Signs of Suicide: A Promising School-Based Suicide Prevention Program in Military Schools

1. Signs of Suicide: A Promising School-Based Suicide PreventionProgramin Military Schools Robert H. Aseltine Jr., PhD

2. Scope of the Problem Youth Suicide: National and International Trends

3. Increasing Rates of Youth Suicide • Nationally, suicide is the 3rd leading cause of death among children ages 15-24 (4,405 deaths in 2006) (CDC, 2004). Only accidents and homicides occurred more frequently. • While suicides accounted for 1.4% of all deaths in the U.S. annually, they comprised 12% of all deaths among 15-24-year-olds. • Adolescent suicidal behavior is deemed to be underreported because many deaths of this type are classified as unintentional or accidental (World Medical Association, 2004). Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2004) [cited 2005 Feb 28]. Available from: URL: www.cdc.gov/ncipc/wisqars.

4. US Suicide Rate Per 100,000 (15-19 year olds) Source: National Center for Health Statistics, 2004

5. Youth Suicide in Industrialized Nations Rate per 100,000 Source: Beautrais, 2002

6. Suicidal Ideation and Suicide Attempts • 2009 Youth Risk Behavior Survey found that: • 26.1% felt so sad or hopeless for 2+ weeks that they stopped doing some usual activity. • 13.8% seriously considered attempting suicide. • 10.9% made a suicide plan. • 6.3% attempted suicide. • 1.9% of those who made an attempt required medical attention • Find the data for your city/state: http://www.cdc.gov/HealthyYouth/yrbs/index.htm

7. Risk Factors

8. Risk Factors for Adolescent Suicide MALESFEMALES Mood disorder 7.5X 34.3X Substance abuse 4.9 36.6 Conduct disorder 5.6 --- Gun in home* 4.5 15.0 Family history of suicide 2.4 --- Past attempt 41.4 59.7 Source: Brent et al 2002

9. Mood Disorders and Suicide • In 2007, 8.2% of adolescents (1 in 12: an estimated 2 million youth aged 12 to 17) reported experiencing at least one major depressive episode in the past year (SAMHSA, 2009). • 76-92% youths committing suicide meet criteria for mood disorder • Primarily major depression, bipolar disorder Andrews & Lewihsohn, 1992; Gould et al, 1998; Mazza & Reynolds, 2001.

10. Alcohol Abuse and Suicide

11. Social Context of Youth Suicide • Adolescence: Transition from parents to peers Most suicidal youth confide concerns to peers (Brent et al., 1988) ~ 25% of peer confidants tell an adult (Kalafat et al., 1993)

12. Preventing Youth Suicide

13. Brief History of School-Based Suicide Prevention • Two types of programs: Universal vs. Selective Universal programs: almost universally disappointing Temporary changes in knowledge and attitudes No impact on behavior

14. SOS Signs of Suicide® Prevention Programs for Middle & High Schools Diane Santoro, LICSW Screening for Mental Health, Inc.

15. Military Children • More than two million American children have had a parent deploy to Iraq or Afghanistan • At least 19,000 children have had a parent wounded in action • Over 2,200 children have lost a parent in Iraq or Afghanistan • Children of military families ages 11 to 17 were found to have a higher prevalence of emotional and behavioral difficulties than children in the general population • Parental deployment places school-age children and adolescents at higher risk for a range of adverse mood and behavioral changes: anger, apathy, anxiety, depression, withdrawal, decline in school performance, loss of interest in normal activities, and social isolation • National Center for Children in Poverty Trauma Faced by Children of Military Families May 2010

16. SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric IllnessCo-morbidity Neurobiology Personality Disorder/Traits Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Illness Suicide Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior

17. What Can Schools Do? “School systems are not responsible for meeting every need of their students. But when the need directly affects learning, the school must meet the challenge.” (Carnegie Task Force on Education) • Schools cannot achieve their mission of educating the young when students’ problems are major barriers to learning and development. • Schools are at times a source of the problem and need to take steps to minimize factors that lead to student alienation and despair • Schools also are in a unique position to promote healthy development and protective buffers, offer risk prevention programs, and help to identify and guide students in need of special assistance Center for Mental Health in Schools at UCLA (http://smhp.psych.ucla.edu)

18. Implementing a Universal Prevention Program • Change environments and systems by applying intervention universally – with particular concern for diversity • Enhance awareness and increase information among students, staff, family, and community • Enhance identification of those at risk and build capacity of school, family, & community to help • Enhance competence related to social and emotional problem solving • Enhance protective buffers

19. SHOW DVD CLIP

20. SOS Signs of Suicide® Program Goals • Decrease suicide and attempts by increasing knowledge and adaptive attitudes about depression • Encourage individual help-seeking and help-seeking on behalf of a friend • Reduce stigma - link suicide to mental illness that, like physical illness, requires treatment • Engage parents and school staff as partners in prevention by educating them to identify signs of depression and suicide and by providing information about referral resources • Encourage schools to develop community-based partnerships.

21. SOS Signs of Suicide® Student Goals • Help youth understand that depression is a treatable illness • Educate youth that suicide is not a normal response to stress but rather a preventable tragedy that often occurs as a result of untreated depression • Inform youth of the risk associated with alcohol use to cope with feelings. • Increase help-seeking by providing students with specific action steps to take if they are concerned about themselves or others and by identifying resources. • Encourage students to engage in discussion about these issues with their friends and with their parents

25. SOS Program Components High School Program • Implementation Guide • Educational DVD & Discussion Guide • Brief Screen for Adolescent Depression (BSAD) - Parent & Student Version • High School Student Newsletter • Customizable Wallet Cards • Posters • Educational Materials for Staff, Students, & Parents

26. SOS Program Components Middle School Program • Implementation Guide • Educational DVD & Discussion Guide • Center for Epidemiological Studies Depression Scale for Children (CES-DC) • Student & Parent Newsletters • Customizable Wallet Cards • Posters • Educational Materials for Staff, Students, & Parents

27. Implementation Overview

28. 1. Identify and Train Your Team • Review program goals and assign roles/responsibilities • Review kit, video, and discussion guide • Review screening form and scoring • Designate time and date for program implementation • Review school policies for handling suicide disclosure, parental consent, record keeping, etc

29. 2. Decide On Format • Provide program school-wide or select target student group based on grade level, class enrollment, or special need • Screening Implementation Options • Eliminate (do not screen) • Non-anonymous • Anonymous with number ID • Anonymous • Anonymous with Response Card

30. BASED ON THE VIDEO AND/OR SCREENING, I FEEL THAT: □ I need to talk to someone … □ I do not need to talk to someone … ABOUT MYSELF OR A FRIEND. NAME(PRINT):_________________________________ HOMEROOM SECTION:_________________________ TEACHER:_____________________________________ IF YOU WISH TO SPEAK WITH SOMEONE, YOU WILL BE CONTACTED WITHIN 24 HOURS. IF YOU WISH TO SPEAK WITH SOMEONE SOONER, PLEASE APPROACH STAFF IMMEDIATELY.

31. 3. Demonstrate the Program • Staff Training Suggestions: • Review the signs of depression and suicide • Answer questions; dispel myths • Show the video and facilitate a discussion • Review the Screening Form • Review the school protocol for handling students who disclose suicidal intent • Review school and community mental health resources

32. 4. Prepare for Follow-Up • Use SAMHSA’s Find Treatment Locator to identify additional referral resources • Contact local mental health facilities and verify their referral procedures, wait lists, insurance details, etc. • Create a Referral Resource List • Track student follow-up • Identify in advance who will be handling emergencies • Notify the nearest crisis response center about the program in advance in order to facilitate referrals.

33. On the Day of the Program • Introduce program • Show video • Facilitate discussion • Students complete screening forms and Response Card • Set expectation about when follow-up can be expected; provide referral information • Follow up with students requesting help • Respond to requests for help; track students seeking help using the Student Follow-Up form

34. Summary: What SOS Does • EDUCATION about depression/suicide • Defines as illness  reduces stigma SCREENING for depression MOBILIZES peers

35. Does SOS Work? In 3 previous randomized controlled studies: Increase in knowledge about suicide and attitudes toward suicide Decrease in suicide attempts No effect on help-seeking On SAMHSA’s National Registry of Evidence-based Programs and Practices

36. Current Study DOD schools Middle school students Program implemented and evaluated by school staff, not research staff

37. Outcome Evaluation of SOS Program among students in military schools Suicidal thoughts and behavior Attitudes and knowledge Help seeking

38. Outcome Evaluation • Involved students in 10 middle schools and 10 high schools • Randomized experiment: • ½ of schools: SOS • ½ of schools: Wait list control • Outcomes assessed at baseline & 3 mos. — anonymous questionnaires during class

39. Measures • Attitudes/Knowledge • Attitudes: 10 item scale • Knowledge: 7item scale • Help-seeking past 3 months: • Treatment Y/N • Talked to parent/guardian, sibling, teacher or guidance counselor, other adult, hotline Y/N • Talked to adult about friend Y/N • Suicidal behavior past 3 months: • Ideation Y/N • Plan Y/N • Attempts Y/N

40. Middle School Participants • Gender • Male 47% • Female 53% • Racial/ethnic self-identification • White, non Hispanic 41% • Black, non-Hispanic 12% • Hispanic 20% • Multiethnic 9% • Other 18%

41. Middle School Participants (Continued) • ESL/ELL • No 81% • Yes 19% • Parental deployment • No 74% • Yes 26%

42. Effects of SOS Program on Knowledge and Attitudes About Depression/Suicide Treatment and controls differ at the .05 level on knowledge only.

43. Standardized Effects of SOS on Knowledge and Attitudes

44. Odds Ratios for Effect of SOS on Attempts in past 3 months

45. Effects of SOS Program: Change in Suicidal Ideation and Suicide Attempts Treatment and controls do not differ at the .05 level for suicide attempts.

46. Help seeking • As in previous studies, no effects on help-seeking were found

47. Summary Increase in knowledge about suicide and attitudes toward suicide in DOD middle school students Sample size too small to estimate effect of SOS on suicide attempts Program successfully implemented by school staff

48. Summary • Next steps: • Implement in high-impact schools • Increase sample size • Long term benefits? • Help-seeking?

49. Acknowledgements • Grateful for financial support from U.S. Department of Defense For more info on program: http://www.mentalhealthscreening.org