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Youth Suicide Prevention in the Foster Care Systempresented by:Karyn Brownson, MSWDirector of Trainingwww.yspp.org

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Introductory scenarioKrystal, age 14, has just been placed in her aunt’s home after her mother and stepfather were incarcerated in a drug bust covered by local media. In your first meeting as her new social worker, she discloses she has been skipping school and avoiding her friends since the arrest because “everyone knows what happened and my life is basically over.”

After saying this, she pushes up her sleeve and you notice a row of small, healed cuts on her forearm. Later in the discussion you ask Krystal if she has ever attempted suicide, and she says, “Once in seventh grade. But I did it wrong and THAT time it didn’t work.”

Write down: • What concerns would you have? • What would you say to Krystal in response?• What actions would you be required to take?• What other actions would you choose to take?

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Networks for Life: A Social Workers Role in Youth Suicide Prevention

I. Introduction: About Youth SuicideII. Prevention: Knowing the Issue III. Youth Suicide in Washington: DataIV. Prevention: Creating a supportive,

preventive environmentV. Intervention: Identifying those at risk

and when to step inVI. Postvention: After a Suicide

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I. Introduction: About Youth Suicide

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Introductions• Your name

• Your role

• How long you have worked in children’s services?

• Initial questions or concerns about youth suicide

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Youth Suicide Prevention Program

Mission• Support and advocate for youth through mental

health promotion, community solutions, and suicide prevention.

Vision• YSPP envisions healthy communities where

youth suicide does not occur.

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Youth suicide: the facts• An average of 2 youth between the ages of 10 and

24 die by suicide each week in Washington State. • 15% of WA 6th graders, 17% of 8th graders, 19% of

10th graders and 17% of seniors reported seriously considering suicide in the last year.

• Youth suicides outnumber youth homicides. Suicide is the second leading cause of death for WA youth.

• Suicide risk is reduced by increasing protective factors and working to change risk factors.

• Peers and adults outside the family play a key role in prevention.

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Everyone has stress and problems

Some people have depression and other mental health issues

Fewer people think about suicide

Even fewer people attempt suicide

Fewer people

die

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Elements of suicide prevention in youth-serving settings

• Prevention– Educating staff– Educating youth and their caregivers– Protective factors in place– Resources like counselors and referrals– Policies and procedures, including crisis

planning

• Intervention– Process for identifying youth at risk– Consistent, coordinated response to identified risk– Process for involving support resources

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Elements of suicide prevention in youth-serving settings

• Postvention– Clear, up-to-date policies and procedures for response

after a youth suicide or attempt– Mechanism for re-entry for youth after hospitalization– Mechanism for identifying those left vulnerable by the

loss– Communications strategies for clients, families, and

media to minimize the risk of suicide contagion– Engagement of resources in the agency and

community, leading to ongoing support– Circles back around to prevention

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Sequence of crisis management

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II. Prevention: Knowing the issue

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Typical adolescent behavior

• Testing rules and limits• Touchy if asked too many questions• Moody at times• Easily embarrassed• Amplified emotions and reactions• Moving away from family – peer-oriented and motivated by peers' approval

How does typical behavior differ for youth who have experienced trauma?

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Risk and protective factors

• Risk factors increase the risk of a negative outcome like suicide.

• Protective factors reduce the impact of risk factors.

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Some common risk factorsPersonal

Characteristics Experiences Health and Mental Health

Personality and Outlook

Member of a vulnerable identity group (gender, race,

disability, location)

Sexual orientation

Family history of mental health problems,

psychiatric hospitalization, substance abuse

ACEs

Loss (death, breakup)

Humiliation (bullying, public failure)

Sudden stress (violence, unplanned

pregnancy, arrest, failing a test)

Instability (frequent moving, unstable family)

Social isolation

Exposure to suicide

History of attempts

Depression

Substance use

Other mental health disorders (anxiety, schizophrenia, bipolar disorder, eating

disorders)

Personality disorders

Physical disability or chronic illness

Cognitive impairment

Traumatic brain injury

Psychological pain or distress

Hopelessness

Feeling like a burden

Perfectionism (especially combined with

depression)

Black and white thinking

Poor problem solving

Feeling trapped

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Foster care youth

• Additional and unique risk factors– Childhood trauma including family abuse or neglect– Higher rates of several mental health problems– Disruption due to removal from home, possible short-

term-term placement, changing homes and schools, separation from siblings

– Special concerns around aging out – homelessness, loss of resources, transition planning

• Less access to protective factors

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This all leads to…

• Unique and elevated risk of depression and other mental health issues

• Unique and elevated risk of suicide

• Difficulty accessing protective factors that could mitigate the risk

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Some common protective factorsIndividual Family Agency or

Organization Community

Good physical and mental health

Willingness to seek help

Problem-solving skills

Self-soothing and coping skills

Self-esteem and self-worth

Risk avoidance

Belief system that discourages suicide

Supportive adults

Safe and stable home environment

Restricted access to means in the home

Responsibilities (pets, for example)

Strong family connections

Family support of identity

Reasonable expectations

 Supportive adults

Access to peer support

Connection to a network of resources

Responsibility and future orientation

Opportunities for participation and skill

building

Safe place, supported by policies and culture

 Adequate and accessible health and mental health

care

Safe spaces

Opportunities for youth to contribute positively

Sense of belonging

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Foster care youth

• Unique protective factors– Educated, prepared foster families– Trained and supported front-line child welfare and service

provider staff– Stable placement– Access to mental health care while in care– Access to educational support while in care– Transition planning and aftercare support

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The more risk factors and fewer protective factors…

• The higher a person’s risk of depression and other mental health issues

• The higher the person’s risk of suicide

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Youth depression: some facts• One in every 8 adolescents may have

depression. Major depression is more common in higher-risk groups.

• The majority of children and adolescents with depression do not get help they need

• Depression is a treatable illness that is not the person’s fault.

• Treatment for depression could include counseling, medication, or both.

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Youth depression: some signs• Irritability• Anxiety and/or persistent feelings of sadness• A drop in school performance• Problems with authority• Indecision, lack of concentration• Overreaction to criticism• Frequent physical complaints

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Other mental health issues linked to higher suicide risk

• Bipolar disorder• Substance use disorders• Schizophrenia• Personality disorders• Eating disorders• Anxiety disorders

Many of these are more common among youth in foster care, foster care alumni and homeless youth.

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Mental health among foster care youth2008 Survey of Washington State Youth in Foster Care: • 9% of youth respondents said that there were times when they

thought they needed counseling or therapy but didn’t get it. The main reasons given were for depression and sadness, help with problems and issues, and needing to talk with someone.

• The main reason for not getting the needed therapy or counseling was not following through to ask for it.

• 50% of youth respondents were currently seeing a psychological counselor, psychiatrist, or therapist. 46% had been seeing this person for more than one year.

• 49% said that this has been very helpful to them, and 36% said it has been somewhat helpful.

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Mental health among foster care alumniNorthwest Alumni Study: • Within the previous 12 months, more than half (54.4%) had

clinical levels of at least one mental health problem, and one in five (19.9%) had three or more mental health problems.

• The prevalence of major depression was significantly higher among alumni (20.1%) than among the general population (10.2%).

• Post-traumatic stress disorder (PTSD) rates for alumni were up to twice as high as for U.S. war veterans. One in four alumni (25.2%) experienced PTSD within the previous 12 months.

• These rates are substantially higher than those of the general population in the age range of the sample.

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III. Youth Suicide in Washington

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The following slides show some patterns and statistics.

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Suicide among foster care youth &alumni

• Little data is available breaking out youth in foster care from the general population.

• In many studies, suicide isn’t addressed or doesn’t look like a large problem.

– 2008 Survey of Washington State Youth in Foster Care: only 3 youth out of 706 said they had needed counseling because of suicidal thoughts

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Depression & suicide among foster care youth and alumni

HOWEVER…

• Suicide attempts and deaths are consistently underreported across populations and locations

• Higher incidence of risk factors gives us cause for concern

• Anecdotal information gives us cause for concern

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Most youth who attempt suicide survive(Washington State youth 2008-2012)

10 to 14 15 to 17 18 to 19 20 to 240

50

100

150

200

250

300

350

400

450

deathhospitalization

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Males are more likely to die by suicide (Washington State DOH 2009-2011)

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5-14

15-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

0 20 40 60 80 100 120

Male Female

Rate per 100,000

Females more likely to be hospitalized(Washington State DOH 2009-2011)

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Nonfatal self-inflicted injuries(Washington State youth 2008-2012)

N = 4354

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cut/piercefirearmpoisoningsuffocation and obstructingother

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Fatal suicide means(Washington State youth 2008-2012)

N = 617

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PoisoningSuffocationDrowningFirearmsJump/fallOther

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Fatal suicide means(Washington State youth 2008-2012)

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Male youth 10-24 (n = 484)

Female youth 10-24(n = 96)

PoisoningSuffocationDrowningFirearmsJump/fallOther

PoisoningSuffocationDrowningFirearmsJump/fallOther

Male youth ages 10-24

n=509

Female youth ages 10-24

n=108

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IV. Prevention: Creating a supportive, preventive environment

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How do your agency practices create a supportive and preventive

environment?

What actions do you take to create a supportive,

preventive environment?

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V. Intervention: When to step in

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Populations at higher risk

• Youth with mental health issues 

• Youth experiencing stresses (current or past) like poverty, abuse, violence, racism or living in low-resource communities• Youth in vulnerable identity groups, including:

• LGBTQ youth (worse with family rejection)• Native American youth• Latina adolescent girls• Foster care youth and alumni• Homeless youth

• Youth who abuse alcohol or other substances 

• Youth who have attempted suicide before 

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Experiences that may increase risk• The death or illness of a family member, friend or

community member, including another teen suicide in the community

• A loss or sudden change in circumstances• A problem with peers, like a breakup, bullying or

conflict with friends• A major stress like failing a test, changing foster

placement, unplanned pregnancy, family conflict or being arrested

• Being abused• Being or feeling socially isolated• Having access to firearms or other lethal weapons

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Signs of suicidal thinking: The FACTS Feelings

Sad, lonely, hopeless, in pain, moody, irritable, increased depression

ActionsPushing away friends and family, giving away important possessions, using alcohol or drugs, making unsafe decisions, making or researching suicide plans, making art or writing about death, saying goodbye

Changes Changes in school performance, changes in appearance or hygiene, changes in personality or attitude, just not seeming like themselves

ThreatsSaying they’re going to kill themselves, saying goodbye

SituationsHas the person had a crisis or trigger situation, especially in thelast couple of weeks?

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Scenario for review

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Cara, age 12, and her brother entered a foster home together when she was five and he was a baby. She has described him as her only link to her birth family. Now in first grade, he is showing some concerning behaviors and a decision has been made that he needs to be in a more specialized setting. Cara has learned they will soon be separated for the first time.

Cara’s foster family has noticed that she has been spending more time alone in her room than usual and asking to miss school frequently because she feels sick. When you check in with her, you see that she looks unusually tired and disheveled. You ask how she is coping with the upcoming change and she says, “Me and my brother just cause trouble for everyone. But soon you won’t have to deal with ME anymore.”

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What are the FACTS?Feelings

Actions

Changes

Threats

Situations

Are you concerned Cara may be at risk of suicide?

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• Show you care

• Ask the question

• Call for help

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Youth Suicide: Intervention Steps

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Show you care

• “I have noticed that ____, and I feel concerned about you because ____.”

• “I want to help. Tell me more about what’s happening.”

• “I care about you and how you’re holding up.”– Use with care and within appropriate boundaries.

• I’m on your side…we’ll get through this.”

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Ask the question• “Sometimes when ___ happens to people, they

think about suicide. Are you thinking about it?”• “When you said ___, it made me wonder if you

were thinking about ending your life. Are you?”• “Have you thought about how you would do it?”• “What thoughts or plans do you have?”

Remember: Asking the question does not cause suicide

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“Can I ask, ‘are you thinking about hurting yourself?’ instead?”

Non-suicidal self injury (NSSI)the deliberate, direct, and self-inflicted destruction of body tissue resulting in immediate tissue damage, for purposes not socially sanctioned and without suicidal intent.

• 13% - 25% of adolescents have a history of NSSI• Less than 10% engage in it chronically and regularly• Higher among LGBTQ youth• Different methods common among girls and boys• Higher among youth with psychiatric diagnoses:

– BPD, dissociative disorders, eating disorders, depression, alcohol abuse

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Distinguishing NSSI from suicide• Not a failed suicide attempt.

– Improves affect while uncompleted suicide attempt worsens it– Uses different means– More likely to be frequent and chronic

• Intent is to reduce negative or overwhelming emotions, not to cause death.

• There IS a correlation between NSSI and suicidality.• Self-injurers who attempt suicide:

– have been self injuring for longer– Have been using more methods– Have thought patterns including self-criticism, attraction to death or

repulsion by life, weak connections to family, and others

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Choosing the question

• “Are you thinking about hurting yourself?” is a valid and important question, BUT

• It is not a question about suicide.

• Ask this also, not instead.

• Follow mental health referral procedures similar to suicide.

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Call for help

• “You were very brave to tell me. We’re going to need more help.”

• “I know where we can get some help.” (Mention specific resource people.)

• “You’re not alone. Let’s visit or call this resource together.”

• “Who are the 3 people in your life that you trust the most?”

• “Together we can figure out how to make you feel better.”

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• Why a safety plan vs. no self harm contract

• Tool for the youth to stay safe

• Reviewed and modified regularly

• Goal is NOT liability reduction or reassuring the provider

Safety planning

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Adapted from the Suicide Prevention Resource Center’s sample safety plan template:

1. What are signs that a crisis is coming? 2. What coping strategies can you use first? 3. Where can go or who can you be with to distract yourself? 4. Who are your support people who you can tell about the

crisis and ask for help? 5. What are the available professional resources? (Therapists,

hotlines, etc.) 6. What can you do to remove risks from your environment?

Who can help? 7. How long can you keep safe before we discuss the plan

again?

Mental health safety planning

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• Give copies to the youth, their guardian, and explore giving copies to other professionals or other supports named in the plan.

• Discuss with the youth how they will keep the plan accessible at all times.

• Set a time within the next day to check in about progress and make any necessary revisions.

After creating a safety plan

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Suicide risk and confidentiality

• If a youth discloses suicide risk, you must take action to keep them safe.

• Never promise that a client’s writing or what they tell you will be confidential in all cases.

• If you need to break confidentiality to protect the client or comply with laws or rules, explain why.

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Tailoring referrals to needsSelection of appropriate referral determined by: • Resources available in the community

• Level of risk

• Intensity of stressors

• Family’s culture and language

• Client’s identity

• Client’s age and ability to consent/guardian availability

• Mental health and treatment history

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Where to get information & help• Existing connections: the youth’s therapist, psychiatrist,

case manager, family, wraparound team or trusted service provider

• Internal crisis resources (supervisor, on-call clinician, etc.) • Your county crisis line • CDMHP• Your Regional Support Network• 211• A crisis phone hotline (1-800-273-TALK, or for LGBTQ

focus, 1-866-4U TREVOR)• Resources available through the appropriate community

center, religious institution or school• The hospital emergency room/911

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Discussion

What local resources do we recommend?

What are local referral limitations/challenges?

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Scenario for review

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Shawn, age 15, is currently living in a group home. There was an option of reunification with his mother if she completed drug treatment and found a full-time job, but she hasn’t succeeded. He has told you he feels angry and discouraged about this.

After each of the last three supervised visitations with his mother, Shawn has had a meltdown at the group home, which has included belligerent behavior, threats of fights with other residents, and talk of suicide. The last time, staff brought him to the hospital, but he was released because the threat was not considered serious.

He was at another meeting today, where he was told that reunification will no longer be an option. The house manager has asked that Shawn see you before he returns there, and he is on the way to your office.

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• Show you care

• Ask the question

• Call for help• Where would

you refer? How?

How would you:

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VI. Postvention: After a suicide

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When adolescents lose a friend or peer to suicide

• It may be their first experience of loss – how to grieve may be unclear or confusing

• Extra devastating because of peer orientation• Feelings of guilt, magical thinking (“I could have

prevented this”). Amplified for youth who were involved or close to the person.

• Feelings of anger or fear• Questioning spirituality or existential crisis• Acting out (impulsive behavior, substance use) or

acting in (sadness, depression, fixating)

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Who is at highest risk after a peer's death? • Peers who witnessed or were near the

incident• Youth who identify with the deceased

peer – teammates, those who share an experience or subculture, classmates, peers who looked up to them

• Youth who were emotionally close to the deceased peer – friends, relatives, dating partners, those in the same clique or social circle

• Peers who are already vulnerable for another reason

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For youth: When you need help with grief

• When the way you’re thinking or feeling worries you or worries someone who cares about you

• When you think talking to someone would help• Signs of depression• Substance use or self injury• Isolation from friends and family – wanting to stop talking to

or hanging out with anyone• Taking dangerous risks or feeling like you don’t care what

happens to you• Thinking about death a lot or not being able to stop thinking

or talking about it

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What can supportive adults do to help?• Take care not to sensationalize or glamorize a peer's death.• Create opportunities to talk, and facilitate the youth

connecting with other adults in their support system.• Make it clear that seeking help is normal and okay.

• Avoid minimizing comments, even if you would cope differently. Use open-ended questions and a nonjudgmental stance.

• Encourage family or guardians to model effective coping skills, including seeking support for their own stress or grief.

• Listen & watch for behavior changes, depression signs, causes for concern. Intervene if you see them.

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Closing: revisiting KrystalKrystal, age 14, has just been placed in her aunt’s home after her mother and stepfather were incarcerated in a drug bust covered by local media. In your first meeting as her new social worker, she discloses she has been skipping school and avoiding her friends since the arrest because “everyone knows what happened and my life is basically over.”

After saying this, she pushes up her sleeve and you notice a row of small, healed cuts on her forearm. Later in the discussion you ask Krystal if she has ever attempted suicide, and she says, “Once in seventh grade. But I did it wrong and THAT time it didn’t work.”

Is there anything you would consider differently or do differently with this case now?

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My contact information:

Karyn Brownson, MSWDirector of Trainingkaryn@yspp.org646-691-0857