Best Practices in Schl-based Suicide Preventin: A Cmprehensive Apprach 2014
Table f cntents: The rle f the schl in yuth suicide preventin....................... 3 Purpse f this guide................................................ 4 Cntext............................................................ 5 Manitba yuth demgraphics...5 Mental health and yuth.......................................... 6 Yuth suicide statistics...9 Planning and prgramming fr yuth suicide preventin in schls...10 A. Creating a cmprehensive apprach...11 1. Plicies and prtcls...11 2. Schl culture and climate...12 3. Gatekeeper training........................................... 13 4. Educatin and awareness prgrams...14 5. Targeting higher risk yuth...16 6. Peer supprt/student invlvement.............................. 17 7. Family partnerships invlving parents/caregivers...18 8. Cmmunity links...19 B. Issues f imprtance t yuth suicide preventin effrts............... 21 Nn-suicidal self injury (NSSI)...21 Bullying...22 Suicide cntagin................................................23 Substance abuse...24 Cultural safety...................................................25 Mnitring and evaluatin...26 C. Pstventin......................................................28 Appendices...30 Links t resurces...................................................49 Yuth crisis services in Manitba......................................49 References...50 2
The rle f the schl in suicide preventin Preventing yuth suicide is an issue that naturally garners supprt frm everyne including parents, plicy makers and yuth directly and indirectly affected. Schls can play a psitive rle in suicide preventin because they ffer cnsistent, direct cntact time with large ppulatins f yung peple. There are ther imprtant reasns why schls shuld be invlved in suicide preventin: 1. Maintaining safe and caring schl envirnments is an essential part f schls verall missin. All schl staff have a rle in creating schl envirnments where students feel safe and cared fr by adults arund them. Prmting psitive mental health and suicide preventin effrts are cnsistent with ther effrts and activities aimed at prmting student safety and creating caring envirnments. Many prgrams and activities designed t prevent vilence, bullying, and substance abuse als reduce suicide risk and prmte healthy, caring relatinships and resilience. 2. Students mental health can affect their academic perfrmance. Mental health prblems can interfere with the ability t learn and can affect academic perfrmance. Accrding t the 2009 Yuth Risk Behavir Survey 1 : Apprximately 1 f 2 high schl students receiving grades f mstly Ds and Fs felt sad r hpeless. But nly 1 f 5 students receiving mstly grades f A felt sad r hpeless. One f 5 high schl students receiving grades f mstly Ds and Fs attempted suicide. Cmparatively, 1 f 25 wh receive mstly A grades attempted suicide. 3. A student suicide can significantly impact ther students and the cmmunity verall. Yuth may be deeply affected when a suicide ccurs and can be susceptible t suicide cntagin (cpycat effect) 2. Knwing what t d fllwing a suicide (pstventin) is essential t supprting ther students cping and preventing similar tragedies. 1 Centre fr Disease Cntrl and Preventin, Yuth Risk Behavir Surveillance, Surveillance Summaries (2009), MMWR 2010;59 (N.SS-#). 2 Guld, M.S., Wallenstein, S, Kleinman, M.H., O Carrll, P. & Mercy, J. (1990) Suicide Clusters: An examinatin f age-specific effects. American Jurnal f Public Health, 80 (211-12). 3
Purpse f this Guide This guide is intended t prvide a framewrk t help schl administratrs and their partners develp cmprehensive planning fr suicide preventin. Infrmatin and tls cntained in this guide will help schls by: identifying and defining the cmpnents and principles f a cmprehensive, schlbased suicide preventin strategy based n research and best practice evidence. suggesting ways t integrate suicide preventin messages int activities which supprt schl plans t create safe and caring envirnments either by enhancing existing prgramming r by integrating new prgram elements including checklists and self-assessment instruments t help schls chse suicide preventin prgramming which fit fr their student ppulatin and evaluate the adequacy f these prgrams prviding a list f ther resurces available nline and in print Cntact infrmatin This guide has been prduced by Manitba s Yuth Suicide Preventin Strategy - Educatin Initiatives Task Team (YSPSEITT). The YSPSEITT is c-led by Manitba Educatin and Training and the Healthy Child Manitba Office and includes gvernment, reginal and cmmunity partners, all f whm are wrking t supprt yuth suicide preventin wrk in Manitba schls and alternative educatin settings. Fr supprt in using this guide, cntact: Cnsultant, Student Services Unit Prgram and Student Services Manitba Educatin and Training 204-1181 Prtage Avenue, Winnipeg, Manitba R3G 0T3 T 204-945-5294 F 204-948-3229 Prgram and Plicy Cnsultant, Adlescent Develpment Healthy Child Manitba Office Manitba Educatin and Training 300-332 Bannatyne Avenue Winnipeg, Manitba R3A 0E2 T 204-945-2785 F 204-948-2585 4
Cntext Understanding the needs f yur schl ppulatin is key t develping effective suicide preventin plans and activities. Manitba has a unique set f demgraphics. Within the prvince, gegraphical areas and even individual cmmunities ften have specialized needs. The implementatin f any prgramming shuld cnsider the lcal cntext including cmmunity demgraphics, suicide rates, mental health and stress in yuth and prtective and risk factrs. Manitba yuth demgraphics Accrding t the 2011 Manitba Health ppulatin estimates: Yuth between ages 10 and 19 accunt fr just ver 13 per cent f the Manitba ppulatin (168,746 yuth). 21 per cent f Manitba First Natins residents are between ages 10 and 19 (ne in five). Prprtin f Yuth (age 10 t 19) in each Reginal Health Authrity (RHA), 2011. 5
Mental health and yuth Accrding t the 2011 Canadian Cmmunity Health Survey, just ver three-quarters (77.3 per cent) f yuth age 12 t 19 perceive their mental health t be very gd r excellent. The rate is slightly lwer amng females (76.2 per cent) than males (78.3 per cent). Yuth have many stressrs in their lives which withut adequate cping skills and supprts can lead sme t develp mental health prblems, including suicide thughts r actins. Many f the stressrs yuth experience relate t, r ccur in the schl setting. Althugh the expectatins and the dynamics that ccur in the schl setting can be the surce f significant stress, schl can als prvide an ideal pprtunity fr engagement f yuth in discussins abut mental health and suicide as well as prviding nging supprt and resurces t enhance prtective factrs. Stress in the lives f yuth balancing relatinships with divrced r separated parents balancing schl, wrk, scial life and family relatinships bullying challenges in relatinships at hme changing bdies/hrmnes changing family dynamics change f schls chsing a career chsing a cllege/university dating and relatinship break-up difficulties at schl scial media facing an envirnment that may encurage drugs, alchl, and sex getting a part-time jb getting gd grades fr cllege/university learning abut sexual identity learning t accept themselves with r withut talents and abilities scial struggles stress f extra-curricular activities and expectatins frm parents and caches the natural separatin frm parents that starts t ccur traumatic experiences (histrical r present) 6
Risk and Prtective Factrs Suicide and suicide related behaviurs (suicide attempts, plans and thughts) in yuth are influenced by multiple, interacting risk and prtective factrs. 3 Risk Factrs are the factrs r cnditins that have been fund t be related t a higher risk f suicide amng yuth. Prtective factrs are the factrs r experiences which reduce the likelihd f suicide despite expsure t risk. These factrs identify strengths which supprt resilience and cping. Prtective factrs d nt necessarily cancel ut risk factrs particularly when immediate risk factrs are present. It is imprtant t nte that there is n specific prfile f a typical yuth wh has thughts f suicide. Each student has their wn unique and persnal circumstances which influence hw they are impacted by risk factrs, althugh evidence suggests that recgnizing, supprting and prmting prtective factrs is imprtant t reducing suicide risk. See Appendix A fr a mre detailed Matrix f Risk and Prtective Factrs Risk Factrs include: Mental health illnesses, particularly md disrders, anxiety disrders, substance use disrders, eating disrders and disruptive disrders. Cccurring disrders (mre than ne disrder and/r in cmbinatin with a substance use disrder) are als very cmmn amng suicidal yuth. Previus suicidal behaviur, including prir suicide attempts and behaviural rehearsal. Hpelessness, aggressin, recklessness and impulsivity. Family factrs, including high levels f parent-child cnflict, parental mental illness and a family histry f suicidal behaviur can elevate the risk fr suicide amng yuth. A histry f childhd physical and/r sexual abuse. Stressful life events, especially in cmbinatin with existing vulnerabilities. These cmmnly include: interpersnal cnflict, rejectin, failure, humiliatin, and lss. Expsure t a peer suicide is als a ptential risk factr amng sme yuth with pre-existing vulnerabilities. Sensatinalized media reprts abut suicide and having access t the means fr suicide are additinal risk factrs fr yuth suicide. Older adlescents, males and Abriginal yuth are statistically mre likely t die by suicide than females, children r yunger adlescents. 3 Preventing Yuth Suicide, Ministry f Children and Family Develpment, B.C. Gvernment. www.mcf.gv.bc.ca/suicide_preventin/factrs.htm 7
Prtective Factrs include: Strng individual cping and prblem-slving skills Experience with success and feelings f effectiveness Strng sense f belnging and cnnectin Interpersnal cmpetence Warm, supprtive family relatinships Supprt and acceptance Success at schl Strng cultural identity Cmmunity self-determinatin Surce: www.mcf.gv.bc.ca/suicide_preventin/factrs.htm 8
Yuth suicide statistics Suicide accunted fr 5028 ptential years f life lst amng Manitbans in 2011. 4 Suicide is the secnd leading cause f death fr yung Canadians between ages 10 and 24. 5 In 2011, 227 Canadian yuth between ages 10 and 19 died by suicide as did an additinal 301 yung adults between ages 20 and 24. 6 Suicide was the cause f 23 per cent f all deaths amng 15 t 24 year lds (almst ne in fur deaths) and 11 per cent f deaths amng 10-14 year lds. 7 Suicide rates are five t seven times higher fr First Natins yuth verall than fr nn- Abriginal yuth. 8 In sme cmmunities hwever, rates are lwer than the natinal average. Males are mre likely t die by suicide than females. The suicide rate amng Canadian males is mre than twice as high as amng females between ages 15 and 24. Mre females attempt suicide than males, and in the last few years, the rate f yung females dying by suicide is increasing. 1. Yuth suicide rates in Canada by age grup, 2007-2011. Surce: Statistics Canada, CANSIM table 102-0551. 4 Statistics Canada, Table 102-0110 Ptential years f life lst, by selected causes f death (ICD-10) and sex, ppulatin aged 0 t 74, Canada, prvinces and territries. Viewed at: www5.statcan.gc.ca/cansim/a26 5 Statistics Canada, CANSIM table 102-0561. Leading causes f death by selected age grups and sex, 2007-2011. Viewed at: www5.statcan.gc.ca/cansim/a26?lang=eng&retrlang=eng&id=1020561&paser=&pattern=&stby- Val=1&p1=1&p2=49&tabMde=dataTable&csid= 6 Statistics Canada CANSIM Table 102-0551. Suicide and Suicide rates by sex and age grup. Viewed at: www.statcan.gc.ca/tables-tableaux/sum-sm/l01/cst01/hlth66d-eng.htm 7 Statistics Canada, CANSIM table 102-0561. Leading causes f death by selected age grups and sex, 2007-2011. 8 Health Canada, First Natins and Inuit Health. Acting n What We Knw: Preventing Yuth Suicide in First Natins. Viewed at: www.hc-sc.gc.ca/fniah-spnia/pubs/prmtin/_suicide/prev_yuth-jeunes/index-eng.php 9
Planning and prgramming fr yuth suicide preventin in schls The fur areas identified belw in the inverted pyramid all represent types f preventin effrts. Preventin effrts reduce the prevalence r incidence f suicide r suicide related behaviurs. A cmprehensive apprach shuld incrprate mental health prmtin strategies as well as preventin prgrams r activities that are geared tward everyne (universal), thse identified with risk factrs (selected), and thse identified at highest risk fr suicide (indicated). Mental Health Prmtin Fcus n verall Psitive Mental Health 9 and quality f life acrss ppulatins by building strengths, cmpetencies, resiliency and resurces f everyne in the ppulatin Universal Preventin All children and yuth Selective Preventin Children and yuth wh have been identified as having risk factrs/being at risk. Indicated Preventin Children and yuth wh have been identified as high risk as they have exhibited signs, symptms f suicide and/r suicide behaviurs. Cmmunity and schl-based interventin, services and supprts 9 10 Psitive Mental Health is defined in the Pan-Canadian Jint Cnsrtium fr Schl Health s Psitive Mental Health Tlkit: www.jcshpsitivementalhealthtlkit.cm
A. Creating a cmprehensive apprach Schl and cmmunity preventin prgrams designed t address suicide and suicidal behaviur as part f a brader fcus n mental health, cping skills in respnse t stress, substance abuse, aggressive behaviurs, are mst likely t be successful in the lng run. - Natinal Institute f Mental Health When cnducting suicide preventin activities, the principle f D N Harm is f utmst imprtance. Schl-based suicide preventin effrts need t be flexible t meet the unique needs and strengths (including cultural) f cmmunities and recgnize that due t the diversity in Manitba as well as the cmplex nature f suicide, a ne-size fits all apprach will nt be effective. Avid reliance n ne prgram. Evidence supprts a whle-schl apprach. This, alng with the blending f universal and selective preventin, allws a strategy t reach ALL students, including yuth wh are at increased risk, as well as build resilience in yuth presently at n risk r lw risk. Whle-schl appraches have als been shwn t be mst effective in bringing abut psitive changes related t student utcmes acrss varius dimensins. The identificatin and referral f vulnerable yung peple t apprpriate supprts is als an imprtant cmpnent f a whleschl apprach. Psitive mental health prmtin prgrams, which can be used as a cmpnent f a whle schl apprach, are likely t include cmpnents designed t: increase awareness f mental health issues amng students de-stigmatize mental illness encurage students t recgnize mental health prblems in themselves and their friends facilitate prcesses fr apprpriate help-seeking fr students and their peers teach self-awareness, cping skills, scial skills and prblem-slving skills increase resilience The fllwing are 8 key aspects f a cmprehensive apprach t schl-based suicide preventin: 1. Plicies and prtcls A schl plicy frmally recgnizes a schl s cmmitment t student suicide preventin. A divisin-wide plicy increases the likelihd that schl suicide preventin prgramming will be effectively and cnsistently implemented thrughut the entire schl system. 11
Develping plicies and a prtcl fr respnding t students at pssible risk f suicide is the first step f a cmprehensive apprach. This shuld ccur befre implementing strategies t identify students at risk f suicide and training persnnel. Establish plicies and prtcls that will assist in the develpment and implementatin f suicide preventin/mental health prmtin prgrams as well as respnding t crisis. These plicies shuld be reviewed annually t ensure cntacts are current and cntent is updated with any new develpments. Tw essential cmpnents that every schl shuld have in place are: prtcls fr helping students at pssible risk f suicide prtcls fr respnding t a suicide death (Pstventin). See Appendix E fr a Sample Schl Plicy See Sectin C fr infrmatin specifically relating t Pstventin. Suggestins fr educating staff abut yur schl s prtcls Educate staff abut the prtcls during staff meetings r in-service trainings. Educate new staff abut the prtcls as part f their rientatin. Remind staff abut prtcls during annual evaluatins, in newsletters r cmmunicatins n related issues. Include cpies f the prtcls in teacher handbks and the schl crisis plan. 2. Schl culture/climate Adlescents perceived schl cnnectedness has been identified as a leading prtective factr against student suicidal behaviur. 10 Students wh feel cnnected t their schl are less likely t experience thughts f suicide and emtinal distress. Schls must be rganized in such a way t allw staff t be respnsive and encurage student help-seeking. A psitive schl climate exists when all students feel cmfrtable, wanted, valued, accepted and secure in an envirnment where they can interact with caring peple they trust. A psitive schl climate affects everyne assciated with the schl: students, staff, parents and the cmmunity. Research has identified 11 key factrs (eight specific and three general) that cntribute t creating a psitive schl climate. 10 Resnick, M.D., Bearman, P.S., Blum, R.W. et al., Prtecting adlescents frm harm: Findings frm the Natinal Lngitudinal Study n Adlescent Health. JAMA (1997), 278 (823-832). 12
Specific factrs cntinuus academic and scial grwth respect: students and staff have high self-esteem and are cnsiderate f thers trust: a sense that peple can be cunted n high mrale: students and staff feel gd abut being there chesiveness: a sense f belnging pprtunities fr input: being able t cntribute ideas and participate renewal: penness t change and imprvement caring: students and staff feel that thers are cncerned abut them General factrs prgram curriculum, activities, and plicies prcess teaching and learning styles, prblem-slving, and cmmunicatin resurces, materials, and schl facilities G t the checklist in Appendix I t understand the schl climate/culture in yur schl Fr mre prcedures and practices assciated with psitive behaviur supprt: Twards Inclusin Supprting Psitive Behaviur in Manitba Classrms www.edu.gv.mb.ca/k12/specedu/behaviur/behaviur_dcument.pdf Twards Inclusin Frm Challenges t Pssibilities Planning fr Behaviur www.edu.gv.mb.ca/k12/specedu/beh/pdf/beh_dcument.pdf 3. Gatekeeper training: In suicide preventin, a gatekeeper is smene wh: knws basic infrmatin abut suicide believes that suicide can be prevented learns basic suicide interventin skills has the cnfidence t respnd can assist in the aftermath f a suicide Gatekeeper training invlves educating natural helpers, r adults wh interact with yuth as part f their regular day, t recgnize warning signs fr suicide and knw hw t respnd apprpriately t smene with thughts f suicide. A gatekeeper shuld be able t prvide a link r pen the gate, between a yung persn and a mental health prfessinal. Evidence supprts this as an effective cmpnent f a cmprehensive apprach. There are different levels f gatekeeper training that prvide a range f skills frm basic awareness and help-giving t risk assessment and interventin skills training. 13
ALL schl persnnel including administratrs, teachers, maintenance, fd service, caches, bus drivers, secretaries, aides, educatinal technicians, ther supprt staff, vlunteers, and parents shuld receive a basic suicide preventin awareness/alertness sessin that includes: a basic interventin t help yuth with suicide thughts and refer them t ther resurces when apprpriate. accurate and current infrmatin abut schl, cmmunity and prvincial resurces fr help. an understanding f the schl suicide preventin prtcls. self-care guidelines In additin, a few designated schl persnnel shuld be specifically trained in suicide assessment and interventin and available t each schl building t identify, intervene, and refer a suicidal yuth. In deciding which staff shuld be trained at this assessment/interventin level, cnsideratin shuld be given t key factrs such as rle f staff persn, the ability t stay true t interventin prtcls, and the accessibility f the staff persn t the students as well as the quality f relatinships. Onging teacher/staff in-services prvided n tpics including suicide warning signs, risk and prtective factrs, healthy relatinships, inclusin and cultural safety will enhance staff s ability t act as gatekeepers in the schl envirnment. The Suicide Preventin Resurce Centre has develped a cmparative list f Gatekeeper training prgrams that are listed in the Best Practice Registry at www.sprc.rg/sites/sprc.rg/files/library/sprc_gatekeeper_matrix_jul2013update.pdf 4. Educatin and Awareness prgrams Educatin and Awareness prgrams prvide infrmatin abut yuth suicide and are usually aimed at brader grups f students. It is imprtant that ther elements f a suicide preventin plan are in place, including the develpment f suicide plicies and prtcls and training fr staff, befre educatin and awareness prgrams are delivered. The timing f implementing educatin and awareness prgrams is als imprtant. Such prgrams shuld nt be implemented at times where there is increased risk in the schl ppulatin due t a suicide r suicide attempt in the schl r cmmunity. 14
Schl-based suicide preventin prgrams tend t have the fllwing gals in cmmn: heighten awareness f the prblem prmte case finding (i.e., teaching teachers and especially ther students t identify thse wh are at risk; increase disclsure f suicidal ideatin by decreasing steretypes that may cause stigma) prvide staff and students with infrmatin abut mental health resurces specifically hw they perate and hw they can be accessed imprve teenagers cping abilities by training in stress management r psitive cping strategies. 11 Hw effective are stand alne schl-based suicide preventin prgrams? Research suggests that n their wn, ne-sht primary preventin educatin and awareness prgrams may nt be as effective as schl persnnel and mental health prfessinals wuld hpe. Fr instance, many studies have fund that while general educatin prgrams may increase students general knwledge abut suicide and warning signs, they d little t change students attitudes abut suicide and help-seeking behaviurs. This finding has held despite effrts such as using better trained instructrs r mre sensitive instruments. This research has primarily examined suicide knwledge and attitudes and has nt lked at actual behaviurs. Reference: www.smhp.psych.ucla.edu/qf/suicide_qt/suicide_schl_invlvement.pdf A cmprehensive schl-based suicide preventin plan shuld nt be based slely n any ne prgram. When selecting a prgram as part f a cmprehensive plan, chse prgrams which: highlight that suicide is nt a nrmal respnse t verwhelming stress but a result f cmplicated and intercnnected factrs integrate suicide preventin prgrams int the existing health, scial/emtinal health r PE curriculum in schls, rather than just added in as a ne-sht apprach are implemented by regular schl persnnel whse rle is relevant t the material being presented Suicide preventin prgrams ften use vides r ther media tls. Chsing a vide r media-based prgram requires cnsideratin t cntent, messaging and the needs f yur schl ppulatin. See Appendix C fr Guidelines fr Yuth Suicide Preventin Vide/Media Selectin. 11 Shaffer, D., Garland, A. Guld, M., Fisher, P., Trautman, P. (1988) Preventing teenage suicide: A critical review. Jurnal f the American Academy f Adlescent Psychiatry, 27(675-87). 15
Suicide Preventin: Guidelines fr public awareness and educatin activities www.gv.mb.ca/healthyliving/mh/dcs/spg.pdf This dcument was created t supprt the use f leading and prmising practice in public awareness and educatin effrts fr suicide preventin. It is intended t guide and enhance creative and effective educatin and awareness campaigns. It is hped that these campaigns will be develped with thughtful and careful cnsideratin and deliberatin f any benefits and risks with the guiding principle f d n harm. 5. Targeting higher risk yuth The identificatin and referral f vulnerable yung peple t apprpriate supprt is an integral cmpnent t whle-schl appraches t yuth suicide preventin. Wrking with students wh are at higher risk f attempting suicide is what is meant by selective r secndary preventin. Secndary preventin can ccur individually r in small grup sessins as needed. Understanding what risk and prtective factrs are present fr yuth is imprtant t identifying thse at highest risk. The individual mst at risk is ne wh has attempted suicide in the past. There are multiple risk factrs which may result in distress and the student being at increased risk fr suicide. Risk and prtective factrs interact in cmplex ways which make it difficult t understand the prfile f a typical yuth wh is having thughts f suicide. See p.7 and Appendix A fr mre infrmatin n risk and prtective factrs. A range f respnsive supprt services fr high risk students can include: grups where they can learn and practise life skills (prblem-slving and cping with life) student supprt teams r ther schl based case management teams that identify, fllw and refer at-risk students fr needed services specialized services r supprt i.e. substance abuse services schl-based r schl-linked mental health services Schl-based Screening tls identify thse students at highest risk fr suicide and prmte help-seeking amng thse identified. These tls are usually brief, self-reprt surveys that can be administered by any staff. Once a student is identified at risk, a mre cmplete assessment (ideally dne by a trained clinician), can ccur t understand the level f risk. The disadvantages t using screening tls include pssible false psitives, fluctuatin f individual results, and the significant staff resurces needed t fllw up n screening results. Hwever, screening tls have had psitive results in that yung peple identified at risk fr suicide are mre likely t access help. 16
What d we knw abut selective preventin and screening tls? Evaluatin evidence n the effectiveness f selective prgrams is limited. Evidence suggests that selective prgrams targeting high-risk yung peple in a schl setting are mst likely t be effective. Althugh nt specifically fcused n preventing suicide, selective prgrams can be effective in addressing risk factrs that are strngly assciated with suicidal behaviurs amng yung peple. There is limited evidence n the usefulness f screening tls with yuth frm diverse ethnic r racial grups. 6. Peer supprt/student invlvement Students are imprtant stakehlders and shuld be included in the develpment f cmprehensive suicide preventin prgramming in the schl. Ensure that yuth have meaningful invlvement in the planning phase by including yuth in planning prcesses and seeking feedback n develping plans. Mst teenagers discuss prblems with their peers, and teens wh are distressed prefer t cnfide in their peers mre s than nn-distressed teens. Schls shuld be practive in implementing peer assistance prgrams. These prgrams educate students abut the warning signs f suicide and prcedures t refer at-risk peers t apprpriate surces f help. Peer supprt prgrams have a range f rles fr peers, ranging frm listening, reprting warning signs f suicidal behaviur t thers trained t help, t prviding supprt and referral. It is f cncern that the negative side effects f peer supprt prgrams are rarely examined. Cautin is required in relatin t the safety and efficacy f peer supprt prgrams as they may increase the vulnerability f sme trubled yung peple. Sme schls in Manitba have begun implementing the Surces f Strength prgram. Surces f Strength describes itself as a cmprehensive wellness prgram that wrks t use peer leaders t change nrms arund cdes f silence and help seeking. The prgram is designed t increase help-seeking behaviurs and cnnectins between peers and caring adults. Surces f Strength has a preventative aim in building multiple surces f supprt arund individuals s that when times get hard they have strengths t rely n. Effrts t evaluate Surce f Strength s efficacy in Manitba are in the beginning stages. 17
7. Family partnerships - invlving parents/caregivers The family remains mst students primary system f care and the family-educatin system partnership is critical, nt nly t their mental wellness, but als t their academic success. Using the term family partnerships instead f parental invlvement, cmmunicates t families their imprtant rle in wrking with the schl t nurture their child s success bth emtinally and academically. When parents/caregivers are educated n suicide they are mre likely t identify and respnd t signs f mental health prblems, help t create and mnitr safe envirnments fr adlescents wh are at risk and can be engaged t slve family cnflicts r stressrs that may be related t adlescent suicide behaviurs. Suicide preventin infrmatin and resurce materials fr parents shuld include: a. why the schl engages in suicide preventin and the imprtance f family partnerships b. suicide warning signs and risk factrs c. available resurces t assist trubled yuth d. hw t supprt grieving yuth after the suicide f a friend r family member There are a number f useful websites n the tpic f yuth suicide preventin that are specifically aimed at parents, including: www.sptsusa.rg/parents/ www.sprc.rg/resurces-prgrams/suicide-preventin-facts-parents www.jasnfundatin.cm/get-invlved/parent/ Ntifying Parents/Guardians Parents r guardians f a yung persn identified as being at risk f suicide shuld be ntified by the schl and must be invlved in subsequent actins. Schls shuld cmply with divisin plicies and prvincial legislatin regarding parental ntificatin. If the schl suspects the student s risk status is the result f abuse r neglect, schl staff must ntify the apprpriate authrities. 18
Including suicide preventin in ther effrts t reach parents Schls have integrated suicide preventin utreach int ther activities by: hlding a parents night abut student safety that includes suicide preventin spnsring events fr the parents f children and yuth wh will be experiencing schl transitins (ie. elementary t middle schl) and addressing issues such as anxiety, depressin, substance use, and bullying, in additin t suicide sending material (ex. a card that fits int a wallet r purse that can be put n the family bulletin bard) t the parents f every middle and high schl student with infrmatin abut hw t help a child in crisis including suicide awareness as part f schl rientatin, safety days, r ther health events at the schl that invlve parents including suicide preventin in parenting classes presenting suicide preventin educatin at a Parent Advisry Cuncil meeting preparing infrmatin/materials fr parents in their first language where there are cultural r linguistic differences inviting family-run grups t be part f the larger team that develps the cmprehensive suicide preventin apprach in yur schl cmmunity See Appendix D fr Guidelines fr Ntificatin f Parents/Guardians 8. Cmmunity links Schls and cmmunity rganizatins/services (ex: plice, clergy, elders, mental health agencies, crisis services) must wrk tgether t establish partnerships and t build cmmn understanding f each thers needs when prviding supprt fr students and schl suicide preventin effrts. Many schls in Manitba already have representatives wh are part f reginal suicide preventin cmmittees. Infrmatin surces t help cmplete a demgraphic prfile: Manitba Yuth Health Survey infrmatin has been cllected fr each participating high schl in 2012. Cntact yur Reginal Health Authrity fr schl level data. Manitba Health - Yearly Ppulatin Estimates by cmmunity, gender age grup. www.gv.mb.ca/health/ppulatin/index.html Manitba Health - Link t Reginal Health Authrities. Search fr Cmmunity Health Assessments fr a brad range f demgraphics, determinants f health and health status infrmatin at reginal level. www.gv.mb.ca/health/rha/index.html Statistics Canada 2011 Census Infrmatin. www12.statcan.gc.ca/census-recensement/index-eng.cfm Fr a list f Manitba reginal suicide preventin cmmittees see Appendix K. 19
Ideally, agreements with crisis service prviders bth in the schl and in the cmmunity, that utline preventin and interventin services t be prvided t the schl shuld be created. Identify wh in the cmmunity can help implement suicide preventin prgramming in yur schl and the rles f schl-based and cmmunity-based partners. Cmpleting a demgraphic prfile f yur schl and cmmunity is imprtant t understanding what prgrams and interventins might wrk best. Several schls and agencies thrughut Manitba already prvide suicide preventin prgrams r mental health prmtin services. Fr a reginal listing f existing prgrams visit www.everynemattersmanitba.ca See Appendix H fr checklists t help create a cmmunity demgraphic prfile and t establish partnerships with cmmunity grups utside the schl setting. 20
B. Issues f imprtance t yuth suicide preventin effrts With each new day cmes new strength and new thughts. - Eleanr Rsevelt Nn-suicidal self injury (NSSI) Nn-suicidal self-injury (NSSI) refers t intentinal, self-effected, lw-lethality bdily harm f a scially unacceptable nature, perfrmed t reduce psychlgical distress (Walsh, 2006, p. 4). Estimates f NSSI amng yuth range frm 14 t 40 per cent in cmmunity ppulatins. The relatinship between suicide and NSSI is cmplex. While students wh self-injure are at increased risk fr suicide (Perrine, Dierker, & Kelley, 2007), many are nt suicidal with the functins f NSSI ften being quite different frm thse f suicide. While suicidal individuals typically want t end all feelings, the individual engaging in NSSI typically wants t feel better. It is imprtant t recgnize that suicide and NSSI are distinct. While engagement in NSSI des nt necessarily mean that a student is suicidal every student wh is identified as engaging in NSSI shuld be assessed fr suicide risk in the initial schlbased risk assessment. As with suicide, it is imprtant that schls have clear guidelines and plicies in the frm f a respnse prtcl. Clear prcedures shuld utline when schl persnnel shuld reprt a student suspected f self-injuring and t whm. As well, the rles f each member f the schl persnnel team shuld be defined. Plicies shuld guide primary assessment, indicate when a student must be referred t utside mental health services and clarify issues relating t parent ntificatin and cntact. NSSI is an issue which may be first identified by teachers r peers at schl. Schl-based mental health prfessinals are encuraged t enhance their knwledge and skills in assessing, treating and supprting yuth wh engage in NSSI. T learn mre abut respnding t and treating nn-suicidal self injurius behaviurs amng yuth, g t Interdisciplinary Natinal Self-Injury Netwrk Canada (www.insync-grup.ca/prfessinals.php). 21
Bullying Media reprts ften link bullying with suicide; hwever, mst yuth wh are bullied d nt have thughts f suicide r engage in suicidal behaviurs. Bullying can cause yuth t feel depressed and have suicidal thughts, but unless ther factrs are present, bullying alne is nt likely t result in suicide. Additinally, specific grups have an increased risk f suicide, including Abriginal and LGBTTQ yuth. At higher risk are yuth wh are already depressed, as well as thse experiencing scial islatin, trauma r majr family prblems. Bullying can make an unsupprtive situatin wrse. While bullying is cnsidered nly ne f many factrs cntributing t suicidal thughts and tendencies, the link between the tw can t be ignred. Further, the victim f bullying is nt the nly ne at risk. Thse wh bully thers are als mre likely t cnsider r attempt t take their wn lives, while children wh bully thers and are victims f bullying are the mst likely t think abut and attempt suicide. 12 Bullying preventin and suicide preventin share cmmn strategies in three areas: (1) schl envirnment, (2) family utreach, and (3) identificatin f students in need f mental and behaviural supprt services (and helping these students and their families find apprpriate services). Preventin recmmendatins: The fllwing actin steps may help create synergy in addressing bth suicide and bullying. Start preventin early. Bullying begins at an age befre many f the warning signs f suicide are evident. Intervening in bullying amng yunger children, and assessing bth bullies and victims f bullying fr risk factrs assciated with suicide, may have significant benefits as children enter the develpmental stage when suicide risk begins t rise. Use a cmprehensive apprach. Reducing the risk f bullying and suicide requires interventins that fcus n the needs f yung peple as well as the envirnment (especially the schl and family envirnments) in which they live. Keep up with technlgy. Bullying ften takes place in areas hidden frm adult supervisin. Cyberspace has becme such an area. At the same time, yung peple may als use scial media and new technlgies t express suicidal thughts that they are unwilling t share with their parents and ther adults. Pay special attentin t the needs f LGBTTQ yuth and yung peple wh d nt cnfrm t gender expectatins. These yuth are at increased risk fr bth bullying victimizatin and suicidal behaviur. It is essential t respnd t the needs f these yung peple, especially the need fr an envirnment in which they feel safe, nt just frm physical harm, but frm intlerance and assaults upn their emtinal well-being. Implement and evaluate strategies that have demnstrated effectiveness at increasing prtective factrs and decreasing risk factrs assciated with bth bullying and suicide. Adapted frm www.sprc.rg/sites/sprc.rg/files/library/suicide_bullying_issue_brief.pdf 12 Kim, Y., & Leventhal, B. (2008). Bullying and suicide: A review. Internatinal Jurnal f Adlescent Medicine an Health, 20(2), 133 154. Kaminski, J., & Fang, X. (2009). Victimizatin by peers and adlescent suicide in three U.S. samples. Jurnal f Pediatrics, 155(5), 683 688. Kim, Y., Leventhal, B., Kh, Y., & Byce, W. (2009). Bullying increased suicide risk: Prspective study f Krean adlescents. Archives f Suicide Research, 13(1), 15 30. 22
Manitba Educatin and Advanced Learning is cmmitted t supprting schl cmmunities in prviding safe and caring learning envirnments. In Octber 2013 Bill 18 was prclaimed. This Bill amends The Public Schls Act in the areas f bullying and respect fr human diversity. The Bill defines bullying. The definitin recgnizes that bullying can take a variety f frms, including cyberbullying. A schl emplyee, r a persn in charge f pupils during schl-apprved activities, must make a reprt t the principal if they think a pupil has engaged in, r is negatively affected by, cyberbullying. Schl bards must expand their plicies abut the apprpriate use f the internet t include scial media, text messaging and instant messaging. The Bill als requires each schl bard t establish a respect fr human diversity plicy. The plicy is t prmte the acceptance f and respect fr thers in a safe, caring and inclusive schl envirnment. The plicy must accmmdate student activity that prmtes the schl envirnment as being inclusive f all pupils, including student activities and rganizatins that use the name gay-straight alliance. Fr mre infrmatin n Safe and Caring Schls initiatives and resurces please visit www.edu.gv.mb.ca/k12/safe_schls/index.html Suicide cntagin Suicide cntagin refers t a cluster r multiple incidents f suicides r suicidal behaviurs that ccurs in an accelerated time-frame r defined gegraphical area. Suicide cntagin can happen after a schl r cmmunity has experienced ne suicide. Studies shw that adlescents appear t be mre vulnerable t suicide cntagin. This is largely because yung peple identify mre strngly with the actins f their peers, and because adlescence is a perid f increased vulnerability t mental health issues which increase the risk f suicide. 13 13 Zenere, F. (2009). Suicide clusters and cntagin. Principal Leadership, 10(2) 23
Wh is at risk f suicide cntagin? Fllwing a suicide, thse at mst risk include yung peple wh: have attempted suicide in the past; were clse friends f family members f the persn wh died; may be part f a suicide pact with the persn wh died and thers; witnessed the death; are already dealing with stressful life events; had cntact with the persn shrtly befre they died; are preccupied with thughts f death and dying; and have experienced ther lsses r suicides in the past. Aviding discussin f suicide with yung peple des nt help manage the risk f suicide cntagin. Prviding permissin and a safe place fr yung peple t talk abut their feelings can actually reduce distress and may decrease the likelihd that suicide will be rmanticized in their minds. There are a number f ways t reduce the risk f suicide cntagin in a schl cmmunity. Please refer t Sectin C fr infrmatin n suicide pstventin and Appendix E fr an example f a suicide pstventin plicy. Substance abuse Substance abuse is a significant risk factr fr suicidal behaviur amng yung peple. Suicide, depressin and substance abuse als have many shared symptms and thse wh reprt substance abuse and suicidality, ccurring at the same time, are at particularly high risk fr suicide. 14 Sme yuth may use alchl r ther substances t self-medicate r cpe with the emtinal pain that may result frm mental illness, family prblems r ther prblems which may als be assciated with suicide risk. Research shws that yuth wh have substance abuse prblems are at much higher risk f attempting r cmpleting suicide and having multiple suicide attempts. 15 Fr a yung persn wh is already dealing with persnal r family prblems, using substances can increase risk significantly, since being under the influence has an effect n md, decreases inhibitins and the ability t prblem slve effectively. 16 Alchl and drug use als ften have a negative effect n ther areas f a yuth s life (ex: increasing stress, interpersnal prblems) which can increase risk fr suicide behaviurs (ex: ideatin, attempts). Fr many yuth wh struggle with these issues, there may als be a histry f schl prblems (ex: attendance r disciplinary) and pssibly learning difficulties. Peer cnnectins (friends wh are als abusing alchl r drugs and wh may als be depressed r suicidal) may als cntribute t maintaining substance abusing behaviur and suicidality. 14 Espsit-Smythers, C. & Spirit, A. (2004) Adlescent substance use and suicidal behavir: A review with implicatins fr treatment research. Alchlism: Clinical and Experimental Research, 25(5); 77S-88S. 15 Espsit-Smythers, C. & Gldstn, D.B. (2008) Challenges and pprtunities in the treatment f adlescents with substance use disrders and suicidal behavir. Substance Abuse, 29(2); 5-17. 16 Makhija, N & Sher, L. (2007) Preventing suicide in adlescents with alchl use disrders. Internatinal Jurnal f Adlescent Medicine and Health, 19(1), 53-59. 24
Preventin recmmendatins: 1) Understand that a student wh is abusing substances (alchl, street r prescriptin drugs) may be at higher risk fr suicide and shuld be assessed fr suicidality. Cnnect them t individual help, apprpriate assessment and supprt as early as pssible. 2) Enhance prtective factrs, including schl cnnectedness, which can have the added benefit f imprving schl perfrmance. 3) Ensure that staff, parents and students are educated abut the relatinship between substance abuse and suicide. (SAMHSA 2012) p. 45 Cultural safety in yuth suicide preventin Manitba is a diverse prvince with unique strengths and needs. Schl and cmmunity based suicide preventin effrts need t reflect principles f cultural safety and recgnize and hnur all types f knwledge including traditinal and cultural knwledge. Wrking with students, families and cmmunity leaders cllabratively is imprtant when designing and implementing culturally safe suicide preventin activities. Ensuring that suicide preventin activities reflect culturally safe principles mean that these take int accunt pwer imbalances that exist between cultures, institutinal discriminatin, histrical clnizatin and the structural factrs which perpetuate inequities and disadvantages. The cncept f cultural safety mves beynd cultural cmpetency mdels which tend t fcus n knwledge f custms and beliefs and hw these values influence thinking and attitudes. Culture is als cmplex and ften changes ver time. The culture f a grup that shares a cmmn histry is nt always best captured by an indigenus, ethnic r race definitin. LGBTTQ, disabled, islated yuth are examples f ther grups wh have specific needs that need t be taken int accunt when develping suicide preventin appraches. The fllwing recmmendatins are made fr ensuring that suicide preventin activities effectively respnd t cultural needs: 1. Actively shw an understanding f and respect fr the cultures f students and their families. 2. Be sensitive t risk factrs related specifically t particular cultural grups. 3. Create culturally sensitive services that build n a culture s strengths and prtective factrs. 4. Engage families actively in guaranteeing a yung persn s safety and in any therapy prcess. 5. Be sensitive t stigma arund issues f suicide, help-seeking and mental health services. It may be useful t ffer services in settings nt assciated with mental health treatment. (SAMHSA, 2012) p. 51 25
Chse preventin prgrams carefully, especially gatekeeper prgrams and assessment services. Cnsider whether the prgram has been used with a demgraphic similar t yur cmmunity/schl ppulatin. Determine whether mdificatins can be made t tailr the prgram t best suit the needs f yur ppulatin. Lk fr evidence that supprts the use f the prgram with a demgraphic that is clsest t yur cmmunity demgraphic. T create a Cmmunity Demgraphic Prfile, use the Checklist in Appendix H. Mnitring and evaluatin Incrprating evaluatin int suicide preventin activities is essential. Planning, prcess, and utcme evaluatin are imprtant cmpnents f any cmprehensive apprach. Onging prgram elements can be mnitred regularly (annually r mre ften) t ensure the prgram is prducing the expected utcmes. Sme prgrams have been evaluated in Manitba. Summaries and results f Manitba research n suicide preventin prgramming are available n www.everynemattersmanitba.ca Why evaluate? t ensure that the prgram is meeting the key pririty t d n harm t help determine if the apprach is wrking t prvide pprtunity t demnstrate successes t funders t refine yur prgram r apprach based n results t add t a bdy f knwledge abut what wrks fr (Manitba) yuth Steps in evaluating a prgram: 6 Engage Stakehlders Describe the Prgram Ensure Use and Share Lessns Learned STEPS 5 Utility Prpriety Justify Cnclusins 1 Gather and Analyze Evidence 4 STANDARDS 2 Fcus the Evaluatin Design Accuracy Feasibility 3 1. Engage stakehlders Evaluatin cannt be dne in islatin. Invlving cmmunity partners, parents, yuth and ther stakehlders will ensure that varius perspectives are understd and cnsidered. 2. Describe the Prgram Understanding the prgram s bjectives, activities and intended utcmes will help t fcus the evaluatin. 3. Evaluatin design Cnsider the infrmatin needs (key evaluatin questins), the best techniques fr measuring the key evaluatin questins and wh can help yu get the evidence. 4. Gathering and analyzing data Surces f evidence can be peple, dcuments and bservatins. Ptential surces are surveys, fcus grups, persnal interviews and dcuments. 5. Using evaluatin findings Once the data has been analyzed, stakehlders can be brught tgether t review and interpret the findings, determine recmmendatins and lessns learned and plan next steps. 26
The The fllwing link prvides infrmatin and guidance n evaluating suicide preventin prgrams. www.sprc.rg/search/evaluatin 27
C. Pstventin At sme pint suicide pstventin evlves int a preventin respnse with emphasis being placed n recgnitin f risk factrs and warning signs. - New Hampshire Natinal Alliance fr the Mentally Ill, 2005 Pstventin refers t the activities and prcesses that are carried ut after a suicide has ccurred. Pstventin respnses need t be crdinated and guided by what is knwn t wrk best based n evidence. The apprach shuld include identifying yuth wh are at pssible risk, reducing the risks fr suicide cntagin and subsequent mental health prblems and assisting thse affected express grief in healthy ways. When smene in the schl cmmunity dies by suicide, the schl becmes a likely place t prvide suicide pstventin services. Types f suicide pstventin prgrams: Schl-based Family-fcused Cmmunity-based Gals f suicide pstventin Supprt the grieving prcess (Hazell, 1993; Underwd and Dunne-Maxim, 1997). Prevent imitative suicides (Hazell, 1993; Underwd and Dunn-Maxim, 1997). Identify and refer at-risk survivrs (Guld and Kramer, 2001) Reduce identificatin with victim Re-establish healthy schl climate (King, 2001). Prvide lng-term surveillance (Guld and Kramer, 2001). Current knwledge abut pstventin Pstventin strategies are directed at peer survivrs f a yuth suicide as they can be at heightened risk fr psychlgical distress and imitative suicidal behaviurs. Current evidence n effectiveness f pstventin strategies is limited A crdinated cmmunity respnse is an imprtant part f an effective pstventin respnse Tentative supprt exists fr the effectiveness f pst suicide screening effrts in facilitating detectin f thse at ptential risk Prximity t the persn wh died by suicide might nt be the nly factr t cnsider in determining ptential risk fr imitative suicidal behaviur. Other factrs include perceived similarities t the deceased including age, gender and ethnicity. It is pssible t identify and respnd t yuth at risk fllwing an utbreak f suicides and suicide behaviurs thrugh a standardized and systematic apprach t detecting risk and by facilitating referrals fr immediate crisis respnse. Adapted frm: www.mcf.gv.bc.ca/suicide_preventin/pdf/pys_practitiners_guide.pdf 28
Psychlgical debriefing, Critical Incident Stress Management (CISM), Critical Incident Stress Debriefing (CISD) are nt recmmended. These are psychtherapeutic interventins that have been used in schls with students and staff affected by suicide, accidental death r trauma. These appraches d nt have evidence which supprts their effectiveness r safety with large grups f yung peple in schls settings. 17 Interventins which invlve re-living, re-wrking r recllecting trauma events in a grup may cause harm. Cultural cnsideratins Attitudes tward suicidal behaviur vary cnsiderably frm culture t culture. While sme cultures may view suicide as apprpriate under certain circumstances, thers have strng sanctins against all such behaviur. These cultural attitudes have imprtant implicatins fr bth the bereavement prcess and suicide cntagin. RECOMMENDATIONS Avid the use f schl-wide suicide pstventin prgrams that require participatin f all. Investigate gatekeeper training fr schl persnnel. Prvide utreach t family survivrs f suicide that can infrm them abut grief cunselling available in their cmmunities. If suicide pstventin prgrams are implemented in the prvince cnduct methdlgically sund evaluatins. Pstventin resurces: Fr an verview f key cnsideratins, general guidelines fr actin, templates, and sample materials, applicable t diverse ppulatins and cmmunities see: After a Suicide: A Tlkit fr Schls www.sprc.rg/sites/sprc.rg/files/library/afterasuicidetlkitfrschls.pdf Other resurces: Manitba Guidelines: Kerr M.M., Brent D.A., McKain B., McCmmns P.S.A guide fr a schl s respnse in the aftermath f sudden death. 4th Editin. (2003). www.sprc.rg/resurces-prgrams/pstventin-standards-manual-guide-schls-respnseaftermath-sudden-death See Appendix F fr Suicide Pstventin Prtcl and Appendix G fr a Pstventin checklist. 17 Rberts, N., Kitchiner, N., Kenardy, J., & Bissn, J. (2009). Systematic review and meta-analysis f multiple-sessin early interventins fllwing traumatic events. American Jurnal f Psychiatry, 166(3), 293-301. Rse, S., Bissn, J., Churchill, R., & Wessely, S. (2002). Psychlgical debriefing fr preventing pst traumatic stress disrder (PTSD). Cchrane Database Syst Rev, 2(2). Szumilas, M., Wei, Y., & Kutcher, S. (2010). Psychlgical debriefing in schls. Canadian Medical Assciatin Jurnal, 182(9), 883-884. 29