Adolescent Suicide Assessment Protocol Kay Redfield Jamison…”The suffering of the suicidal is private and inexpressible, leaving family members, friends, and colleagues to deal with an almost unfathomable kind of loss, as well as guilt. Suicide carries in its aftermath a level of confusion and devastation that is, for the most part, beyond description.” Kay Redfield Jamison 20 Questions That Could Save a Life

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

First of all, suicide as an unmentionable/unaddressed term is detrimental to our youth. We all have opinions and perspective regarding suicide. As clinicians, we are taught to meet the client where they are, in suicide prevention, it is imperative that we are able to do just that. In efforts of acknowledging such a place…write down the three most important things in your life…cross off the top two…What does that feel like? Death occurs due to the following acronym: N=natural A=accident S=suicide H=homicide

WHO?

ADOLESCENTS

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. Every suicide completed among 14-25 year olds, 100-200 attempts are made Every day an additional 1500 individuals attempt suicide…every minute of each day Between 650,000 and 1.8 million individuals attempt suicide each year 25-33% of adolescents who completed made a prior attempt

C O L L E G E

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 Two groups that might be at an even higher risk students with a pre-existing (before college) mental health condition students who develop a mental health condition while in college Reasons attributed to the appearance or increase of symptoms/disorders: new and unfamiliar environment academic and social pressures feelings of failure or decreased performance alienation family history of mental illness lack of adequate coping skills

VETERANS

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 Civilian suicide rate is 19.5 per 100,000

Gender Issues

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

WHAT?

Particular Risk for Suicide Extreme hopelessness Lack of interest in activities Heightened anxiety or panic attacks Irritability and agitation Global insomnia Prior history of suicide attempts Talk about suicide Learning about suicide makes it possible for us to overcome our fears about asking the “S” question

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

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

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

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

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

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

WHERE?

Every day 91 Americans take their own life 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 For young people 15-24 years old, suicide is the second leading cause of death More teenagers die from SUICIDE than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined.

There are now twice as many deaths due to suicide than due to HIV/AIDS 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 Think of how much press homicide and HIV/AIDS receives each year. Suicide does not compare to this even though it is a larger public health concern.

WHEN?

During our lifetime: 20% of us will have a suicide within our immediate family. 60% of us will personally know someone who dies by suicide. 1 in 64 Americans is a survivor of suicide Within a typical high school classroom, it is likely that three students (one boy and two girls) have made a suicide attempt within the last year Not all adolescent attempters may admit their intent Suicide has become the Last Taboo – we can talk about AIDS, sex, incest, and other topics that used to be unapproachable. We are still afraid of the “S” word Reducing stigma about suicide and its causes provides us with our best chance for saving lives Ignoring suicide means we are helpless to stop it

Survivors Limited answers Hind-sight questioning of personal actions and objectives Prolonged sense for reason Distorted sense of responsibility Feelings of stigma Elevated levels of anger Feelings of guilt and blame Suicide is not the end of pain, But rather the transfer of pain to someone else It is taking oneself out of the equation of pain The people left are suffering The term survivors acknowledges those who have lost a loved one to suicide Keep in mind that the grief of suicide survivors is unique

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.

WHY?

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) 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) Stigma about having mental health problems keeps people from seeking help or even acknowledging their problem Reducing the fear and shame we carry about having such “shameful” problems is critical People must learn that depression is truly a disorder that can be treated – not something to be ashamed of, not a weakness

Depression 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 Often co-occurs with anxiety and substance abuse disorders Depression is the most prevalent form of mental malady in the US

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

Bullying Bullying is a correlated link to adolescent suicide. Students who are bullied may be at a greater risk for developing antisocial behavior and depression. Bullying occurs in multiple environments. Not only do students go to school and deal with it daily, but now the bullying follows them home in that there is cyber-bullying. Bullying is a serious issue. We can say ignore, ignore, but as one of the students on the show said “I have ignored for 8 years, I just can’t do it anymore.” Some of the statements “it is not going to ever go away, didn’t know how to get help.”

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

Bullying Effects Interferes with school learning May increase absenteeism and dropout rates 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 Involves repeated acts of physical, emotional, or social behavior that are intentional, controlling, and hurtful. Bullying can be direct or indirect Boys more typically engage in direct bullying and girls in indirect bullying, but that is not always the case Safe Schools/Healthy Students 15+ Make Time to Listen, Take Time to Talk…About Bullying

HOW?

Suicide is the 2nd leading cause of death for WV youth ages 15-24 WV ranked 7th in the nation with an overall suicide rate of 16.58 per 100,000 people. Among youth ages 15-24, the suicide rate is 14.45 deaths per 100,000 people, ranking 11th in the nation Suicide is the 2nd leading cause of death for WV youth ages 15-24 This is a public health concern that doesn’t get the attention it deserves. It is important however that you understand that suicide is a problem for West Virginia. Children in our own communities are feeling so hopeless that they identify suicide as the viable solution to their pain. Talk about stats above…. Firearms were involved in 51% of the youth suicides Suffocation was 18%

West Virginia Youth Suicides by county Ages 14-25 2000-2008 Rate per 100,000 Population Hancock 5 (13.4) Brooke 5 (14.6) Ohio 7 (10.2) WV Average Rate 13.0/100,000 Marshall 13 (30.4) Wetzel Monongalia Morgan 3 (14.4) 13 (5.8) 4 (22.2) Marion Preston Berkeley Tyler 11(12.9) 5 (12.1) 14 (11.4) Pleasants 5(44.6) Mineral Jefferson 0 (0.0) Dodd- Harrison Taylor Hampshire 8 (21.8) 5 (7.1) ridge 5 (23.5) 2 (7.5) Ritchie 15 (16.1) Wood 1 (9.2) Grant 3 (29.3) Barbour Tucker 10 (8.8) 2 (13.7) 4 (17.6) 2 (23.4) Hardy Wirt Lewis 2 (12.5) 2 (25.3) Cal- Gilmer 3 (14.2) houn 2 (13.6) Upshur Randolph Jackson 3 (29.1) 3 (7.3) Mason 5 (13.4) 2 (5.1) Roane Braxton Pendleton 5 (14.5) 1 (4.6) 2 (10.5) 0 (0.0) 18.9 – 44.6 Putnam Webster Clay Cabell 8 (11.5) 3 (22.8) 4 (25.8) 13.4 – 17.6 Numbers are based on reports at the county level. Though numbers are descriptive quantifiers, they do not represent the significance of the issue as suicides tend to be underreported …accidents In looking at this map, there are very few counties not touch by at least one suicide. One suicide is somebody’s son, daughter, sister, brother, grandson, nephew, potential husband, etc. It is important however that you understand that suicide is a problem for West Virginia. Children in our own communities are feeling so hopeless that they identify suicide as the viable solution to their pain. 21 (12.6) Kanawha Nicholas 50 (19.5) Pocahontas 4 (11.1) 2 (18.9) 9.0 – 12.9 Wayne Lincoln Boone 6 (10.1) 3 (9.0) 2 (5.5) Fayette 0.0 – 8.2 15 (22.0) Greenbrier Logan 8 (18.5) 10 (19.0) Raleigh Mingo 9 (8.2) Wyoming Summers 4 (9.9) Monroe 1 (2.9) 2 (11.7) 0 (0.0) Mercer McDowell 12 (13.5) 3 (9.0)

Percentage of High School Students Who Seriously Considered Attempting Suicide,* by Sex** and Race/Ethnicity, 2007 Nationwide in 2007, 16.9% of high school students had seriously considered attempting suicide during the 12 months before the survey. Overall, the prevalence of having seriously considered attempting suicide was higher among female than male students. This is a general trend as Are you hearing me, these youth think suicide is an option, they do not acknowledge there potential, promise, or despair transitioning to healing of a continued productive, fulfilling life These are alarming statistics

Learning about suicide makes it possible for us to overcome our fears about asking the “S” question Take it seriously---75% of all suicides had given some warning of their intentions If you think that someone is suicidal, ASK THEM Be willing to listen and don’t show shock or disapproval Be actively involved in seeking professional help Avoid trying to explain away the feelings---don’t say things like “You have a lot to live for” or “You are just confused right now.”

ADOLESCENT SUICIDE ASSESSMENT PROTOCOL ASAP-20 Brief, user-friendly, structured clinical interview Intended for use by mental health workers and/or school counselors to provide an initial objective assessment of adolescent suicidal risk Classifies adolescent as either low, medium, or high risk Organized into four domains: Historical, Clinical, Contextual and Protective

History of Attempt A suicide attempt is defined as an intentional, self-harming act with greater than zero probability of death (O’Carroll, et al., 1996). Fremouw, de Perczel, and Ellis (1990) state that “the history of an individual’s prior suicide attempts is the most significant historical factor that must be considered in assessing current suicide risk” (p. 39). Research indicates that 25 to 33 percent of adolescents who completed suicide made prior attempts. Furthermore, boys who have a history of prior suicide attempts are especially at risk (30-fold increase); girls are slightly less at risk (3-fold increase) of completing suicide (Gould & Kramer, 2001).

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

Physical/Sexual Abuse 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 risk of suicide becomes greater as the length and frequency of the abuse increases (Kaplan, 1996) and may be more likely to result in completed suicide (Brent, 2001). A high number of occurrences of the abuse will increase the risk of suicide attempt. Additionally, ongoing abuse qualifies as a higher risk factor than abuse that has ceased. Finally, high intensity abuse will predict a more severe risk for the adolescent

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

Antisocial Behavior 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). Data from the New York Autopsy Study revealed that the rate of suicide in boys with antisocial behavior is 35 per 100,000, as compared to a base rate of 11 per 100,000; and for girls with antisocial behavior the risk is 7 per 100,000 (Gould, Shaffer, Fisher, Kleinman, & Morishima, 1992).

Questions to ask… History of Antisocial Behavior 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 on probation or had any legal conflicts? Explain

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). “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. Gould, Shaffer, Fisher, Kleinman, and Morishima (1992) report that in the New York Psychological Autopsy Study, “approximately 40% of the suicide completers had a first- or second-degree relative who had previously attempted or committed suicide” (p.138). Although genetic factors or general family dysfunction may contribute to this pattern of suicidal behavior, Gould and Kramer (2001) report that family histories “increase suicide risk even when studies have controlled for poor parent-child relationships and parental psychopathology” (p. 9).

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

Depression In addition to questions about depressed mood, also inquire about other depressive symptoms, such as: Disturbances in sleep and eating patterns Complacency or lethargy Social withdraw Feelings of worthlessness Brent et al. (1993) state that in the Pittsburgh Autopsy Study, “affective disorder, most specifically, major depression, was the single most significant risk factor for completed suicide in adolescents” (p. 524

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

Hopelessness 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 is a dominant characteristic of adolescent suicide attempters

Questions to ask… Hopelessness 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?

Anger 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).

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

Impulsivity 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.

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

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. 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

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

Recent Loss 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.

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

Firearm Access 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 85% of WV homes have firearms

Questions to ask… Firearm Access Are there any firearms in your home? 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?

Family Dysfunction Fremouw et al. (1990) state that “foremost among contributing environmental factors [for suicide risk] is the child’s 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

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

Peer Problems 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

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

School/Legal Problems 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.

Questions to ask School/Legal Problems Do you attend school regularly? 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?

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

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

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

Know Your Resources National Suicide Lifeline 1-800-273-8255

WV Adolescent Suicide Prevention and Early Intervention ASPEN Project Barri Sky Faucett Project Director (304) 415-5787 Hope M. Siler, MSW Regional Director (304) 618-5044 Mark Mason, BA Trainer (304) 415-8872

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