Presentation on theme: "Albert Camus, The Myth of Sisyphus (1942)"— Presentation transcript:
1Albert Camus, The Myth of Sisyphus (1942) 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)
2Outline: What suicide is and how it is studied What it isn’t: myths and opinions vs. factsEpidemiology, especially pediatricWarning signsPrevention, intervention, and postventionSuicide and your clinical skills: assessment, intervention, and risk
3Facing the facts: 900,000 per year, worldwide; about 1% of deaths; 1 death by suicide every 40 seconds;10-20 million suicide attempts per year: 1:8 ratio of attempters vs. completers;395,000 emergency department visits per year are self-inflicted injuries3rd leading cause of death among year olds (following accidents and homicide);2nd leading cause among year olds;8 per 100,000 among US college students;
4Suicidolgy, epidemiology CDC, WHO, NASP, IASP Methods of suicideTable 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).
5Suicide Trends Among Youths and Young Adults Aged 10--24 Years --- United States, 1990--2004 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.
6Suicidology: 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!
7More 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.
8What 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)
9Definition(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.
10What suicide is NOT A disease An immorality A biological anomaly A neurological dysfunctionIt is unlikely that any one theory will ever explain phenomena as complex and varied as acts of human self-destruction. (Leenars, 1995)
11Facts vs. MythsMyth: People who talk about suicide won’t really do it.Fact: 8 of 10 suicides have given a definite warning.
12Facts vs. Myths Myth: Suicide happens without warning. Fact: Almost all suicidal people give many warnings.
13Facts vs. Myths Myth: Suicidal persons are fully intent on dying. Fact: Most are undecided and ambivalent.
14Facts vs. MythsMyth: 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.
15More facts and mythsMyth: 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.
16Facts vs. MythsMyth: 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.
17Probably 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.
18Unbearable psychological pain DepressionMasked depressionHostility, anxiety, guilt, shame, hopelessnessOverwhelming, painful EMOTION, not depression per seConstricted thinking as a result of emotional pain
19Cognitive constriction RigidNarrow focus (tunnel vision)ConcretenessDysfunction in emotions, logic, perceptionsInability to adjustAggression, confusion, humiliation
20PSYCHIATRIC SYMPTOMS ASSOCIATED WITH SUICIDE HopelessnessImpulsivity / AggressionAnxietyCommand hallucinations
21Interpersonal difficulties RejectionAggressionIdentification with a lost loved oneShame and humiliation that is deemed unfair, especially public shame (losing one’s license to practice; failing out of school)
22Biology of suicide Learning disabilities: right brain dysfunction Physical illness and disabilitiesBiomarkers: corticosteroids, thyrotropin releasing hormone, norepi:epi ratioSmall samples sizes, problems with data collection, confounding variables
23Family background of suicide Lack of generational boundariesInflexible family system (secretiveness, denial, poor communication, patterns of authoritarian disciplineSymbiotic parent-child relationshipLong term family disorganizationAdolescents who feel a lack of control over their environment
25Suicide SUICIDE: A MULTI-FACTORIAL EVENT Jacobs, 2003 Psychiatric Illness Co-morbidityPersonality Disorder/TraitsNeurobiologyImpulsivenessSubstance Use/AbuseHopelessnessSevere MedicalIllnessSuicideFamily HistoryAccess To WeaponsPsychodynamics/Psychological VulnerabilityLife StressorsSuicidalBehaviorJacobs, 2003
26Suicidal 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 1950sA child or adolescent commits suicide in the U.S. approximately every 2 hoursSuicide rates are highest among high school students, although there have been recent increases among middle school students
27Suicidal 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 combinedSurvey research suggests approximately 20% of high school students experience serious suicidal thoughts in a given year, and that about 4-8% make actual attemptsOver 2000 children and adolescents commit suicide annuallyThese statistics likely underestimate actual figures, although the degree to which this occurs is uncertain(National Association of School Psychologists)
28Suicidal Behavior in Children and Adolescents In any given year in a typical high school class of 30 students:6 will seriously consider suicide2 to 3 will attempt suicide1 will make an attempt sufficiently harmful to require medical attention
29Suicidal Behavior in Children and Adolescents: Demographics GenderAdolescent females attempt suicide at a rate of 2:1/ 3:1 compared to adolescent malesAdolescent males commit suicide at a rate of nearly 5:1 compared to adolescent femalesAgeRates of suicidal behavior increase as children get older, hitting peak in early 20s
30Suicidal Behavior in Children and Adolescents: Demographics RaceWhite males currently at highest riskOther high risk groups: Native-American youth; African-American malesLimited data available on other groupsGeographyHighest suicide rates in Western states and AlaskaLowest suicide rates in Northeastern statesHigher suicide rates in rural than in urban areas
31Suicidal Behavior in Children and Adolescents: Demographics When:Slightly more suicides occur during SpringMonth with least amount of suicides: DecemberSuicide rates lower just before and during holidaysWhere:Most adolescent suicides occur at home, where primary means for suicide (typically firearms) are available
32Suicidal 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.
33Suicide Ideation, Attempts, and Completion Three different types of suicidal behaviors (ideators, attempters, and completers) reflect different types of individualsTypical youth suicide attempter: Adolescent female who ingests pills in front of her family during an argumentTypical youth suicide completer: Adolescent male who is a victim of a gunshot wound
34Attempters vs. Completers An overlapping group8:1 ratio overallIn young people, 50:1 ratioParasuicideDistinguishing among the two: a slippery slopePerturbation and lethality are rated high, medium, or low, on a 1-9 scaleLethality 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
35Common 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
36Prevention 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.
38Protective Factors in General Population Children in the home, except among those with postpartum psychosisPregnancyDeterrent religious beliefsLife satisfactionReality testing abilityPositive coping skillsPositive social supportPositive therapeutic relationship
39Child/Adolescent Risk Factors in Youth Suicide Previous suicide attemptCurrent suicidal ideation, intent, and planPsychiatric Disorders and ProblemsDepressionHopelessnessConduct problemsDrug and/or alcohol abuseImpulse control problems (e.g., shoplifting; gambling; eating disorders; self-injury)
40Child/Adolescent Risk Factors in Youth Suicide Gay or lesbian sexual orientationUnwillingness to seek help because of perceived stigmaFeelings of isolation or being cut off from othersIneffective copingInadequate problem-solving skills, low emotional intelligenceCultural and/or religious beliefs (e.g., belief that suicide is a noble or acceptable solution to a personal dilemma)
41Environmental/Situational/Family Risk Factors in Youth Suicide Access to lethal methods, especially firearms;Exposure to suicide and/or family history of suicideLoss (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.
42Environmental/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.
43Suicide 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
44Youth Suicide Clusters: Community Characteristics Lack of integration and belongingRapid community growth and large schoolsHigh rates of substance abuseEmphasis on material possessionLack of mental health services and little awareness of problem of youth suicideNo 24-hour crisis hotlinesLack of networking and coordination among community agencies
45Warning Signs for Youth Suicide Suicide threatsSuicide plan/method/accessMaking final arrangementsSudden changes in behavior, friends, or personalityChanges in physical habits and appearancePreoccupation with death and suicide themesIncreased inability to concentrate or think clearlyLoss of interest in previously pleasurable activitiesSymptoms of depressionIncreased use and abuse of alcohol and/or drugs
46Suicide 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?
47Suicide 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?
48Suicide 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).
49“No-Suicide” or “Safety” Contracts Widely used and recommended, but there is increasing controversy regarding their useIn reality, they are neither contractual nor ensure genuine safetyThey tend to emphasize what students won’t do rather than what they will doMay be viewed by students as coercive, since failure to sign may force hospitalizationMay give clinicians a false sense of securityBetter approach: Encourage students to commit to treatment rather than merely promising “safety”
50Suicide 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?
51Suicide 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?
52Suicide 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)?
53Special 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 intentMost typical form of self-injury is cuttingSelf-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 feelingsAlthough 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
54Special 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 functionsAn individual attempting suicide is trying to end his/her life, whereas the individual engaging in self-injury is typically trying to maintain itIn contrast to suicide completion, self-injury appears to be more prevalent in girls than boysSelf-injury typically begins in early adolescence and may persist for years if not adequately treatedThe number of children and youth engaging in self-injury is likely underestimated and increasing
55Immediate Interventions for Suicidal Youth Assess severity of suicidal riskRemove access to methodsNotify parents/caregivers and others as neededSupervise at all times“Suicide-proof” the environmentSeek support and collaboration from colleaguesMobilize a support team for the individualDocument all actions
56What 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 helpDon’t rush – establish contact and get the person to someone who can help; you are not trying to completely resolve the crisisDon’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.
57What 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.
58Suicide PostventionSchools 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.
59Suicide Postvention: Recommended “Dos” and “Don’ts” Do plan in advance of any crisisDo select and train a crisis teamDo verify that a suicide occurredDo disseminate information to faculty, students, and parents; be truthful but avoid unnecessary detailDo report information to students in small groups (classrooms) using fact sheets and uniform statementsDo not release information about the suicide in a mass assembly or over a loud speakerDo have extra counselors available on site for students and staff
60Suicide Postvention: Recommended “Dos” and “Don’ts” Do not dismiss school or stop classesDo 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 funeralDo not make special arrangements to send all students from a class or school to the funeralDo contact the family and offer any assistanceDo collaborate with media, law enforcement, and community agencies
61Suicide Postvention: Media Guidelines Do not sensationalize with front page coverage and/or details of suicide methodAvoid phrases like “successful suicide,” “failed attempt”Do not print pictures of deceasedDo not report the suicide as simplistic or romanticDo emphasize that no one person or thing is to blameDo provide information on suicide preventionDo provide information about where students can go for help, including both school and community resourcesDo emphasize that suicide is a preventable problem, and that we all have a role in it
62Your Clinical Skills Assessment: Knowledge of the risk factors 1. Biological2. Family3. Psychological4. Personal5. Contextual6. MSE
63Biological risk factors Family history of psychiatric disordersLow serotonin, poor impulse control
64Family Risk Factors Family history of suicide Death of parent Early separation from parentHostile family relationshipsChaotic family environment
66Personal risk factors Age (Adolescent, elderly) Ethnicity (White, male)Marital status (single)Live alonePrevious attemptPoor healthHistory of abuseRecent lossAccess to means, presence of firearms
67The Specific Suicide Inquiry Ask About:Suicidal ideationSuicide plansGive Added Consideration to:Suicide attempts (actual and aborted)First episode of suicidality (Kessler 1999)HopelessnessAmbivalence: a chance to intervenePsychological pain history(Jacobs, 1998)Emphasize increased risk of suicide attempts in year following initial onset of suicidal ideation. - Kessler
68Mental status examMood, affect (hate of self or other, aloneness, fear, fatigue, hopelessness, helplessness)Suicide preoccupation: ideation, intent, plan, access, fantasies about deathReality testingCapacity for differentiationCognitive constriction
69THERE IS NO SINGLE DEFINITIVE PREDICTIVE BEHAVIOR Previous attemptsVerbal statementsCognitive constrictionHigh perturbationSudden behavioral changesLife threatening behaviorsAccess to means
70Adolescent warning signs Withdrawal from friends and family membersTrouble in romantic relationshipsDifficulty getting along with othersChanges in the quality of schoolwork or lower gradesRebellious behaviorsUnusual gift-giving or giving away own possessionsAppearing bored or distractedWriting or drawing pictures about deathRunning away from homeChanges in eating habitsDramatic personality changesChanges in appearance (for the worse)Sleep disturbancesDrug or alcohol abuseTalk of suicide, even in a joking wayHaving a history of previous suicide attempts
71Negligence, forseeability, and the legal issues of pediatric suicide SchoolsPrimary Care ProvidersMental Health Clinicians: Psychologists, Clinical social workers, licensed counselors, psychiatrists, and to a lesser extent, clergy
72Suicidal 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 suicidalSchools not responsible ultimately, but must demonstrate they made appropriate, “good faith” efforts to prevent suicide from occurring
73Suicidal 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.
74Legal issues for mental health specialists: Majority of lawsuits pertained to inpatient suicide, or recently released inpatientFailure to diagnose: misdiagnosis or failing to predictAbandonmentPrecautions for all health care providers:DOCUMENTATION
75When 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 passesBefore discharge
76Firearms and the assessment of lethality If present - document instructionsIf absent - document as pertinent negative
77American Academy of Pediatrics 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 suicideprecipitates 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 understandtheir 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
78Examples of Adolescents at Low, Moderate, and High Risk for Suicide Low riskTook 5 ibuprofen tablets after argument with girlfriend. Impulsive; told mother 15 minutes after taking pillsNo serious problems at home or schoolOccasionally feels “down” but has no history of depression or serious emotional problemsHas a number of good friendsWants help resolving problems and is no longer considering suicide after interview
79Moderate riskSuicidal ideation precipitated by recurrent fighting with parents and failing grades in schoolWants to “get back” at parentsCut both wrists while at home alone; called friend 30 minutes laterParents separated, changed school this semester, history of attention-deficit hyperactivity disorderSymptoms of depression for the last 2 months, difficulty controlling temperBinge drinking on the weekendsAnswers all the questions during the interview, agrees to see a therapist if parents get counseling, will contact the interviewer if suicidal thoughts return
80High riskThrown out of house by parents for smoking marijuana at school, girlfriend broke up with him last night, best friend killed in autocrash last monthWants to be dead; sees no purpose in livingTook father’s gun; is going to shoot himself where “no one can find me”Gets drunk every weekend and uses marijuana dailyHates parents and school; has run away from home twice and has not gone to school for 6 weeksHospitalized in the past because he “lost it”Does not want to answer many of the questions during the interview and hates “shrinks”
81Pediatricians 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
82ReferencesBerman, A.L., Jobes, D.A., & Silverman, M.M. (2006). Adolescent suicide: Assessment and intervention, 2nd 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: NASPJacobs, D. Suicide Assessment. University of Michigan Colloquium series, 2003.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
83Web-Based Resources National Association of School Psychologists American Association of SuicidologyAmerican Foundation for Suicide PreventionCenters for Disease Control