Children & Adolescents

1. Children & Adolescents Mental Health/Crisis and Suicide

2. Children & Adolescents Mental Health

3. Children’s Mental Health Mental health is an essential part of children’s overall health. This has a complex interactive relationship with their physical health and their ability to succeed in school, work, and society. Physical and mental health affect how we think, feel and act on the inside and outside. (www.apa.org)

4. Children’s Mental Health • An estimated 15 million of our nation’s young people can currently be diagnosed with a mental health disorder. • Only about 7% of these youth who need services receive appropriate help. www.cdc.gov www.teensuicide.us

5. Factors Related to the Development of Childhood Disorders • Temperament- Likely based on biogenetic factors that constitute a disposition that influences the child’s interaction with his/her world by affecting the nature and style of interacting with others. • Identity- Internal mental construct that involves the child’s developing sense of self over time and situations. • Gender- A component of identity, it often defines individuals and embodies specific behavior characteristics. • Neuropsychological deficits- Deficits in cognitive functioning an involve the processes by which the child will process, organize, and recall information. • Affect- The child’s repertoire of emotional responses both automatic and learned. • Coping style- The child’s characteristic mode of adapting to internal and external stressors.

6. Factors Related to the Development of Childhood Disorders – Cont. • Environmental stressors-This includes child’s family, school, religious training, and he stability of the systems. • Motivation- Reflects the “why” of behavior. • Social facility- The child’s repertoire of social interaction skills which will assist the child in relating to, and coping with others. • Cognitive development-The child’s current cognitive level. • Basic schemas- The rules the child uses to understand his/her world.

7. Children’s Mental Health Symptoms of teen depression: • Withdrawing from family and friends • Losing interest in social and extracurricular activities • Displaying a lack of energy • Anxiety • Irritability • Anger • Significant weight changes • Sleep pattern changes • Indifference about the future • Guilty feelings • Decrease in self-esteem • Suicidal thoughts www.cdc.govwww.teensuicide.us

8. Children’s Mental Health Types of teen depression: 1. Major depression Short duration but severe. 2. Dysthymia Lasts longer and not as severe. 3. Adjustment disorder with depressed mood Results from a major life event. www.cdc.gov www.teensuicide.us

9. Children & Adolescents Parents and Guardians

10. Parent/Legal Guardian • A “minor” is a person under 18 who has never been married or declared an adult by a court. • Generally, minors do not have the legal capacity to consent to medical treatment. • Texas law gives all parents the duty of providing medical and dental care to their children which gives them the explicit right to consent to that treatment (including medical, dental, psychiatric, psychological and surgical treatment). • As a general rule, if a minor requires treatment then a consent from a parent should be obtained. www.cdc.gov www.teensuicide.us

11. Parent/Legal Guardian Authorization agreement for nonparent relative: • This is an agreement between the parent of the child and the child’s grandparent, adult sibling, or aunt/uncle. • Includes authorization of medical, dental, psychological, or surgical treatment; medical insurance, school enrollment, etc. www.cdc.gov www.teensuicide.us

12. Parent/Legal Guardian The authorization agreement must contain: • Name and signature of the relative • Relationship of the relative to the child • Current address and phone of relative • Name and signature of the parent(s) • Current address and phone of parent(s) • A statement that the relative has been given authorization to perform the function listed in the agreement voluntarily • A statement of when the agreement expires • Space for signatures and a notary www.cdc.gov www.teensuicide.us

13. Parent/Legal Guardian Emergency circumstances: • Texas law does not require consent in emergency circumstances where it is not possible to obtain consent from the parent or guardian. • The statute states, “consent for emergency care for an individual is not required if…the individual is a minor who is suffering from what reasonably appears to be life-threatening injury or illness and whose parents or guarding, is not present.” www.cdc.gov www.teensuicide.us

14. Parent/Legal Guardian The appropriate staff should continue efforts to notify a parent to secure consent for continuing treatment. DCMHMR Procedure: • Clinicians should make every effort to contact the parent/guardian prior to the risk of harm assessment. • After making reasonable attempts, the clinician should consult with triage to determine the next steps. • If the parent/guardian is not able to be contacted, the clinician should contact CPS before a risk of harm assessment. www.cdc.gov www.teensuicide.us

15. Children & Adolescents Suicide

16. Considerations When Working with Youth • Youth are the only demographic group that can generally predict their environment for their foreseeable future. • The majority of youth spend 12 years with a relatively stable peer group, representing up to 90% of their living years in some cases. • This cocooning effect can magnify positive experiences and negative experiences alike; a special consideration when dealing with youth. • Coupling physical reality with recent technical advances creates a vulnerability for suicide in youth. (2012 Suicide Prevention and Postvention Toolkit for Texas Communities, p.68)

17. Definitions • SuicideDeath caused by self-directed injurious behavior with any intent to die as a result of the behavior. (cdc.gov) • Suicide attemptA non-fatal, self-directed, potentially injurious behavior with any intent to die as a result of the behavior.  A suicide attempt may or may not result in injury. (cdc.gov) • Self-Injurious Behavior Self-injury, also called self-harm, is the act of deliberately harming your own body, such as cutting or burning yourself. It's typically not meant as a suicide attempt. Rather, self-injury is an unhealthy way to cope with emotional pain, intense anger and frustration. (mayo clinic.com)

18. Definitions • Suicidal ideationThinking about, considering, or planning for suicide. (cdc.gov) • Passive Thoughts of Death Also known as morbid thoughts. For example, “I wish I was dead” or “It would be easier if I weren’t around”. Although these may be serious, and may develop into suicidal ideations, they are not considered suicidal ideations.

19. Suicide • In 2010, 267 children between the ages of 10-14 completed suicide. • In 2010, suicide was the third leading cause of death for young people ages 15 to 24, after accidents and homicide. It was the second leading cause of death for this same age group in Texas. It results in approximately 4600 lives lost each year. Of every 100,000 young people in each age group, the following number died by suicide: • Children ages 5 to 14 - 0.7 per 100,000 • Adolescents/Young Adults ages 15 to 24 -10.5 per 100,000 www.cdc.gov www.teensuicide.us

20. Suicide • Risk of attempted (non-fatal) suicides for youth are estimated to range between 100-200-1. • The 2011 Youth Risk Behavior Survey found that 15.8% of U.S high school students had seriously considered attempting suicide in the previous year, 12.8% had made a suicide plan, and 8% reporting trying to take their own life. • 157,000 youth between the ages of 10-24 received medical care for self-inflicted injuries at emergency rooms. www.cdc.gov www.teensuicide.us

21. Suicide • Young people are much more likely to use firearms, suffocation, and poisoning than other methods of suicide. • Firearms 45% • Suffocation 40% • Poisoning 8% • Children 14 and under are more likely to use suffocation. • 90% of young children who complete suicide have some type of mental health disorder. Also likely to be victims of sexual or physical abuse and engage in antisocial behavior. www.cdc.gov www.teensuicide.us

22. Suicide • More than 30% of LGBT youth report at least one suicide attempt within the last year. • More than 50% of Transgender youth will have had at least one suicide attempt by their 20th birthday. • Youth suicides out number youth homicides. www.cdc.gov www.teensuicide.us • Highest state averages for ages 15-24 are Alaska (46.0 per 100,000), Wyoming (31.9 per 100,000), and South Dakota 26.9 per 100,000). (2010, cdc.gov)

23. Suicide Deaths by Method and Age in Texas 2005-2010(Rates per 100,000 – CDC WISQARS)

24. Suicide Deaths in Texas2005-2010 Rates Per 100,000 (Crude Rates per 100,000 – CDC WISQARS)

25. Suicide Suicide among pre-adolescents (9-14): • Pre-adolescents lack the abstract thinking skills to allow them to understand the finality of death. • Pre-adolescents are inherently impulsive and may lack the cognitive skills necessary to imagine a better future or realize the fleetingness of most of their troubles. • Pre-adolescents lack the strategies older kids have to seek help or cope with problems. www.cdc.gov www.teensuicide.us

26. Suicide Suicide among pre-adolescents (9-14): • Most pre-adolescent suicides involve hanging, with a minority involving firearms, asphyxiation and poison. • Suicide risk is relatively high for pre-adolescent boys who suspect they might be gay. www.cdc.gov www.teensuicide.us

27. Suicide Gender differences in suicide among young people: • Nearly five times as many males as females ages 15 to 19 died by suicide. • Just under six times as many males as females ages 20 to 24 died by suicide. • Of the reported suicides the 10 to 24 age group, 81% of the deaths were males and 19% were females. • Girls are more likely to report attempting suicide than boys. www.cdc.gov www.teensuicide.us

28. Suicide Cultural variations in suicide rates also exist. • Native American/Alaskan Native youth have the highest rates of suicide-related fatalities. • Hispanic youth were more likely to report attempting suicide than black and white, non-Hispanic peers in grades 9-12. www.cdc.gov www.teensuicide.us

29. Suicide: Youth Warning Signs • Disinterest in favorite extracurricular activities • Problems at work and losing interest in a job • Substance abuse • Behavioral problems/risk taking behaviors • Withdrawing from family and friends • Sleep changes • Changes in eating habits • Begins to neglect hygiene and personal appearance • Emotional distress causing physical complaints • Hard time concentrating • Declining grades in school • Loss of interest in schoolwork • Bullying www.cdc.gov www.teensuicide.us

30. Suicide: Youth Warning Signs – Cont. • Verbal hints-”I won’t trouble you anymore”, “I want you to know something” • Giving/throwing away belongings • Writes suicide note • Extreme mood swings • Unhealthy peer relationships (www.cdc.gov and www.teensuicide.us) • Becoming suddenly cheerful after a period of depression-this may mean that the student has already made the decision to escape all problems by ending his/her life. • Refusing help, feeling “beyond help” • Complaining of being a bad person or feeling “rotten inside”. Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth Suicide prevention school based guide – Issue Brief 3a: Risk Factors: Risk and Protective Factors, and Warning Signs. Tampa, FL: Department of Child and Family Studies, Division of State and Local Support Louis de la Parte Florida Mental Health Institute, University of South Florida. (FMHI Series Publication ( #218-3a,4, 6c)

31. Suicide: Youth Warning Signs – Cont. • Making statements about hopelessness, helplessness, or worthlessness. • Not tolerating praise or rewards • Actually talking about suicide or a plan • Exhibiting impulsivity such as violent actions, rebellious behavior or running away. • Using social media to convey messages 4 out of 5 teen suicide attempts have been preceded by clear warning signs. Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth Suicide prevention school based guide – Issue Brief 3a: Risk Factors: Risk and Protective Factors, and Warning Signs. Tampa, FL: Department of Child and Family Studies, Division of State and Local Support Louis de la Parte Florida Mental Health Institute, University of South Florida. (FMHI Series Publication ( #218-3a,4, 6c)

32. Acute Risk Factors For Suicide – Mnemonic from the AAS I – Ideations of Suicide (Threats to hurt self, talking or writing about death) S - Substance Use Increase P - Purposeless (perception of no reason for living, no sense of purpose) A – Anxiety (agitation, inability to sleep) T – Trapped (feeling like there is no way out of situation) H – Hopeless (no sense/perception the future will be better) W - Withdrawn (from friends, family, work, and society in general) A – Angry (uncontrollable rage/anger/revenge seeking) R – Recklessness (engaging in risky behavior, activities, seemingly without thought) M – Mood Swings (dramatic, unpredictable mood changes)

33. Chronic Risk Factors Of Suicide for Youth • Previous Suicide Attempts • Diagnosable Mental Illness • Previous Mental Health Hospitalizations • Chronic Isolation • Family History or exposure to suicide • Mental Health Issues • Childhood Abuse • Significant Medical Illness • Low Self-Esteem • Poor Coping Skills (www.suicidology.org)

34. Chronic Risk Factors of Suicide for Youth • Life Stressors/Losses/School and family problems/Living Alone • Being Bullied • Sexual Orientation • Juvenile Delinquency/Incarceration • Self-Injurious Behavior • Access to Firearms Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth Suicide prevention school based guide – Issue Brief 3a: Risk Factors: Risk and Protective Factors, and Warning Signs. Tampa, FL: Department of Child and Family Studies, Division of State and Local Support Louis de la Parte Florida Mental Health Institute, University of South Florida. (FMHI Series Publication ( #218-3a,4, 6c)

35. Triggers for Suicide in Youth • Being bullied • Break up with girlfriend/boyfriend • Death of a parent • Divorce • Being ridiculed by peers/not being accepted • A humiliating experience • Contagion

36. Children & Adolescents Case Study – Rating High, Moderate or Low Risk

37. Issues of Suicide Cluster and Contagion in Youth Suicide Contagion:A phenomenon whereby susceptible persons are influenced towards suicidal behavior through knowledge of another person’s suicidal acts. The CDC specifies that a contagion occurs when the death and/or attempts are connected by person, place, or time. Suicide Cluster: The CDC specifies that a cluster has occurred when attempts and/or deaths occur at a higher number than would normally be expected for a specific population in a specific area.

38. Issues of Suicide Cluster and Contagion in Youth • Youth are more vulnerable than adults because they may identify more readily with the behavior and qualities of their peers. • Contagion is rare – only accounting for 1-5% of all suicide deaths annually. (After a Suicide Toolkit 2011: American Foundation for Suicide Prevention and Suicide Prevention Resource Center: p.11, 35, 40-41, 43) • Media coverage can contribute to contagion. Front page stories, simplistic explanations of suicide, graphic depictions and printing photos of the victim can be contributing factors. (Suicide Prevention and Postvention Toolkit for Texas Communities: p.71&78)

39. Issues of Suicide Cluster and Contagion in Youth • Avoiding any sensationalizing, romanticizing or glorification of the suicide or the victim. • Remember anniversary dates can also be a time of increased risk. • Encourage students to get involved with living memorials which may help prevent other suicide deaths. (Suicide Prevention and Postvention Toolkit for Texas Communities: p.71&78)

40. Social Media and Suicide • A suicide death will be discussed using this medium and there will often be a spontaneous memorial posted. • Someone should monitor discussions on social media. Look for rumors, information on gatherings, derogatory messages and indications that a youth may need assistance. Language such as “I am going to join you soon,” “I can’t take life without you,” should be taken seriously and followed-up on. (After a Suicide Toolkit 2011: American Foundation for Suicide Prevention and Suicide Prevention Resource Center: p.11, 35, 40-41, 43)

41. Social Media and Suicide • Be a part of the memorial by posting positive and accurate help related information and hotline numbers. • Find a student leader to help in these efforts and assure them that you are interested in supporting a healthy response to their peer’s death and not trying to thwart communication. (After a Suicide Toolkit 2011: American Foundation for Suicide Prevention and Suicide Prevention Resource Center: p.11, 35, 40-41, 43)

42. Social Media and Suicide • Facebook has specific policies concerning users that have died. These are located at the Facebook Help Center: https://www.facebook.com/help/search?q=death+report • Immediate family members can request removal of the site, the immediacy of social networking creates a critical time lag between the death and removal of the site, which can have serious consequences relating to contagion and cluster activity. • It is critical that the deceased’s site be monitored until a final plan can be developed and executed on how to manage the Facebook page. (A Suicide Prevention and Postvention Toolkit for Texas Communities, 2012, p.180-181)

43. Social Media and Suicide • Immediate family should notify Facebook of the death. This is done by providing information through an online form located at the Facebook Help Center: https://www.facebook.com/help/contact/?id=305593649477238 • A moderator should be identified for the person’s online accounts (usually parents or friend of the deceased). • Provide information to explain how social networking sites can impact further suicidal ideations. (A Suicide Prevention and Postvention Toolkit for Texas Communities, 2012, p.180-181)

44. Suicide Prevention • Parents and teachers can foster early coping skills. • Raise awareness to de-glamorize television and film on suicide. • 2:37 (2006) A drama telling the tale of six high school students whose lives are interwoven with situations they face. The story takes place during a normal school day. At 2:37 pm a tragedy will occur, affecting the lives of a group of students and their teachers. www.cdc.gov www.teensuicide.us

45. Suicide Prevention • Arm youth with accurate information on warning signs, risk factors, how to intervene and link to assistance. • Encourage participation in a gatekeeper training such as ASIST, QPR, ASK, or another evidence based program to develop skills.

46. Protective Factors • Family connectedness and school connectedness • Reduced access to firearms • Safe schools • Academic achievement • Self-esteem (American Association of Suicidology – www.suicidology.org

47. Protective Factors Cont. • Positive relationships with other school youth • Lack of access to any means • Help-seeking behavior • Impulse control • Problem solving/conflict resolution abilities • Stable environment • Access to care for mental/physical and Substance Use Disorders • Responsibilities for others/pets • Spiritual connectedness/Religion Remember that anything a youth indicates as a reason for living can be a protective factor! Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth Suicide prevention school based guide – Issue Brief 3a: Risk Factors: Risk and Protective Factors, and Warning Signs. Tampa, FL: Department of Child and Family Studies, Division of State and Local Support Louis de la Parte Florida Mental Health Institute, University of South Florida. (FMHI Series Publication ( #218-3a,4, 6c)

48. Children & Adolescents Bullying

49. Bullying • According to Merriam Webster : VERB 1: To treat abusively 2: To affect by means of force or coercion Involves an imbalance of power, intentions to cause harm and repetition of incidents. See HB 1942 definition.

50. Types of Bullying - Physical • Physical bullying involves real bodily contact between a bully and his or her victim, for the purpose of intimidation or control. • Biting, Kicking, punching, wrestling, scratching, slapping, poking and choking may be involved • May involve destroying personal property • Sometimes called “hazing”