Conducting Suicide Risk Assessments in Clinical and School Settings Unique Challenges Associated with the Assessment of Suicide Risk in School Settings DANA E. BOCCIO, PH.D. ADELPHI UNIVERSITY GARDEN CITY, NY NYS SUICIDE PREVENTION CONFERENCE SEPTEMBER 12-13, 2016 ALBANY, NY

The Assessment of Youth Suicide Risk: A Complicated Enterprise  Discrepancy between the widespread experience of suicidal ideation and the infrequency of suicide  The dynamic presentation of ideation and intent  The anxiety-provoking nature of the task  Inadequate training

Suicide Prevention: A Multi-Systemic Issues  “The SMHP will be the staff member with the most training in identifying youth at risk but the least likely to interact with students who are not already identified as needing mental health services.”  From “Suicide in Schools” by Erbacher, Singer, & Poland (2015, p. 21)

Systemic Barriers to Suicide Safety  Culture of secrecy  Stigma  Difficulty obtaining parental involvement  Administrator attitudes and support  Failure to incorporate evidence-based theoretical constructs into the risk determination process  E.g., Joiner’s Interpersonal-Psychological Theory of Suicidal Behavior  Inappropriate referrals due to training deficits, anxiety, and concerns over liability  Poor communication within and across settings  Insufficient community resources and alternatives to emergency department referrals

Obstacles to Continuity of Care Study  51% of school psychologists received training in a standard, structured protocol for suicide risk assessment.  68% felt they needed more training in how to evaluate suicide risk in youth  Confidence in SRA skills (1 = “Not Confident”; 10 = “Very Confident”)  M (Total Sample) = 7.42 ( SD = 1.98)  M (Training in Protocol) = 8.12 (SD = 1.62)  M (No Training) = 6.75 (SD = 2.13) Relationship between confidence in SRA skills and anxiety levels r = -.531, p <.001 How anxious do you feel when a potentially suicidal student is referred to you for evaluation? % Not at all 10.0 Slightly 42.0 Moderately 38.0 Very 8.0 Extremely 2.0

Insufficient Resources “Typically, families wait 4+ hours to speak with a social worker, then are discharged. I think hospitals are understaffed.” “The family may wait 3 hours for a 15-minute exam. Unfortunately, it all depends on how busy the hospital is that day.” “Not enough beds/support/treatment.” “Local hospitals need to have more psych staff in the ERs.”

Denial of Suicidal Ideation and Intent How often do the students you assess because of concern over suicide risk deny suicide intent? And when they get to the hospital…?  “Typically, given the length of time between the referral and being seen by someone in the ER, the student is no longer in active crisis, so they deny their true level of intent because of fear of being admitted.”  “By the time the student reaches an ER, they minimize their level of intention or a plan – fear of hospitalization sets in.”  “Kids tend to think of the consequences of their statements and then retract or change them.”

Insufficient Resources

Perceptions of Emergency Departments and Communication with ED Personnel Description of Communication:% None – no communication at all 18.4 Minimal – only to be made aware that a student is on his way 28.6 Moderate – school shares information relevant to intake interview/evaluation 40.8 Good – communication surrounds treatment planning/management of risk 12.2 Excellent – work together on prevention strategies to minimize risk, continued updates on progress of at-risk individual, involvement of both parties in discharge planning or at least communication regarding discharge plans % reported “partnerships” with nearby hospitals…  “I have a good relationship with a couple of psychiatrists who actually return my call and share information regarding the case.”  “I have established relationships with staff on several inpatient units.”  “We have had several meetings with limited results.”  “Admitting department personnel contacted for each referral.”

Perceptions of Emergency Departments and Communication with ED Personnel Mean % admitted for hospitalization =  “Hospital staff should consult with school staff to gather more information about the student before making a decision to admit or not.”  “Hospitals in this area do not value school psychologists’ input.”  “Psychiatrists/hospitals need to take the school’s view and assessment more seriously.”  “We send info, write letters, and get nothing in return.”

Perceptions of Communication with ED Personnel Regarding Discharge

Liability Concerns Strongly Disagree DisagreeNeutralAgreeStrongly Agree Referred a student to hospital ED because wanted a second opinion, even if not sure student required hospitalization. 12.5%16.7%14.6%54.2%2.1% Referred a student to hospital ED because felt it would reduce school’s liability if student were to engage in suicidal behavior. 10.4%35.4%16.7%27.1%10.4% Not at AllA LittleSomewhatQuite a Bit Extremely How concerned would you be that a surviving family might file a lawsuit? 2.9%11.4%25.7%34.3%25.7% How concerned would you or your school be that you might be found liable for the student’s death? 5.7%11.4%37.1%11.4%34.3%

Recommendations  Educate students, school staff, and parents regarding risk factors and warning signs  Develop clear referral and risk assessment procedures  Cultivate relationships/communication within and across settings  Establish a continuum of services/alternatives to hospital referral  Improve training of school mental health professionals  Also, educate school mental health professionals regarding standard of care, bases for liability, and role of ED  Improve coordination of discharge planning  Establish clear procedures for school re-entry and engage in safety planning  Recognize need for continued assessment and monitoring  Make use of resources provided by AAS, SPRC, AFSP, and others (e.g., Continuity of Care for Suicide Prevention: The Role of Emergency Departments, Model School District Policy on Suicide Prevention)

Contact Dana E. Boccio