Please stand by for realitme captions -- Please stand by for realitme captions . Hello? Are you there? -- Good afternoon. The webinar will begin at 11:30 AM Eastern time. Thank you for your patience. Please continue to standby. >>> -- Good morning and welcome to the suicide and self-harm prevention in schools webinar sponsored by SAMSHSA and presented under TA coalition contract by mental health America. My name is Kelle from the national Association of State mental health program directors and would like to thank you all for joining us today. Before we introduce the presenters, I would like to go over a few housekeeping items. Today's webinar is being recorded. The recording, along with a PowerPoint presentation slide, will be available on www.mental health America www.mentalhealthAmerica.net in the www.NASMHPD.org within 3 to 5 days. For participants only audio is being streamed through your computer speakers. There is no need to connect by phone, must necessary. The phone number is listed on your screen. If you're having any technical difficulties during this webinar, please type your comments in the Q&A pod on the right side of your screen and someone will be able to assist you. Please also type your questions for the presenters in the Q&A pod, and at the end of the presentation, we will ask as many questions as we can. The PowerPoint slides are available at the top of your screen where it says PowerPoint slides. Please click on upload file to download the presentation. We will have a short evaluation at the end of the webinar for you to give us feedback. Please take a few moments to complete that. We do not offer CEU credit for our webinars, but we will send you a letter of attendance upon request. My email address will be available at the top of the screen during the evaluation. I would like to thank SAMSHSA for allowing us to share this information with you , and again, thank you for joining us. I will now turn it over to Michelle, program manager of policy and programs mental health America, who will introduce the prudent -- presenters.

Good afternoon everyone. Today's speakers are Molly Adrian and Aaron Lyon. Molly Adrian was born and raised in St. Paul Minnesota and set West to explore undergraduate studies in biology and psychology at the University of Puget Sound. Molly started her postcollege career at Seattle Children's Hospital , which confirmed her desire to pursue graduate study that would allow her to contribute to the health and well-being of children and adolescents. She completed her graduate studies at the University of Maine and a residency and fellowship at the University Washington approach is now an assistant professor at University of Washington and attending clinical psychologist at the division of Child and adolescent psychiatry at Seattle Children's Hospital. Aaron Lyon is an associate professor in the Department of psychiatry at the University of Washington. He is also the director of the University of Washington school of mental health assessment research and training center. Implementation research and technical assistance center focuses on support -- evidence-based behavioral health practices in the education sector. 's research focuses on increasing the accessibility, efficiency and effectiveness of interventions for children, adolescents and families. [ Indiscernible ] that retune the provide care to chronically underserved populations. He

is currently principal of and -- investigator on the grounds of national Institute of mental health national Institute of Justice, Institute of education, science is a very local and national foundations in the U.S. I will now hand it over to Molly and Aaron Lyon.

--

Thank you for that kind introduction. We are delighted to be with you all today to talk about suicide and self-harm prevention in the context of schools. As Michelle mentioned, this is developed under contract from SAMSHSA in collaboration with mental health America. Today we are really hoping to help participants understand the spectrum of behaviors related to self-harm and the public health burden of suicide. We're also going to highlight some of the benefits and challenges of a school-based prevention effort towards reducing self-harm. And then learn about best practices that are outlined through the multitiered system of support and the SAMSHSA toolkit for high schools. To support the prevention of self-harm. Sadly, while there has been reductions in the burden of other health problems, the problem of suicide has in recent years not Dese creased in its burden, but increased for all age groups over 75. So the figures shown here under -- on the slide, on the left it shows the rates of suicide for women from 1999 through 2014. And then the rates in blue orf -- are for men. You can see increases in suicide, particularly for girls in the 10 through 14 age range and 45 through 64 years old. Smaller increases for men , but sadly, tells a story that our efforts to reduce suicide are not currently enough. When we are talking about suicide risk and self-harm risk, we are really thinking about a spectrum of behaviors. Of course, the tip of the iceberg is death by suicide, but underneath that fatal outcome is a range of behaviors that are important to think about and define prior to embarking on any prevention efforts. The suicide attempt is probably easily recognized by all of our participants here. That is a self-injurious behavior that is associated with at least some intent to die and is often characterized by ambivalent intent. Are high school estimates of that behavior are about 8.6% of high school students across the U.S. indicate that they have made a suicide attempt in the past year. So that is one of our stronger predictors of suicide and multiple attempts have a more robust association with death by suicide, and this also has a moderate false positive rate. So just by being a reliable predictor, not all of use who have -- young people who have died of suicide had a prior attempt. Thinking through some of the other behaviors related to the spectrum of suicide risk, there is also an interrupted attempt. This is when a person begins taking steps towards making a suicide attempt, but somebody else stops them before any self-injurious behavior occurs. We really don't have any idea about how often this occurs nationwide. We are not clear on its predictive stories in relation to death -- strength in relation to death by suicide, but one could rely on theory to think about any word of preparatory acts as increasing your risk towards engaging in that behavior. Another dimension of suicide risk behavior is around an aborted attempt. This is similar to an interrupted attempt where the person begins taking steps towards a suicide attempt, but stops themselves before any self-injurious behavior. Similar to an

interrupted attempt, we are unclear about how often this occurs and how it is related to death by suicide. Nonsuicidal self injury is a behavior that is increased in youth in recent years. This is a self-injurious act without any intent to die. So it is often associated with other functions like to relieve distress, internal turmoil or to feel something. For adolescents, this behavior is equally as predictive to a suicide attempt when we are thinking about future suicide attempts. So this behavior is really important when we are thinking about preventing self-harm. We want to encompass efforts that would reduce both nonsuicidal self injury and suicide attempts and behaviors -- as those behaviors are connected to finally, the last dimension that is important to think about before embarking on a prevention program is suicidal ideation. That is thinking about suicide, and that has a big range in severity and persistence. It ranges from a passive wish to be dead or thinking a lot about death and dying to very active thoughts about killing oneself and making detailed plans about that. And about 17.7% of our high school students endorse thinking about their own death in an empowering way -- impairing way over the year. Now that we have does it -- defined the specular -- the spectrum of behaviors, I want to talk through some risk factors for self-harm. We have divided here the risk factors into distal risk factors are more proximal risk factors it is important to note that there is no single cause for self-harm, it is all -- always multiply determined. Distal risk factors to pay attention to include prior self injury, psychopathology , particularly comorbidities that are both internalizing and externalizing in nature, impulsive aggressive traits, and there are patterns by race and ethnicity with our Native American populations being much more likely to die by suicide than other ethnic minority groups and is most likely related to social conditions and the stress and disruption of social structure . We also think through disturbed family context, including family history of suicide and early life in verse three -- adversity. Men and boys are much more likely to die by suicide, where as girls and women are more likely to engage in nonsuicidal self injury. There is also sexual minority youth at higher risk for engaging in this behavior and youth with a history of abuse. Thinking about some of the more proximal risk factors that occur prior to self-harm , typically we find that there are stressful life circumstances, particularly associated with high levels of shame and embarrassed, having accessible means to harm oneself is related to that act. The combination of an intense effective -- affect of state like panic and sleep disturbance, that combination is particularly toxic because one is not able to think through distressing situations under those conditions. Academic and employment difficulties are frequently noted. Functional impairment and pain, suicide in Social Milieu and talking to others about suicide to others and purposeless nets are conditions that occur prior to self-harm. Clearly because this behavior is multiply determined, we need multiple prevention strategies to combat it. Helen Christiansen had written a beautiful article in JMS psychiatry about the need for innovative suicide prevention strategies. When we think through the seven major strategies that are occurring, we can divide them into our universal strategies, strategies that everyone is exposed to, selective strategies and indicate of strategies. -- Indicative strategies. You can see here that we have estimated the number of suicide attempts vented and the number of -- prevented in the

number of death by suicide prevented. And we have some promising indicative strategies with coordinated aftercare and psychosocial treatments, and that we have some other promising strategies for death by suicide that are selective and include gatekeeper training, making those individuals and professionals that are close to use -- youth aware of the protocol for intervening and general practitioner training so all healthcare providers and school-based personnel are really aware of the problem and feel competent to respond. Then we have many universal strategies that include public awareness, media guidelines, means restriction and school-based programming that are really important to think through and combine in order to reduce the burden of suicide. So we are going to focus on a school-based program today and incorporating this integration of universal selective and indicative strategies in the school context. With that, I will turned -- turn to my colleague Aaron Lyon to talk about the role of schools in preventing suicide.

Even though on the previous figure school-based approaches were included only in the universal kind of domain, schools are a setting in which a range of intervention approaches can be used for all manner of mental health difficulties, including but not limited to -- including suicide. One of the reasons at the smart center we find schools compelling, mental and academic health problems cooccur. In general, I would say that the different types of problems tend to cluster together, and that is certainly true for academic achievement and mental health problems, with problematic achievement predicting mental health problems as well as the reverse of that with mental health problems being a significant predictor of problematic school achievements and other types of school relevant outcomes, things that might not be directly in the achievement bucket, but things like school attendance, which really needs to be a threshold behavior for kids who want to ultimately be academically successful. For a lot of these reasons, schools have consistently been identified as the most common setting for the delivery of mental health services . Some studies indicate that up to 70% to 80% of kids who receive mental and behavioral health services in schools, there are differing estimates, but all of them point to at least 50% of kids who are getting these kinds of services tend to get them in schools, which translates into about 20% of all students receiving some manner of school mental health services annually, which is a massive number of kids and a considerable public health and population health impact opportunity. This is made that much more compelling by the fact that schools tend to improve service access in a disproportionately positive way for traditionally underserved youth. These are low economic status or ethnic and racial minority youth or youth from those types of backgrounds. That is exactly what we found in the paper we did a number of years ago where we looked at different service youth , specialty mental health, schools and private care the big three. We looked across different ethnic and racial groups, and what you can see is that schools were largely a great equalizer in terms of providing accessible services for kids who had pretty differing levels of access in more traditional mental health settings. High school certainly provides an accessible setting for identifying at-risk youth. Not just high schools, but often talk about high schools when we are specifically targeting youth suicide risk, though she -- we should not

limit ourselves to high school. We have some methods for doing universal screening, and there is been great research over the last few decades supporting those -- the value of that screening. But what we also know is that the actual practice of school-based screening for things like emotional health, suicide risk, could be substantially improved. There is a lot of different things that load on this issue and that interfere. Some of them are practical concerns. Who is going to spend the time to do this, where are we going to cut into instructional time, which is always an issue in schools, as well as who is going to deal with any particular identified youth who will need follow-up support. That is often the most commonly reported barrier to doing some degree of universal emotional health screening in schools. What some of our colleagues do -- have found is that a lot of the kids who are identified based on something like a universal screening actually tend to need types of services that may not be traditional mental health services. They found some -- of they have done great work over the last few decades focused on this and of identified the many kids who screen positive in an emotional health screening in schools actually need things like homework support, and that those things are actually more closely linked to some of their distress in things that would necessitate some more traditional mental health prevention. For all of these reasons, we have very you schools carrying out routine emotional health screening when they do, they tend to happen at best maybe once a year. We know that things like depression and suicide risk can be cyclical and sometimes those things don't match up perfectly. One thing that we used to conceptualize school-based mental and behavioral health services, and we are certainly not alone in this and did not invent it by any stretch of the imagination, is what has come most recently to be known as multitiered systems of support. This is based on the traditional public health model that Molly was referencing earlier in her figure for different types of services related to suicide. We have universal approaches that are roughly applicable -- I think the standard percentage that gets thrown around when discussing things like multitiered systems of support is 80% of students in a particular school would be in the universal part of the pyramid. Selected services, short-term and sometimes group-based interventions would be the result of some degree of screening and those who would need more intensive services, up to 5% of the student population would require more intensive types of services. These are really universal selected and indicated types of interventions in schools. This is applied often in schools, or at least discussed often in schools, even if it is -- to both mental and behavioral health programming as well as academic programming as well.

SAMSHSA has also outlined a framework for high schools to consider the prevention of self-harm. What we would like to do for the next part of the webinar is overlap the SAMSHSA framework with the MTSS framework to integrate those components that are outlined as best practice in SAMSHSA and the MTSS framework of universal indicative and selective intervention to give people an idea about the opportunities in school-based programming to reduce likelihood of self-harm. There are six core components in the toolkit for preventing suicide in high schools. I will walk through these components and the support for the components, and then I will turn it back to Aaron Lyon to think

through the practical issues and how implementation science can reduce the gap between what we know works and the usual operating procedures in school. Thinking about three of the six components outlined by SAMSHSA, they are really about education for staff, parents and students about self-harm. There are programs for students that include suicide and self-harm specific information like signs of suicide, sources of strength and a local program to provide education about those definitions of self-harm risk and how to compassionately talk with individuals that you believe are at risk and escalate them to the next level of care. When thinking about education for students, we also need to consider parents and their role in helping support their use and -- youth and also find resources when what they are currently doing is not working. And of course, staff we need to be trained in education programs. There are several programs outlined like UPA or -- QPR and Asist that have solid gatekeeper training in order to help staff be aware of the signs. Another part of the universal component for self-harm prevention includes universal screening for students. The data for screening highlights that particularly for internalizing problems, youth are identified who are not service-connected and it is useful to identify those kids and provide the more support and our colleagues have a long history of that work. For parents, they would also need information about the screening and the warning signs and the school response, and of course, staff needs education regarding the crisis response procedures. Another area of universal exposure for students is around integrated social and emotional learning curriculum. States are increasingly adopting mandates that their public schools have this curriculum to help youth understand their emotions and social competencies and have that as a part of the standard learning that occurs in schools in a more systematic way. Thinking through the effects of education programs, parent and staff education, the Garrett Lee Smith legislation highlights the effectiveness of the gatekeeper training strategy and shows both reduced suicide attempts and death by suicide, however, there are really important lessons in that work that the training efforts have to be are going to really show reductions in these suicide related behaviors. So as soon as the training and implementation supports are reduced, than those effects are reversed. For student education, the existing work highlights the skill acquisition, that it may be a critical component important to include for the school-based prevention efforts. We have some data to show that the education is really critical as a component, and that schools are struggling for how to adopt these programs. We talked about screening a bit, we have highlighted that the effective identification is really critical, but the screening and follow-up assessment places so many demands on gatekeepers and clinicians that feasability is really a concern. Thinking about selected interventions, the next level of MTSS and how that overlaps with the SAMSHSA framework, the assessment following screening would be an activity that students are engaged in, and then finding supports for those students. In order to do that effectively with students, staff really need to be trained to have their key duties identified to determine how to talk to students about their emotional health status and provide them increased support. And then, determine how to give the right level of support when needed for students. The indicative education component is for youth who have already demonstrated self-harm behaviors . Really for students, the

individual intervention is well-established that safety planning and crisis prevention planning is a critical component of care and providing referrals to evidence-based self-harm specific treatments is indicated. Parents, of course, need to be involved in these decisions, but there is an absence of data for us to rely on best practices here, so schools are really left on their own to develop their existing relationships with parents to figure out how to communicate effectively with them to reduce risk. Staff have a lot of [ Indiscernible ] to do in this area where the responding to nonlethal suicidal behavior is really challenging for people. It requires some training that is outside of what is expected for support students academically. And staff also needs to be trained on how to respond to death by suicide as, sadly, this occurs in schools more frequently than we would like and has an impact on all of the -- every single person in the school. I am going to turn out to Aaron Lyon to have us talk about translating this framework to the school context and how it has been challenging.

We have evidence-based practices or at the very least best practices surrounding a lot of ways that schools can respond to suicide risk or attempts. However, I think in schools we wind up experiencing a phenomenon and problem that is also rampant through other sectors and all of healthcare per it is really this overarching issue that all the research we have done an effective interventions and practices we have found are rarely implemented and even less commonly implemented well come up with adequate fidelity, to expect the result that would be intended. There is a classic study that those of us who do work and implementation like to reference with some regularity, and that is the fact that it takes 17 years for just 40% of original research to benefit practice. I think this really -- 14% of original research to benefit doctors and speaks to the difficulty in getting effective programs and practices and policies into place. It is an issue in schools, but we're certainly not alone. Back from training, I got a big binder, the training is already forgotten, but the by the -- binder will last forever, a living monument to peppery knowledge. This is probably one of the most -- temporary knowledge. This is probably one of the most common things you will see. The reason this get so much airtime is because this reflects one of the more robust findings within implementation science but that is that --. That is that trainings are fairly ineffective as a way to change professional practice. It is much more complicated and requires a lot more posttraining support if people are going to do more than just absorb knowledge and really change what they are doing and what people are doing in schools this moves into the need to think critically and explicitly about the variables that drive successful implementation strategies to address them and ways to evaluate their success. Implementation determinants are your barriers and facilitators. These are the factors that obstruct changes in professional behavior or service delivering processing. There are a number of helpful determinate resources out there, conceptual frameworks like the consolidated framework for implementation research that details a lot of different determinants that are relevant in various taxonomies of determinants and measures a particular determinants, things like the implementation leadership scale or the implementation climate scale that our colleagues have put together.

There are plenty of other examples as well. I think one of the important things to recognize is that determinants exist across system levels some of them may be individually oriented , could be the attitudes, perspectives or training backgrounds of the individuals involved, and also organizational level determinants we often conceptualize as occurring at the level of the school building or the district to the extent to which leadership engages in munication techniques and modeling in order to demonstrate the importance of delivering evidence-based mental health practices. Implementation strategies are the methods or techniques used to enhance the adoption, implementation and sustainment of practices. So these are things that are really intended to address determinants, either leverage of the philia to determinants or to minimize the impact of those that might be inhibitory Brooke these are things -- inhibiting. These are things like making a training dynamic. This comes from work we have done where we took an existing compilation of implementation strategies developed by our colleagues and others for a project and adapted these for a school-based service delivery. I did this in collaboration with Clay Cook and other people affiliated with the center. What we did was get ratings from school-based behavioral health consultants about the feasibility and importance of particular strategies. We have things like make training dynamic is actually the most feasible and important in the perspective of the 200 behavioral health consultants who participated in the study. We also have things like distribute educational materials being relatively feasible and important. Down here we have change school or community sites which is relatively difficult to deal. Create or change credentialing or professional development standards. Both the policy changes that I think are often seen as is feasible and less important. One thing we see here is feasibility and importance tend to be related in a fairly linear sense. Anyway, I think that is probably a positive. I also want to get into implementation outcomes. We have our determinants, strategies impacting determinants, and in our Logix chain we have implementation outcomes as a result of the strategies that then leads to service outcomes. So if limitation outcomes are the effects of deliver it -- deliberate actions to implement new practices. This is a slightly adapted version of work done in St. Louis demonstrating the implementation outcomes, things like the extent to which a practices adopted and seen as appropriate to context. These kinds of things. Fidelity is a cornerstone. They are related to service outcomes, things like effectiveness, equity, student centeredness and ultimately student outcomes of functioning and improvement in symptoms. >> We have spent 40 minutes talking about our conceptual frame about how the integration of the SAMSHSA principles and MTSS framework can really be utilized to help develop well thought out suicide prevention strategies, and we found that after talking a long time about conceptual issues, people frequently want to know what to do when they believe a youth is at risk for harming themselves. We want to spend the rest of the time talking through the core tasks for any person interacting with youth to do when they believe that the child is at risk. Really, the first thing that we need to do is ask the question about self harm. I am going to walk through the set tasks, and then we will open it up for questions. We want to ask the question, understand the motivations for self harm because it is clearly serving a purpose if it is repetitive, assess the severity and present options

for alternatives, and then monitor status, and try to ensure continuity of care and connect with behavioral health if that is not your role. So often we get the question that for youth that are self harming, there is concern from individuals that if they ask, are you thinking about harming yourself or suicide, that that may be interpreted by the teenager as a suggestion. There are some well-designed studies that suggest that there is no iatrogenic effect of asking individuals about self harm. In fact, the youth report feeling relieved and understood when people just come out and asked the question, have you harmed yourself, have you thought about harming yourself, are you thinking about suicide so if there is one thing that people should remember from the webinar today, I would like this slide to be it. The second task is really around understanding the function of self harm. You want to have communication strategies that have been highlighted primarily around substance abuse, and now extended to many other areas and are well-suited for adolescent development. It is really around motivational interviewing. Asking questions that are needed for assessment can also generate a change. You want to be thinking about the function. You can ask things like, are there disadvantages to continuing self harming, are there things that are motivating you to stop hurting yourself, and there are lots of options for help, what do you think you would need. So really continuing in the Socratic method to highlight the choice, to look for readiness for change, and augment that any sort of change that you are hearing from the adolescent. I think that checking your own values about self harm and your assumptions about that behavior a really critical before interacting with a youth with this history. Once you have done that, you can have a curious yet dispassionate communication style about self harm. People worry a lot about either being judgmental or being reinforcing, and somewhere in the middle is what we would recommend. So being really matter-of-fact and curious about how this behavior is working for them and what they would need to change can be the most effective way to proceed. Also tried to really validate the distress in their struggle -- and their struggle. Anyway you can weave in validation strategies, communication style that would highlight that their actions make sense given the context and what they are going through right now. Some common validation strategies or statements I use are things like, it has been really stressful for you right now, you're not sure how to handle this, it is hard for you to think of other solutions because cutting has been working for you, even though in the long term you can highlight a lot of problems. Really trying to validate what is valid , finding the kernel of truth, can help you connect with the youth in order to help them fill understood and more ready to changed we also want to be familiar --. We also want to be familiar with the risk factors and be able to assess the core dimensions of the suicide risk. There are many different short assessment tools out there. Often we know that people like acronyms to help them remember what sort of assessment questions to ask. So we have highlighted one here for those who are looking for something handy that has been evaluated in the literature that you can use the acronym stops fire. Suicidal ideation, asking directly if you they have thought about killing themselves, does this occur when you are harming yourself or other times. And then youth who are having thoughts of suicide and self injuring are at higher risk. You really want to understand the type of self harm they have been doing, in what ways they injure

themselves. As you might expect, more methods is an indication of higher risk. You want to ask about onset. When the behavior first began. You want to ask about place and location, with genitals and face being more unusual and associated with higher risk. You want to ask about the medical severity. If it has cause tissue damage, if they have got medical treatments and the higher severity is of course associated with higher risk. Any hospitalization or reopening of liens associated with higher risk -- wounds associated with higher risk. And then you want to understand what is working with the function. Often we see functions of escape from distress. Kids will say they just want their burdens to go away or they just want to not be dead so they are not thinking about the situation anymore. And clearly in a relationship with suicide shows a higher risk than those behaviors that don't. I ask kids to re-intensity. What the urges are like on a typical day. And how much repetition is occurring, and then the episodic frequency. In a typical we, how often is this behavior occurring. As I mentioned before, this is just one of many assessments out there, but I think this highlights the key areas that are important for a provider to make a determination about next steps, whether it would be a referral to ongoing behavioral health our weather an emergency depart Drush or whether an emergency -- or whether an emergency department evaluation needs to be done. Think about management and treatment. There are no FDA medications for treatment of self harm. There are several promising psychotherapy practices. There is a recent analysis I encourage folks to look at. The dialectical behavior therapy is a therapy that has been well established in adults for reducing the spectrum of suicide risk behaviors and is downward extended for youth with emerging data showing a lot of promise. Metallization and problem-solving therapies -- mental association and problem-solving therapies and the collaborative assessment and management of suicidality is another intervention that is been downward ex tended for youth and has data showing promise for suicidal ideation and attempts. But no data on self harm. When thinking about the promising psychotherapy practices and the common elements, they really focus on observing and describing thoughts and emotions and working on more accurately interpreting one's own and others' behavior. Skills related to mindfulness, emotion regulation and interpersonal effectiveness are all key to the reduction of self harm risk. So in conclusion, we think that people working in high schools are likely to encounter teenagers who self harm and clinicians, whether they are a nurse practitioner or a school psychologist or behavioral health therapist, can be prepared for these encounters by understanding the MTSS framework and SAMSHSA framework to support students, by exploring their own reactions to self harm, focusing on the function and course of self harm for the youth in front of them, and being prepared to address the problem with both validation and motivational interviewing strategies, and know when to refer and who to refer to when teenagers are willing, when harm is dangerous or repetitive, or indicates high risk. With that, it looks like there are several questions that have come about during the discussion. So we can turn to questions.

The first question for presenters, a confirmation that you said that the [ Indiscernible ] was a strong predictor of suicide attempts.

Yes. I am confirming that statement. There are several manuscripts that a been published that highlight that nonsuicidal self injury and suicide attempts are equally predictive in the adolescent age range for future suicide attempts. When we think about that, we could lean on a model about the capacity to harm oneself. Once you have acquired that capacity to harm yourself, you have reduced your thought of harming yourself, that is a barrier removed and you are more likely to do so in the future.

I am curious about talking about suicide as a proximal risk factor. And you speak more -- I want to know how much weight is on that risk factor as I thought that was a misconception of suicide risk.

I definitely pay attention to anyone who is talking about suicide. It is pretty unusual behavior. It would warrant a follow-up. Certainly, there could be other functions of that messaging, of talking about suicide, but it is one that would need further assessment to clarify. It is not a miss -- misconception to consider that behavior risk factor. It is legitimate and real.

How are they percentages calculated on the slide that showed reduction in suicide and attempts by prevention strategy?

That was based on the work of Helen Christiansen and the JAMA psychology article that took the existing literature and calculated percentage of self harm prevented based on the -- each intervention. I could send you that article. It is a good one. >> I am in -- do you have suggestions on effective universal screeners we can use for high school students?

There are several out there that have good psychometric properties. I think it would really depend on what your goals are for the screening. We have a screening project we are doing right now that we are using the strengths and difficulties questionnaire combined with the suicide behavior questionnaire revised because we were interested, not only in suicide specific domains of risk, but also interested in internalizing and externalizing problems. Another suicide specific measure that I would recommend is Lisa horror whisk -- Lisa Horwitz ASQ that is in the NIH toolkit and has been evaluated and has solid psychometric properties for suicide risk specifically. >> Is SAMSHSA working with the Department of Education to provide resources to encourage states to implement QPR and Asist?

I don't know. Do you know? [ Laughter ]

We can follow up on that. Next question, -- is there a SAMSHSA Representative with us?

I will make sure these questions are sent to the appropriate person to get the answers. Next question, can the dispassionate communication style be further clarified?

Yes.

She worries it might come across as disengaged and disinterested to the struggling of the youth .

That is a great point. I think the idea here is to feel like you have considered your own reaction. So you are not overly invested in the interactions. But I think balancing -- I tried to be warm and curious, but not overly so. I think we know that for some youth there is a social function to their self injury and it can reduce burdens, social burdens and expectations in their life. We just want to, even though that is a minority of youth, we want to be aware that there can be a social function and that we have a role in reinforcing all farm. -- Self harm. That is the essence that I was trying to convey with the dispassionate response. You don't want to, in response to a child self harming at school, you don't want to send them home and have -- and be over accommodating to the child and really just remain curious and calm in order to learn more about the behavior not be afraid to talk about the behavior directly.

Where does social media fit?

We are -- we don't know yet. Where social media falls into the core tasks for clinicians or school personnel. We are involved in a project where we are evaluating exactly that, how would social media data be used in understanding risk for suicide and how would school personnel -- how would they manage that information. Is it helpful, burdens and -- burdens and -- burden some? We know that they are heavy users of social media data and prevent suicide risk behaviors on social media, but unfortunately now we don't have great guidelines about how to incorporate that in the clinical care.

I think there is opportunity there. Our project is designed to adapt an existing machine learning algorithm to address social media postings in order to ideally build a system that can remain continually awake to risk. Earlier we were talking about -- even when screening occurs, it is likely only to occur maybe once a year at best. And anything that can get us into more of an active awareness state has potential promise.

Even in my role as a social worker, I ask all these questions, but what efforts can be taken to ensure the safety of the child and also avoid liability?

That is a great question. I think the main responsibility You have is do not be the sole keeper of that information. So once you have established what the behavior is and its severity, you want to work with the teenager following your school procedures about who to communicate with next, whether it is a referral to more frequent behavioral health interventions, munication with the parents, communication with the primary care physician. After you have done that assessment, but we do is connect with the teenager and develop a support plan. Try to get them motivated and tapped into creating a plan for change, and then negotiate with them about how to communicate this information to their other support people in their life.

We created a districtwide mental health subcommittee if years ago made up of district support staff, administrators, parents, occasional youth and school committee members. It is been successful in some ways and limited in others. To have any best practice research on the most effective role in advancing this work?

That is a great question. I don't feel like I have seen anything that explicitly evaluated or set out best practices for developing or maintaining that kind of a committee. It sounds like a lot of the critical stakeholders are involved in the committee that was just reference. The one thing that may or may not have been in one of the categories is external supports as well because, even within the multitiered systems of support approach, there is a relatively small percentage that might be receiving the most intensive services, there is a threshold that is variable depending on district and building resources as well as the available community resources or supports where sometimes the most effective thing to do is to do a good job of facilitating a referral and making sure it happens. So just taking a comprehensive approach to something like suicide risk or intervention for suicide risk, ensuring that there are clear connections to external providers as well is going to create more of a partnership where the school does not not -- need to go it alone.

It sounds like they are already doing really impressive work and to stick with it and keep going, even though there are roadblocks, that will be a key to helping the work it done.

-- Get done.

Do the parents always have to be included in these processes? Some teenagers want help at the thought of parents being involved would stop them.

I think in our state, we are in Washington state, in the age of consent for psychological treatment is 13. Depending on the level of risk, and our confidence in the support plan, we would -- if a kid was at low risk and we thought there was some indication the parents would not be helpful, then we would proceed without parental involvement, but I would say the majority of cases we do include parents and have to be -- we have to have some indication that it would not be helpful to exclude them from the process. >> If you us as a teenager and realize they are at high risk, how do you move the conversation to referring?

That is a good question. I just try to be as straightforward as possible. I say, thanks so much for talking with me about these areas, I know it is really hard to talk about this, and I am really concerned that what you're doing right now is harmful to you in the long term and that we need to develop a plan for helping you get more support so you're not feeling so overwhelmed and engaging in this behavior.

I have seen liability issues in sending students to hospitals due to the ignorance around self harm pretty agree this could make the child worse and call extreme attention to their coping behavior?

I think that there are a lot of low-level interventions that can be done prior to sending a student to the emergency department. The emergency department for evaluation is a high-level intervention that I think should be reserved for those at high risk. If there is no assurance of safety in the community. It is costly and burdensome for the child, for the family, for the healthcare system. So I agree it should be used only when kids are indicated at high risk. >> Once a school already provides universal suicide prevention education, what further types of programs should we look into? Support groups etc.

Can you repeat that? >> She would like to provide additional programs. What types of programs do you recommend to look at?

That is great that your wanted to do more for your community and school. I would think about the -- what sort of training that staff are getting to be gatekeepers. I would think about the universal strategies for youth. There are SEL curriculum outlined for different age ranges that can be found on the Castle website. There are also emerging work using the dialectical behavior therapy strategies in the school context and there is a book on how to do that.

-- It sounds like some good work about what mental health problems are, how they are different from typical adolescent development and you can augment that work by having some future training around suicide specific risk and skill-based work for all youth.

As a community behavioral clinician, do you have any suggestions on how we can partner with schools that have limited ability to spend time assessing students as school counselors become overwhelmed with a large caseload and responsibilities?

Absolutely. What a great question. I think that what we were talking about earlier about being involved with the district and having those handouts would be one really natural way to help contribute. I also think that, if your organization is available and willing to do some of those evidence-based strategies, including crisis prevention planning, means restriction, looking at those indicative interventions that could really be lifesaving for kids would be a huge help to the school. >> Has there been anyone looking at the rate of suicide or attempts through the Netflix show 13 reasons why?

That is a good question. I know there was so much discussion about that show and concerns about the presentation, that it was not accurate to what a suicide crisis looks like, that they did not follow best practice guidelines and how to present talking about suicide and preventing media about suicide. There was also local concern here about the increased volumes at emergency departments around self harm risk. That is all anecdotal as far as I can tell. I have not seen databased publications regarding the impact of that show on youth . So given how slow the pipeline is from analysis to publication, perhaps there is something in the works that I have not yet seen that will be

forthcoming soon. But I do know there was a lot of concern and discussion about the show anecdotally. >> What [ Indiscernible ] to see between students with suicidal ideation and mass shootings? Are students willing to do self harm more at risk of shootings?

That is a good question in such a low base rate behavior that it would be hard for me to draw any conclusions for you about that connection. The thing we know about youth who are at risk for harming others, the best predictor of future behavior is past behavior. So if there is -- instead of focusing on suicidal ideation, I would be focusing on identifying homicidal ideation, thoughts about harming others and doing an assessment and safety planning around that. I think for the vast majority of youth who are suicidal, they will not go on to be mass shooters. To target that group, we need to target homicidal ideation.

Have there been any research into using an act as a screening tool?

-- App as a screening tool?

Yes, definitely. I have not seen much of that work in the school context, but Laura Richardson, colleagues in pediatrics, have used an app called checker software, -- check yourself, youth do screaming -- screening and can discuss the results with their physician. I would think a very similar type of app-based program would be adaptable to the school context as well. I think it reduces some of the feasibility concerns around who is going to print, distribute, score the questionnaire, but there is still a set of feasibility concerns in the school context that are not yet address, which would be who will respond to the high risk youth and how we are going to monitor and track those high risk youth.

Are there any evidence-based peer-to-peer programs or do you find peer-to-peer programs to be too risky to implement?

I don't think that peer-to-peer programs are too risky to implement. I think it is really an emerging area of work and has so much promise. If we can get youth who are motivated to talk about the issue and teach their peers, I think it is super promising and compelling and may have better affects than the teacher led and clinician led trainings occurring now. However, this is all very much a conceptual discussion. I have no data to support that. But I love the idea of peer to peer training. Given the right environment where peers have high quality training and support to do that, I think it could be beautiful and a very acceptable, feasible approach. >> When training teachers, what considerations should they be taught when students have the majority of students that are Latino and other minority populations?

I think that the goals of teacher training are really in that case he beer -- gatekeeper capacity. So being aware of the distress that students are experiencing and part of being aware of that is being aware of cultural differences and what acceptable expression of distress is, and how families might respond to the behavior. So I think taking an individualized approached and thinking through the

cultural questions would be very applicable here given how stigmatized the issue is, and that stigma can be different across different cultural groups. >> Is it possible to differentiate attention seeking self harm behaviors and that of suicidal risk?

Attention seeking self harm behaviors can also have suicidal risk because any nonsuicidal self injury can turn into a lethal self injury provided an unfortunate circumstance. So I think you are exactly right, this can escalate and lead to unattended -- unintended consequences. The main way to differentiate between the social function of nonsuicidal self injury and the emotion regulation function of nonsuicidal self injury would be to use a functional analysis. Looking at the antecedents to the behavior, what it is and the consequences of the behavior. Functional analysis, chain analysis evaluating those conditions and the effect on the person's experience, that would be the only way to determine that.

What are your thoughts on [ Indiscernible ] for building the capacity of informal support for youth?

I think that program has a lot of promise. It is certainly being adopted across the nation and has useful concepts that will reduce stigma and will increase capacity for empathic responding. I like the message that we are very likely to run into someone who is in crisis, or more likely to run into that sort of situation that we are with someone who is having -- a need for CPR. I think it is a solid program with good messaging.

Are there any plans to coordinate a national resource center for areas who experience suicide contagion?

I think that is above my pay grade. Maybe that is a SAMSHSA directed question.

We can put that in the cluster of SAMSHSA questions that we will be able to answer. Do you know of the severity rating scale effectiveness with youth?

They are is flexible use of the Columbia, and their website has detailed information about youth versions of the screener, and there are now a handful of publications that highlight the psychometric properties and utility. In my experience, training on that measure, I think people struggle a little bit initially and might need help to identify the core spectrum of behaviors assessed, but once they take that initial leap, they feel comfortable.

What is the best course of treatment for students that are chronically self harming with no suicide ideation who have no motivation to stop, even after years of therapy?

It seems to me that you would want an intervention that has a strong motivational interviewing enhancement component. I would think that dialectical behavior therapy would be an appropriate fit with this type

of presentation. It is a real struggle when youth have no motivation to change and are at high risk. I think that DBT operates well with those principles given that heavy emphasis on creating conditions for change and balancing that with acceptance and validation. That would be my go to. I think there are other self harm specific interventions that can be useful like the [ Indiscernible ] and other CBT strategies, but it is really hard if you don't have a motivated kid, we tend to lean on family members to help create conditions of engagement if our best therapeutic strategies are not working.

What are some best practices at the community level? Everything seems to be centered around health professionals and those at the school level.

That was the focus of the webinar. We just focused on the school context for sure. I think the lessons here are certainly applicable in other community-based settings. So you want to think about the universal selected and indicated interventions for folks in the resources to deploy those. The principles of training people to be aware of what a self harm crisis looks like and how to respond to that is generalizable across contexts.

In the presentation you mentioned a connection between socioeconomic status and risk. Do you think this is true of both urban and rural areas?

Yes. I think the conditions of distress, poverty we know is terrible for child development, and there are some differences that we need to attend to in both rural and urban settings, particularly access to specialty care . So as much as we can train people in the principles of being aware, asking the questions and referring, I feel like in those rural communities, the options are so limited that we really need more capacity to be able to treat children when they are at high risk. I think that is a huge challenge ahead of us. We hope to have a technological response to that where we have online and telehealth interventions that are accessible to people wherever they are. But I think the promise of that solution is yet to come. >> What is the rate of suicide contagion in is there more specific protocol to address that?

That is a great question. We do know -- I wish I had figures off the top of my head, but I don't. We know that contagion is kind of a developmentally specific phenomenon that occurs in adolescence through merging -- emerging adulthood. The primary ways in which contagion have been managed is around media reporting, and then following up with youth who we believe are at high risk . So that high risk indication would be youth who have had prior self harm and who are close to the person who had died. So the best practices are outlined in the SAMSHSA toolkit and the CDC also has some guidelines about their recommendations for managing suicide contagion that I would direct people to. >> Last question, does the research yield a comparison of teen suicide within southern states in comparison to the opioid crisis, doesn't modify your approaches to prevention models?

-- Does that modify your approaches to prevention models?

That is a great question. Certainly something want to ask about, kids who are using substances, the comorbidity where youth with internalizing problems like depression and panic combined with externalizing problems like substance abuse are certainly at higher risk, and over half of suicide attempts across a lifespan occur when people are intoxicated or under the influence. So it is a great point that it is something we need to think through and also be treating when present. I don't think it changes the approach at all, but it would change the indicated strategies that are occurring if a person is addicted to opioids.

Thank you for presenting such an awesome presentation. Michelle, thank you for facilitating the questions. For the questions we were unable to answer on the webinar, I will download them and send them over to the doctors to answer and respond to you directly. The questions that were geared a little bit more towards SAMSHSA, I will send those questions to our representative at SAMSHSA and ask him to help us out with those and respond directly to you with those. Thank you again for joining us today. Thank you SAMSHSA for allowing us to share this information. I am now going to switch the screen to a short evaluation and ask you to take the time to fill that out for us. Again, thank you for joining us. If you would like a letter of attendance, please send an email to me and I will send one to you as soon as possible. Thank you again for joining us today and enjoy the rest of your afternoon. [ Event concluded ]