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Child and Adolescent Suicide: Risks, Intervention and Prevention Michael E. Mitchell, LCSW Child and Adolescent Suicide, 20141.

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Presentation on theme: "Child and Adolescent Suicide: Risks, Intervention and Prevention Michael E. Mitchell, LCSW Child and Adolescent Suicide, 20141."— Presentation transcript:

1 Child and Adolescent Suicide: Risks, Intervention and Prevention Michael E. Mitchell, LCSW Child and Adolescent Suicide, 20141

2 DISCLOSURE Child and Adolescent Suicide,  The presenter DOES NOT have an interest in selling a technology, program, product, and/or service to CME/CE professionals.  The presenter DOES have an interest in selling a technology, program, product and/or service to CME/CE professionals.  Michael Mitchell, LCSW has nothing to disclose with regard to commercial relationships.  The content of this presentation does not relate to any product of a commercial interest. Therefore, there are no relevant financial relationships to disclose.

3 Prevention Assessment and Treatment What we know Overview 3Child and Adolescent Suicide, 2014

4 What we know Child and Adolescent Suicide,  Suicide : “…suicide is a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution”. ( Leenaars,1999) “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”. Camus- The Myth of Sisyphus

5 The Stats… Child and Adolescent Suicide,  38,285 people die from suicide 10 th cause of death (International Classification of Diseases, 2009 )  Guns, suffocation, poison  Gender  Frequency: Males x4  Method: Males >  Fatality  Maine: 2009  Higher than homicide  15 th Nationally  14 th males  12 th females  95% of people who die from suicide have diagnosable mental health issue  Few seek/receive behavioral health treatment  Contact with health care professional before attempt

6 Suicides, by Age Group, Sex and Mechanism Child and Adolescent Suicide, 20146

7 7

8 Maine Stats Child and Adolescent Suicide, 20148

9 Maine Data Child and Adolescent Suicide, 20149

10 Maine by County Child and Adolescent Suicide,

11 Summary: Highest Risk Child and Adolescent Suicide, Male Ages Access to firearms Hx of mental health issues Substance abuse Previous attempts Internalized emotional regulation High life stress Isolation Piscataquis, Knox, Waldo counties

12 Why suicide… Child and Adolescent Suicide, Psychological pain: “psychache” Override urge to live Desire for death “Best Solution” Perceived Burdensomeness Thwarted Belongingness Acquired Capacity (Joiner,2005) Constituents of the Desire for Death

13 Typical Motivations Child and Adolescent Suicide, a desire to influence another person to make someone feel guilty to express anger or gain attention to escape a difficult situation Shneidman’s 3 Clarifications of Suicide 1. Acute suicidal crisis is an interval of relatively short duration: Time 2. The suicidal person is ambivalent 3. Suicidal events are interpersonal events

14 Acquired Capacity to Enact Lethal Self-injury (Joiner,2005) Child and Adolescent Suicide, Increased exposure to pain Decreased aversion to pain Habituation to pain Potential “positive” definition Suicidal capacity

15 Child and Adolescent Suicide, Suicide capacity Perceived burdensomeness Thwarted belongingness Serious attempt or completion

16 Suicide in Children and Adolescents Child and Adolescent Suicide, Little flowers I shall remember forever and will never forget. Monday: my money was taken. Tuesday: names called. Wednesday: my uniform torn. Thursday: my body pouring with blood. Friday: it's ended. Saturday: freedom. The final diary pages of 13-year-old boy. He was found hanging from the banister rail at his home. JIMMY, AGE 13, a fraternal twin, was also raised in a family that struggled with substance abuse and depression.  Mother had a long history of using alcohol, cocaine, and heroin. His parents were never married, but when Jimmy was five, his father took custody of the boys after charges of neglect by the mother.  Several allegations of neglect and residence changes  By adolescence, Jimmy’s twin brother was involved with the juvenile system.  Before a final child welfare home visit could be made, Jimmy was found hanging in a closet during a family gathering. Endangered Youth, 2006

17 Adolescent Suicide… Child and Adolescent Suicide,  Nationally  Ages 1-24, 3 rd leading cause of death(4600 lives lost)  8% of girls and 3% of boys admitted to at least one attempt in their life  Doubled from 1960 to 2001  Maine:  Ages 15-19: 2 nd  Ages 10-14: 5 th  Ages 0-10: ?  35% to 50% have made, or will make, a suicide attempt  Age increases lethality  Gender difference  2008 rates: 12.9 in males vs. 2.7 in females  Females higher attempts  Males higher completed suicides  Male more lethal: gun, hanging, motor vehicle  Females: pill (s) OD or cut wrist  More deadly methods since the mid s

18 2009 CDC Youth Risk Behavior Survey Child and Adolescent Suicide, Suicide Ideations & Attempts:  Grades 9  19% of teens have suicidal ideation- N= 13,601  Suicidal ideation:  19.0% with plan  14.8% Suicide attempt  8.8% with med attention  2.6% Suicide attempt

19 Adolescent Risk Factors Child and Adolescent Suicide,  Family engagement  School engagement  ACE level  Social engagement  Mental Health  Substance use  Sexuality/gender  Pregnancy  Temperament  Suicide exposure/acceptability  Firearm access  Previous attempts  Cluster risk/Copycat  Psychiatric inpatient

20 Adolescents, SSRIs and Suicide Child and Adolescent Suicide,  Early 2000s increased concerns  October 2004, the FDA issued a black-box warning  December 2006 black-box extended to young adults  Limited research  Psychological autopsy studies  Effectiveness vs risk  Black-box warning reconsidered  “The result of this study is that antidepressants do show evidence of an antidepressant effect in the pediatric population and that the risk of nonfatal suicidal acts or suicidal ideation is less than that estimated by the FDA in its earlier analyses, yielding a clearly positive benefit-to-risk ratio.”

21 Gender Male Female Child and Adolescent Suicide,  School engagement  Weapon possession  Same sex attraction  High risk behavior  Higher SI tolerance  Lethal means  13 years of age show an abrupt increase SI  Emotional well-being  Trauma  Somatic symptoms  Friend SI  Hx mental health tx Beautrais, 2003

22 Gifted Adolescents Child and Adolescent Suicide,  Above average grades/intelligence  More severe attempts  More likely to complete  High perfectionism  High expectations  Uneven abilities  Adult perspective in a child’s life: Existential Nihilism “Being gifted, I have a strong sense of future, because people are always telling me how well I will do when I grow up …My feelings fluctuate from a sense of responsibility for everything to a kind of "leave me alone-quit pushing.“ (Delisle,1986)

23 LBGT and Suicide Child and Adolescent Suicide,  LGB youth attempt suicide 2-3x more frequently than straight peers.  Higher lethal intent  30.1 percent of transgender individuals reported attempted suicide  No #s re: numbers of died by suicide  Higher rates of depression, anxiety and SA  High rates of victimization  Severe family rejection

24 Adolescent Summary Child and Adolescent Suicide,  Similar to adults  Life transition issues  Accumulative effect  Child issues  Adolescent perspective  Gender gap  Substance abuse  Sub-populations

25 Childhood Suicide Facts Child and Adolescent Suicide,  Fifth (Sixth) leading cause of death in 5-14 yr. age group  Statistics unclear  Unintentional?  Experience fewer risk factors than late- adolescent  Limited research  Early minimization/ misreported

26 Child and Adolescent Suicide, Gabriel was removed from his mother's care in June 2008 and placed for 10 months in foster care. In the summer of 2008 Gabriel was sexually abused by a 14 yr. old boy and subsequently began to act out sexually on other children with whom he came into contact. Gabriel was placed in several foster homes He threw epic tantrums and told a therapist ''he was evil and born to lie." A foster parent described Gabriel accordingly, "And when he's bad, he's really, really bad, and his mood can change suddenly.'' Left in the care of the 19 year old son of foster parent, the teen made Gabriel a bowl of soup and Gabriel threw the soup in the garbage. The teen sent him to his room. Gabriel locked himself in the bathroom and wrapped a detachable shower hose around his neck. By the time his teenaged caregiver broke into the bathroom with a screwdriver, Gabriel was unresponsive. Gabriel was 7 years old

27 Child’s Concept Of Death Child and Adolescent Suicide,  By 6-7 know everyone dies  Not final  Only for the sick  Like sleeping/can wake up  Media portrayal:  Love loss  Revenge  Anger  Pouting

28 Child and Adolescent Suicide, Jacob, age 10, threatened to kill himself by jumping from the second floor window Therapist: You said that you are sick of life; that means that you suffer a lot. Jacob: They want me to do things at home, to take care of my brother. They don’t let me play... I am sick of it. Therapist: You told your teacher the other day that you want to die. I want to kill myself. What do you mean? Jacob: I want to kill myself here in school. Therapist: Why here in school? Jacob: The school is responsible for all the children, and if something happens to me in school, the principal will have to pay my parents a lot of money, and my father would not have to work hard and they will find a cure for my brother. Therapist: What happens to people when they die? Jacob: They are buried; they stink and rot and turn into bones.... Therapist: What do you think will happen to you if you die? Jacob: [Angrily] How do I know? I don’t know these things [pause]. I will ask God to help my parents and cure my brother. Jacob, age 10, threatened to kill himself by jumping from the second floor window Therapist: You said that you are sick of life; that means that you suffer a lot. Jacob: They want me to do things at home, to take care of my brother. They don’t let me play... I am sick of it. Therapist: You told your teacher the other day that you want to die. I want to kill myself. What do you mean? Jacob: I want to kill myself here in school. Therapist: Why here in school? Jacob: The school is responsible for all the children, and if something happens to me in school, the principal will have to pay my parents a lot of money, and my father would not have to work hard and they will find a cure for my brother. Therapist: What happens to people when they die? Jacob: They are buried; they stink and rot and turn into bones.... Therapist: What do you think will happen to you if you die? Jacob: [Angrily] How do I know? I don’t know these things [pause]. I will ask God to help my parents and cure my brother.

29 Pediatric Risk Factors Child and Adolescent Suicide,  Previous attempts  Psychopathology  BPD  Thought Disorder  Severity  Co-morbidity  Preoccupation with death  Poor social adjustment  Family History  Psychopathology  Suicide  6-fold increased risk  More likely to attempt at a younger age  Environmental  Violence  School  Bullying  Predicts later suicide behavior

30 Complications… Child and Adolescent Suicide,  Sub-clinical presentations  Little pre-suicide indicators  Unexpected  Developmental factors

31 Assessment and Treatment Child and Adolescent Suicide,

32 DSM-V Suicide Assessment Dimension Level of concern about potential suicidal behavior: (sum of items coded as present) 1. 0: Lowest concern : Some concern : Increased concern : High concern Suicide risk factor groups: Any history of a suicide attempt Long-standing tendency to lose temper of become aggressive with little provocation Living alone, chronic severe pain, or recent (within 3 months) significant loss Recent psychiatric admission/discharge or first diagnosis of MDD, bipolar disorder or schizophrenia Recent increase in alcohol abuse or worsening of depressive symptoms Current (within last week) preoccupation with, or plans for, suicide Current psychomotor agitation, marked anxiety or prominent feelings of hopelessness

33 Screening and Assessment Child and Adolescent Suicide, Shneidman’s 3 clarifications of suicide 1. Acute suicidal crisis is an interval of relatively short duration 2. The suicidal person is ambivalent 3. Suicidal events are interpersonal events Constituents of the Desire for Death  Perceived Burdensomeness  Thwarted Belongingness  Acquired Capacity (Joiner,2005)

34 Screening Child and Adolescent Suicide,  Formal vs. Informal  Developmentally appropriate  360 degree perspective  “Iceberg effect”  Prior/escalating attempts  Triggering life event  Referral

35 for the past month SUICIDE IDEATION DEINITIONS AND PROMPTS YN Have you wished that you were dead or wished you could go to sleep and not wake up? Have you actually had thoughts of killing yourself? If YES to 2, ask questions 3, 4, 5, and 6. If NO on 2, go directly to question 6. Have you been thinking about how you might kill yourself? Have you had these thoughts and had some intention of acting on them? Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Have you ever done anything, started to do anything, or prepared to do anything to end your life? If YES, ask: How long ago did you do any of these? Over a year ago Between three months and a year Within the last three months? COLUMBIA-SUICIDE SEVERITY RATING SCALE Screen Version Questions Child and Adolescent Suicide,

36 Columbia: Children’s Version Child and Adolescent Suicide, SUICIDAL IDEATION 1. Wish to be Dead : Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up. Have you thought about being dead or what it would be like to be dead? Have you wished you were dead or wished you could go to sleep and never wake up? Do you ever wish you weren’t alive anymore? 2. Non-Specific Active Suicidal Thoughts Have you thought about doing something to make yourself not alive anymore? Have you had any thoughts about killing yourself? 3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act Have you thought about how you would do that or how you would make yourself not alive anymore (kill yourself)? What did you think about? 4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan When you thought about making yourself not alive anymore (or killing yourself), did you think that this was something you might actually do? This is different from (as opposed to) having the thoughts but knowing you wouldn’t do anything about it. 5. Active Suicidal Ideation with Specific Plan and Intent Have you ever decided how or when you would make yourself not alive anymore/kill yourself? Have you ever planned out (worked out the details of) how you would do it? What was your plan? When you made this plan (or worked out these details), was any part of you thinking about actually doing it? INTENSITY OF IDEATION : The following feature should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 being the least severe and 5 being the most severe). Most Severe Ideation: ___________ _________________________________________________ Type # (1-5) Description of Ideation Most Severe Most Severe Frequency How many times have you had these thoughts? Write response________________________________ (1) Only one time (2) A few times (3) A lot (4) All the time (0) Don’t know/Not applicable ____ ____

37 Assessment Child and Adolescent Suicide,  Immediate risk  Lethality/instrumental  Intent, ideation, plan, access, means  Risk factors, multiple  Protective factors  Care giver perspective  Support system Time Escalation Active Resolution Trajectory of Risk

38 Intervention Child and Adolescent Suicide,  Safety, safety, safety…  Candid inquiry  Realities about death by suicide  Safety plan: A, B, C  Decrease access to firearms, drugs, etc.  “ With everything you’re saying, I wonder if you sometimes feel you would be better off dead?”  “Sometimes kids who deal with these things have seriously thought about how to kill themselves, have you?”  “You talk a lot about your death, have you ever thought about what it’s really like for people after a suicide?”

39 Treatment Focus Child and Adolescent Suicide,  Amplify ambivalence  Buy time  Build alternative skills  Diminish acquired ability  Challenge perceived burdensomeness  Increase belonging  Developmentally adjusted  Put it in the light! Screen Assess Intervene Follow up

40 Factors in Child and Adolescent Assessments What’s going with the child?What’s going on with the family What is needed to resolve the situation? How do I factor into the intervention? Child and Family Assessment40

41 Crisis Dispositions Child and Adolescent Suicide,  11 Crisis programs  Emergency Room  Family doctor  Home with nothing  Home with treatment  Crisis bed  Inpatient  Involuntary  Placement impact  Post intervention risk  Don’t assume people understand  On-going relationship  Ideation-attempt- completion  Re-enforcing “institutionalized nurturance”

42 Types of Family’s Experience Break thru- 1 st contact with crisis systemExperienced- Many contact and familiar with processRespite- Break down of natural supports Primary problem- Family chaos is significantly contributing to the child’s presenting problem Child and Family Assessment42

43 Prevention Child and Adolescent Suicide,  Early intervention  Candid confrontation  Realistic alternatives  Intercept points  Transitions  Breakthroughs  Outcries  Micro and Macro education  School, PCPs, sports, providers

44 Child and Adolescent Suicide,

45 Questions Child and Adolescent Suicide,

46 References Child and Adolescent Suicide,  Works Cited  Beautrais, A. (2003). Suicide and Serious Suicide Attempts in Youth: A Multiple-Group Comparison Study. American Journal of Psychiatry, Jun;160(6):  Borowsky, I., Ireland, M., & Resnick, M. (March 2001). Adolescent suicide attempts: risks and protectors. Pediatrics,  Delisle, J. (1986). Death with honors: Suicide among gifted adolescents. Journal of Counseling and Development, 64:  Dore, M., Aselthine, R., Franks, R., & Schultz, M. (January 2006). Endangered Youth: A report on suicide among adolescents involved with the child welfare and juvenile justice system. CHILD WELFARE LEAGUE OF AMERICA.  Greydanus, D.. Suicide in Children and Adolescents. Michigan State University, College of Human Medicine.  Joiner, T. (2205). Why People Commit Suicide. Cambridge MA: Harvard University Press.  Leenaars, A. (2010). Edwin S. Shneidmanon Suicide. Suicidology Online, 1:5-18.  Leenaars, A. (1999). Lives and deaths: Selections from the works of Edwin S. Shneidman's. Philadelphia: Brunner/Mazel.  Mishara, B. L. (2003). How the media influences children’s conceptions of suicide. Journal of Crisis Intervention and Suicide Prevention, 24:  Pfeiffer, C. (1986). The Suicidal Child. Guilford Press.  Pompeii M, M. I. (2005). Childhood Suicide Care Issues in Comprehensive Pediatric Care, 28:  Shneidman's, E. (1992). A conspectus for conceptualizing the suicidal scenario. In r. Maris, A. Berman, J. Maltsberger, & R. Yufit,. Assessment and prediction of suicide (pp ). New York: Guilford Press.

47 Child and Adolescent Suicide, Contact information Michael Mitchell, LCSW Clinical Director Crisis and Counseling Centers 10 Caldwell Rd Augusta, Me x1143 org


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