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Adolescent Suicide Assessment Protocol 20 Questions That Could Save a Life.

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1 Adolescent Suicide Assessment Protocol 20 Questions That Could Save a Life

2 Objectives Participants will be introduced to significance of suicide as a public health concern Participants will learn to recognize and respond to suicidal risk factors and warning signs Participants will learn to administer the Adolescent Suicide Assessment Protocol

3

4 WHO?

5 ADOLESCENTS

6 An average of one youth (ages 15-24) completes suicide every 2 hours and 2.1 minutes. An average of one youth (ages 15-24) completes suicide every 2 hours and 2.1 minutes. If suicides completed by youth under age 15 are included, that increases to an average of one every hour and 54.5 minutes. If suicides completed by youth under age 15 are included, that increases to an average of one every hour and 54.5 minutes.

7 COLLEGECOLLEGECOLLEGECOLLEGE

8 It is estimated that there are more than 1,000 suicides on college campuses each year. One in 12 college students has made a suicide plan 1997 reports indicate completed suicides rates: 7.5 per 100,000

9 VETERANS

10 The army suicide rate is now higher than that among the general American population at 20.2 per 100,000 About 18 veterans complete suicide daily Attempted suicides at a rate of 13,000per year

11 Gender Issues

12 WOMEN Women perceived as being at higher risk than men Women perceived as being at higher risk than men Women do make attempts 4 x as often as men Women do make attempts 4 x as often as men Womens risk rises until midlife, then decreases Womens risk rises until midlife, then decreases MEN Complete suicide 4x as often as women Complete suicide 4x as often as women Mens risk, always higher than womens, continues to rise until end of life Mens risk, always higher than womens, continues to rise until end of life

13 WHAT?

14 Particular Risk for Suicide Extreme hopelessness Extreme hopelessness Lack of interest in activities Lack of interest in activities Heightened anxiety or panic attacks Heightened anxiety or panic attacks Irritability and agitation Irritability and agitation Global insomnia Global insomnia Prior history of suicide attempts Prior history of suicide attempts Talk about suicide Talk about suicide

15 Know the Danger Signals Prior suicide attempts Prior suicide attempts Psychiatric problems Psychiatric problems Substance Abuse Substance Abuse Contagion Contagion History of family suicide attempts History of family suicide attempts Accessibility of firearms Accessibility of firearms

16 Other Risk Factors History of trauma or abuse History of trauma or abuse Loss of a relationship (friend, girlfriend/boyfriend, divorce of parents) Loss of a relationship (friend, girlfriend/boyfriend, divorce of parents) Lack of social support Lack of social support Stigma associated with seeking help Stigma associated with seeking help

17 You May See… Writing, talking or drawing about death Writing, talking or drawing about death Evidence of a previous suicide attempt Evidence of a previous suicide attempt Self-destructive acts (i.e. cutting, burning) Self-destructive acts (i.e. cutting, burning) Drug or alcohol abuse Drug or alcohol abuse Declining school performance Declining school performance

18 You May See… Chronic truancy or running away Chronic truancy or running away Complaints of boredom Complaints of boredom Social Isolation, quitting activities Social Isolation, quitting activities Poor concentration Poor concentration Inability to engage in relationships Inability to engage in relationships

19 You May See… Change in interactions with family and friends Change in interactions with family and friends Giving away of prized possessions Giving away of prized possessions Suspiciousness, paranoia Suspiciousness, paranoia Acquiring a gun or stock-pilling pills Acquiring a gun or stock-pilling pills Impulsivity / increased risk taking Impulsivity / increased risk taking

20 You May Also See… Recent disappointment or rejection Recent disappointment or rejection Increased sensitivity to rejection or failure Increased sensitivity to rejection or failure Argumentativeness, aggression Argumentativeness, aggression Unexplained anger, aggression and irritability Unexplained anger, aggression and irritability Acting sick or lazy frequently Acting sick or lazy frequently Sudden changes in moods Sudden changes in moods

21 WHERE?

22 Every 16 minutes another life is lost to suicide- taking the lives of more than 34,000 Americans every year Every 16 minutes another life is lost to suicide- taking the lives of more than 34,000 Americans every year Every day 91 Americans take their own life Every day 91 Americans take their own life For young people years old, suicide is the second leading cause of death For young people years old, suicide is the second leading cause of death

23 For every two victims of homicide in the US there are three deaths from suicide. For every two victims of homicide in the US there are three deaths from suicide. There are now twice as many deaths due to suicide than due to HIV/AIDS There are now twice as many deaths due to suicide than due to HIV/AIDS

24 WHEN?

25 During our lifetime: 20% of us will have a suicide within our immediate family. 20% of us will have a suicide within our immediate family. 60% of us will personally know someone who dies by suicide. 60% of us will personally know someone who dies by suicide. 1 in 64 Americans is a survivor of suicide 1 in 64 Americans is a survivor of suicide

26 Survivors Limited answers Limited answers Hind-sight questioning of personal actions and objectives Hind-sight questioning of personal actions and objectives Prolonged sense for reason Prolonged sense for reason Distorted sense of responsibility Distorted sense of responsibility Feelings of stigma Feelings of stigma Elevated levels of anger Elevated levels of anger Feelings of guilt and blame Feelings of guilt and blame

27 Bereaved children have a strong need to know that their world will be maintained and that their needs will be taken care of by a supporting adult. Unfortunately, their usual family support may have crumbled as each member mourns the death.

28 WHY?

29 Depression As many as one in every 33 children and one in eight adolescents may have depression. As many as one in every 33 children and one in eight adolescents may have depression. (United States Center for Mental Health Services [CMHS], 1996) (United States Center for Mental Health Services [CMHS], 1996) Once a young person has experienced a major depression, he or she is at risk of developing another depression within the next five years. (CMHS, 1996) Once a young person has experienced a major depression, he or she is at risk of developing another depression within the next five years. (CMHS, 1996)

30 Depression Two-thirds of children with mental health problems do not get the help they need. (CMHS, 1996) Two-thirds of children with mental health problems do not get the help they need. (CMHS, 1996) About 2/3 of people who complete suicide are depressed at the time of their deaths About 2/3 of people who complete suicide are depressed at the time of their deaths

31 No one is safe from the risk of suicide – wealth, education, intact family, popularity cannot protect us from this risk

32 Bullying Bullying is a correlated link to adolescent suicide. Bullying is a correlated link to adolescent suicide. Students who are bullied may be at a greater risk for developing antisocial behavior and depression. Students who are bullied may be at a greater risk for developing antisocial behavior and depression.

33 Bullying Bullying affects more than 5 million children grades 6-11 Bullying affects more than 5 million children grades 6-11 One out of 7 students reports being victimized daily One out of 7 students reports being victimized daily National Institute of Health, 2000

34 Bullying Effects Interferes with school learning Interferes with school learning May increase absenteeism and dropout rates May increase absenteeism and dropout rates Children often face years of constant anxiety, insecurity and low self-esteem Children often face years of constant anxiety, insecurity and low self-esteem Ignoring the problem can lead to violence toward others and increased suicidal ideations Ignoring the problem can lead to violence toward others and increased suicidal ideations Safe Schools/Healthy Students 15+ Make Time to Listen, Take Time to Talk…About Bullying

35 HOW?

36 WV ranked 7 th in the nation with an overall suicide rate of per 100,000 people. WV ranked 7 th in the nation with an overall suicide rate of per 100,000 people. Among youth ages 15-24, the suicide rate is deaths per 100,000 people, ranking 11 th in the nation Among youth ages 15-24, the suicide rate is deaths per 100,000 people, ranking 11 th in the nation Suicide is the 2 nd leading cause of death for WV youth ages Suicide is the 2 nd leading cause of death for WV youth ages 15-24

37 Barbour Berkeley Boone Braxton Brooke Cabell Clay Fayette Gilmer Grant Greenbrier Hampshire Hancock Hardy Harrison Jackson Kanawha Lewis Lincoln Logan McDowell Marion Mason Mercer Mineral Mingo Monongalia Monroe Morgan Nicholas Ohio Pendleton Pocahontas Preston Putnam Raleigh Randolph Ritchie Roane Summers Taylor Tucker Tyler Upshur Wayne Webster Wetzel Wirt Wood Wyoming JeffersonPleasants Dodd- ridge Cal- houn 5 (13.4) 5 (14.6) 7 (10.2) 13 (30.4) Marshall 13 (5.8) 5 (12.1)11(12.9) 15 (16.1) 5 (23.5) 4 (17.6)2 (23.4) 3 (14.2) 5(44.6) 1 (9.2) 3 (14.4) 3 (29.3) 0 (0.0) 10 (8.8) 2 (25.3) 3 (29.1) 2 (13.6) 1 (4.6)0 (0.0) 2 (13.7) 2 (12.5) 8 (21.8) 2 (7.5) 4 (22.2) 14 (11.4) 2 (5.1) 2 (18.9) 3 (22.8) 3 (7.3) 2 (10.5) 5 (13.4) 5 (14.5) 8 (11.5) 3 (9.0) 21 (12.6) 4 (25.8) 4 (11.1) 50 (19.5) 15 (22.0) 10 (19.0) 6 (10.1) 2 (5.5) 9 (8.2) 2 (11.7) 12 (13.5) 3 (9.0) 1 (2.9) 4 (9.9) 8 (18.5) 0 (0.0) 5 (7.1) West Virginia Youth Suicides by county Ages Rate per 100,000 Population WV Average Rate 13.0/100, – – – – 8.2

38 Percentage of High School Students Who Seriously Considered Attempting Suicide,* by Sex** and Race/Ethnicity, 2007

39 Learning about suicide makes it possible for us to overcome our fears about asking the S question

40 ADOLESCENT SUICIDE ASSESSMENT PROTOCOL ASAP-20

41 History of Attempt A suicide attempt is defined as an intentional, self-harming act with greater than zero probability of death (OCarroll, et al., 1996). A suicide attempt is defined as an intentional, self-harming act with greater than zero probability of death (OCarroll, et al., 1996).

42 ASAP-20 Sample Questions History of Suicide Attempts History of Suicide Attempts Have you ever tried to kill yourself? Have you ever tried to kill yourself? Describe what you did Describe what you did

43 Physical/Sexual Abuse According to Brent (2001) ongoing physical or sexual abuse is a particularly ominous precipitant… (p. 109) for suicidal behavior. According to Brent (2001) ongoing physical or sexual abuse is a particularly ominous precipitant… (p. 109) for suicidal behavior. The rating of physical and sexual abuse of the adolescent should involve three dimensions: frequency, duration, and intensity. The rating of physical and sexual abuse of the adolescent should involve three dimensions: frequency, duration, and intensity.

44 Questions to ask History of Physical/Sexual Abuse History of Physical/Sexual Abuse Have you ever been physically or sexually abused? Have you ever been physically or sexually abused? If so: When did the abuse occur? If so: When did the abuse occur? If so: How often did the abuse occur? If so: How often did the abuse occur?

45 Antisocial Behavior Adolescents displaying antisocial behaviors have an increased risk of suicide attempts. Adolescents displaying antisocial behaviors have an increased risk of suicide attempts. The risk is particularly high if these individuals have encounters with the law (Marttunen et al., 1998). The risk is particularly high if these individuals have encounters with the law (Marttunen et al., 1998).

46 Questions to ask… History of Antisocial Behavior History of Antisocial Behavior Have you ever been in any fights at school/in neighborhood? Describe Have you ever been in any fights at school/in neighborhood? Describe Have you ever been arrested or PLACED in jail? Explain Have you ever been arrested or PLACED in jail? Explain Have you ever been on probation or had any legal conflicts? Explain Have you ever been on probation or had any legal conflicts? Explain

47 Family History Numerous studies have found that suicidal behavior in family members significantly increases the risk for adolescents attempting or completing suicide (Gould & Kramer, 2001; Goldman & Beardslee, 1999). Numerous studies have found that suicidal behavior in family members significantly increases the risk for adolescents attempting or completing suicide (Gould & Kramer, 2001; Goldman & Beardslee, 1999). Family should include relatives outside the immediate family unit, such as grandparents. Aunts, uncles, and cousins should also be considered if interaction with the adolescent is frequent and significant to him/her. Family should include relatives outside the immediate family unit, such as grandparents. Aunts, uncles, and cousins should also be considered if interaction with the adolescent is frequent and significant to him/her.

48 Questions to ask… History of Family Suicide Attempts/Completions History of Family Suicide Attempts/Completions Have any of your close family members ever attempted suicide? Have any of your close family members ever attempted suicide? Have any of your close family members ever completed suicide? Have any of your close family members ever completed suicide?

49 Depression In addition to questions about depressed mood, also inquire about other depressive symptoms, such as: In addition to questions about depressed mood, also inquire about other depressive symptoms, such as: Disturbances in sleep and eating patterns Disturbances in sleep and eating patterns Complacency or lethargy Complacency or lethargy Social withdraw Social withdraw Feelings of worthlessness Feelings of worthlessness

50 Questions to ask… Depression Depression Do you feel depressed or sad? Do you feel depressed or sad? Have there been any changes in sleeping/eating? Have there been any changes in sleeping/eating? Have you lost interest in previously enjoyable activities? Have you lost interest in previously enjoyable activities?

51 Hopelessness Hopelessness, states Fremouw et al. (1990) is especially indicative of suicide risk (p. 65). Hopelessness, states Fremouw et al. (1990) is especially indicative of suicide risk (p. 65). Hopelessness includes feelings of despair, lack of control, and pessimism about the future (Fremouw et al., 1990). Hopelessness includes feelings of despair, lack of control, and pessimism about the future (Fremouw et al., 1990). Hopelessness is a dominant characteristic of adolescent suicide attempters Hopelessness is a dominant characteristic of adolescent suicide attempters

52 Hopelessness Hopelessness How do you feel about your future: okay, slightly negative, discouraging, or clearly hopeless like nothing will ever work out for you? How do you feel about your future: okay, slightly negative, discouraging, or clearly hopeless like nothing will ever work out for you? What are your future plans: next week? Next year? What are your future plans: next week? Next year? Questions to ask…

53 Anger Anger is prevalent in most adolescents, and many studies demonstrate that anger is correlated significantly with adolescent suicide. Anger is prevalent in most adolescents, and many studies demonstrate that anger is correlated significantly with adolescent suicide. The emotion of anger can be externalized and displayed as aggression. Conversely, anger can be internalized and manifested as depression (Myers et al, 1991). The emotion of anger can be externalized and displayed as aggression. Conversely, anger can be internalized and manifested as depression (Myers et al, 1991).

54 Questions to ask… Anger Anger How often do you feel angry or lose your temper? How often do you feel angry or lose your temper? Would people describe you as hot-headed? Would people describe you as hot-headed? Have you ever threatened or assaulted anyone when you were angry? Have you ever threatened or assaulted anyone when you were angry?

55 Impulsivity Research suggests that impulsivity may cause problem-solving deficits in suicidal adolescents. Research suggests that impulsivity may cause problem-solving deficits in suicidal adolescents. Research by Horesh, Gotheif, Ofek, Weizman, and Apter (1999) demonstrate that impulsivity is a stronger risk factor of adolescent suicide for males than females. Research by Horesh, Gotheif, Ofek, Weizman, and Apter (1999) demonstrate that impulsivity is a stronger risk factor of adolescent suicide for males than females.

56 Questions to ask… Impulsivity Impulsivity Do you act on whim/do things without thinking first? Do you act on whim/do things without thinking first? Are you impatient? Are you impatient? Have you been told that you have ADHD? Have you been told that you have ADHD?

57 Substance Abuse Gould and Kramer (2001) suggest that substance abuse is the most significant difference between those who actually attempt suicide and those with suicidal ideation. Gould and Kramer (2001) suggest that substance abuse is the most significant difference between those who actually attempt suicide and those with suicidal ideation. Suicide completions are the result of a combination of factors; however, studies have found that the most deadly combinations involve an element of substance abuse Suicide completions are the result of a combination of factors; however, studies have found that the most deadly combinations involve an element of substance abuse

58 Questions to ask… Substance Abuse Substance Abuse How often do you indulge in alcohol and/or drugs? How often do you indulge in alcohol and/or drugs? How often are you intoxicated? How often are you intoxicated? What type(s) of drug do you use? What type(s) of drug do you use? What is your drug of choice? What is your drug of choice?

59 Recent Loss Interpersonal loss and conflict with peers or family may trigger adolescent suicide (Overholser & Spirito, 2003). Interpersonal loss and conflict with peers or family may trigger adolescent suicide (Overholser & Spirito, 2003). Interpersonal loss is operationalized as death of a loved one, the abandonment, divorce or separation of a parent, or a breakup from a romantic relationship. Interpersonal loss is operationalized as death of a loved one, the abandonment, divorce or separation of a parent, or a breakup from a romantic relationship.

60 Questions to ask… Recent Losses Recent Losses Have you recently had conflict with a peer, significant other or parent? Have you recently had conflict with a peer, significant other or parent? Have your parents divorced or separated recently? Have your parents divorced or separated recently? Have you recently lost someone due to a breakup or a move? Have you recently lost someone due to a breakup or a move? Did someone you were close to recently die? Did someone you were close to recently die?

61 Firearm Access Firearms is the most frequent method for suicide. Firearms is the most frequent method for suicide. Households that contain firearms are the strongest situational predictive factor of committing suicide, especially for adolescents who have made previous suicide attempts Households that contain firearms are the strongest situational predictive factor of committing suicide, especially for adolescents who have made previous suicide attempts 85% of WV homes have firearms 85% of WV homes have firearms

62 Questions to ask… Firearm Access Firearm Access Are there any firearms in your home? Are there any firearms in your home? Do you have access to any firearms anywhere else? Do you have access to any firearms anywhere else? If yes to 1 and/or 2: Are they locked up? If no: Can you gain access to them? If yes to 1 and/or 2: Are they locked up? If no: Can you gain access to them?

63 Family Dysfunction Fremouw et al. (1990) state that foremost among contributing environmental factors [for suicide risk] is the childs family system (p. 62). Fremouw et al. (1990) state that foremost among contributing environmental factors [for suicide risk] is the childs family system (p. 62). Parents of children who attempt or commit suicide have significantly high rates of mood disorders, substance abuse, and psychopathology (Brent, 2001; Gould & Kramer, 2001 Parents of children who attempt or commit suicide have significantly high rates of mood disorders, substance abuse, and psychopathology (Brent, 2001; Gould & Kramer, 2001

64 Questions to ask Family Dysfunction Family Dysfunction Do you communicate with your family? Do you communicate with your family? Does anyone living with you suffer from depression, substance abuse or other psychopathology? Does anyone living with you suffer from depression, substance abuse or other psychopathology? How stable do you think your home life is/has been? How stable do you think your home life is/has been? Is your family supportive? Is your family supportive?

65 Peer Problems Research has sited interpersonal factors, and specifically difficulties in peer functioning, as precipitants to adolescents suicidal behavior Research has sited interpersonal factors, and specifically difficulties in peer functioning, as precipitants to adolescents suicidal behavior Although minimal research has focused on this specific area, several studies have found relationships between suicidal behavior and social isolation, sexual orientation, and peer rejection Although minimal research has focused on this specific area, several studies have found relationships between suicidal behavior and social isolation, sexual orientation, and peer rejection

66 Questions to ask… Peer Problems Peer Problems Do you have friends? Do you have friends? Do you feel like you have support from your friends? Do you feel like you have support from your friends? Have you been bullied or rejected by peers? Have you been bullied or rejected by peers? Do you attend school? God to work? Do you attend school? God to work?

67 School/Legal Problems Many studies have shown that there is an increased risk of suicide for those adolescents not in school and not working. Many studies have shown that there is an increased risk of suicide for those adolescents not in school and not working. Difficulties in school and/or impending disciplinary crisis also increase the risk of suicide for some adolescents. Difficulties in school and/or impending disciplinary crisis also increase the risk of suicide for some adolescents.

68 School/Legal Problems School/Legal Problems Do you attend school regularly? Do you attend school regularly? Have you ever been expelled, suspended, or placed in in-school suspension? Have you ever been expelled, suspended, or placed in in-school suspension? Have you been in trouble with the police, such as an arrest, probation, or state custody? Have you been in trouble with the police, such as an arrest, probation, or state custody? Questions to ask

69 Contagion Contagion is also referred to as imitation or cluster suicide Contagion is also referred to as imitation or cluster suicide Contagion can be caused by the media or by peer groups Contagion can be caused by the media or by peer groups Contagion suicides normally occur within two weeks of the original suicide Contagion suicides normally occur within two weeks of the original suicide

70 Questions to ask… Contagion Contagion Has someone that you have known or admired committed suicide lately? Has someone that you have known or admired committed suicide lately? If yes: How does this make you feel? If yes: How does this make you feel?

71 Protective Factors Reasons for Living Reasons for Living How does your faith view suicide? How does your faith view suicide? What are your expectations about your life problems improving? What are your expectations about your life problems improving? Do you think things will get better for you? Do you think things will get better for you? How important is your family to you? How important is your family to you? Are you afraid of dying? Are you afraid of dying? Current Treatment Current Treatment Are you currently seeing a therapist, counselor, or psychologist? Are you currently seeing a therapist, counselor, or psychologist? If so, how long have you been in treatment? If so, how long have you been in treatment?

72 Know Your Resources National Suicide Lifeline National Suicide Lifeline

73 WV Adolescent Suicide Prevention and Early Intervention ASPEN Project Barri Sky Faucett Project Director (304) Hope M. Siler, MSW Regional Director (304) Mark Mason, BA Trainer (304)

74 Your willingness to listen and to help can rekindle hope. HOPE MAKES ALL THE DIFFERENCE.


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