Successfully Dealing With Teen Self-Harm Behavior

1. Successfully Dealing With TeenSelf-Harm Behavior Oregon School-Based Health Care Network Annual Institute October 12, 2007 Kirk D. Wolfe, M.D.

2. Goals • To Recognize: • The Major Impact of Youth Depression And Suicide on Our State • Risk and Protective Factors With Suicide • Keys in Evaluating a Suicidal Student • Keys to Treating Suicide/Depression

3. Oregon Youth Suicide Facts- 1990’s • Rate Was 30-40% Above The US Average • Rate Increased 400% In 40 Years • #2 Cause of Death • 75 Suicides Every Year • 2/3 With Firearms

4. Oregon Youth Suicide Facts-1999-2005 • ~63 deaths per year- 16 % decrease • Why the decrease?

5. Youth Risk Behavior Survey-2005 • U.S. High School Students, Past Year: • 28.5% Depressed 2 Weeks or Greater • 17% Seriously Considered Suicide • 13% Report Specific Plan • 8.4% Suicide Attempt • 2.3% Attempt Leading to Medical Attn

6. U.S. Youth Suicide Facts-1990-2003 • #3 Cause of Death • Highest Psychiatric Risk- Major Depression • Peak rate- late 1980’s • 28% Decrease in Rate through 2003 • Why the decrease?

7. U.S.Youth Suicide Facts-2004 vs. 2003 • 8% Increase, largest in 15 years • 76% Increase, Females aged 10-14 yrs • 32% Increase, Females aged 15-19 yrs • 9% Increase, Males aged 15-19 yrs • Why the increase?

8. U.S. Youth Suicide Facts- Rates per 100,000, Females, 2004 • Ages 10-14 years: All methods 0.95 Hanging/suffocation (72%), poison (16%) • Ages 15-19 years: All methods 3.52 Hanging/suffocation (49%), firearm (28%) • Ages 20-24 years: All methods 3.59 Hanging/suffocation (34%), firearm (32%)

9. U.S. Youth Suicide Facts-Rates per 100,000, Males, 2004 • Ages 10-14 years All methods 1.71 Hanging/suffocation (73%), firearm (27%) • Ages 15-19 years All methods 12.65 Firearm (51%), hanging/suffocation (37%) • Ages 20-24 years All methods 20.84 Firearm (53%), hanging/suffocation (32%)

10. Risk Factors for Youth Suicide • Later adolescence/young adult • Male • Ethnicity- Highest Rate- Native American Greatest Number- Caucasian • Stressful Life Events • Previous Attempt(s) • Access to Lethal Means • Contagion/ Imitation • Chronic Physical Illness (esp. epilepsy)

11. Risk Factors for Youth Suicide • Youth Psychiatric Disorder - Major Depressive Disorder - Substance Abuse - Bipolar Disorder - Conduct Disorder- Aggressive/Impulsive • Physical/ Sexual Abuse • Hopelessness or Isolation • Sexual Orientation • FH of mood disorders/suicide/substance abuse

12. Protective Factors • Family Cohesion • Good Coping/Problem-Solving Skills • Help-Seeking/ Advice-Seeking • Academic Achievement • Social Integration • Access/care for mental/physical/subst. d/o’s • Responsibility for others/pets • Religion/spirituality

13. Teen Psychological Autopsy-Case-Control Study • Brent et al, JAACAP, 1993,32,3:521-529 • Psychiatric Risk Factors for Teen Suicide: (1) Major depression (OR=27.0) (2) Bipolar mixed state (OR=9.0) (3) Substance abuse (OR= 8.5) (4) Conduct disorder (OR= 6.0) • ~31% depressed suicide deaths- depressed <3 months

14. Columbia Teen Screen-Screening for Suicide • Focus: on depression, suicide, substance use • Need parental and student consent - Brief self-report screen (Teen Screen) - DISC if positive screen - Clinical interview if DISC positive - Make referral for further assessment • 74% teens with SI not of concern to school • 50% with prior attempt not of concern to school • 30% of highest risk unknown to school or MHP • www.teenscreen.org

15. Evaluating a Suicidal Student-Thorough Assessment Essential • (1) Evaluate the suicide attempt thoroughly • (2) Evaluate for underlying mental illness- this will determine treatment • (3) If no underlying mental illness- - still need to take safety precautions - get second and third sources to corroborate - need to look for underlying cause(s) - look to support the student (and family) - remain vigilant with close follow up

16. MDD/Suicide Risk Tip Offs • Major Problems Home/School/Peers/Job/Hygiene • Overall Very Negative Presentation • History of Loss, Abuse, Exposure to Violence, Significant Life Stress • “Superachievers” With Vegetative Changes • Hallucinations • Substance Abuse • FH Mood/Anxiety Disorders, Suicide, Substance Abuse, Jail

17. Impact Of DepressionEmotional • Youth • Family • Peers • Classroom • Workplace • Juvenile Justice System

18. Physical Effects • Obesity • Smoking • Alcohol • Drugs • Heart Disease

19. Financial • 19 Million Americans Yearly • More Than 1 In 5 Oregon Youth • $23.8 Billion in Absenteeism And Lost Productivity • Education System • SOSCF • OYA • Medical Costs

20. Possible Signs Of Depression • Low Self Esteem • Anger Management Problems • Alienation Or Withdrawal From Others • Running Away • School Avoidance • Decreased Or Failing Grades • Cruelty To Animals

21. Possible Signs Of Depression • Gang Involvement • Violent Behavior • Fire Setting • Legal Problems • Early Pregnancy • Nutrition Problems / Obesity • Physical Health Problems

22. Possible Signs Of Depression • Becoming A Smoker • Using Alcohol Or Drugs • Homicide Attempts • Death By Homicide • Suicide Attempts • Death By Suicide

23. Why Youth Become DepressedBiopsychosocial Approach • Biological • Psychological • Social Depression Is A Medical Illness

24. Evaluating Suicidal Thinking • Look for in times of stress- empathic connection- “Some teens will think about hurting or killing themselves.” • “Have you ever felt like hurting yourself?” • “Have you ever felt like killing yourself?” • “Have you ever wished you were dead?” • Look at non-verbal cues in response • “Ever had a plan? Would you be able to?” • “What kept you from doing it?” • “Ever try to kill yourself?Tell me what happened.” • “Anyone in your family attempt / die by suicide?”

25. Evaluating a Suicide Attempt • Connect in non-judgmental manner • What was done? Lethality? Perceived lethality? • When? • Where? • With whom? CONTEXT OF RELATIONSHIPS • Why then? IDENTIFY STRESSOR(S) • How long planned? The final straw? • What did student hope would happen? • Who else knows? • CUTTING BEHAVIOR- TIP OF ICEBERG

26. Evaluating Past Attempts • Identify each attempt -lethality -context of relationships -theme with stressors -awareness/reaction of others? -receive treatment? -type of treatments? Compliant? Helpful?

27. Evaluating a Suicide Attempt • Getting a Second (and third) Informant • Issues of Safety- Loss of confidentiality yet need to maintain alliance • Empathic Connection with Student- Can student put self in parent/peer/school shoes in looking at student’s self-harm? Want student to understand why you are looking to get support for the student

28. Major Depressive Episode • Represents A Change • 2 Weeks Or Longer • Depressed Or Irritable Mood • Loses Interest In Most Activities • Most Of The Day, Nearly Every Day • Causes Problems • Need 5 Or More Symptoms

29. Depressed Or Irritable Mood • Easily Irritated • Rebellious Behavior • Rarely Looks Happy • Crying Spells • Wears Somber Clothes • Music Has Depressing Or Violent Themes • Friends Are Depressed Or Irritable

30. Decreased Interest • “I’m Bored” • Spends Much Time In Their Room • Declining Hygiene • Changes To More Troubled Peer Group Or Activity

31. Change In Appetite Or Weight • Being A Picky Eater • Eats When Stressed • Quite Thin Or Overweight

32. Changes In Sleeping Patterns • Delayed Sleep • Multiple Awakenings • Sleeps More Than Normal

33. Psychomotor Agitation Or Slowing • Agitated • Always Moving Around • Moping Around The House Or School

34. Fatigue Or Loss Of Energy • Too Tired To Do Schoolwork, Play or Work • Comes Home From School Exhausted • Too Tired To Cope With Conflict

35. Feelings Of Worthlessness Or Inappropriate Guilt • Sees Self As “Bad” Or “Stupid” • No Hope Or Goals For The Future • Always Trying To Please Others • Blames Self For Causing Divorce Or Death

36. Decreased Concentration • Often Responds “I Don’t Know!” • Takes Much Longer To Get Work Done • Drop In Grades • Headaches, Stomach aches • Poor Eye Contact

37. Recurrent Thoughts Of Death Or Suicide • Giving Away Personal Possessions • Asks If Something Might Cause Death • Wanting To Join A Person In Heaven • “I’m Going To Kill Myself” • Actual Suicide Attempts

38. Normal Reaction Hours-Days Affects Mood Briefly Not Cause Suicide Good Listener Helps Medical Illness Weeks-Years Mood, Thinking, Body Functions Possible Suicide Needs Psychiatric Treatment The Blues vs. Depression

39. Evaluation Of Depression • Biopsychosocial Approach is Essential • Identify Interests/Strengths and Use in Tx • Distinguishing Normal vs. Abnormal is Critical (e.g. sleep, bereavement, problems created) • Determine (Impairment of) Function in Settings- home, school, peer activities, job • Recognize Cultural Context • Who Does the Student See as an Ally? • Ask About Mania • FH Can Make a Big Difference- now and in future

40. Substance Use/Abuse/Dependence • In utero Exposure? • Cigarettes/Alcohol/Drugs • Current Extent of Use/ Most Recent Use • Specific Use With Suicidal Ideation/Action • Problem Pattern of Use - Legal Problems - Failure to Fulfill Roles - Recurrent Use Despite Problems • Like Fuel to the Fire of Depression!

41. Completing The Evaluation • Screening Q’s- Anxiety Disorders • Psychosis • ADHD • Autism Spectrum Disorder • Conduct Disorder • Eating Disorder • Sleep Disorder • Personality Traits

42. Completing The Evaluation • Past Psychiatric History • Medical History- updated complete PE • Developmental History • Family History- Psychiatric and Medical • Social History • Mental Status Exam

43. Case Study • High school student, h/o ADHD • C.C.: gradual decline academically h/o B/C’s, now D/F’s stimulant med since age 8, helpful now withdrawn, sad, poor hygiene Goth attire, hair dyed black • Diagnosis?

44. Evaluating Risk for Suicide-Look at the Big Picture • Low or Moderate Risk - May have voiced suicidal thoughts but no plan or access - No past attempts - Minor impairment in functioning - Actively involved parents, good support

45. Evaluating Risk for Suicide-Look at the Big Picture • Extreme Risk - Voiced active intent - Had recent serious attempt - May or may not have had past attempts - Severe impairment in functioning - Has access to lethal means - Stressed family

46. Completing The Evaluation • Sharing Your Impression • Recognizing This is a Tough Time • What Happened Was Serious • Help Student Understand Support Needed • Student Needs to Keep Self Safe • Treatment Will Be Essential • Will Need to Notify Parents, School Admin • How is Student Responding to Discussion?

47. Documentation • Needs to be timely and legible • Estimate: -degree of risk -known data -basis for diagnosis -planned interventions (e.g., consultation, referral, notify parent/admin, med, follow-up) • Develop (or update) treatment plan

48. TreatmentSafety • Eliminate Access To Guns And Sharp Objects • All Medications In Locked Cabinet • Eliminate Hanging Materials • Appropriate Support and Supervision • Psychiatric Hospitalization May Be Necessary • Intensive Services May Be Needed • Don’t rely on a “safety contract”

49. Treatment- Safety on Ongoing Basis • Close and Frequent Reassessment • Has the student and family kept their word? • Recognize the Teen Life and Mind- NOT STATIC! • Anticipate Future Stressors- preparing the student to react safely

50. Treatment • Reestablishing Connections: - with family, school, friends (psychosocial) - between neurons (biology)