Children and Families Forum: Suicide Prevention for Children and Adolescents
By Liza Greville, MA, LCSW
Social Work Today
Vol. 17 No. 5 P. 32

With the release of the Netflix drama 13 Reasons Why in March 2017, social workers from middle schools to colleges and universities across the country found themselves plunged into conversations with adolescents and young adults around topics related to suicide. While many mental health professionals objected strongly to the series, saying it contains harmful messages about the inevitability of suicide, the ability to achieve revenge through suicide, the absence of helpful others, and insufficient messages about the availability of help and support, most professionals acknowledged that, apart from these concerns, the series opened a space for conversation on a topic that is shrouded in stigma, fear, pain, and misunderstanding.

By having an accurate understanding of the scope of the problem, confronting myths and imprecise language, and using best practices in screening, intervention, and prevention, social workers have a critical role in helping children, adolescents, and young adults move through a suicidal crisis to emotional wellness.

Data on Suicide
According to the Centers for Disease Control and Prevention (CDC), suicide was the 10th-leading cause of death for all ages in 2013. Suicide was the third-leading cause of death among persons aged 10 to 14, and the second among persons aged 15 to 34, though middle-aged adults accounted for the largest proportion of suicides (56% in 2011). The percentage of adults having serious thoughts about suicide was highest among adults aged 18 to 25 (7.4%), followed by adults aged 26 to 49 (4%), then by adults aged 50 and older (2.7%) (Centers for Disease Control and Prevention, 2015).

The following were noted among students in grades nine through 12 during 2013:

• Seventeen percent of students seriously considered attempting suicide in previous 12 months (22.4% of females and 11.6% of males).

• 13.6% of students made a plan about how they would attempt suicide in the previous 12 months (16.9% of females and 10.3% of males).

• Eight percent of students attempted suicide one or more times in previous 12 months (10.6% of females and 5.4% of males).

• 2.7% of students made a suicide attempt that resulted in an injury, poisoning, or an overdose that required medical attention (3.6% of females and 1.8% of males) (Centers for Disease Control and Prevention, 2015).

New research presented in May 2017 at the Pediatric Academic Societies Meeting analyzed hospital admissions with a diagnosis of suicidal thoughts or behaviors and serious self-harm from 32 children's hospitals across that nation from 2008 to 2015. Researchers found the number of admissions has more than doubled during the past decade. The research found the largest increases among girls, and seasonal variations with the spring and fall having higher admission rates than summer (American Academy of Pediatrics, 2017, May 4).

Dispelling Myths and Using Precise Language
Adam Lesser, LCSW, is deputy director of the Columbia Lighthouse Project at New York State Psychiatric Institute and an assistant professor of clinical psychiatric social work in the division of child and adolescent psychiatry at Columbia University College of Physicians and Surgeons. He believes that pervasive myths and imprecise terminology impede efforts to communicate effectively about suicide, ultimately reinforcing stigma and ineffective collaboration to aid a person at risk of suicide. In order to avoid confusion stemming from vaguely defined terms and pejorative language, the CDC has issued recommendations eliminating use of the following terms: manipulative act, parasuicide, suicidality, suicide gesture, suicide threat, failed attempt, and completed suicide. Acceptable terms include suicidal ideation, suicidal behavior, attempted suicide, and died by suicide.

In addition to use of confusing language, Lesser cites two pervasive myths that inhibit effective intervention. The first myth is that if someone wants to kill themselves, there is no way to stop them, so trying is futile. To the contrary, Lesser states, "research shows us that 95% of suicide attempters are ambivalent about wanting to die. Suicidal impulses are a symptom that ebbs and flows when coping skills are overwhelmed, so if you can help someone in their peak moment of crisis, they may never get that suicidal again."

The second myth is that asking about suicide may "put the idea in someone's head," thereby increasing risk; however, Lesser notes that all recent research has confirmed that asking suicide-related questions does not increase the likelihood of suicidal thoughts or behaviors, even when universal screening is conducted in high schools. "The real risk," he says, "is not asking," noting that "most people want to be asked and want help, so ask, because you can save a life."

Screening and Intervention
The Columbia-Suicide Severity Rating Scale (C-SSRS) is an assessment tool designed to gather information on the full range of suicidal ideation and suicidal behavior. It was developed in an effort led by the National Institutes of Mental Health and measures ideation severity, ideation intensity, behaviors, and lethality of actual suicide attempts. C-SSRS is suitable for use across the lifespan from young children to elder adults, and use of the screen is highly feasible, as nonmental health professionals can effectively administer it.

Because of strong empirical support, the C-SSRS has been endorsed, recommended, adopted, or mandated by many national and international agencies, including the Department of Defense, the Substance Abuse and Mental Health Services Administration (SAMHSA), National Action Alliance for Suicide Prevention, and the World Health Organization.

In thinking about how to implement the C-SSRS as a screening tool in a school or higher education setting, Lesser describes a universal training program. "Ideally, all faculty and staff (teachers, administrators, coaches, custodial staff, police/security staff, residential staff, and cafeteria/dining staff, etc.) would have some exposure to training on suicide and understand the important questions to ask when concerned about someone, as well as knowledge of where to 'hand off' a student of concern," he says. The school guidance counselors, social workers, or counseling center staff would be additionally trained in use of C-SSRS, as well as safety planning and linkages to community mental health providers. Students and parents would be educated on the risk factors for suicide, that it is okay to ask friends, and what to do when worried about friends. Finally, Lesser cautions against implementing education and screening programs only in middle and high schools and ignoring elementary schools, noting that it is uncommon but not unheard of for children as young as six to eight to wish to be dead and even attempt suicide.

In terms of intervening with a student who has been identified as at-risk due to suicidal ideation or behaviors, Lesser cites the following best practices: means restriction, safety planning, the Collaborative Assessment and Management of Suicidality treatment model, other cognitive behavioral treatment methods, and psychopharmacology for underlying mood disorders.

Prevention
Sources of Strength is a suicide prevention program designed to build socioecological protective influences around youths and to reduce the likelihood that vulnerable youths and young adults will become suicidal. Sources of Strength was founded in 1998 and began engaging in randomized trials in 2006. It is considered one of the most heavily researched peer leadership programs in the world and has transformed peer cultures in schools, universities, communities, and faith-based programs across multiple states and tribal settings, as well as in Canada, Uganda, Australia, and New Zealand.

Sources of Strength was listed on the National Best Practices Registry by the Suicide Prevention Resource Center and The American Foundation for Suicide Prevention in 2009, and was added to the National Registry of Evidence-based Programs and Practices by SAMHSA in 2011. Clinical trials demonstrate outcomes including an increase in peer leaders' connectedness to adults, an increase in peer leaders' school engagement, a four-fold increased likelihood among students to refer a suicidal friend to an adult, an increase in positive perceptions of adult support for suicidal youth and the acceptability of seeking help, and an increase in positive perception of adult support in students with history of suicidal thoughts.

Toward those goals, the program relies on peer leaders and trusted adults to implement messaging campaigns focusing on hope, help, and strength; facilitate discussion groups; and enhance referral processes, all grounded in a strengths-based approach that is disseminated through social networks. The core strengths that students are taught to recognize and access include family support, positive friends, mentors, healthy activities, generosity, spirituality, medical care, and mental health care.

According to Mark LoMurray, founder and executive director of Sources of Strength, "the heartbeat of resiliency is the ability to tell your own internalized strengths story, to talk to others about your ups and downs, and how your strengths help you get through." He believes resiliency skills have to do with recognizing and accessing resources and says that Sources of Strength "normalizes the concept that all of us go through some tough or rough times in life, and the strengths are what help us as we go through these times, no matter our age."

LoMurray says emerging research is showing "that mentorship has an umbrella." He says, "A mentoring relationship between a trusted adult and a student increases the perception of credibility and trust of that mentor to a third-degree friend." Consequently, students who feel suicidal and don't trust anyone can borrow the credibility from the increased student-adult connectedness relationships across the setting.

LoMurray describes the program as "upstream prevention," noting the program is designed "to reach whole populations before suicidal crisis and focus on how using multiple strengths can help with the ups and downs that are both normal and serious in nature."

— Liza Greville, MA, LCSW, is in full-time clinical practice in rural Pennsylvania.

References
American Academy of Pediatrics. (2017, May 4). Children's hospital admissions for suicidal thoughts, actions double during past decade. Retrieved from http://www.aappublications.org/news/2017/05/04/PASSuicide050417

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. (2015). Suicide: Facts at a glance. Retrieved from https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf