Best Practice in Suicide Prevention, Assessment, and Intervention Pete B. Marcelo, MSW, Ph.D. Asst. Supt. of Special Education and Student Services at

Best Practice in Suicide Best Practice in Suicide Prevention, Assessment, Prevention, Assessment,

and Interventionand Intervention

Pete B. Marcelo, MSW, Ph.D.Pete B. Marcelo, MSW, Ph.D.Asst. Supt. of Special Education and Student Services at Niles HS Dist. 219 Asst. Supt. of Special Education and Student Services at Niles HS Dist. 219

Clinical and School PsychologistClinical and School PsychologistClinical Social and School Social WorkerClinical Social and School Social Worker

[email protected]@yahoo.com(847)456-6498(847)456-6498

Suicide in the U.S.A.Suicide in the U.S.A.(from the American Association of Suicidology at www.suicidology.org)(from the American Association of Suicidology at www.suicidology.org)

2002 Statistics from the National Vital Statistics Report2002 Statistics from the National Vital Statistics Report In 2002, 31,655 suicides in the U.S.In 2002, 31,655 suicides in the U.S. 1111thth leading cause of death leading cause of death Suicide rates overall relatively stable in recent yearsSuicide rates overall relatively stable in recent years Males complete suicide at a rate 4 times that of females.Males complete suicide at a rate 4 times that of females. Females attempt suicide 3 times that of malesFemales attempt suicide 3 times that of males Firearms are the most common method of completing suicide (54% in 2002)Firearms are the most common method of completing suicide (54% in 2002) Females use poisoning as the most common method of completing suicideFemales use poisoning as the most common method of completing suicide Suicide decreases in times of war and increase in times of economic crisisSuicide decreases in times of war and increase in times of economic crisis 25 attempts for each death by suicide, but between 100 - 200 to 1 in youth25 attempts for each death by suicide, but between 100 - 200 to 1 in youth

Youth Youth SuicideSuicide Fact Sheet Fact Sheet(from the American Association of Suicidololgy and Poland & Lieberman)(from the American Association of Suicidololgy and Poland & Lieberman)

33rdrd cause of death for youth between the ages of 15-19 and 15- cause of death for youth between the ages of 15-19 and 15-24 following accidents and homicides. 24 following accidents and homicides. 44thth cause of death in those 10-14 years old cause of death in those 10-14 years old1.3% of all deaths in U.S. and 12.3% of all deaths in youth 1.3% of all deaths in U.S. and 12.3% of all deaths in youth between the ages of 15-24.between the ages of 15-24.For 15-19, 4.4 male suicide : female suicideFor 15-19, 4.4 male suicide : female suicide10-14 year olds, 2.7 male : 1 female10-14 year olds, 2.7 male : 1 female10 suicides for every 100,000 youth10 suicides for every 100,000 youth11 youth 15-24 die each day from suicide11 youth 15-24 die each day from suicideIn 2001, 3971 suicides for youth between the ages of 15 to 24In 2001, 3971 suicides for youth between the ages of 15 to 24Firearms most commonly used suicide method among youth Firearms most commonly used suicide method among youth accounting for 57% of completed suicides (regardless of gender, accounting for 57% of completed suicides (regardless of gender, age, and race)age, and race)

Test Your Adolescent Suicide IQTest Your Adolescent Suicide IQ Prepared By Prepared By John Jochem, Psy.D.John Jochem, Psy.D.

Highland Park HospitalHighland Park Hospital

True or False?True or False?1.1. Adolescent suicide is an increasing problem in the U.S.Adolescent suicide is an increasing problem in the U.S.

TRUETRUE While the rate of suicide in the general population has While the rate of suicide in the general population has been generally stable since the 1950’s, adolescent been generally stable since the 1950’s, adolescent suicide rates have more than tripled.suicide rates have more than tripled.

2.2. Most teenagers will reveal that they are suicidal or if they having Most teenagers will reveal that they are suicidal or if they having problems?problems?TRUETRUE Most teens who are experiencing active suicidal ideation Most teens who are experiencing active suicidal ideation

will admit their plans to someone who is concerned and will admit their plans to someone who is concerned and inquires about their distress.inquires about their distress.

3.3. Adolescents who talk about suicide are not the ones who actually Adolescents who talk about suicide are not the ones who actually make an attempt?make an attempt?FALSEFALSE People usually give some advance indication of suicidal intent; People usually give some advance indication of suicidal intent;

suicidal threats, preoccupation or behavior must always be suicidal threats, preoccupation or behavior must always be taken seriously.taken seriously.

4.4. Talking with someone about suicide may promote suicidal ideas and Talking with someone about suicide may promote suicidal ideas and behavior?behavior?FALSEFALSE It is inner distress, psychiatric illness, serious life stressors and It is inner distress, psychiatric illness, serious life stressors and

irrational thinking that lead to suicidal behavior, irrational thinking that lead to suicidal behavior, notnot expressions of concern by others.expressions of concern by others.

Source:Source: Florida Institute of Mental Health / University of South Florida (2003)Florida Institute of Mental Health / University of South Florida (2003)

Test Your Adolescent Suicide IQTest Your Adolescent Suicide IQPrepared By Prepared By John Jochem, Psy.D.John Jochem, Psy.D.


5. Parents are often unaware of their child’s suicidal ideation and behavior?5. Parents are often unaware of their child’s suicidal ideation and behavior?TRUE Studies have shown that, among parents of children found to TRUE Studies have shown that, among parents of children found to have suicidal ideation, up to 86% of parents were unaware of have suicidal ideation, up to 86% of parents were unaware of their child’s suicidal risk. their child’s suicidal risk.

6.6. The majority of adolescent suicides occur unexpectedly with no The majority of adolescent suicides occur unexpectedly with no warning signs?warning signs?FALSE Over 90% of suicidal adolescents give clues to others FALSE Over 90% of suicidal adolescents give clues to others

prior to their attempt.prior to their attempt.7.7. Most adolescents who attempt suicide fully intend to die?Most adolescents who attempt suicide fully intend to die?

FALSE As a rule, survivors of suicide attempts are relieved to FALSE As a rule, survivors of suicide attempts are relieved to have lived through their suicidal crisis and are grateful have lived through their suicidal crisis and are grateful for intervention.for intervention.8.8. There are differences between adolescent males & females regarding There are differences between adolescent males & females regarding

suicidal behavior?suicidal behavior?TRUE Females attempt suicide more frequently than males TRUE Females attempt suicide more frequently than males

(3:1), however males complete suicide more frequently than (3:1), however males complete suicide more frequently than females (4:1) because boys tend to use more lethal means (e.g., females (4:1) because boys tend to use more lethal means (e.g., firearms)firearms)9.9. Since adolescent females complete suicide less often than males Since adolescent females complete suicide less often than males

their attempts should not be taken seriously?their attempts should not be taken seriously?FALSE A prior attempt is a significant risk factor for later death by FALSE A prior attempt is a significant risk factor for later death by

suicide—suicide—everyevery threat must be taken seriously. threat must be taken seriously.

Test Your Adolescent Suicide IQTest Your Adolescent Suicide IQ Prepared By Prepared By John Jochem, Psy.D.John Jochem, Psy.D.


10.10. Adolescent suicide occurs mostly with lower SES (socioeconomic Adolescent suicide occurs mostly with lower SES (socioeconomic status) kids than among wealthier kids who have access to greater status) kids than among wealthier kids who have access to greater resources?resources?FALSEFALSE Adolescent suicide is a threat to kids of every Adolescent suicide is a threat to kids of every

socioeconomic level.socioeconomic level.11.11. The only one who can be of help to a suicidal adolescent is a trained The only one who can be of help to a suicidal adolescent is a trained

mental health professional?mental health professional?FALSEFALSE Most adolescents contemplating suicide are not under the care Most adolescents contemplating suicide are not under the care

of a mental health professional and are more likely to initially of a mental health professional and are more likely to initially come to the attention of non-professional, who then facilitates a come to the attention of non-professional, who then facilitates a referral.referral.

12.12. A teacher who observes distress or warning signs in his/her student A teacher who observes distress or warning signs in his/her student should not betray the student’s trust by referring the student to the should not betray the student’s trust by referring the student to the school social worker?school social worker?FALSEFALSE Adolescent suicide is a serious public health issue and referral Adolescent suicide is a serious public health issue and referral

to in-school mental health resources should always occur to in-school mental health resources should always occur whenever warning signs of suicide are observed.whenever warning signs of suicide are observed.

13.13. If an adolescent wants to commit suicide there is nothing anyone If an adolescent wants to commit suicide there is nothing anyone can do to prevent its occurrence?can do to prevent its occurrence?FALSEFALSE Prompt identification, intervention, means restriction, support Prompt identification, intervention, means restriction, support

and treatment of an underlying condition are all effective means and treatment of an underlying condition are all effective means to prevent suicide.to prevent suicide.

Source:Source: Florida Institute of Mental Health / University of South Florida (2003)Florida Institute of Mental Health / University of South Florida (2003)

Critical FactCritical Fact

Having a gun in the house more than Having a gun in the house more than

ss the likelihood that an adolescent will the likelihood that an adolescent will successfully complete a suicide!successfully complete a suicide!

Signs/Symptoms of At-risk for Signs/Symptoms of At-risk for Suicide Suicide

*Problem, these are not exclusive to suicide behavior also correlated with mental *Problem, these are not exclusive to suicide behavior also correlated with mental health.health.

Physical DomainPhysical Domain Behavioral DomainBehavioral Domain-fatigue or hyper-fatigue or hyper -withdrawing/running away-withdrawing/running away-sleep disturbance-sleep disturbance -neglect of appearance-neglect of appearance-change in appetite-change in appetite -giving away possessions-giving away possessions-frequent complaints of physical-frequent complaints of physical -loss of interest in pleasurable -loss of interest in pleasurable symptoms symptoms activities activities

-decline in previous level of -decline in previous level of functioning (academics, attendance, etc.)functioning (academics, attendance, etc.)-use of alcohol/drugs-use of alcohol/drugs

Affective DomainAffective Domain Cognitive DomainCognitive Domain-depressed-depressed -decrease in concentration-decrease in concentration-crying-crying -pre-occupied with death-pre-occupied with death-hopeless-hopeless-anger-anger-marked change-marked change

Signs/Symptoms of At-risk for Signs/Symptoms of At-risk for Suicide (continued)Suicide (continued)

Verbal Comments (hint at their thinking)Verbal Comments (hint at their thinking)-Its no use-Its no use-I won’t be a problem for you-I won’t be a problem for you-Nothing matters-Nothing matters-I won’t see you again-I won’t see you again-The world would be better without me-The world would be better without me-Nobody would miss me anyway-Nobody would miss me anyway

Situational CrisesSituational Crises

1.1. Recent loss of a friend, family member, Recent loss of a friend, family member, pet, divorcepet, divorce

2.2. Break-up with significant otherBreak-up with significant other3.3. Unplanned pregnancyUnplanned pregnancy4.4. Trouble with law or school disciplineTrouble with law or school discipline5.5. Victim of abuse/neglectVictim of abuse/neglect6.6. PovertyPoverty7.7. Peer difficulties/BullyingPeer difficulties/Bullying

Childhood and Adolescent DepressionChildhood and Adolescent Depression

DSM-IV-TR categories with symptoms of DSM-IV-TR categories with symptoms of depression: Major Depression, Dysthmic depression: Major Depression, Dysthmic Disorder, Adjustment Disorder with Depressed Disorder, Adjustment Disorder with Depressed Mood, and Bi-Polar DisorderMood, and Bi-Polar Disorder

Possible symptoms of depressionPossible symptoms of depression: : depressed mood, loss of interest, irritabilitydepressed mood, loss of interest, irritability often do not identify feeling depressed.often do not identify feeling depressed. significant weight loss or weight gain. Younger significant weight loss or weight gain. Younger

children, “failure to thrive”children, “failure to thrive” insomnia or hypersomniainsomnia or hypersomnia


Possible symptoms of depression:Possible symptoms of depression: psychomotor agitation or retardation psychomotor agitation or retardation fatigue or loss of energy fatigue or loss of energy feeling worthlessfeeling worthless diminished ability to think or concentrate diminished ability to think or concentrate recurrent thoughts of deathrecurrent thoughts of death impairment in previous level of functioning.impairment in previous level of functioning. low self-esteemlow self-esteem feelings of hopelessnessfeelings of hopelessness feeling unlovedfeeling unloved somatic complaints (stomach aches, headaches) somatic complaints (stomach aches, headaches) whiny, withdrawn,self-destructive,absenteeism whiny, withdrawn,self-destructive,absenteeism


Possible symptoms of depressionPossible symptoms of depression:: difficulty staying on task,difficulty staying on task, not interested in anything, “lazy” not interested in anything, “lazy” bullying behaviorbullying behavior negative thoughts about themselves, the world negative thoughts about themselves, the world

and the future (the cognitive triad).and the future (the cognitive triad). irrational thoughts like awfulzing and need irrational thoughts like awfulzing and need

statementsstatements


PrevalencePrevalence major depression and dysthymic disorder in major depression and dysthymic disorder in

children is 2% and 6% for adolescents annuallychildren is 2% and 6% for adolescents annually 7 to 14% of children experience major 7 to 14% of children experience major

depression before the age of 15 often not depression before the age of 15 often not diagnosed.diagnosed.

equal numbers of boys and girls in childhood, equal numbers of boys and girls in childhood, but 2:1 ratio of major depression of female to but 2:1 ratio of major depression of female to male adolescents.male adolescents.

major depressive disorder is 1.5 to 3 times more major depressive disorder is 1.5 to 3 times more common if first degree biological relativecommon if first degree biological relative


Co-morbidityCo-morbidity ADHD, eating disorders, conduct disorder, ODD, ADHD, eating disorders, conduct disorder, ODD,

substance abuse, LD/EDsubstance abuse, LD/ED

Considerations for school districtsConsiderations for school districts how do you phrase feedback? not too negative, how do you phrase feedback? not too negative,

avoid blame, what and how to say it avoid blame, what and how to say it get kids involved – recess – structured activitiesget kids involved – recess – structured activities link them with other kids (recess/groups)link them with other kids (recess/groups) build on individual strengthsbuild on individual strengths

Possible Psychiatric FactorsPossible Psychiatric Factors Associated with SuicideAssociated with Suicide

1. Diagnosis of the following conditions1. Diagnosis of the following conditions Bi-Polar DisorderBi-Polar Disorder Depression Depression Conduct DisorderConduct Disorder Personality DisorderPersonality Disorder

2. Chronically Poor Coping skills with 2. Chronically Poor Coping skills with negative emotionsnegative emotions

Self-Injurious Behavior Self-Injurious Behavior

CategoriesCategories MajorMajor - most serious - large part of body or limb - most serious - large part of body or limb

is injured. cutting off one’s arm or self-castration. is injured. cutting off one’s arm or self-castration. Very rare. Very rare.

StereotypicStereotypic – repetitive self-injury often seen in – repetitive self-injury often seen in those with mental retardation and autism. Head those with mental retardation and autism. Head banging, biting oneself, etc.banging, biting oneself, etc.

Superficial SelfSuperficial Self--MutilationMutilation – most common. – most common. Often involves cutting, burning, hitting, Often involves cutting, burning, hitting, scratching, choking, etc. scratching, choking, etc.

Self-Injurious BehaviorSelf-Injurious Behavior

Incidence? / Demographics?Incidence? / Demographics? Under reported - at least 2 million people Under reported - at least 2 million people

self-harm. Unsure if estimate is national or self-harm. Unsure if estimate is national or international international

Common for self-injurious behavior to begin Common for self-injurious behavior to begin in adolescencein adolescence

Other countries like Australia, Canada, New Other countries like Australia, Canada, New Zealand, and England Zealand, and England

Johnny Depp, Roseanne, and Princess DianaJohnny Depp, Roseanne, and Princess Diana


different reasons for why self-mutilate different reasons for why self-mutilate relieves intense feelings such as anger, rage, relieves intense feelings such as anger, rage,

depression, etc.depression, etc. maladaptive coping strategy to cope with life, maladaptive coping strategy to cope with life,

and not attempt at ending life. and not attempt at ending life. possible victims of physical and/or sexual possible victims of physical and/or sexual

abuse. control of the abuse, making oneself abuse. control of the abuse, making oneself less attractive, punishing oneself less attractive, punishing oneself

followed by feelings of relief, tranquility, and followed by feelings of relief, tranquility, and possibly even euphoria. possibly even euphoria.


MythsMyths self injury is a failed suicide attemptself injury is a failed suicide attempt self injury is always attention seeking self injury is always attention seeking self-mutilators are dangerous to othersself-mutilators are dangerous to others

TreatmentTreatment bio-psycho-social approach may be bio-psycho-social approach may be

treatment of choice.treatment of choice. anti-depressants and/or anti-anxiety anti-depressants and/or anti-anxiety

medicationsmedications teach student coping skills and ways of teach student coping skills and ways of

expressing negative emotions expressing negative emotions


Treatment considerationsTreatment considerations treat underlying causal factors like treat underlying causal factors like

depression, low self-esteem, history of depression, low self-esteem, history of abuse, etc.abuse, etc.

cognitive behavioral therapy – change cognitive behavioral therapy – change irrational thoughts irrational thoughts

teach student and family risk management teach student and family risk management like the removal of razors, etc.like the removal of razors, etc.

Provide hotline/crisis phone number.Provide hotline/crisis phone number. find and identify triggers for self-abusefind and identify triggers for self-abuse


Treatment considerationsTreatment considerations:: Teaching more appropriate functional Teaching more appropriate functional

behaviors - working out intensely, holding, behaviors - working out intensely, holding, ice cube, snap rubber band on wristice cube, snap rubber band on wrist

support groupsupport group

What Should Schools Do?What Should Schools Do? Staff/teachers refer to counselor, social Staff/teachers refer to counselor, social

worker, nurse, administrator, and/or worker, nurse, administrator, and/or psychologist (Track history of self-injurious psychologist (Track history of self-injurious behavior including frequency, duration, and behavior including frequency, duration, and intensity). intensity).

Self-Injurious BehaviorSelf-Injurious Behavior assessment out of realm of competence, call assessment out of realm of competence, call

parent and refer outparent and refer out keep in mind the impact on the studentkeep in mind the impact on the student do not be critical. Student may already feel do not be critical. Student may already feel

guilty and ashamed.guilty and ashamed. provide safe environment when stressed. provide safe environment when stressed.

(nurse’s office? guidance office? ) (nurse’s office? guidance office? ) be supportive of the student. be supportive of the student. communicate when student appears to be communicate when student appears to be

having a particularly bad day.having a particularly bad day. counseling mandated as a condition of counseling mandated as a condition of

attendance in school? Who pays for services?attendance in school? Who pays for services?

AssessmentAssessment1.1. Clinical Assessment/Interview with student ****limits of confidentialityClinical Assessment/Interview with student ****limits of confidentiality

Sample process and questionsSample process and questions

Assess risk factors and documentationAssess risk factors and documentation

Assess Risk Factors and DocumentationAssess Risk Factors and DocumentationMore interview questions and DocumentationMore interview questions and Documentation

***Handout – sample form***Handout – sample form

2. 2. Rating Scales and Diagnostic Structured InterviewsRating Scales and Diagnostic Structured Interviews-No universally accepted instrument at this time that has specificity and predictive validity-No universally accepted instrument at this time that has specificity and predictive validity

3. 3. Interview with others (parents, teachers, etc) if necessaryInterview with others (parents, teachers, etc) if necessary

4.4. Do you have any interview questions or assessment techniques that you like to use in your Do you have any interview questions or assessment techniques that you like to use in your interview?interview?

InterventionsInterventions1.1. Constant supervision and referral for high risk studentsConstant supervision and referral for high risk students2.2. No-suicide contractNo-suicide contract Common practice as part of an interventionCommon practice as part of an intervention No formal research that I know of that has shown that it is efficacious No formal research that I know of that has shown that it is efficacious Sample No Suicide ContractSample No Suicide Contract3.3. Increase number of counseling sessionsIncrease number of counseling sessions4.4. Remove meansRemove means5.5. Inform parentsInform parents6.6. CBTCBT7.7. Teach coping skillsTeach coping skills8.8. Develop emergency plan and review with student and family with hotline numbers, Develop emergency plan and review with student and family with hotline numbers,

use of ER, etc.use of ER, etc.9.9. Hospitalization Hospitalization 10.10. Require a psychological assessment before returning to school? Are you Require a psychological assessment before returning to school? Are you

available 24/7 for emergency calls? Should you see a student who is at high risk available 24/7 for emergency calls? Should you see a student who is at high risk as the only provider of service?as the only provider of service?

11.11. Any other ideas?Any other ideas?

DOCUMENTDOCUMENT

Sample record that parent has been inforSample record that parent has been informed of student’s suicidal ideationsmed of student’s suicidal ideations

Record source, content, and date of Record source, content, and date of information used in assessment; your information used in assessment; your conclusions regarding risk, and what conclusions regarding risk, and what action taken and whyaction taken and why

Legal and/or Ethical IssuesLegal and/or Ethical Issues1.1. Duty to Protect (inform whom?)Duty to Protect (inform whom?) -You will not be held responsible if you have done what a good clinician would do-You will not be held responsible if you have done what a good clinician would do

(assess/evaluate, plan, and implement)(assess/evaluate, plan, and implement)

2.2. Have a policy, practice/training of policy/procedure, implement the Have a policy, practice/training of policy/procedure, implement the policy/procedure (see IL School Code 105 ILCS 5/10-22.39 In-service Training policy/procedure (see IL School Code 105 ILCS 5/10-22.39 In-service Training Programs)Programs)*Almost worse to have a policy/procedure that isn’t practiced and implemented.*Almost worse to have a policy/procedure that isn’t practiced and implemented.

** District 219’s APDistrict 219’s AP**** District 219’s APDistrict 219’s AP****** District 219’s APDistrict 219’s AP

Do you have a plan? Do you practice/train?Do you have a plan? Do you practice/train?

3.3. Duty to Provide Referrals (rule of thumb 3 that are known to provide appropriate Duty to Provide Referrals (rule of thumb 3 that are known to provide appropriate service) service)

PreventionPrevention Sample prevention letter to parentsSample prevention letter to parents

Infusing coping skills/social skills into the curriculumInfusing coping skills/social skills into the curriculum

Anti-bullying programsAnti-bullying programs

Student assistance team referralsStudent assistance team referrals

Student assistance programsStudent assistance programs

Educating students, staff, parents, community on mental health Educating students, staff, parents, community on mental health issues Raising Kids: A Risky Business Network | Google Groupsissues Raising Kids: A Risky Business Network | Google Groups

ResourceResource

Practice parameters for the assessment aPractice parameters for the assessment and treatment of child and adolescent suicidnd treatment of child and adolescent suicidal behavioral behavior

Resources for the Development of Resources for the Development of Crisis PlansCrisis Plans

NEA resourceNEA resource

Maine Task ForceMaine Task Force

Sample Crisis PlanSample Crisis Plan1.1. Sudden Death General GuidelinesSudden Death General Guidelines2.2. Sample Plan for a Sudden DeathSample Plan for a Sudden Death3.3. ********Support/counseling for the crisis team*****************Support/counseling for the crisis team*********4.4. Sample Letter to parentsSample Letter to parents5.5. Media GuidelinesMedia Guidelines

Documents

Best Practice in Suicide Prevention, Assessment, and Intervention Pete B. Marcelo, MSW, Ph.D. Asst. Supt. of Special Education and Student Services at