Best Practice in Suicide Prevention, Assessment,

Best Practice in SuicideBest Practice in Suicide
Prevention, Assessment,Prevention, Assessment,
and Interventionand Intervention
Pete B. Marcelo, MSW, Ph.D.Pete B. Marcelo, MSW, Ph.D.
Clinical and School PsychologistClinical and School Psychologist
Clinical Social and School Social WorkerClinical Social and School Social Worker
Dr.petemarcelo@yahoo.comDr.petemarcelo@yahoo.com

Suicide in the U.S.A.Suicide in the U.S.A.
(from the American Association of Suicidology at www.suicidology.org)(from the American Association of Suicidology at www.suicidology.org)
2002 Statistics from the National Vital Statistics Report2002 Statistics from the National Vital Statistics Report
 In 2002, 31,655 suicides in the U.S.In 2002, 31,655 suicides in the U.S.
 1111thth
leading cause of deathleading cause of death
 Suicide rates overall relatively stable in recent yearsSuicide rates overall relatively stable in recent years
 Males complete suicide at a rate 4 times that of females.Males complete suicide at a rate 4 times that of females.
 Females attempt suicide 3 times that of malesFemales attempt suicide 3 times that of males
 Firearms are the most common method of completing suicide (54% in 2002)Firearms are the most common method of completing suicide (54% in 2002)
 Females use poisoning as the most common method of completing suicideFemales use poisoning as the most common method of completing suicide
 Suicide decreases in times of war and increase in times of economic crisisSuicide decreases in times of war and increase in times of economic crisis
 25 attempts for each death by suicide, but between 100 - 200 to 1 in youth25 attempts for each death by suicide, but between 100 - 200 to 1 in youth

YouthYouth SuicideSuicide Fact SheetFact Sheet
(from the American Association of Suicidololgy and Poland & Lieberman)(from the American Association of Suicidololgy and Poland & Lieberman)
33rdrd
cause of death for youth between the ages of 15-19 and 15-cause of death for youth between the ages of 15-19 and 15-
24 following accidents and homicides.24 following accidents and homicides.
 44thth
cause of death in those 10-14 years oldcause of death in those 10-14 years old
1.3% of all deaths in U.S. and 12.3% of all deaths in youth1.3% of all deaths in U.S. and 12.3% of all deaths in youth
between the ages of 15-24.between the ages of 15-24.
For 15-19, 4.4 male suicide : female suicideFor 15-19, 4.4 male suicide : female suicide
10-14 year olds, 2.7 male : 1 female10-14 year olds, 2.7 male : 1 female
10 suicides for every 100,000 youth10 suicides for every 100,000 youth
11 youth 15-24 die each day from suicide11 youth 15-24 die each day from suicide
In 2001, 3971 suicides for youth between the ages of 15 to 24In 2001, 3971 suicides for youth between the ages of 15 to 24
Firearms most commonly used suicide method among youthFirearms most commonly used suicide method among youth
accounting for 57% of completed suicides (regardless of gender,accounting for 57% of completed suicides (regardless of gender,
age, and race)age, and race)

Test Your Adolescent Suicide IQTest Your Adolescent Suicide IQ
Prepared ByPrepared By John Jochem, Psy.D.John Jochem, Psy.D.
Highland Park HospitalHighland Park Hospital
True or False?True or False?
1.1. Adolescent suicide is an increasing problem in the U.S.Adolescent suicide is an increasing problem in the U.S.
TRUETRUE While the rate of suicide in the general population hasWhile the rate of suicide in the general population has
been generally stable since the 1950’s, adolescentbeen generally stable since the 1950’s, adolescent
suicide rates have more than tripled.suicide rates have more than tripled.
2.2. Most teenagers will reveal that they are suicidal or if they havingMost teenagers will reveal that they are suicidal or if they having
problems?problems?
TRUETRUE Most teens who are experiencing active suicidal ideationMost teens who are experiencing active suicidal ideation
will admit their plans to someone who is concerned andwill admit their plans to someone who is concerned and
inquires about their distress.inquires about their distress.
3.3. Adolescents who talk about suicide are not the ones who actuallyAdolescents who talk about suicide are not the ones who actually
make an attempt?make an attempt?
FALSEFALSE People usually give some advance indication of suicidal intent;People usually give some advance indication of suicidal intent;
suicidal threats, preoccupation or behavior must always besuicidal threats, preoccupation or behavior must always be
taken seriously.taken seriously.
4.4. Talking with someone about suicide may promote suicidal ideas andTalking with someone about suicide may promote suicidal ideas and
behavior?behavior?
FALSEFALSE It is inner distress, psychiatric illness, serious life stressors andIt is inner distress, psychiatric illness, serious life stressors and
irrational thinking that lead to suicidal behavior,irrational thinking that lead to suicidal behavior, notnot
expressions of concern by others.expressions of concern by others.
Source:Source: Florida Institute of Mental Health / University of South Florida (2003)Florida Institute of Mental Health / University of South Florida (2003)

5. Parents are often unaware of their child’s suicidal ideation and behavior?5. Parents are often unaware of their child’s suicidal ideation and behavior?
TRUE Studies have shown that, among parents of children found toTRUE Studies have shown that, among parents of children found to
have suicidal ideation, up to 86% of parents were unaware ofhave suicidal ideation, up to 86% of parents were unaware of
their child’s suicidal risk.their child’s suicidal risk.
6.6. The majority of adolescent suicides occur unexpectedly with noThe majority of adolescent suicides occur unexpectedly with no
warning signs?warning signs?
FALSE Over 90% of suicidal adolescents give clues to othersFALSE Over 90% of suicidal adolescents give clues to others
prior to their attempt.prior to their attempt.
7.7. Most adolescents who attempt suicide fully intend to die?Most adolescents who attempt suicide fully intend to die?
FALSE As a rule, survivors of suicide attempts are relieved toFALSE As a rule, survivors of suicide attempts are relieved to
have lived through their suicidal crisis and are gratefulhave lived through their suicidal crisis and are grateful
for intervention.for intervention.
8.8. There are differences between adolescent males & females regardingThere are differences between adolescent males & females regarding
suicidal behavior?suicidal behavior?
TRUE Females attempt suicide more frequently than malesTRUE Females attempt suicide more frequently than males
(3:1), however males complete suicide more frequently than(3:1), however males complete suicide more frequently than
females (4:1) because boys tend to use more lethal means (e.g.,females (4:1) because boys tend to use more lethal means (e.g.,
firearms)firearms)
9.9. Since adolescent females complete suicide less often than malesSince adolescent females complete suicide less often than males
their attempts should not be taken seriously?their attempts should not be taken seriously?
FALSE A prior attempt is a significant risk factor for later death byFALSE A prior attempt is a significant risk factor for later death by
suicide—suicide—everyevery threat must be taken seriously.threat must be taken seriously.

10.10. Adolescent suicide occurs mostly with lower SES (socioeconomicAdolescent suicide occurs mostly with lower SES (socioeconomic
status) kids than among wealthier kids who have access to greaterstatus) kids than among wealthier kids who have access to greater
resources?resources?
FALSEFALSE Adolescent suicide is a threat to kids of everyAdolescent suicide is a threat to kids of every
socioeconomic level.socioeconomic level.
11.11. The only one who can be of help to a suicidal adolescent is a trainedThe only one who can be of help to a suicidal adolescent is a trained
mental health professional?mental health professional?
FALSEFALSE Most adolescents contemplating suicide are not under the careMost adolescents contemplating suicide are not under the care
of a mental health professional and are more likely to initiallyof a mental health professional and are more likely to initially
come to the attention of non-professional, who then facilitates acome to the attention of non-professional, who then facilitates a
referral.referral.
12.12. A teacher who observes distress or warning signs in his/her studentA teacher who observes distress or warning signs in his/her student
should not betray the student’s trust by referring the student to theshould not betray the student’s trust by referring the student to the
school social worker?school social worker?
FALSEFALSE Adolescent suicide is a serious public health issue and referralAdolescent suicide is a serious public health issue and referral
to in-school mental health resources should always occurto in-school mental health resources should always occur
whenever warning signs of suicide are observed.whenever warning signs of suicide are observed.
13.13. If an adolescent wants to commit suicide there is nothing anyoneIf an adolescent wants to commit suicide there is nothing anyone
can do to prevent its occurrence?can do to prevent its occurrence?
FALSEFALSE Prompt identification, intervention, means restriction, supportPrompt identification, intervention, means restriction, support
and treatment of an underlying condition are all effective meansand treatment of an underlying condition are all effective means
to prevent suicide.to prevent suicide.
Source:Source: Florida Institute of Mental Health / University of South Florida (2003)Florida Institute of Mental Health / University of South Florida (2003)

Critical FactCritical Fact
 Having a gun in the house more thanHaving a gun in the house more than
ss the likelihood that an adolescent willthe likelihood that an adolescent will
successfully complete a suicide!successfully complete a suicide!

Signs/Symptoms of At-risk forSigns/Symptoms of At-risk for
SuicideSuicide
 *Problem, these are not exclusive to suicide behavior also correlated with*Problem, these are not exclusive to suicide behavior also correlated with
mental health.mental health.
 Physical DomainPhysical Domain Behavioral DomainBehavioral Domain
-fatigue or hyper-fatigue or hyper -withdrawing/running away-withdrawing/running away
-sleep disturbance-sleep disturbance -neglect of appearance-neglect of appearance
-change in appetite-change in appetite -giving away possessions-giving away possessions
-frequent complaints of physical-frequent complaints of physical -loss of interest in pleasurable-loss of interest in pleasurable
symptomssymptoms activitiesactivities
-decline in previous level of-decline in previous level of
functioning (academics, attendance, etc.)functioning (academics, attendance, etc.)
-use of alcohol/drugs-use of alcohol/drugs
Affective DomainAffective Domain Cognitive DomainCognitive Domain
-depressed-depressed -decrease in concentration-decrease in concentration
-crying-crying -pre-occupied with death-pre-occupied with death
-hopeless-hopeless
-anger-anger
-marked change-marked change

Signs/Symptoms of At-risk forSigns/Symptoms of At-risk for
Suicide (continued)Suicide (continued)
 Verbal Comments (hint at their thinking)Verbal Comments (hint at their thinking)
-Its no use-Its no use
-I won’t be a problem for you-I won’t be a problem for you
-Nothing matters-Nothing matters
-I won’t see you again-I won’t see you again
-The world would be better without me-The world would be better without me
-Nobody would miss me anyway-Nobody would miss me anyway

Situational CrisesSituational Crises
1.1. Recent loss of a friend, family member,Recent loss of a friend, family member,
pet, divorcepet, divorce
2.2. Break-up with significant otherBreak-up with significant other
3.3. Unplanned pregnancyUnplanned pregnancy
4.4. Trouble with law or school disciplineTrouble with law or school discipline
5.5. Victim of abuse/neglectVictim of abuse/neglect
6.6. PovertyPoverty
7.7. Peer difficulties/BullyingPeer difficulties/Bullying

Childhood and Adolescent DepressionChildhood and Adolescent Depression
 DSM-IV-TR categories with symptoms ofDSM-IV-TR categories with symptoms of
depression: Major Depression, Dysthmicdepression: Major Depression, Dysthmic
Disorder, Adjustment Disorder with DepressedDisorder, Adjustment Disorder with Depressed
Mood, and Bi-Polar DisorderMood, and Bi-Polar Disorder
Possible symptoms of depressionPossible symptoms of depression::
 depressed mood, loss of interest, irritabilitydepressed mood, loss of interest, irritability
 often do not identify feeling depressed.often do not identify feeling depressed.
 significant weight loss or weight gain. Youngersignificant weight loss or weight gain. Younger
children, “failure to thrive”children, “failure to thrive”
 insomnia or hypersomniainsomnia or hypersomnia

Possible symptoms of depression:Possible symptoms of depression:
 psychomotor agitation or retardationpsychomotor agitation or retardation
 fatigue or loss of energyfatigue or loss of energy
 feeling worthlessfeeling worthless
 diminished ability to think or concentratediminished ability to think or concentrate
 recurrent thoughts of deathrecurrent thoughts of death
 impairment in previous level of functioning.impairment in previous level of functioning.
 low self-esteemlow self-esteem
 feelings of hopelessnessfeelings of hopelessness
 feeling unlovedfeeling unloved
 somatic complaints (stomach aches,somatic complaints (stomach aches,
headaches)headaches)

Possible symptoms of depressionPossible symptoms of depression::
 difficulty staying on task,difficulty staying on task,
 not interested in anything, “lazy”not interested in anything, “lazy”
 bullying behaviorbullying behavior
 negative thoughts about themselves, the worldnegative thoughts about themselves, the world
and the future (the cognitive triad).and the future (the cognitive triad).
 irrational thoughts like awfulzing and needirrational thoughts like awfulzing and need
statementsstatements

PrevalencePrevalence
 major depression and dysthymic disorder inmajor depression and dysthymic disorder in
children is 2% and 6% for adolescents annuallychildren is 2% and 6% for adolescents annually
 7 to 14% of children experience major7 to 14% of children experience major
depression before the age of 15 often notdepression before the age of 15 often not
diagnosed.diagnosed.
 equal numbers of boys and girls in childhood,equal numbers of boys and girls in childhood,
but 2:1 ratio of major depression of female tobut 2:1 ratio of major depression of female to
male adolescents.male adolescents.
 major depressive disorder is 1.5 to 3 times moremajor depressive disorder is 1.5 to 3 times more
common if first degree biological relativecommon if first degree biological relative

Co-morbidityCo-morbidity
 ADHD, eating disorders, conduct disorder, ODD,ADHD, eating disorders, conduct disorder, ODD,
substance abuse, LD/EDsubstance abuse, LD/ED
Considerations for school districtsConsiderations for school districts
 how do you phrase feedback? not too negative,how do you phrase feedback? not too negative,
avoid blame, what and how to say itavoid blame, what and how to say it
 get kids involved – recess – structured activitiesget kids involved – recess – structured activities
 link them with other kids (recess/groups)link them with other kids (recess/groups)
 build on individual strengthsbuild on individual strengths

Possible Psychiatric FactorsPossible Psychiatric Factors
Associated with SuicideAssociated with Suicide
1. Diagnosis of the following conditions1. Diagnosis of the following conditions

Bi-Polar DisorderBi-Polar Disorder

DepressionDepression

Conduct DisorderConduct Disorder

Personality DisorderPersonality Disorder
2. Chronically Poor Coping skills with2. Chronically Poor Coping skills with
negative emotionsnegative emotions

Self-Injurious BehaviorSelf-Injurious Behavior
CategoriesCategories
 MajorMajor - most serious - large part of body or limb- most serious - large part of body or limb
is injured. cutting off one’s arm or self-castration.is injured. cutting off one’s arm or self-castration.
Very rare.Very rare.
 StereotypicStereotypic – repetitive self-injury often seen in– repetitive self-injury often seen in
those with mental retardation and autism. Headthose with mental retardation and autism. Head
banging, biting oneself, etc.banging, biting oneself, etc.
 Superficial SelfSuperficial Self--MutilationMutilation – most common.– most common.
Often involves cutting, burning, hitting,Often involves cutting, burning, hitting,
scratching, choking, etc.scratching, choking, etc.

Incidence? / Demographics?Incidence? / Demographics?
 Under reported - at least 2 million peopleUnder reported - at least 2 million people
self-harm. Unsure if estimate is national orself-harm. Unsure if estimate is national or
internationalinternational
 Common for self-injurious behavior to beginCommon for self-injurious behavior to begin
in adolescencein adolescence
 Other countries like Australia, Canada, NewOther countries like Australia, Canada, New
Zealand, and EnglandZealand, and England
 Johnny Depp, Roseanne, and Princess DianaJohnny Depp, Roseanne, and Princess Diana

 different reasons for why self-mutilatedifferent reasons for why self-mutilate
 relieves intense feelings such as anger, rage,relieves intense feelings such as anger, rage,
depression, etc.depression, etc.
 maladaptive coping strategy to cope with life,maladaptive coping strategy to cope with life,
and not attempt at ending life.and not attempt at ending life.
 possible victims of physical and/or sexualpossible victims of physical and/or sexual
abuse. control of the abuse, making oneselfabuse. control of the abuse, making oneself
less attractive, punishing oneselfless attractive, punishing oneself
 followed by feelings of relief, tranquility, andfollowed by feelings of relief, tranquility, and
possibly even euphoria.possibly even euphoria.

MythsMyths
 self injury is a failed suicide attemptself injury is a failed suicide attempt
 self injury is always attention seekingself injury is always attention seeking
 self-mutilators are dangerous to othersself-mutilators are dangerous to others
TreatmentTreatment
 bio-psycho-social approach may bebio-psycho-social approach may be
treatment of choice.treatment of choice.
 anti-depressants and/or anti-anxietyanti-depressants and/or anti-anxiety
medicationsmedications
 teach student coping skills and ways ofteach student coping skills and ways of
expressing negative emotionsexpressing negative emotions

Treatment considerationsTreatment considerations
 treat underlying causal factors liketreat underlying causal factors like
depression, low self-esteem, history ofdepression, low self-esteem, history of
abuse, etc.abuse, etc.
 cognitive behavioral therapy – changecognitive behavioral therapy – change
irrational thoughtsirrational thoughts
 teach student and family risk managementteach student and family risk management
like the removal of razors, etc.like the removal of razors, etc.
 Provide hotline/crisis phone number.Provide hotline/crisis phone number.
 find and identify triggers for self-abusefind and identify triggers for self-abuse

Treatment considerationsTreatment considerations::
 Teaching more appropriate functionalTeaching more appropriate functional
behaviors - working out intensely, holding,behaviors - working out intensely, holding,
ice cube, snap rubber band on wristice cube, snap rubber band on wrist
 support groupsupport group
What Should Schools Do?What Should Schools Do?
 Staff/teachers refer to counselor, socialStaff/teachers refer to counselor, social
worker, nurse, administrator, and/orworker, nurse, administrator, and/or
psychologist (Track history of self-injuriouspsychologist (Track history of self-injurious
behavior including frequency, duration, andbehavior including frequency, duration, and
intensity).intensity).

 assessment out of realm of competence, callassessment out of realm of competence, call
parent and refer outparent and refer out
 keep in mind the impact on the studentkeep in mind the impact on the student
 do not be critical. Student may already feeldo not be critical. Student may already feel
guilty and ashamed.guilty and ashamed.
 provide safe environment when stressed.provide safe environment when stressed.
(nurse’s office? guidance office? )(nurse’s office? guidance office? )
 be supportive of the student.be supportive of the student.
 communicate when student appears to becommunicate when student appears to be
having a particularly bad day.having a particularly bad day.
 counseling mandated as a condition ofcounseling mandated as a condition of
attendance in school? Who pays forattendance in school? Who pays for
services?services?

AssessmentAssessment
1.1. Clinical Assessment/Interview with student ****limits of confidentialityClinical Assessment/Interview with student ****limits of confidentiality
 Sample process and questionsSample process and questions
 Assess risk factors and documentationAssess risk factors and documentation
 Assess Risk Factors and DocumentationAssess Risk Factors and Documentation
More interview questions and DocumentationMore interview questions and Documentation
***Handout – sample form***Handout – sample form
2.2. Rating Scales and Diagnostic Structured InterviewsRating Scales and Diagnostic Structured Interviews
-No universally accepted instrument at this time that has specificity and predictive validity-No universally accepted instrument at this time that has specificity and predictive validity
3.3. Interview with others (parents, teachers, etc) if necessaryInterview with others (parents, teachers, etc) if necessary
4.4. Do you have any interview questions or assessment techniques that you like to use in yourDo you have any interview questions or assessment techniques that you like to use in your
interview?interview?

InterventionsInterventions
1.1. Constant supervision and referral for high risk studentsConstant supervision and referral for high risk students
2.2. No-suicide contractNo-suicide contract
 Common practice as part of an interventionCommon practice as part of an intervention
 No formal research that I know of that has shown that it is efficaciousNo formal research that I know of that has shown that it is efficacious
 Sample No Suicide ContractSample No Suicide Contract
3.3. Increase number of counseling sessionsIncrease number of counseling sessions
4.4. Remove meansRemove means
5.5. Inform parentsInform parents
6.6. CBTCBT
7.7. Teach coping skillsTeach coping skills
8.8. Develop emergency plan and review with student and family with hotline numbers,Develop emergency plan and review with student and family with hotline numbers,
use of ER, etc.use of ER, etc.
9.9. HospitalizationHospitalization
10.10. Require a psychological assessment before returning to school? Are you availableRequire a psychological assessment before returning to school? Are you available
24/7 for emergency calls? Should you see a student who is at high risk as the only24/7 for emergency calls? Should you see a student who is at high risk as the only
provider of service?provider of service?
11.11. Any other ideas?Any other ideas?

DOCUMENTDOCUMENT
 Sample record that parent has beenSample record that parent has been
informed of student’s suicidal ideationsinformed of student’s suicidal ideations
 Record source, content, and date ofRecord source, content, and date of
information used in assessment; yourinformation used in assessment; your
conclusions regarding risk, and whatconclusions regarding risk, and what
action taken and whyaction taken and why

Legal and/or Ethical IssuesLegal and/or Ethical Issues
1.1. Duty to Protect (inform whom?)Duty to Protect (inform whom?)
 -You will not be held responsible if you have done what a good clinician would do-You will not be held responsible if you have done what a good clinician would do
(assess/evaluate, plan, and implement)(assess/evaluate, plan, and implement)
2.2. Have a policy, practice/training of policy/procedure, implement theHave a policy, practice/training of policy/procedure, implement the
policy/procedure (see IL School Code 105 ILCS 5/10-22.39 In-service Trainingpolicy/procedure (see IL School Code 105 ILCS 5/10-22.39 In-service Training
Programs)Programs)
*Almost worse to have a policy/procedure that isn’t practiced and implemented.*Almost worse to have a policy/procedure that isn’t practiced and implemented.
Do you have a plan? Do you practice/train?Do you have a plan? Do you practice/train?
3.3. Duty to Provide Referrals (rule of thumb 3 that are known to provide appropriateDuty to Provide Referrals (rule of thumb 3 that are known to provide appropriate
service)service)

PreventionPrevention
 Sample prevention letter to parentsSample prevention letter to parents
 Infusing coping skills/social skills into the curriculumInfusing coping skills/social skills into the curriculum
 Anti-bullying programsAnti-bullying programs
 Student assistance team referralsStudent assistance team referrals
 Student assistance programsStudent assistance programs
 Educating students, staff, parents, community on mental healthEducating students, staff, parents, community on mental health

ResourceResource
 Practice parameters for the assessmentPractice parameters for the assessment
and treatment of child and adolescentand treatment of child and adolescent
suicidal behaviorsuicidal behavior

Resources for the Development ofResources for the Development of
Crisis PlansCrisis Plans
 NEA resourceNEA resource
 Maine Task ForceMaine Task Force

Sample Crisis PlanSample Crisis Plan
1.1. Sudden Death General GuidelinesSudden Death General Guidelines
2.2. Sample Plan for a Sudden DeathSample Plan for a Sudden Death
3.3. ********Support/counseling for the crisis team*****************Support/counseling for the crisis team*********
4.4. Sample Letter to parentsSample Letter to parents
5.5. Media GuidelinesMedia Guidelines

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