Presentation on theme: "Suicide “There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering."— Presentation transcript:
Suicide “There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.” Albert Camus, The Myth of Sisyphus (1942)
Outline: What suicide is and how it is studied What it isn’t: myths and opinions vs. facts Epidemiology, especially pediatric Warning signs Prevention, intervention, and postvention Suicide and your clinical skills: assessment, intervention, and risk
Facing the facts: 900,000 per year, worldwide; about 1% of deaths; 1 death by suicide every 40 seconds; million suicide attempts per year: 1:8 ratio of attempters vs. completers; 395,000 emergency department visits per year are self-inflicted injuries 3 rd leading cause of death among year olds (following accidents and homicide); 2 nd leading cause among year olds; 8 per 100,000 among US college students;
Suicidolgy, epidemiology CDC, WHO, NASP, IASP Methods of suicide Table 1 also indicates the most common methods of suicide in the participating countries. In Australia, Japan, New Zealand, Pakistan, and Thailand, hanging dominates as the most common method of suicide. In China, Hong Kong SAR, and Singapore, jumping (typically from apartment buildings) is the most frequent method used (Ung, 2003; Yip,1996). In countries with larger rural populations, such as China, India and the Republic of Korea, poisoning (usually by pesticides) is common (Bose et al., 2006; Shin et al., 2004). Some new methods are also emerging, such as carbon monoxide poisoning by intentionally burning charcoal in a confined space. In China, Hong Kong SAR charcoal-burning accounted for a single suicide in 1997 but it is currently among the top three most common methods of suicide (Chan et al., 2005; Chung et al., 2001; Yip et al., 2007) (italics added).
Suicide Trends Among Youths and Young Adults Aged Years --- United States, In 2004, suicide was the third leading cause of death among youths and young adults aged years in the United States, accounting for 4,599 deaths (1,2)…. From 2003 to 2004, the rate increased by 8.0%, from 6.78 to 7.32 (2), the largest single- year increase during CDC analyzed data recorded during , the most recent data available. Results indicated that, from 2003 to 2004, suicide rates for three sex-age groups (i.e., females aged years and years and males aged years) departed upward significantly from otherwise declining trends. Suicides both by hanging/suffocation and poisoning among females aged years and years increased from 2003 to 2004 and were significantly in excess of trends in both groups. The results suggest that increases in suicide and changes in suicidal behavior might have occurred among youths in certain sex-age groups, especially females aged years. Closer examination of these trends is warranted at federal and state levels. Where indicated, health authorities and program directors should consider focusing suicide-prevention activities on these groups to help prevent suicide rates from increasing further.
Suicidology: Important caveats: Many actual suicides fail to be classified as such. Suicide rates vary by country, gender, and age. Studies of suicide are hampered by low base rates and after-the-fact data. It is a social construction. Societies view suicides very differently!
More epidemiology 4:1 Male to female ratio worldwide Firearms, poison, suffocation and/or hanging; Access to firearms is the #1 predictor among pediatric suicides in the US; Teens and elderly are most at risk worldwide; Physician suicide rate is four times the national average.
What it is: Medical: one of 4 modes of death (NASH) Legal: the deliberate taking of one’s life; in common law, formerly considered a crime, but no longer; Historical/cultural: ever evolving (e.g. early Christian martyrs vs. the contemporary Vatican stance. “the fruit of illogical action resulting from funnel thinking, which prevents a person from perceiving alternatives to self-destruction” (Hef) “alienation’s last word” (Gomezil) “the most tragic decision of a man who found nobody to hold out a hand to him” (Kielanowski) “a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual” (Schneidman)
Definition(s): The act of causing ones own death. Positive: taking ones own life with purpose and intention. Negative: not doing what is necessary to escape death (not leaving a burning building; stopping insulin treatments). Direct: having the intention of causing ones own death, either as an end, or as a means to an end (to avoid ruin or disgrace, or escape condemnation). Indirect: (and not usually called suicide) death is not necessarily desired, but one commits an act which courts death, as in tending someone with SARS knowing that one may succumb to the same illness.
What suicide is NOT A disease An immorality A biological anomaly A neurological dysfunction It is unlikely that any one theory will ever explain phenomena as complex and varied as acts of human self-destruction. (Leenars, 1995)
Facts vs. Myths Myth: People who talk about suicide won’t really do it. Fact: 8 of 10 suicides have given a definite warning.
Facts vs. Myths Myth: Suicide happens without warning. Fact: Almost all suicidal people give many warnings.
Facts vs. Myths Myth: Suicidal persons are fully intent on dying. Fact: Most are undecided and ambivalent.
Facts vs. Myths Myth: Once a person is suicidal she/he is suicidal forever. Fact: Individuals who wish to kill themselves are suicidal for only a limited period of time.
More facts and myths Myth: Improvement following suicide crisis means the risk is over. Fact: Most suicides occur within 3 months of “improvement” when the person has more energy to carry through. Myth: Suicides strike more among the rich (or poor). Fact: Suicide is very democratic and represented proportionally among all levels of society.
Facts vs. Myths Myth: All suicide individuals are mentally ill, and suicide is always the act of a severely depressed or psychotic person. Fact: Studies of hundreds of suicide notes indicate that although the person was in unbearable pain, he or she was not necessarily mentally ill. About percent of suicides do NOT have a mental illness.
Probably the most dangerous myth: Asking about suicide or suicidality will increase the risk of suicide. Fact: Assessing suicidal thoughts and behaviors prevents suicide by identifying individuals at risk and by inviting people who are in pain to communicate.
Unbearable psychological pain Depression Masked depression Hostility, anxiety, guilt, shame, hopelessness Overwhelming, painful EMOTION, not depression per se Constricted thinking as a result of emotional pain
Cognitive constriction Rigid Narrow focus (tunnel vision) Concreteness Dysfunction in emotions, logic, perceptions Inability to adjust Aggression, confusion, humiliation
Interpersonal difficulties Rejection Aggression Identification with a lost loved one Shame and humiliation that is deemed unfair, especially public shame (losing one’s license to practice; failing out of school)
Biology of suicide Learning disabilities: right brain dysfunction Physical illness and disabilities Biomarkers: corticosteroids, thyrotropin releasing hormone, norepi:epi ratio Small samples sizes, problems with data collection, confounding variables
Family background of suicide Lack of generational boundaries Inflexible family system (secretiveness, denial, poor communication, patterns of authoritarian discipline Symbiotic parent-child relationship Long term family disorganization Adolescents who feel a lack of control over their environment
SUICIDE: A MULTI-FACTORIAL EVENT Neurobiology Severe Medical Illness Impulsiveness Access To Weapons Hopelessness Life Stressors Family History Suicidal Behavior Personality Disorder/Traits Psychiatric Illness Co-morbidity Psychodynamics/ Psychological Vulnerability Substance Use/Abuse Suicide Jacobs, 2003
Suicidal Behavior in Children and Youth: An Overview Suicide is the third-leading cause of death among children and adolescents in the U.S. Suicide rate among children and youth has increased over 300% since the 1950s A child or adolescent commits suicide in the U.S. approximately every 2 hours Suicide rates are highest among high school students, although there have been recent increases among middle school students
Suicidal Behavior in Children and Youth: An Overview More children and adolescents die annually from suicide than from cancer, heart disease, AIDS, birth defects, and other medical conditions combined Survey research suggests approximately 20% of high school students experience serious suicidal thoughts in a given year, and that about 4-8% make actual attempts Over 2000 children and adolescents commit suicide annually These statistics likely underestimate actual figures, although the degree to which this occurs is uncertain (National Association of School Psychologists)
Suicidal Behavior in Children and Adolescents In any given year in a typical high school class of 30 students: –6 will seriously consider suicide –2 to 3 will attempt suicide –1 will make an attempt sufficiently harmful to require medical attention
Suicidal Behavior in Children and Adolescents: Demographics Gender –Adolescent females attempt suicide at a rate of 2:1/ 3:1 compared to adolescent males –Adolescent males commit suicide at a rate of nearly 5:1 compared to adolescent females Age –Rates of suicidal behavior increase as children get older, hitting peak in early 20s
Suicidal Behavior in Children and Adolescents: Demographics Race –White males currently at highest risk –Other high risk groups: Native-American youth; African-American males –Limited data available on other groups Geography –Highest suicide rates in Western states and Alaska –Lowest suicide rates in Northeastern states –Higher suicide rates in rural than in urban areas
Suicidal Behavior in Children and Adolescents: Demographics When: –Slightly more suicides occur during Spring –Month with least amount of suicides: December –Suicide rates lower just before and during holidays Where: –Most adolescent suicides occur at home, where primary means for suicide (typically firearms) are available
Suicidal Behavior in Children and Adolescents: Demographics How : –Firearms are most popular method among both males and females who commit suicide in U.S. –Worldwide, hanging is the most frequently used method of youth suicide, and the second most popular method among U.S youth. –Risk of suicidal behavior is a function of intent and lethality; youths with high level of intent who use methods of high lethality (e.g., firearms) present the greatest risk.
Suicide Ideation, Attempts, and Completion Three different types of suicidal behaviors (ideators, attempters, and completers) reflect different types of individuals Typical youth suicide attempter: Adolescent female who ingests pills in front of her family during an argument Typical youth suicide completer: Adolescent male who is a victim of a gunshot wound
Attempters vs. Completers An overlapping group 8:1 ratio overall In young people, 50:1 ratio Parasuicide Distinguishing among the two: a slippery slope Perturbation and lethality are rated high, medium, or low, on a 1-9 scale Lethality is what kills. ALL ATTEMPTS SHOULD BE TAKEN AS A SERIOUS COMMUNICATION. Words like blackmail, manipulation, and attention seeking are perjorative and only reveal our own attitudes and fears. A third group = contemplators, very little research on them
Common Myths About Youth Suicide Adolescents who talk about suicide are just looking for attention; Listening to certain types of music (e.g., “heavy metal”) or engaging in certain activities (e.g., watching particular movies) causes people to become suicidal; Preventing access to lethal means will not prevent suicide - students will simply choose another method; Most dangerous myth: Talking about suicide will encourage suicidal behavior
Prevention Schools and communities. EDUCATION and knowledge vs. fear and judgments. Secondary prevention: identification and intervention. Tertiary prevention: siblings, children of people who complete suicide. Pediatricians and postpartum depression or postpartum psychosis.
ASSESSMENT AND INTERVENTION
Protective Factors in General Population Children in the home, except among those with postpartum psychosis Pregnancy Deterrent religious beliefs Life satisfaction Reality testing ability Positive coping skills Positive social support Positive therapeutic relationship
Child/Adolescent Risk Factors in Youth Suicide Previous suicide attempt Current suicidal ideation, intent, and plan Psychiatric Disorders and Problems –Depression –Hopelessness –Conduct problems –Drug and/or alcohol abuse –Impulse control problems (e.g., shoplifting; gambling; eating disorders; self-injury)
Child/Adolescent Risk Factors in Youth Suicide Gay or lesbian sexual orientation Unwillingness to seek help because of perceived stigma Feelings of isolation or being cut off from others Ineffective coping Inadequate problem-solving skills, low emotional intelligence Cultural and/or religious beliefs (e.g., belief that suicide is a noble or acceptable solution to a personal dilemma)
Environmental/Situational/Family Risk Factors in Youth Suicide Access to lethal methods, especially firearms; Exposure to suicide and/or family history of suicide Loss (e.g., death; divorce; relationships); Victimization/exposure to violence (e.g., bullying); School crisis (e.g., disciplinary; academic); Family crisis (e.g., abuse; domestic violence; running away; child-parental conflict); Influence (either through personal contact or media representations) of significant people who died by suicide; Barriers to accessing mental health treatment.
Environmental/Situational/Family Risk Factors in Youth Suicide Experiences of disappointment or rejection; Feelings of stress brought about by perceived achievement needs; Unwanted pregnancy, abortion; Infection with HIV or other sexually transmitted diseases; Serious injury that may change the individual’s life course (e.g., Traumatic Brain Injury); Severe or terminal physical illness; Death of a loved one; Separation from family or friends.
Suicide Clusters (Copycat suicides) Defined as more suicides or suicide attempts than expected, close together in time and location. Teens most susceptible to contagion. Appears to represent 1-5% of all suicides. Centers for Disease Control (CDC) estimates that teens die in clusters annually. Media reporting may contribute to clusters
Youth Suicide Clusters: Community Characteristics Lack of integration and belonging Rapid community growth and large schools High rates of substance abuse Emphasis on material possession Lack of mental health services and little awareness of problem of youth suicide No 24-hour crisis hotlines Lack of networking and coordination among community agencies
Warning Signs for Youth Suicide Suicide threats Suicide plan/method/access Making final arrangements Sudden changes in behavior, friends, or personality Changes in physical habits and appearance Preoccupation with death and suicide themes Increased inability to concentrate or think clearly Loss of interest in previously pleasurable activities Symptoms of depression Increased use and abuse of alcohol and/or drugs
Suicide Risk Assessment: Questions to Ask How’s your mood? Have you ever thought about suicide? Have you ever tried to hurt yourself? Do you have a plan to harm yourself now? What is your plan? Have you told anyone about your plan?
Suicide Risk Assessment: Issues to Cover What do you think others say if you were dead? Have you made any final arrangements? Who are your support system (e.g. parents, caregivers, other adults, friends, etc.) Are there reasons why you wouldn’t?
Suicide Risk Assessment: Interviewing Children and Youth Calmly gather information. Be direct and unambiguous in asking questions. Assess lethality of method and identify a course of action. Use effective listening skills by reflecting feelings, remaining non-judgmental, and not minimizing the problem. Communicate caring, support, and trust while providing encouragement for coping strategies. Be hopeful; emphasize the individual’s abilities to solve problems. Determine if he/she has a thorough understanding of the finality of death (suicide is a permanent solution to a temporary problem).
“No-Suicide” or “Safety” Contracts Widely used and recommended, but there is increasing controversy regarding their use In reality, they are neither contractual nor ensure genuine safety They tend to emphasize what students won’t do rather than what they will do May be viewed by students as coercive, since failure to sign may force hospitalization May give clinicians a false sense of security Better approach: Encourage students to commit to treatment rather than merely promising “safety”
Suicide Risk Assessment: Questions for Teachers Have you noticed any major changes in your student’s schoolwork recently? Have you noticed any behavioral, emotional, or attitudinal changes? Has the student experienced any trouble in school? What kind of trouble? Does the student appear depressed and/or hostile and angry? If so, what clues does the student give? Has the student either verbally, behaviorally, or symbolically (in an essay or story) threatened suicide or expressed statements associated with self-destruction or death?
Suicide Risk Assessment: Questions for Parents/Caregivers Has any serious change occurred in your child’s or family’s life recently? (If yes) How did your child respond? Has your child had any accidents or illnesses without a recognizable physical basis? Has your child experienced a loss lately? Has your child experienced difficulty in any areas of his/her life? Has your child been very self-critical, or does he/she seem to think that you or teachers have been very critical lately?
Suicide Risk Assessment: Questions for Parents/Caregivers Has your child made any unusual statements to you or others about death or dying? Any unusual questions or jokes about death or dying? Have there been any changes you’ve noticed in your child’s mood or behavior over the last few months? Has your child ever threatened or attempted suicide before, or attempted to harm himself/herself? Have any of your child’s friends or family, including yourselves, ever threatened or attempted suicide? How have these last few months been for you? How have you reacted to your child (e.g., with anger, despair, empathy)?
Special Issues in Suicide Risk Assessment: Self-Injury Self-injury (also known as self-mutilation) involves the intentional self-destruction of body tissue without deliberate suicidal intent Most typical form of self-injury is cutting Self-injury appears to provide rapid but temporary relief from stress and tension, a sense of security or control, and/or decreases in distressing thoughts or feelings Although youth who engage in self-injury are at increased risk for suicidal behavior, self-injury and suicide are two different types of problems and are not synonymous
Special Issues in Suicide Risk Assessment: Self-Injury Making an accurate distinction between suicidal behavior and self-injury is critical, because despite some similarities in appearance they serve different functions An individual attempting suicide is trying to end his/her life, whereas the individual engaging in self-injury is typically trying to maintain it In contrast to suicide completion, self-injury appears to be more prevalent in girls than boys Self-injury typically begins in early adolescence and may persist for years if not adequately treated The number of children and youth engaging in self-injury is likely underestimated and increasing
Immediate Interventions for Suicidal Youth Assess severity of suicidal risk Remove access to methods Notify parents/caregivers and others as needed Supervise at all times “Suicide-proof” the environment Seek support and collaboration from colleagues Mobilize a support team for the individual Document all actions
What NOT to do: Don’t leave the person alone or send him away Don’t overreact – don’t be shocked by anything he (she) says. Listen and express willingness to help Don’t rush – establish contact and get the person to someone who can help; you are not trying to completely resolve the crisis Don’t minimize the person’s concerns: “this is not worth killing yourself over.” Remember to acknowledge: “I see this is very upsetting to you and I want to get help for you.” Don’t argue whether suicide is right or wrong. Don’t preach or moralize: “you have everything to live for.” The issue is the problem or bind the person feels he (she) is in, not life and death per se.
What NOT to do, cont’d. Don’t discount or make light of the suicidal threat: “you don’t really want to kill yourself.” Don’t challenge or get into a power struggle. You will do everything you can to get help right now, but ultimately he (she) has control over his decision. Don’t think the person just needs reassurance. You can reassure that you will get help. Don’t promise to keep the conversation confidential. There is limited confidentiality in life-threatening situations. Remember that all persons who are at risk for suicide need help. It is always better to overreact (in terms of taking action) than to fail to take action. It is better to have someone angry with you or embarrassed than dead.
Suicide Postvention Schools and communities are frequently not prepared for suicide, yet few events have greater impact on parents, staff, and other youth. In schools, primary goal of postvention is to prevent further suicidal behavior and possible contagion effects. Among clinicians, primary goal is to offer support to family members.
Suicide Postvention: Recommended “Dos” and “Don’ts” Do plan in advance of any crisis Do select and train a crisis team Do verify that a suicide occurred Do disseminate information to faculty, students, and parents; be truthful but avoid unnecessary detail Do report information to students in small groups (classrooms) using fact sheets and uniform statements Do not release information about the suicide in a mass assembly or over a loud speaker Do have extra counselors available on site for students and staff
Suicide Postvention: Recommended “Dos” and “Don’ts” Do not dismiss school or stop classes Do not dedicate a memorial, fly flag at half-mast, or have a moment of silence for deceased; develop living memorials instead (e.g., student assistance programs) Do allow students, with parental permission, to attend the funeral Do not make special arrangements to send all students from a class or school to the funeral Do contact the family and offer any assistance Do collaborate with media, law enforcement, and community agencies
Suicide Postvention: Media Guidelines Do not sensationalize with front page coverage and/or details of suicide method Avoid phrases like “successful suicide,” “failed attempt” Do not print pictures of deceased Do not report the suicide as simplistic or romantic Do emphasize that no one person or thing is to blame Do provide information on suicide prevention Do provide information about where students can go for help, including both school and community resources Do emphasize that suicide is a preventable problem, and that we all have a role in it
Your Clinical Skills Assessment: Knowledge of the risk factors 1. Biological 2. Family 3. Psychological 4. Personal 5. Contextual 6. MSE
Biological risk factors Family history of psychiatric disorders Low serotonin, poor impulse control
Family Risk Factors Family history of suicide Death of parent Early separation from parent Hostile family relationships Chaotic family environment
Personal risk factors Age (Adolescent, elderly) Ethnicity (White, male) Marital status (single) Live alone Previous attempt Poor health History of abuse Recent loss Access to means, presence of firearms
The Specific Suicide Inquiry Ask About: Suicidal ideation Suicide plans Give Added Consideration to: Suicide attempts (actual and aborted) First episode of suicidality (Kessler 1999) Hopelessness Ambivalence: a chance to intervene Psychological pain history (Jacobs, 1998)
Mental status exam Mood, affect (hate of self or other, aloneness, fear, fatigue, hopelessness, helplessness) Suicide preoccupation: ideation, intent, plan, access, fantasies about death Reality testing Capacity for differentiation Cognitive constriction
THERE IS NO SINGLE DEFINITIVE PREDICTIVE BEHAVIOR Previous attempts Verbal statements Cognitive constriction High perturbation Sudden behavioral changes Life threatening behaviors Access to means
Adolescent warning signs Withdrawal from friends and family members Trouble in romantic relationships Difficulty getting along with others Changes in the quality of schoolwork or lower grades Rebellious behaviors Unusual gift-giving or giving away own possessions Appearing bored or distracted Writing or drawing pictures about death Running away from home Changes in eating habits Dramatic personality changes Changes in appearance (for the worse) Sleep disturbancesSleep Drug or alcohol abusealcohol abuse Talk of suicide, even in a joking way Having a history of previous suicide attempts
Negligence, forseeability, and the legal issues of pediatric suicide Schools Primary Care Providers Mental Health Clinicians: Psychologists, Clinical social workers, licensed counselors, psychiatrists, and to a lesser extent, clergy
Suicidal Behavior and Schools: Legal Issues School districts have been found liable for not offering suicide prevention programs, for providing inadequate supervision of at- risk students, and for failing to notify parents when their children were suicidal Schools not responsible ultimately, but must demonstrate they made appropriate, “good faith” efforts to prevent suicide from occurring
Suicidal behavior and physicians: Legal issues Most common: PCP did not make a referral to mental health providers or (in a few cases) for psychiatric hospitalization; Second most common: PCP did not assess for suicidal thoughts, or documentation of assessment was not present or insufficient.
Legal issues for mental health specialists: Majority of lawsuits pertained to inpatient suicide, or recently released inpatient Failure to diagnose: misdiagnosis or failing to predict Abandonment Precautions for all health care providers: DOCUMENTATION
When to document suicide assessment: At first assessment or admission. With occurrence of any suicidal behavior or ideation. Whenever there is any noteworthy clinical change. For inpatients: Before increasing privileges/giving passes Before discharge
Firearms and the assessment of lethality If present - document instructions If absent - document as pertinent negative
All adolescents with symptoms of depression should be asked about suicidal ideation, and an estimation of the degree of suicidal intent should be made. No data indicate that inquiry about suicide precipitates the behavior. In fact, adolescents often are relieved that someone has heard their cry for help. For most adolescents, this cry for help represents an attempt to resolve a difficult conflict, escape an intolerable living situation, make someone understand their desperate feelings, or make someone feel sorry or guilty. Suicidal thoughts or comments should never be dismissed as unimportant. Adolescents must be told by pediatricians that their plea for assistance has been heard and that they will be helped. American Academy of Pediatrics
Examples of Adolescents at Low, Moderate, and High Risk for Suicide Low risk Took 5 ibuprofen tablets after argument with girlfriend. Impulsive; told mother 15 minutes after taking pills No serious problems at home or school Occasionally feels “down” but has no history of depression or serious emotional problems Has a number of good friends Wants help resolving problems and is no longer considering suicide after interview
Moderate risk Suicidal ideation precipitated by recurrent fighting with parents and failing grades in school Wants to “get back” at parents Cut both wrists while at home alone; called friend 30 minutes later Parents separated, changed school this semester, history of attention-deficit hyperactivity disorder Symptoms of depression for the last 2 months, difficulty controlling temper Binge drinking on the weekends Answers all the questions during the interview, agrees to see a therapist if parents get counseling, will contact the interviewer if suicidal thoughts return
High risk Thrown out of house by parents for smoking marijuana at school, girlfriend broke up with him last night, best friend killed in auto crash last month Wants to be dead; sees no purpose in living Took father’s gun; is going to shoot himself where “no one can find me” Gets drunk every weekend and uses marijuana daily Hates parents and school; has run away from home twice and has not gone to school for 6 weeks Hospitalized in the past because he “lost it” Does not want to answer many of the questions during the interview and hates “shrinks”
Pediatricians should: Be informed, know the risk factors; Ask questions about depression and suicidal thoughts during routine exams throughout adolescence; Ask about firearms in the home and discuss safety with parents; Recognize the signs, refer to mental health clinicians, and follow up; Know the community resources; Be a relentless patient advocate with insurance companies. American Academy of Pediatrics
References Berman, A.L., Jobes, D.A., & Silverman, M.M. (2006). Adolescent suicide: Assessment and intervention, 2 nd edition. Washington, DC: APA. Brock, S.E. (2002). School suicide postvention. In S.E. Brock, P.J. Lazarus, and S.R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp ). Bethesda, MD: NASP Jacobs, D. Suicide Assessment. University of Michigan Colloquium series, Kalafat, J., & Lazarus, P.J. (2002). Suicide prevention in schools. In S.E. Brock, P.J. Lazarus, & S.R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp ). Bethesda, MD: NASP. Lenaars, A. (1995). Suicide. Wass, H., & Neimeryer, R. (Eds), Dying: Facing the Facts, Washington, DC, Taylor and Francis. Lieberman, R., & Poland, S. (2006). Self-mutilation. In G. Bear & K. Minke (Eds.), Children’s needs III. (pp ). Bethesda, MD: NASP. Miller, D.N., & McConaughy, S.H. (2005). Assessing risk for suicide. In S.H. McConaughy Clinical interviews for children and adolescents (pp ). New York: Guilford. Stillion, J. (1996). Survivors of Suicide. In Doka, K. (Ed.), Living with grief after sudden loss (41- 51). NY: Hospice Foundation of America. American Academy of Pediatrics, Policy statements. Online at
Web-Based Resources National Association of School Psychologists –www.nasponline.org American Association of Suicidology –www.suicidology.org American Foundation for Suicide Prevention –www.afsp.org Centers for Disease Control –www.cdc.govwww.cdc.gov