Introduction to Youth Suicide Prevention/Intervention/Postvention

1. Center and Crisis Services & An Introduction to Youth Suicide Prevention/Intervention/ Postvention

2. What will be covered: • Overview of DCMHMR and regular services • Overview of Crisis Services • Suicide Myths and Truths • Legal Implications for Schools • Best Practices for School Suicide Prevention/Intervention / Postvention • Statistics for Youth Suicide • Crisis Model and How to Identify a High Risk Student • Do’s and Don'ts for Suicide Intervention and Postvention • Social Networking • Peer Support • Suicide Contagion/Clusters/Copy Cat • Role Play and Case Studies

3. Who is Denton County MHMR?

4. Who is Denton County MHMR? • The local mental health and mental retardation authority for all of Denton County • Non – profit organization (501 C-3) • Unit of local government administered by a nine member board of trustees which are appointed by the Denton County Commissioners Court • Contract provider for the Texas Department of State Health Services and Texas Department of Aging and Disability Services

5. Child and Adolescent Services Denton County MHMR Serves Children and Adolescents from the ages of 3-17 that have severe emotional, behavioral or mental disorders. All potential clients must receive an intake which can be scheduled through the hotline. We accept Children and Adolescents with Medicaid or those that are uninsured. Fees are determined according to a sliding scale.

6. Child and Adolescent Services • Psychiatry: Includes assessment of symptoms and prescription/ monitoring of medications. • Assessment Services • Case Management and Rehabilitative Services. • Counseling: Time Limited individual and family counseling.

7. Child and Adolescent Services • Crisis Hotline and Resolution Services • Skills Training: Facilitates the client’s community integration and provides opportunities for improved functioning. • Family Partner: Provides wraparound team process. • Parent Support Group: Tuesdays in Lewisville and Denton once a month at 6:00 pm.

8. Intellectual and Developmental Disability (IDD) Services Home and Community-Based Services (HCS): • Care Coordination • Service Coordination • Adaptive aids • Minor home modifications • Counseling and therapies (includes audiology; speech/language pathology, occupational or physical therapy; dietary services; social work; and psychology) • Dental treatment • Nursing • Residential assistance • Supported home living • Foster/companion care • Supervised living • Residential support • Respite • Day habilitation • Supported employment

9. Intellectual and Developmental Disability (IDD) Services General Revenue (GR) Services: • Service Coordination • Community Support • Respite • Employment Assistance • Supported Employment • Nursing • Behavioral Support • Specialized Therapies • Vocational Training • Day Habilitation

10. Intellectual and Developmental Disability (IDD) Services Texas Home Living Waiver Program Services: • Adaptive aids • Minor home modifications • Specialized therapies • Behavioral support • Dental treatment • Nursing • Community support • Respite • Day habilitation • Employment assistance • Supported employment

11. Crisis Redesign • Denton County MHMR was granted additional funding by the state to expand and improve mental health crisis services within Denton County. • Crisis Redesign was implemented December 1, 2007

12. Pre-Crisis Redesign • Two clinicians to assess individuals during business hours and one after hours. • Response/wait time was long. • Averaged 80 emergency screenings per month. • No immediate crisis services available.

13. After Crisis Redesign Since December 1, 2007: -Average 180-200 emergency screenings per month. - Response time has decreased. - Case management - Psychiatric services if appropriate. - Counseling services if appropriate. - Mobile Crisis Outreach Teams increased – over 25 day staff! Does not count after hours teams! - Substance abuse counseling. - Additional availability of short term hospital contract bed days.

14. Denton County MHMR Emergency Screening Statistics

15. Denton County MHMR Emergency Screening Statistics From December 1, 2010 – May 31, 2011 The Crisis Team has completed 928 Screenings so far!

16. C&A Emergency Screenings

17. Crisis –VS- Emergency • A crisis is a stressful situation or set of events that are perceived or experienced as intolerable and unsolvable because the individual’s customary coping strategies and problem solving skills are exceeded • In a crisis an appropriate coping response is unknown, but in an emergency it can readily be implemented. • DCMHMR defines a crisis as someone who has thoughts of suicide, homicide and/or has deteriorated to the point to where they are a risk of harm to themselves or others.

18. Crisis Line • Denton County MHMR provides a crisis hotline service accredited by the American Association of Suicidology (AAS) • Hotline staff will provide information, support, intake appointments, intervention, and referrals to callers 24 hours a day, 7 days a week. • Hotline is available to anyone • Hotline Number:1-800-762-0157 • TTY Hotline Number:1-800-269-6233

19. What is the purpose of an assessment? • To determine the risk of harm to self or others. • To assess Acute and Chronic risk factors of suicide. • To check the individual’s mental status for impaired or disturbed thought patterns. • To assess the individual’s social environment for distress or support. • To assess substance abuse. • To determine what is the least restrictive environment in which an individual can safely function and receive treatment. • To facilitate inpatient treatment for the individual if the clinician determines that to be the least restrictive environment.

20. Triage • All Screenings undergo the following assessment process: • Emergency criteria met • Drug/alcohol levels acceptable for mental health treatment. BAC must be at below .08 or 80 and be Narcan free for 24 hours for team to screen. • Client must be medically stable for team to screen. • Physical problems - See Hospital Exclusionary Criteria for considerations • Intellectual and Developmental Disabilities considerations

21. Triage • Secure locations include jail, DCMHMR office and Hospitals (medical and psychiatric). • In the Hospital ~ has the psychiatric consult recommended inpatient treatment? If so, is the patient insured and will they go voluntarily? • Police to stay for entire assessment if environment is an unsecure location or client is combative. • If it is a child, we attempt to locate the parent/guardian. CPS will be contacted for any unaccompanied minors. • Response time goal is within one hour.

22. Mobile Crisis Outreach Team(MCOT) • Mobile Crisis Outreach Teams (MCOTs) provide face-to-face clinical assessments to individuals in crisis 24 hours a day, 7 days a week in Denton County. • A MCOT consists of 2 individuals, a Qualified Mental Health Professional, and a licensed professional. The licensed professional can either be a Licensed Professional of the Healing Arts (LPC, SW, etc.) or a Registered Nurse. • All MCOT Team Members are AAS Certified Crisis Workers. • Teams will respond to appropriate crisis calls from hotline or walk-ins during business hours at our Denton and Lewisville outpatient clinics.

23. Crisis Outpatient Services • Crisis outpatient services consist of psychiatric services, medication, cognitive behavioral counseling, chemical dependency counseling, case management and referrals to outside organizations. • All individuals seen for a crisis assessment meet face to face with a crisis staff member within 24 hours for a follow-up if outpatient services are recommended. • Individuals are then seen by the team at least weekly. • Crisis Services are time limited.

24. Access to Crisis Review If there is a student that has been identified as high risk, do the following: • DO NOT LEAVE THE CHILD ALONE. • Notify the parents and make every attempt to have them come in. • Have campus security or police secure the scene. • Call the Crisis Line who will in turn contact MCOT. Please make sure the number of the person most familiar with the situation is left with the hotline • MCOT will determine the student’s least restrictive options.

25. Youth SuicideMyth –vs.-Truth

26. Suicide Myths vs. Truth Myth: Adolescents who talk about suicide do not attempt or complete suicide. Truth: One of the most dire warning signs of adolescent suicide is talking repeatedly about one’s own death. Adolescents who make threats should be taken seriously and provided the help they need (25,16). Myth: Educating teens about suicide leads to increased suicide attempts, since it provides them with ideas and methods about killing themselves. Truth: When issues concerning suicide are taught in a sensitive and educational context they do not lead to, or cause further suicidal behaviors (23).

27. Suicide Myths vs. Truth Myth: Suicidal behavior is inherited. Truth: There is no specific suicide gene that has ever been identified in determining or contributing to the expression of suicide (15,20,17,5). Myth: Most teenagers will not reveal that they are suicidal or have emotional problems for which they would like emotional help. Truth: Most teens will reveal that they are suicidal. Although studies have shown that they are more willing to discuss suicidal thoughts with a peer than a school staff member (25).

28. Suicide Myths vs. Truth Myth: Adolescent suicide occurs only among poor adolescents. Truth: It occurs in all socioeconomic groups (5,4,19) and socioeconomic variables have not been found to be reliable predictors of adolescent suicidal behavior. Assessing social and emotional characteristics are more helpful to determine if a youth is at increased risk (25,15,5,4,19). Myth: Suicide occurs in great numbers around holidays in November and December. Truth: Highest rates are in May and June and lowest rates are in December. (3)

29. Suicide Myths vs. Truth Myth: Elementary school children are not at risk for suicide. Truth: While rates of completed suicide are considerably lower in this population, statistics show that it does happen (22).

30. Suicide and Schools: Legal Implications Landmark Case: Wyke vs. Polk County School Board 11th Federal Circuit Court 1997: Found the district liable for not offering a suicide prevention program, providing inadequate supervision of a suicidal student and failing to notify parents when their child was suicidal.

31. Suicide and Schools:Legal Implications Landmark Case: Mares vs. Shawnee Mission Schools Johnson County District Court 2007: The school system settled out of court after being sued following the suicides of two brothers. The key issue in the case was failure to implement suicide postvention procedures after the first death.

32. Best Practices for Suicide Prevention/Intervention/Postvention

33. Structure Have a strong Crisis Management Plan and Policies as well! • The plan should include the most current information about suicidal behavior, risk factors, protective factors, contagion and prevention guidelines. • The Crisis Response team should be identified and provided additional training to fulfill individual roles (11). • The plan should include detailed instructions identifying each person’s role in response to suicide threats, attempts or completed suicide (11). This should include staff that are identified and not identified as Crisis Response Team Members.

34. Structure - Continued • This plan should be practiced and reviewed regularly (11). • Each teacher and counselor should keep a copy of the plan in the classroom as well as offices so it is easily accessible (11). • Encourage all staff to collaborate in recognizing at risk/high risk students (11). • Provide parents and students with opportunities to become involved in suicide prevention strategies offered by the school (11).

35. Control • Identify who your front line staff will be for children at higher risk. • Front line staff should screen high risk youth using an approved tool (11). • Consider having front line staff accredited through AAS Program. • Conduct repeated screenings on high risk students once or twice every school year (11). • Consider providing peer assistance programs. • Evaluate the current plan/policies for effectiveness regularly (11). Who will address media, notify parents and begin to bring in community resources?

36. Support • Establish collaborative relationships with community agencies such as police, clergy and mental health centers (11). • Provide staff with contact information on these resources so appropriate referrals are made. • If you identify a student as being a moderate or high risk of suicide, call the Denton County MHMR Hotline.

37. Statistics for Youth Suicide

38. Suicide and Youth • Suicide is the third leading cause of death for youth ages 10-24 behind accidents and homicides (7). • In 2007, there were 4,320 completed suicides for youth ages 10-24. For those aged 20-24 the rate was 12.5 per 100,000. For those aged 15-19 the rate was 6.9 per 100,000. For those aged 10-14, less than 1 per 100,000 (7). • Male youth die by suicide five times more frequently than female youth (7). Females attempt three times more frequently than males (7). • The majority of youth who died by suicide used firearms (45%) and suffocation was the second most commonly used method (38%) (7).

39. Suicide and Youth A Survey Conducted by the CDC among High School Students in 2009 revealed the following: • 13.8% of students in grades 9-12 seriously considered suicide in the previous 12 months (17.4% of females and 10.5% of males)(6). • 6.3% of students reported making at least one suicide attempt in the previous 12 months (8.1% of females and 4.6% of males)(6).

40. Suicide and Youth Findings from a study conducted by scientists at the Centers for Disease Control and Prevention indicate that youth threatened or injured by a peer were 2.4 times more likely to report suicidal thoughts, and 3.3 times more likely to report suicidal behavior than non-victimized peers (14). 

41. Youth Suicide and Race • Native American/Alaska Native Youth have the highest rate of suicide with 14.8 per 100,000. White youth are next highest with 7.3 deaths per 100,000 (7). • While the rate of completed suicide for Hispanic youth is lower than that for Non-Hispanics (5.4 per 100,000)(6), school aged Hispanic youth self-report higher rates of feeling sad or hopeless, of thinking about suicide, and of attempting suicide (7).

42. Youth Suicide – Lesbian, Gay, Bisexual, Transgendered and Questioning Population • Lesbian, gay, and bisexual youth are up to four times more likely to attempt suicide than their heterosexual peers (18). •  More than 1/3 of LGB youth report having made a suicide attempt (10). • Nearly half of young transgender people have seriously thought about taking their lives and one quarter report having made a suicide attempt (13). • LGB youth who come from highly rejecting families are more than 8 times as likely to have attempted suicide than LGB peers who reported no or low levels of family rejection (21).

43. Youth Suicide – Denton CountyICD 10 DataTexas Department of State Health Services

44. Crisis Model TriggerGrowth/Healing Accumulation of Pre-Crisis Losses Cycle of Escape Passage of Time Crisis

45. Early Warning Signs • Withdrawal from family and friends (11) • Preoccupation with death (11) • Marked personality change and serious mood change(11) • Difficulty concentrating (11) • Difficulties in school (decline in quality of work) (11) • Change in eating and sleeping habits (11) • Loss of interest in pleasurable activities & things one cares about (11). • Frequent complaints about physical symptoms, often related to emotions such as stomach aches, headaches, fatigue, etc (11). • Persistent boredom (11).

46. Late Warning Signs • Actually talking about suicide or a plan (11) • Exhibiting impulsivity such as violent actions, rebellious behavior or running away (11). • Refusing help, feeling “beyond help”(11) • Complaining of being a bad person or feeling “rotten inside” (11). • Making statements about hopelessness, helplessness, or worthlessness (11). • Not tolerating praise or rewards (11) • Giving verbal hints such as: “ I won’t be a problem for you much longer,” “Nothing matters,” “It’s no use,” and “I won’t see you again” (11).

47. Late Warning Signs – Continued • Becoming suddenly cheerful after a period of depression-this may mean that the student has already made the decision to escape all problems by ending his/her life (11) • Giving away favorite possessions (11) • Making a last will and testament (11) • Saying other things like: “I’m going to kill myself,” “I wish I were dead,” or “I shouldn’t have been born.” (11) • Using social media to convey these messages.

48. How to Identify a High Risk Youth (2) Acute Risk Factors: I – Ideations of Suicide W - Withdrawn S -Substance Use Increase A – Angry R – Reckless/Self-Injury P - Purposeless M – Mood Swings A – Anxiety/Insomnia T - Trapped H – Hopeless Are there Firearms in the household? Contagion or Imitation a possibility?

49. How to Identify a High Risk Youth:Chronic Risk Factors • Previous Suicide Attempts (2) • Diagnosable Mental Illness (2) • Previous Mental Health Hospitalizations (2) • Chronic Isolation (2) • Family History or exposure to suicide (2) • Mental Health Issues (2) • Childhood Abuse (2) • Significant Medical Illness (2) • Low Self-Esteem (2) • Poor Coping Skills (2) • Life Stressors/Losses/School problems/Living Alone(11) • Being Bullied(11) • Sexual Orientation(11) • Juvenile Delinquency (11)

50. Acute Suicide Risk Rating Chart (2)