 396 397 CASTsskillstrainingsessionstargetthreeoverallgoals:increasedmoodmanagement 398 (depressionandanger),improvedschoolperformance,anddecreaseddruginvolvement.Group 399 sessionsincorporatekeyconcepts,objectives,andskillsthatinformagroupgenerated 400 implementationplanfortheCASTleader.Sessionsfocusongroupsupport,goalsettingand 401 monitoring,selfesteem,decisionmakingskills,bettermanagementofangeranddepression, 402 schoolsmarts,controlofdrugusewithrelapseprevention,andselfrecognitionofprogress 403 throughtheprogram.Eachsessionhelpsyouthapplynewlyacquiredskillsandincreasesupport 404 fromfamilyandothertrustedadults.Detailedlessonplansspecifythetypeofmotivational 405 preparation,teaching,skillspractice,andcoachingactivitiesappropriateforatriskyouth.Every 406 sessionendswithLifeworkassignmentsthatcallfortheyouthtopracticethesessionsskills 407 withaspecificpersonintheirschool,home,orpeergroupenvironment(descriptionfrom 408 NREPPWebsite). 13
14 409 410 HealthCurriculumandClassroomInstruction 411 Wesuggestthatdistrictsreviewoutlinesofhealthcurriculaanddiscusswithsomeeducators 412 howtheydelivertheircoursecontent.Werecommendthatcurriculumsupervisorsmonitorany 413 informalactivitiesthatmightexposestudentstothesuicidalityofothers(e.g.,activitiesin 414 whichastudentmightdisclosesuicidalideationorattemptssuchasautobiographicalactivities 415 usedinsomehighschoolclasses).Whilewediscouragetheuseofastressmodeltoexplain 416 suicide,wedoendorsehighqualityeffortstoteachstudentshealthyapproachestomanaging 417 stress. 418 419 Werecommendthatdistrictspullfromcirculationtextbooksthatshowthenamesofthe 420 deceasedstudents(i.e.,thestudentsnameappearsinthefrontofthetextbookbecausethe 421 studentwasissuedthatbookfortheyear).Districtsshouldnot,however,coveroverthese 422 names,lestotherstudentslaterdiscoverthem. 423 424 Libraries 425 Werecommendthatdistrictlibrariansevaluateholdingsofnonfictionbooksregardingsuicide, 426 substanceabuse,andothermentalhealthtopics(forprofessionalsaswellasforstudents). 427 Mentalhealthtreatmenthaschangeddramaticallyduringthepasttwodecades,offeringfar 428 morehopethaninprioryears.Oldervolumesmaynotcontainaccurateinformationormay 429 contributetothestigmaofhelpseekingformentalhealthorsubstanceabuseproblems. 430 Excellenttextsforprofessionals,parents,andyouthcanbefoundontheCOPE,CARE,DEAL 431 website(www.copecaredeal.org).ThissiteisfundedbytheAnnenbergTrustthroughits 432 AdolescentMentalHealthInitiativeandisextensivelypeerreviewedbyexperts.Thewebsite 433 synthesize(s)anddisseminate(s)scientificresearchonthepreventionandtreatmentofmental 434 disordersinadolescents.TheInitiativecreatesbooksandwebmaterialsforadolescentson 435 topicsincludingdepression,bipolardisorder,anxiety,schizophrenia,andsuicideprevention 436 (descriptionfromCope,Care,Dealwebsite). 437 438 SchoolbasedSupportServices 439 Recommendationsinthisarenarequireacomprehensivereviewofdistrictschoolbasedstudent 440 supportservices.However,werecommendfordistrictsconsiderationthesegeneral 441 suggestions: 442 443 1. Often,severalstaffmembershavespecializedexpertise(e.g.,havingworkedasamental 444 healthcrisisspecialist,agencysocialworkerordrugandalcoholcounselor).Districtsmay 445 wanttosurveystudentsupport(andotherstaff)toinventorythesespecializedskillsand 446 considerhowbesttousetheseindividualstalents.Forexample,onewhohasextensive 447 workinmentalhealthcrisisintakewouldbeanidealmemberoftheteamwritingthe 448 studentassessmentprotocolorthecrisisprocedures. 449 2. Schoolbasedhealthclinicscanreducethestigmaofhelpseekingbehaviorandimprove 450 accesstoservices.Weencouragedistrictstoconsiderpartneringwithlocalprovidersto 14
15 451 createschoolbasedmentalhealthclinicsstaffedbymentalhealthspecialists.Theseshould 452 operateatlowornocosttodistricts. 453 3. Notsurprisingly,schoolssometimesexperienceredundancyinservices,withcounselors, 454 socialworkers,andthechildstudyorstudentassistanceteamseachseeingstudents 455 seekingorneedingsupport.Thismultiplepathwaysapproachisnotnecessarilya 456 problemanddoesofferstudentsmultiplesourcesofaid.Indeed,staffmembersshouldbe 457 encouragedtohavegenuineconnectionswithstudentsandtheirfamiliesandtobe 458 availabletoyouththroughouttheschoolday.Giventhecomplexityandnumberof 459 communicationsregardingatriskstudents,however,eachschoolmightreminditsstaff, 460 parents,andstudentsannuallyofthestepstheycantaketomakeareferralorgethelpfora 461 studentofconcern.Parentsandstudentsmusthavenonschoolhourcontactsand 462 numberstocallaswell,becauseoftencrisesoccurduringnights,weekends,andschool 463 breaks. 464 465 Often,wefindthatstaffmembersusedifferent(orno)interviewquestionswhenfacedwithan 466 atriskstudent.Werecommendthatdistrictsreviewscreeningprotocolsandconsideradopting 467 auniformprotocolforinterviewingstudentsatriskforsuicideandalsoforsubstanceuseand 468 abuse. 469 470 DrugandAlcoholServices 471 Manystudentsarestrugglingwithdrugandalcoholproblemsthemselvesorwithintheir 472 families.Supportgroupsforstudentswhoareinrecoveryorwhoarecopingwithsubstance 473 issuesintheirfamiliesareimportanttorecoveryandcanbehostedinthecommunity. 474 475 Inaddition,wesuggestthatdistrictsconsiderdesignatingadrugandalcoholcoordinator 476 (typicallysomeonealreadyonstaff)foreachofitsmiddleandhighschools. 477 478 Adistrictmaywanttoinstituteanddisseminateadirectoryoffamilieswhopledgenottoserve 479 alcoholtominors.Familieswhoparticipateorreadaboutthismayfeelstrengthenedintheir 480 attemptstolimittheirchildrensunderageuseofalcohol. 481 482 ParentEducation 483 Districtcommunicationswithparentsconstituteanopportunityforimportantpsychoeducation. 484 Werecommendthatdistrictsdraftconsistentlanguageincommunications19regardingsuicide 485 prevention,referencingtheresearchcitedinthisreport,tooutlinesafeguardsparentscan 486 implement,includinglethalmeansrestrictionandwarningsaboutthelinkbetweensuicideand 487 substanceabuse. 488 Communicationsincludeconversationswithparents,parentforums,parenthandbooks,parentletters, 19 andcommunicationstothepublicthatmaybeheardorreadbyparents.Seesamplesuicidepolicyand procedureforexamples. 15
16 489 Despiteoutreachefforts,weoftenfindthatparentsdonotknowhowtoaccessqualitymental 490 healthservices.Werecommendthatcommunityprovidersworkwithdistrictstoprovide 491 parentsinformationonwhenandhowtoaccessmentalhealthservices,forcrisisandnoncrisis 492 situations,includingnights,weekends,andschoolbreaks.Thismayrequirecollaborationwith 493 commercialinsurersaswell. 494 495 ActionstoAvoid 496 Districtsshouldavoidsomeapproaches,includingthosethat: 497 heightentheriskofcontagionamongvulnerableyouth.Everysuiciderelatedeventand 498 communicationshouldbevettedwithmentalhealthprofessionalswhocanevaluatethe 499 riskofcontagion 500 maypromotediscriminationorculturalbias. 501 depictsuicidethroughavideotapeorpersonalmessagethathasnotbeenreviewedand 502 endorsedbyexpertsinsuicidetreatmentandprevention. 503 deliverthemessagethatteenagersareresponsibleforsavingtheirfriends. 504 involvelargestudentassemblyformatsandpublicaddressannouncements,becausea) 505 theyareperceivedasimpersonalandb)theydonotallowacompetentadulttolookfor 506 signsofdistressinstudents. 507 5.InteragencyandCommunityCollaboration 508 InteragencyCouncil 509 Manydistrictshaveworkedhardtocreatetiestothecommunity,asevidencedbyformaland 510 informalcollaborations.Yet,itcanbedifficulttoconvenesomanyprovidersandtoproblem 511 solvespecificsituations.Tomakeoptimaluseofthoseconnectionsandtostrengthen 512 communitypreventionandinterventionefforts,werecommendthatdistrictsandcommunity 513 leadersconveneaproblemsolvinggroupcomprisedoflocalagenciesthatrespondtoyouth, 514 including: 515 juvenilecourtanddistrictcourts 516 childprotectiveservices* 517 policeforces 518 hospitalsprovidingmentalhealthandpediatricservices 519 drugandalcoholtreatmentproviders 520 faithbasedleadership 521 countydepartmentofhealth 522 emergencyresponders* 523 coronersoffice/childdeathreviewteam* 524 organizationsrepresentinglocalhealthcareproviders(e.g.,AmericanAcademyof 525 Pediatricschapter) 526 (*indicatesgroupwhomayneedtojointhemeetingsforparticulardiscussionsonly.) 527 528 Werecommendthatthisgroupmeetmonthlywithtightlystructuredagendastoa)review 529 availableriskdata,b)anticipatesituationsoreventsthatindicateheightenedrisktaking 530 behavior(e.g.,proms,introductionofchokinggametotheregion,andincreasesinuseof 531 particulardrugsinthearea),c)formactionplansforpreventingrisk,d)forgestrongeralliances 16
17 532 forsharinginformationandexpeditingservices,ande)seekadditionalfundingand/or 533 resourcesforpreventionandinterventionefforts. 534 535 ThecommunitymaywanttoconsideradoptionofanassetbuildingsuchastheSEARCH 536 Institutetosupportyouth(http://www.searchinstitute.org/developmentalassetsarefree),and 537 programsthatlimitaccesstolethalmeanssuchasfirearms,drugs,andalcohol. 538 539 EmergencyDepartmentMeansRestrictionProtocol 540 Werecommendthatcommunitytreatmentproviders,includingemergencydepartmentof 541 hospitals,considerusingtheprotocoloutlinedinEmergencyDepartmentMeansRestriction(SPRC 542 Classification:Effective) 543 Thegoalofthisinterventionistoeducateparentsofyouthathighriskforsuicideaboutlimiting 544 accesstolethalmeansforsuicide.Educationtakesplaceinemergencydepartmentsandis 545 conductedbydepartmentstaff(anunevaluatedmodelhasbeendevelopedforuseinschools). 546 Emergencydepartmentstaffsaretrainedtoprovidetheeducationtoparentsofchildrenwhoare 547 assessedtobeatriskforsuicide.Lethalmeanscoveredincludefirearms,medications(overthe 548 counterandprescribed),andalcohol.Tohelpwiththesafedisposaloffirearms,collaborationwith 549 locallawenforcementorotherappropriateorganizationsisadvised. 550 Thecontentofparentinstructionincludes: 551 1.Informingparent(s),apartfromthechild,thatthechildwasatincreasedsuicideriskand 552 whythestaffbelievedso; 553 2.Informingparentsthattheycanreduceriskbylimitingaccesstolethalmeans,especially 554 firearms;and, 555 3.Educatingparentsandproblemsolvingwiththemabouthowtolimitaccesstolethalmean 556 (descriptionfrom:http://www.sprc.org/featured_resources/bpr/ebpp_PDF 557 /emer_dept.pdf). 558 Contacttheauthorofthisprotocolforacopy:MarkusJ.Kruesi,MD,(843)7920135. 559 560 SubstanceAbuseintheCommunity 561 Manystaffandcommunitymembersexpressseriousconcernaboutcommunityyouthengaged 562 insignificantsubstanceabuse,includingalcoholservedinfamilyhomes(sometimeswith 563 parentknowledge),useandsaleofprescriptiondrugsthatyouthaccessathome,andtheuseof 564 highlyaddictiveillegaldrugs. 565 566 Substanceabusepreventionisnotthesoleresponsibilityofaschooldistrict.Substanceabuse 567 preventionrequiresacommunitytoundertakeenvironmentalchangeincludingchangesin 568 thesupervisionofitsyouth,thenormsofthecommunity,thesanctionsforviolations,and 569 supportsforassessment,treatment,andaftercare.Nevertheless,districtsconcernsregarding 570 suicidecannotbeaddressedadequatelywithoutamajorcommunitysubstanceabuseprevention 571 effort,giventhegenerallinkbetweensubstanceabuseandyouthsuicide.TheInteragency 572 Councilproposedabovemayimprovesomeofthesecommunicationsandnorms. 573 574 17
18 575 6.PublicAwareness 576 577 Therearemanycommunitybasedapproachesforsuicideprevention.Theseprogramsare 578 appealingtolaypeopleinpartbecausetheydonotrequirehighlevelsofexpertise.Theyoften 579 conveyapersonalconnectionthroughasurvivorofsuicideandtendtobecompellingand 580 engaging.Suchgrassrootseffortsareusuallylowcostandlendthemselvestotraineroftrainers 581 andotherrapiddissemination. 582 583 YellowRibbonProgram 584 Gatekeeperprogramstrainindividualstorecognizewarningsignsofriskybehaviorandtoseek 585 helpfortheindividualofconcern.OnesuchprogramistheYellowRibbonprogram(Yellow 586 RibbonInternationalSuicidePreventionProgram,2008).Thisprogrampromoteshelpseeking 587 behaviorthroughincreasingawarenessonsuicideprevention,traininggatekeepers,and 588 facilitatingthebehaviorbydistributingaskforhelpcards.YellowRibbonleadershold 589 planningsessionswithschoolandcommunityleaders.Theyprovidetrainingforstaffand 590 youthleaders,followedbyschoolwideassembliesaswellasboostertraining.Trainingfornew 591 staffmembersandstudentsisalsoprovided.Communitytaskforcesareestablishedtoensure 592 ongoingresourceconnections,awarenessreminders,eventcoordination,andexpanded 593 gatekeepertraining. 594 595 Despiteitspopularity,theYellowRibbonprogramhasnotbeensystematicallyevaluated. 596 CorrespondencewiththeU.S.SubstanceAbuseandMentalHealthServicesAgency(SAMHSA) 597 confirmedthis.ConcernsabouttheYellowRibbonCampaignincludeitspotentialtoincrease 598 suicidecontagion20andthetendencyofgroupstomisunderstanditsacknowledgedlimited 599 mission. 600 601 InlieuoftheYellowRibbonProgram,districtsmaywanttoinvolvethecommunityin 602 promotingaresearchvalidatedprogram(SeeinformationregardingSafeTALKbelow),and/or 603 otherapproachessuchasstigmareduction,suchasStigmabusters(NationalAlliancefor 604 MentalIllness(NAMI)).Anotherfocusmightbethepromotionofthe1800273TALKservice 605 knownastheNationalSuicidePreventionLifeline.Studentsincrises(orconcernedindividuals) 606 cancallthisnumberfreeofchargetospeakimmediatelywithalocalcounselor.TheSEARCH 607 Institutescommunityassetbuildingmightbeafocusforaschoolcommunityeffort,asmight 608 oneoftheresearchvalidatedmentalhealthscreeningprogramsdiscussedbelow. 609 610 611 612 20Beautrais, A. A Framework for Selecting Prevention Approaches for the New Zealand Suicide PreventionStrategy.Availablefrom http://www.chmeds.ac.nz/research/suicide/Framework_Nz_Prevention_Strategy.pdf. 18
19 613 OtherGatekeeperPrograms 614 Gatekeepertrainingprogramscanbeaneffectivepartofasuicidepreventionplanwhenthese 615 practicesareputintoplace.Thefollowingsectiondescribesagatekeeperprogramsupported 616 byresearch. 617 618 SafeTALKisahalfdaytrainingprogramthatteachesparticipantstorecognizeandengagepersonswho 619 mightbehavingthoughtsofsuicideandtoconnectthemwithcommunityresourcestrainedinsuicide 620 intervention.SafeTALKstressessafetywhilechallengingtaboosthatinhibitopentalkaboutsuicide.The 621 programrecommendsthatanASISTtrainedresourceorothercommunitysupportresourcebeatall 622 trainings.ThesafeofsafeTALKstandsforsuicidealertnessforeveryone.TheTALKlettersstandfor 623 thepracticeactionsthatonedoestohelpthosewiththoughtsofsuicide:Tell,Ask,Listen,andKeepSafe. 624 625 ThesafeTALKlearningprocessishighlystructured,providinggraduatedexposuretopracticeactions. 626 Theprogramisdesignedtohelpparticipantsmonitortheeffectoffalsesocietalbeliefsthatcancause 627 otherwisecaringandhelpfulpeopletomiss,dismiss,oravoidsuicidealertsandtopracticetheTALK 628 stepactionstomovepastthesebarriers.Six6090secondvideoscenarios,eachwithnonalertandalert 629 clips,areselectedfromalibraryofscenariosandstrategicallyusedthroughthetrainingtoprovide 630 experientialreferentsfortheparticipants(descriptionfromUSSuicidePreventionResource 631 Center(SPRC)BestPracticeRegistry). 632 633 7.Postvention 634 635 Postventioneffortshelptomeettheimmediateneedsofschoolsandcommunitiesincrisisafter 636 atragicloss,suchasasuddendeath.Inaddition,postventionallowsforfacetofacescreenings 637 ofthoseatriskandprovidesatimelyresponsetosurvivors.Thisapproachwasdesignedto 638 assistsurvivorswiththegrievingprocess,whilelimitingtheriskofsuicidecontagionand 639 reducingtheharmfuleffectsintheaftermathofasuicide. 640 641 Althoughpostventioncanbeanopportunitytoimprovetheschoolspreventionapproaches,it 642 canbequitevariablefromoneschool/providertoanother.Becausethereisverylimited 643 researchandevaluationonpostvention,schoolsandcommunitymustuseapproachesthatare 644 conceptuallygroundedandcomprehensive. 645 646 WerecommendthatdistrictsandcollaboratingprovidersconsideradoptingtheSTARCenters 647 guidelinesforpostvention,21availablefrom 648 http://www.starcenter.pitt.edu/Manuals/6/Default.aspx.Thisguide,basedonclinicalresearch, 649 isextensivelypeerreviewed. 650 21 Kerr,M.M.,Brent,D.A.,McKain,B.,&McCommons,P.S.(2004).Postventionstandardsmanual: Aguideforaschoolsresponseintheaftermathofasuddendeath,4thEdition.Universityof Pittsburgh,ServicesforTeensatRisk(STARCenter). 19
20 651 WealsorecommendthatdistrictsadoptanddisseminatetheguidelinesincludedinSafeand 652 EffectiveMessagingforSuicidePrevention,availableat 653 http://www.sprc.org/sites/sprc.org/files/library/SafeMessagingrevised.pdf. 654 655 InConclusion 656 Thisdocumentofferedguidelinesforpreventionofsuicideandrelatedyouthriskbehaviors, 657 basedonourunderstandingoftheresearchandourexperienceinworkingwithschooldistricts, 658 withthosewhohavelostalovedonetosuicide,andwiththoseatriskforsuicide.Wehope 659 thatreaderswillfindthesuggestionshelpful. 660 661 662 663 20
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