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Associate Professor of Psychiatry, Pediatrics & Education. Stanford University. Director of School Mental Health. Lucile Packard Children's Hospital at ...
Typology: Summaries
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Shashank V. Joshi, MD, DFAACAP, FAAP Associate Professor of Psychiatry, Pediatrics & Education Stanford University Director of School Mental Health Lucile Packard Children’s Hospital at Stanford Steering Committee: Project Safety Net Palo Alto Executive Board, HEARD Alliance
Mary Ojakian, RN AFSP: Greater San Francisco Bay Area Chapter Board Member Santa Clara County Suicide Prevention Oversight Committee Suicide‐‐Prevention and Mental Health Advocate Project Sa f ety Net Coordinator ‐‐ Palo Alto Suicide Prevention Task Force Tall Tree Award Recipient, 2010
Linda Lenoir, RN, MSN, CNS Retired Certificated School Nurse Founding Member of Project Safety Net Executive Board, HEARD Alliance Suicide‐Prevention and Mental Health Advocate Tall Tree Award Recipient, 2008
Jasmine Lopez, MA, NCC 2015 ‐Present School Mental Health Team Coordinator Stanford University ‐ Child & Adolescent Psychiatry Project Coordinator f or the HEARD Alliance
Project Staff 2017:
HIPPA/FERPA Young Minds Advocacy, San Francisco, Ca, Senior Attorney (Licensed in NM, Registered Tara Ford Legal Services Attorney in CA)
Mindfulness John P. Rettger PhD; Director of Mindfulness Early Life Stress and Pediatric Anxiety Program, Lucile Packard Children’s Hospital at Stanford University, Department of Psychiatry and Behavioral Science, Stanford University School of Medicine Renee Burgard LCSW; Mindfulness and Health
Social Emotional Learning Amy Heneghan MD; Palo Alto Medical Foundation and Sutter Health Christine Wang Project Director, Education and School Partnerships, Teen Mental Health Initiative Children’s Health Council Eduardo L. Bunge Ph.D; Associate Professor, Palo Alto University Ramsey Kasho Psy.D; Director of The Center at Children’s Health Council, Clinical Director of The Sand Hill School at CHC Sarah Klem University of Michigan, Ann Arbor Sarah Kremer LPCC, ATR‐BC; Director of Resilience Consultation Program at Acknowledge Alliance Taylor N. Stephens Palo Alto University/ Clinical Psychology Ph.D Student
Research Team from Palo Alto University, Palo Alto, CA: Narey V. Kelediian Shweta Ghosh
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Shashank V. Joshi, MD Director of School Mental Health Lucile Packard Children’s Hospital at Stanford University Steering Committee: Project Safety Net Palo Alto Executive Board, HEARD Alliance
Mary Ojakian, RN AFSP: Greater San Francisco Bay Area Chapter Board Member Project Sa f ety Net Coordinator ‐‐‐ Palo Alto Suicide Prevention Task Force Suicide‐‐‐Prevention and Mental Health Advocate Santa Clara County Suicide Prevention Oversight Committee Tall Tree Award Recipient, 2010
Linda Lenoir, RN, MSN District Nurse, PAUSD Founding member of Project Safety Net Executive Board Member, HEARD Alliance Project Sa f ety Net Steering Committee Tall Tree Award Recipient, 2008
Sami Hart l ey, Stanford University SSRA 2012 ‐‐ 2015 Project Coordinator and Community Liaison f or the HEARD Alliance Stan f ord University School Mental Health Team Coordinator
Erica Weitz, MA 2009 ‐‐‐ 2012 Project Coordinator and Community Liaison f or the HEARD Alliance Stan f ord University School Mental Health Team Coordinator Field Investigator for the American Association of Suicidology
Jonathan Frecceri, MFT Director o f Community Outreach and Education, KARA Grie f Support PR OJ ECT STAFF 2013: Brenda Carri ll o (^) Student Services Coordinator, PAUSD Kath l een Blanchard Parent Consultant Mary Sue Budrow Psychologist: Fairmeadow and Hoover Elementary Schools Kimber l ey Cowe ll Assistant Principal, Gunn High School Todd Da l y Psychologist, Jordan Middle School Roni Gi ll enson, LMFT Adolescent Counseling Services On‐‐‐Campus Counseling Program Director George Green, PhD Psychologist, Gunn High School Tom Jacoubowsky Assistant Principal, Gunn High School Bridget Johnson Health Secretary, PAUSD Bhavna Naru l a Assistant Principal, Terman Middle School Victor Ojakian Santa Clara County Mental Health Board Rita Rodriguez, PhD Psychologist, Palo Alto High School Margaret Sachs Psychologist, Ohlone and Palo Verde Elementary Schools Se l ene Singares Counselor, Palo Alto High School Stephanie Sheridan, PhD Psychologist, Jane L. Stanford Middle School Katya Vi ll a l obos Principal, Gunn High School
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DEDICATION
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Accurate Language and Concepts About Suicide
By changing the way we talk about suicide, we change the way we think of it. In general the language used for any other illness‐based death or sudden loss (such as a heart attack or car accident) is a guiding principle.
Died of suicide (Also ‘Died by suicide’) ‐ Suicide is death due to brain illnesses. In a suicidal state thought processes become distorted because of biological, psychological, social, cultural and/or situational reasons. Suicidal people are not thinking clearly. They are in fact struggling with a kind of illness in their thinking processes. The term “Committed suicide” does not describe accurately what has occurred. Committed implies a crime or immoral act. Suicide is no longer seen as a crime or sin but is recognized to be the result of a mental health condition with a medically treatable cause at least 90% of the time. Often a person with lived experience of suicide will say choice was not involved but instead they were overwhelmingly “compelled” to attempt to kill themselves. Person with lived experience ‐ A person with the lived experience of suicide has struggled with suicidal thoughts or behaviors and may be an attempt survivor. Resilience is a skill that can be developed ‐ one is not “permanently fragile” when they are an attempt survivor. Bereaved by suicide ‐ Someone who has been exposed to the suicide of another person and experiences a high level of psychological, physical and/or social distress for a considerable length of time. In the U.S. the term “loss survivor” is often used. This loss can cause PTSD, complicated grief or other deleterious physical and mental consequences. Everyone grieves differently and on their own timeline. Incorporating such a loss into one’s life requires work and support. Fatal or Non‐fatal Attempt — Applying the general principle of speaking about suicide using illness based language, fatal and non‐fatal is language in line with a fatal or non‐fatal heart attack or other illness. It is not advised to add a value statement to suicide such as calling an attempt failed, successful, or botched, etc. Also the term “completed” suicide is not advised. Completing something implies success.
Suicide is a complex phenomenon. It does not have to do with an individual’s willpower. There is no simple explanation for any suicide. Though an immediate precipitating event may occur, that is not the “reason” someone has died.
People often ask what to say to a person who has lost someone to suicide. Generally, it is advised to think of what one would say or do if the person had lost their loved one suddenly in a fatal car crash or a heart attack ‐ then do and say that.
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AAC I Asian Americans for C ommunity Involvement
AC S Adolescent Counseling Service
AFSP Ameri can Foundat ion for Suicide Prevention
AR Administrative Regulation
ASIST Applied Suicide Intervention Skills Training
CDC Cen t ers for Disease Con t rol an d Preven t ion
CRT Crisis Response Tea m
ERMHS Educationally ‐‐‐ Related Mental Health Ser vices
FER PA Family Educational Rights and Privacy Act
HEARD Health C are Alliance for Response to Adolescent Depression
HIPAA Health Insurance Portability and Accountability Act (Privacy and Security Rules)
IRP Individualized Re ‐‐‐ Entry Plan
LPCH/SM HT Lu cile Packa rd Children’s Hospital/S chool M en tal Healt h Tea m
MYSP P Mai ne Youth Sui cide P reventi on P rogram
NI M H Nat iona l Institute of Mental Healt h
PBIS Positive Behavioral Int erven ti ons and Suppo r t
PSN Project Safet y Net
PTSD Post Traumatic Stress Disorder
QPR Que s ti on, Pe rs uad e , Re fer ‐‐‐ Gatek eeper Training
SAMHSA Substance Abuse and Mental Health Services Administration
SBP or BP School Board Policy
SPRC Suicide Prevention Resource Center
UFS Uplift Family Services
USF Universit y of South Fl orida
INTRODUCTION
“No matter where we live or what we do every day, each of us has a role in preventing suicide. Our actions can make a difference.” Regina M. Benjamin, MD, MBA VADM, U.S. Public Health Service Surgeon General 2012 National Strategy for Suicide Prevention https://www.surgeongeneral.gov/library/reports/national‐strategy‐suicide‐prevention/full_report‐rev.pdf
This Toolkit was created in 2013 in response to a need for schools to address student mental and emotional wellness to prevent suicide and, in particular, how to respond after a suicide loss. California law AB 2246, enacted in 2016, requires that all public schools have a “Pupil Suicide Prevention Policy.” This document has been updated to reflect both this need and this policy requirement.
The 2013 Toolkit quoted SAMHSA’s 2012 “Preventing Suicide: A Toolkit for High Schools”. It states, “Schools have an essential role to play in preventing suicide and in promoting behavioral health among America’s young people”. Through the promotion of youth behavioral health, the ability of students to learn and thrive is enhanced. The tools and resources provided in this updated Toolkit are meant to complement what schools may already have in place and to help initiate the implementation of a “Pupil Suicide Prevention Policy”.
Statistics tell us many things. In California the rate of youth mental health hospitalizations has risen by 50% between 2007 and 2015. In 2011‐13 nearly one fifth (19%) of California public school students in grades 9 and 11 seriously considered attempting suicide in the past year. In 2013‐14 21% of California youth ages 12‐17 reported needing help for emotional or mental health problems (“Hospitalizations for Mental Health Issues”, 2016). Fifty percent of all lifetime cases of mental illness begin by age 14 and seventy five percent by age 24 (“Mental Health Facts,” 2014). Suicide is the second leading cause of death for youth and young adults ages 10 to 24 (“Ten Leading Causes of Death,” 2014).
Though data informs about a great deal it does not paint the entire picture. It cannot quantify the grief, anguish, confusion, guilt and devastation felt by the family, friends and community of an adolescent who dies by suicide. It does not inform about the increased risk youth face for PTSD, other mental health problems or even their own suicide after the loss of a peer to suicide. It does not reveal the uncomfortable reactions evoked by suicide; the fear, blame, isolation, stigmatization, silence and secrecy that surrounds suicide.
Suicide is a major, preventable public health problem. Reducing the number of suicides requires the engagement and commitment of people in many sectors including education. This Toolkit contains information schools need to further the goals of emotional health promotion and suicide prevention for youth. Some actions schools can take include these delineated in Lucile Packard Foundation Kids Data. Setting school policies that foster a positive, supportive environment and promote student engagement in school, and supporting comprehensive K‐12 education for social‐emotional learning, including communication skills, problem‐solving skills, and stress management
Ensuring adequate funding and training for a range of school staff to recognize signs of mental distress and refer students to services; such training also should focus on how to promote a safe and supportive environment for all students, including LGBT youth (“Hospitalizations for Mental Health Issues”, 2016).
Tools to accomplish these actions are found in the sections of this document; Promotion of Mental Health and Wellness, Intervention in a Suicidal Crisis, Postvention Response to Suicide and Appendices. Each section is related to the others. None functions entirely on its own. Though one area may apply in a particular situation all are meant to work together. For instance, when a student is noted to be struggling, actions described in the “Intervention in a Crisis” section may need to be activated and as the student is supported through the crisis mental wellness promotion actions may become more applicable. Or, should a student death due to suicide occur, students may experience a crisis and part of postvention may involve actions described in the intervention section. All parts are necessary and all function together.
The goal of this document is to ensure that schools can participate fully in the broader community effort to promote youth emotional and mental health and prevent youth suicide. It is our intention and hope that the full participation by schools in student behavioral health promotion will lead to more fulfilling and productive lives for all their students.
Cultural Issues in Mental Health Promotion and Suicide Prevention
The students and families that school personnel and child mental health professionals interact with comprise an increasingly diverse group with unique needs. The acceptability of children’s mental health services is highly influenced by attitudes, beliefs, and practices from their families’ cultures of origin. (Pumariega, et al. 2010a)
This Toolkit has been written and compiled under the presumption of multiculturalism, with a broad definition of culture that has been chosen, not limited to ethnic or racial makeup, but rather one that embraces the variable values, attitudes, beliefs, and behaviors shared by a people, and that is often transmitted between generations. Multiculturalism assumes that no single “best” way exists to conceptualize human behavior or explain the realities and experiences of diverse cultural groups. Rather, it is more useful to assume that everyone has a unique culture, and that cultural influences are woven into personality like a tapestry (McDermott, 2002). From this perspective, three of the major tasks for school professionals include (1) developing a broad knowledge base about cross‐cultural variations in child development and childrearing; (2) integrating this knowledge in a developmentally relevant way to make more informed assessments and interventions; and (3) developing a culturally sensitive attitude and therapeutic stance in all interactions with students and their families, including those of the same background as the school staff (Pumariega, 2010; Joshi, 2015).
For additional resources that may be helpful for specific cultural populations, please see Attachment 1.
SECTION I: PROMOTION OF MENTAL HEALTH AND WELLNESS
Section one includes a comprehensive approach to wellness. Students need to be taught what mental health is and given the skills to achieve it, including the soci al‐emot ional skills needed for mental and physical w e ll‐be i ng. These are defined in the Health Education Content Standards for Californ ia Public Schools (h ttp: //www. cde. c a.g ov/b e /s t/ ss / doc ume nt s /healt hs tan dma r08.p df).
Educational opportunities that specifically relate to depression and suicidal ideation need to be provided for students, staff and parents. Mental health resources need to be compiled, reviewed, and regularly updated and disseminated to students, staff and parents. A safe and caring school climate needs to be maintained. Students of concern need to be identified, monitored and supported. Promotion of w e ll‐b ei ng is co mp rised of ed uc at ion, a s a fe an d c a ri ng school e n viron me nt, t he ident ific at ion an d mo n i t ori ng of students of concern, and the provision of mental health resources (see Appendix B2, “Mental Health Resources”).
Key staff and teaching faculty receive training in recognizing depressive symptoms; the warning signs, risk factors, and protective factors for suicide (see Attachment 1.2, “Risk Factors for Youth Suicide”, Attachment 1.3, “Protective Factors Against Youth Suicide”, and Attachment 1.4, “Recognizing and Responding to Warning Signs of Suicide,” see Attachment 1.5, “Red Folder Initiative”) and the procedures for referring students to the appropriate school personnel (i.e. principal, assistant principal, guidance counselor, school based mental health counselor, nurse). Training will be scheduled before the school year begins or during staff development days. New staff will receive suicide prevention training, resou rces , an d i n for mat ion as part of their orientati on.
Trai n i n g for key staff memb e rs i nclud es: a. Gatekeeper training (for example QPR) and a refresher course every 2‐ 3 years (see Attachment 1.8a, “QPR as a Un ivers al Int ervent ion, an d Atta chment 1. 8 b, “QPR Gui de li nes ” )
Recomm ended trai n i n g for Crisis Respo nse T eam (C RT) memb ers i nclud es: a. A member of each CRT and key representatives at the district office will be trained in ASIST (Applied Suicide Intervention Skills Training) or similar professional training. b. Comprehensive CRT trainings occur each year.
Most youth who are suicidal communicate with peers about their concerns rather than with adults, yet as few as 25% of peer confidants tell an adult about their suicidal peer (Kalafat, 2003). Student programs that address suicide can play a significant role in reducing risk for suicide when they are used in conjunction with other strategies, such as intervention protocols and staff training. There are three types of student programs, each with different objectives. They are as follows:
a. Curriculum
● Best practice includes a comprehensive health curriculum for students at all elementary, middle and high schools that meets the Health Education Content Standards for California Public Schools. ● Curricula for all students informs them about suicide prevention, promotes positive attitudes about mental health, increases students’ ability to recognize if they or their peers are at risk for suicide, and encourages students to seek help for themselves and their peers. Two depression education curricula recommended for use in high school classes are the American Foundation for Suicide Prevention’s “More Than Sad” and Children’s Hospital Boston’s “Break Free from Depression.” Parents are informed about the topics of depression and suicide being presented, and are invited to a parent evening to view the video presentation and participate in a discussion.
b. Programs ● Skill building programs such as QPR (Question Persuade Refer) help identify and support at‐risk students by building coping, p rob l em‐solving and cognitive skills while addressing related problems such as stress, depression and other brain conditions, and substance abuse. ● Peer leader programs such as Sources of Strength teach selected students skills to identify and help peers who may be at risk. Some programs teach peer leaders to build connectedness among students and also between students and staff, which improves the school climate. ● For more information about s tu dent ‐ orient ed programs see Attachment 1.7, “Types of Student Programs.”
c. Resources for Bay Area Students At the beginning of the school year each middle and high school will list their site resources and hotlines on the back of their student ID cards. These numbers may include such resources as the Santa Clara County Suicide and Crisis Hotline, 1 ‐ 855 ‐ 278 ‐4204, the school’s mental health support resource, or Reach Out Online Forum at us.reachout.com. Links to these will be provided on the school website. A full list of recommended resources can be found in Appendix B2, “Mental Health Resources”.
Although parents may be aware that children and teens die by suicide, they often do not think it could happen to their child or in their community. Parents, primary caregivers and the entire school community need information about: ● The prevalence of suicide and suicide attempts among youth ● The warning signs of suicide ● How to respond when they recognize their child or another youth is at risk ● Where to turn for help in the community when a crisis occurs
a. The school sites will work with PTA/ PTSA and PTAC and strongly encourage them to have a parent education program. This program could incorporate information about soci al‐‐‐ emot ional and physical wellness, and suicide prevention. i. To promote attendance this program could be publicized as one of the following examples: ● “Promoting Behavioral Health and Wellness” ● “Eliminating Barriers to Learning”
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little they slept. Additionally, each additional hour of sleep decreased the likelihood of suicidal thoughts. (University of Pennsylvania: https://www.pennmedicine.org/news/news‐releases/2013/may/more‐sleep‐ reduces‐suicide‐ris)
Signs and Solutions
Some signs that indicate a student might not be getting enough sleep include: Having trouble waking up most mornings Acting irritable in the early afternoon Falling asleep easily during the day Having a sudden drop in grades Sleeping for very long periods on the weekends (UCLA Sleep Disorders Center)
So what can we do about it? Good sleep is essential to a good outlook on life and thus decreased risk of suicidality. The treatment fundamentals for insomnia (the most common sleep disturbance) are the same regardless of whether one is suffering from a mental health issue, or just struggling to get the amount of rest they need. The UCLA Sleep Disorders Center recommends the following list of tips for families who are hoping to help youth get the sleep they need.
Tips for Parents
A safe and caring school climate includes feeling safe at school, feeling part of decision‐‐‐making, and having a sense of school connectedness, which “is the belief by students that adults and peers in the school care about their learning as well as about them as individuals” (CDC, 2009b, SAMHSA Toolkit, p. 12).
Suicidal behavior can be reduced as a sense of school connectedness is increased. Combining suicide
prevention with efforts to increase connectedness furthers both goals.
The Centers for Disease Control and Prevention has cited the promotion and strengthening of connectedness at personal, family, and community levels as a key suicide prevention strategy, explaining that “positive attachments to community organizations like schools and churches can increase an individual’s sense of belonging, foster a sense of personal worth, and provide access to a larger source of support” (CDC, 2012).
Strategies include: a. For Staff: i. Providing professional development and support for teachers and other school staff to enable them to meet the diverse cognitive, emotional and social needs of students such as the “More Than Sad: Preventing Teen Suicide Program for Teachers and Staff.” On ‐‐‐ site staff will provide facilitation of the program with the help of
community partners.
ii. Using effective classroom management and teaching methods to foster a positive learning environment
(e.g., Positive Behavioral Intervention and Support, PBIS).
b. For Students:
i. Providing students with the academic, emotional and social skills necessary to be actively engaged in
school.
c. For Families:
i. Providing education and opportunities to enable families to be actively involved in their childrenʼs academic and school life. Most schools are already actively engaged in this process.
d. For All: i. Employing decision ‐‐‐ mak i ng processes that facilitate student, family and community engagement,
academic achievement, and staff empowerment.
ii. Creating trusting and caring relationships that promote open communication among
administrators, teachers, staff, students, families, and communities. This is an ong oi ng effort that requires
collaboration and evaluation with our community and school partners. Evaluation will occur on a regular basis
through instruments such as the California Healthy Kids survey.
Part of mental health promotion and suicide prevention in youth lies in the development of students’ social and emotional wellness. (Note: “wellness” refers to overall emotional well‐being for the purposes of this document.) Two evidence based strategies, Social Emotional Learning (SEL) and Mindfulness, share similar goals and outcomes for the emotional, social, and academic development of youth. Both enhance youth academic achievement and wellness, decrease risky behaviors, and improve relationships with peers and teachers. Each uses a different approach to achieve these outcomes (Lantieri, Zakrzewski, 2015). The SEL framework promotes intra‐personal, interpersonal and cognitive competencies. Mindfulness, paying attention is a systematic way, deepens the internal ability to apply the skills learned through SEL. These strategies complement each other. SEL develops skills and Mindfulness enhances the ability to apply those skills such that a student can better understand themselves and others, develop meaningful relationships, and make constructive decisions. This section will first address SEL and then Mindfulness.
a. SOCIAL EMOTIONAL LEARNING (SEL) Introduction Psychological wellness is key to a youth’s healthy development. “Psychological well‐being refers to how individuals self‐evaluate and their ability to fulfill certain aspects of their lives, such as relationships, support, and work” (Cripps & Zyromski, 2009, p. 2). Greater well‐being, as well as improved school performance, can be achieved through the mastering of social‐emotional competencies (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011).Schools have the potential to impact large numbers of children and to reduce suicide rates. SAMHSA states, “Schools have an essential role to play in preventing suicide and in promoting behavioral health among America’s young people” ( Preventing Suicide: A Toolkit for High Schools, 2012. SAMHSA, p. 14). Evidence‐based SEL programming can be implemented in the school setting and can be part of the “upstream prevention” of youth suicide. Upstream prevention is defined as “approaches that reduce risk factors or enhance protective processes that influence the likelihood that a young person will become suicidal” (AAS & SPTS, 2012, p. 1). Through promotion of skills needed for mental wellness, schools can provide for “upstream prevention” of youth suicide.
The skills and strategies that children and teens gain through SEL have been shown to increase protective factors and reduce risk factors associated with suicide (AAS & SPTS, 2012). Effective SEL develops skills in problem solving, conflict resolution, nonviolent ways of handling disputes as well as a sense of connectedness all of which serve as protective factors for youth against suicide and other self‐destructive behaviors during transitions or crises. Among students aged 13 to 17, shifts in self‐control over time tend to influence behavioral issues, social functioning, and the ability to adapt to the demands of secondary school (Ronen, Hamama, Rosenbaum, & Mishlely‐Yarlap, 2016). The competencies and skills gained through SEL can provide a foundation for improved adjustment abilities and academic performance, evidenced by less emotional distress and conduct problems, and by improved grades/test scores (Durlak et al., 2011).
As well as increasing protective factors, skills learned in SEL have been shown to reduce risk factors associated with suicide (AAS & SPTS, 2012). High risk behaviors such as drug and alcohol abuse, feelings of helplessness and hopelessness, impulsive and aggressive tendencies, and feelings of being cut off from other people (isolated) have been reduced through SEL (AAS & SPTS, 2012).
Further, by implementing SEL in schools, students, teachers, and administrators are more aware of and skilled in identifying and responding to mental health issues when the behavior first presents itself. Currently, by the age of fourteen 50% of all lifetime mental illness are evident (AAS & SPTS, 2012, p.3). Instead of addressing these issues when these behaviors or reactions have escalated, schools are more prepared to effectively
