April
decisions are made about who passes and who fails;
&
parties and proms to celebrate the end of the year
can have some negative side effects.
Of special concern are youngsters who seem depressed.
It's time to prevent;
it's time to help;
and there's still time to enable many students
to turn it all around.
KEEPING PROBLEMS IN PERSPECTIVE
In the Summer, 1999 and Fall, 2002 issues of the Center's newsletter, we discussed "Youth Suicide/Depression/Violence." We introduced the discussion as follows: Too many young people are not very happy. This is quite understandable among those living in economically impoverished neighborhoods where daily living and school conditions frequently are horrendous. But even youngsters with economic advantages too often report feeling alienated and lacking a sense of purpose.
Youngsters who are unhappy usually act on such feelings. Some "internalize;" some "act out;" and some respond in both ways at different times. The variations can make matters a bit confusing. Is the youngster just sad? Is s/he depressed? Is this a case of ADHD? Individuals may display the same behavior and yet the causes may be different and vice versa. And, matters are further muddled by the reality that the causes vary.
The causes of negative feelings, thoughts, and behaviors range from environmental/system deficits to relatively minor group and individual vulnerabilities on to major biological disabilities (that affect only a relatively few individuals). It is the full range of causes that account for the large number of children and adolescents reported as having psychosocial, MH, or developmental problems.
Recent highly publicized events and related policy initiatives have focused renewed attention on youth suicide, depression, and violence. Unfortunately, such events and the initiatives that follow often narrow discussion of causes and how best to deal with problems.
The Classification of Child and Adolescent Mental Diagnoses in Primary Care (DSM-PC) developed by the American Academy of Pediatrics is a useful resource to help counter this tendency to overpathologize (see attached below).
ABOUT SEASONAL VARIATIONS
(From: "Temporal Variations in School-Associated Student Homicide and Suicide Events --- United States, 1992--1999" Morbidity and Mortality Weekly Report, 2001, August, 10:50(31):657-60.)
| "... By describing temporal variations in school-associated student homicide and suicide events, this report provides information that can assist school administrators and faculty in planning the timing and focus of violence prevention programs. ... The findings on suicide are consistent with other studies that have shown increased suicide rates in the general population during the spring .... Programs designed to prevent suicide and suicidal behavior among students should recognize that the spring semester is the period of highest risk. The Surgeon General recommends training teachers to recognize students that show signs of risk for suicide and refer them to a mental health professional for assessment and treatment .... Prevention programs can be effective in preventing youth violence .... Effective programs often focus on both individual risk factors and environmental conditions that may predispose young persons toward violent behavior." |
A Few Related References
- Chew KSY, McCleary R. The spring peak in suicides: a cross-national analysis. Soc Sci Med 1995;40:223--30.
- Dwyer K, Osher D. Safeguarding our children: an action guide. Washington, DC: US Departments of Education and Justice, American Institutes for Research, 2000.
- Kachur SP, Stennies GM, Powell KE, et al. School-associated violent deaths in the United States, 1992 to 1994. JAMA 1996;275:1729--33.
- Thornton TN, Craft CA, Dahlberg LL, et al. Best practices of youth violence prevention: a sourcebook for community action. Atlanta, Georgia: US Department of Health and Human Services, CDC, 2000.
- US Department of Health and Human Services. Youth violence: a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, CDC; Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; and National Institutes of Health, National Institute of Mental Health, 2001.
- US Public Health Service. The Surgeon General's call to action to prevent suicide. Washington, DC: US Public Health Service, 1999.
SOME CENTER RESOURCES TO GUIDE PREVENTION AND EARLY INTERVENTION
For specific intervention ideas, see the following Center Resources:
Quick Training Aids on:
- Suicide Prevention (materials for staff development including screening tools and descriptions of evidence based programs)
- Assessing & Screening
- Case Management in the School Context
- School Interventions to Prevent and Respond to Affect and Mood Problems
Resource Aid Packet: Screening/Assessing Students: Indicators and Tools
Technical Assistance Sampler: School Interventions to Prevent Youth Suicide
Quick Finds on: Suicide Prevention; Depression; related topics
BELOW ARE SOME TOOLS FOR STAFF DEVELOPMENT
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In the Technical Assistance Sampler: School Interventions to Prevent Youth Suicide, you will find the following Excerpts from… Guidelines for School Based Suicide Prevention Programs circulated by the American Association of Suicidology, 1999, http://www.suicidology.org Conceptual Basis for Prevention Approaches A clear conceptual basis gives us the rationale for choosing a particular prevention strategy for a particular problem, with a particular population, in a particular setting. Part of the effort to build the conceptual base for prevention in general has resulted in typology intended to clarify prevention methodology (Institute of Medicine,1994) which included:
The goal of universal approaches is to raise the overall supportiveness and responsiveness of the at risk youths' environment. The role of the school is seen as critical, but limited. All schools are not assumed to possess the resources to treat suicidal or emotionally disturbed students. They can enhance their capacity to identify and get help for these students as part of their mandate to socialize and protect their students. The overall goals of the universal program are to increase the likelihood that school gatekeepers (administrators, faculty, and staff) and peers who come into contact with at-risk youth can more readily identify them, provide an appropriate initial response to them, will know how to obtain help for them, and are consistently inclined to take such action. Protective Factors & Wellness Promotion Some longitudinal research indicates that the presence of protective factors may have a stronger influence on the likelihood that risk behaviors will occur than the presence of risk factors. These protective factors include personal characteristics such as social problem solving competencies; and, environmental characteristics such as contact with a caring adult and a school climate that promotes students' involvement, contribution, and sense of connection with their school. One caveat concerning resilient youth is in order. Research indicates that youth who come from high risk environments and yet do well in school and peer relations still evidence a greater prevalence of anxiety and depression than peers who do not come from such environments. Anxiety and depression are significant risk factors for suicide, and these internalizing disorders are more likely to go undetected than the externalizing behaviors. Selective Prevention Programs While subgroups that are at greater risk for suicide will by definition be exposed to universal programs, these programs are aimed more at their peers and may not be of sufficient dosage or focus to affect specific vulnerable subpopulations such as disenfranchised or depressed students. Some of these students may become known to school officials, particularly if school personnel and parents are educated to identify troubled students before they make overt statements or attempts. Thus gatekeeper training is a common selective program that has shown promise for increasing identification and referral. There is some evidence that students are more likely to use telephone crisis and referral services because they are anonymous, and don't require fees, transportation, or appointments. Publicizing these services (e.g. through wallet cards continuously available throughout the school) and linking them to established screening teams can facilitate contact with at risk youth. However, these services are still underutilized by males. Indicated Prevention Programs The goal of indicated programs is to reduce the incidence of suicidal behaviors among students who already display risk factors or early warning signs associated with suicide such as frequent suicidal thoughts, previous attempts, depression, or substance abuse. Indicated programs require the presence in schools of individuals who are trained to screen students and to provided the indicated programs. School faculty or special services staff such as guidance counselors can be trained to provide the programs, but professionals such as psychologists or social workers would have to conduct the screening. There are a growing number of school-linked services (community gatekeepers who provide assessment and counseling services on site) and school based service centers or clinics that can house indicated interventions. The overall goals of indicated programs are to identify at risk students, preferably through existing school procedures, and provide them with accessible, brief interventions that include support, skill training, and opportunities to bond with the school and maintain contact with a caring adult.
Requirements for Effective Prevention Programs
. . . Comprehensive programs are multilevel, multicomponent interventions that include the following components, usually implemented in this order:
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The following screening tools are from our Center's Technical Assistance Sampler on School Interventions to Prevent Youth Suicide.
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Student's Name:_____________ Date:_________ Interviewer: ________ (Suggested points to cover with student/parent) (1) PAST ATTEMPTS, CURRENT PLANS, AND VIEW OF DEATH
(2) REACTIONS TO PRECIPITATING EVENTS
(Such changes often are related to recent loss or threat of loss of significant others or of positive status and opportunity. They also may stem from sexual, physical, or substance abuse. Negative feelings and thoughts often are expressions of a sense of extreme loss, abandonment, failure, sadness, hopelessness, guilt, and sometimes inwardly directed anger.) (3) PSYCHOSOCIAL SUPPORT
(4) HISTORY OF RISK-TAKING BEHAVIOR
*Use this checklist as an exploratory guide with students about whom you are concerned. Each yes raises the level of risk, but there is nosingle score indicating high risk. A history of suicide attempts, of course, is a sufficient reason for action. High risk also is associated with very detailed plans (when, where, how) that specify a lethal and readily available method, a specific time, and a location where it is unlikely the act would be disrupted. Further high risk indicators include the student having made final arrangements and information about a critical, recent loss. Because of the informal nature of this type assessment, it should not be filed as part of a student's regular school records. |
____(1) As part of the process of assessment, efforts will have been made to discuss the problem openly and nonjudgmentally with the student. (Keep in mind how seriously devalued a suicidal student feels. Thus, avoid saying anything demeaning or devaluing, while conveying empathy, warmth, and respect.) If the student has resisted talking about the matter, it is worth a further effort because the more the student shares, the better off one is in trying to engage the student in problem solving. ___(2) Explain to the student the importance of and your responsibility for breaking confidentiality in the case of suicidal risk. Explore whether the student would prefer taking the lead or at least be present during the process of informing parents and other concerned parties. ___(3) If not, be certain the student is in a supportive and understanding environment (not left alone/isolated) while you set about informing others and arranging for help.
___(4) Try to contact parents by phone to
____(5) If a student is considered to be in danger, only release her/him to the parent or someone who is equipped to provide help. In high risk cases, if parents are unavailable (or uncooperative) and no one else is available to help, it becomes necessary to contact local public agencies (e.g., children's services, services for emergency hospitalization, local law enforcement).
Agencies will want the following information:
____(7) Document all steps taken and outcomes. Plan for aftermath intervention and support. ____(8) Report child endangerment if necessary.
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Developmental Variations: Behaviors within the
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DEVELOPMENTAL VARIATIONS
Sadness Variation
Bereavement
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Early Childhood
Middle Childhood
Adolescence |
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Thoughts of Death Variation Anxiety about death in early childhood. Focus on death in middle childhood or adolescence.
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Early Childhood In early childhood anxiety about dying may be present
Middle Childhood
Adolescence |
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Thoughts of Death Problem The child has thoughts of or a preoccupation with his or her own death. If the child has thoughts of suicide, consider suicidal ideation and attempts (...).
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Early and Middle Childhood The child may express a wish to die through discussion or play. This often follows significant punishment or disappointment.
Adolescence
Between 12% and 25% of primary school and high school children have
some form of suicidal ideation. Those with a specific plan or specific
risk factors should be considered at most risk. |
| *Adapted from The Classification of Child and Adolescent Mental Diagnoses in Primary Care. (1996) American Academy of Pediatrics. Notes: Dots (...) indicate that the original text has a reference to another section. | |
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Problems -- Behaviors Serious Enough to Disrupt Functioning with Peers,
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Sadness Problem
These symptoms should be more than transient and have a mild impact on the child's functioning. Bereavement that continues beyond 2 months may also be a problem.
*Adapted from The Classification of Child and Adolescent Mental Diagnoses in Primary Care. (1996) American Academy of Pediatrics. Notes: Dots (...) indicate that the original text has a reference to another section. |
Early Childhood
Middle Childhood
Adolescence
Sadness is experienced by some children beyond the level of a normal developmental variation when the emotional or physiologic symptoms begin to interfere with effective social interactions, family functioning, or school performance. These periods of sadness may be brief or prolonged depending on the precipitating event and temperament of the child. Reassurance and monitoring is often needed at this level. If the sad behaviors are more severe, consider major depressive disorders. The potential for suicide in grieving children is higher. Evaluation of suicidal risk should be part of a grief workup for all patients expressing profound sadness or confusion or demonstrating destructive behaviors toward themselves or others. Behavioral symptoms resulting from bereavement that persist beyond 2 months after the loss require evaluation and intervention. Depressed parents or a strong family history of depression or alcoholism (...) puts youth at very high risk for depressive problems and disorders. Family and marital discord, ... exacerbates risk. Suicidal ideation should be assessed (see Suicidal Thoughts or Behaviors cluster).
Lying, stealing, suicidal thoughts (see Suicidal Thoughts or Behaviors
cluster), and promiscuity may be present. Physical symptoms may include
recurrent headaches, chronic fatigue, and abdominal pain (...). |
In working on this important problem during a time when the dangers are increased, those working to support students in schools will find their skills in working with staff, administrators, families, and community resources are especially important.
| To download a copy of this material in pdf format, click here. |
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Center for Mental Health in Schools WebMaster: Perry Nelson (smhp@ucla.edu) |
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