SUICIDE RISK AWARENESS: THE KEY TO PREVENTION AND SUCCESSFUL INTERVENTION IN THE SCHOOL AGE POPULATION

SUICIDE RISK AWARENESS: THE KEY TO PREVENTION AND SUCCESSFUL INTERVENTION IN THE SCHOOL AGE POPULATION^©

Ruth N. Fagan, LMSW-ACP, PhD, Saul B. Wilen, MD,

Daneen A. Milam, PhD, Murray A. Brown, MD, and

David M. Madorsky, MD, MPH

International Horizons Unlimited, Ltd., San Antonio, Texas

www.intlhorizons.com

While suicide often becomes a headline when prominent people are involved, the fact is, almost all Americans know of at least one person, friend, family member, or co-worker who has chosen to take their own life. Suicide touches all of us: it happens approximately once every eleven minutes in the United States, a number totaling approximately 31,000 suicides per year. Friends and family are left devastated by this avoidable tragedy. When children are left by a parent’s suicide, or parents survive a child’s suicide, life-long emotional trauma can ensue.

As suicide is the 8^th leading cause of death for all age groups in the United States, and the 3rd leading cause of death of young people in the United States, the Surgeon General declared suicide a “serious public health threat” in August, l999. Who is at risk and what are the factors that contribute to these risks? Though suicide affects all age and ethnic groups, there are primarily two high-risk groups: Anglo men age 65 or older, and young adults under the age of 25. The fastest growing at-risk group is males ages 10 to15, with a 200% increase in suicide in this age group seen during the 1990’s. Gender differences in the United States are pronounced with men having four times the rate of completing suicide as women, even though women may actually attempt suicide at higher rates. One explanation for this difference is the more common use of firearms by men in attempting suicide, with more than 80% of all firearm suicides committed by men. The use of firearms has a much higher potential lethality than a drug overdose, the method most often used by women in suicide attempts.

What We Know About Suicidal Individuals

Though each case is individual, there is a body of psychiatric research which has identified several common themes about suicidal individual of all ages. Suicidal individuals feel they are stuck in an intolerable situation from which there is no way out. They may have struggled with the problem (whether external to themselves such as a significant loss, or internal such as a mood disorder) for a considerable period of time prior to the suicide attempt. They most often do not want to die, but rather to escape from the psychological pain they are in. Depression has clouded their ability to think clearly about the problem(s), and often alcohol or drugs may be further affecting their judgment. A great many suicidal individuals want help, but have difficulty asking for assistance – the suicide attempt itself may be their cry for help.

The most significant aspect of any discussion of suicide risk is that suicidal individuals, including adolescents and children generally leave clues as to their suicidiality (intent to commit suicide) which, if recognized and acted upon, can be used as the stimulus to prevent the suicide. Therefore, as with any public health concern, educating families, health care providers, educators, counselors, the clergy, and the general community to recognize, respond to, and get appropriate help for those with suicidal intent, is the most important first step towards saving lives. Awareness is the key to prevention.

WHAT TO LOOK FOR

SUICIDE RISK IN ADOLESCENTS

Three or more of these behaviors lasting over a two month period of time would signal the need for referral to a family physician, psychiatrist, or other mental health provider:

· Significant changes in appetite or sleep patterns that persist over a two month period of time.

· Loss of interest in usual interests or activities (school, friends, athletics).

· Frequent and unexpected outbursts of anger.

· Preoccupation with tapes, CDs, and movies that deal with death, loss, suicide and violence.

· Sudden and dramatic change in appearance (style of dress, hair).

· Excessive use of alcohol or drugs (over half of all adolescents who make a suicidal gesture are under the influence of alcohol).

· Recent (within past six month) significant loss in relationship or status (break-up with boyfriend, girlfriend, “kicked off” an athletic team).

· Withdrawal from family and friends – preference to spend long periods of time alone.

· Has had a peer or friend commit suicide within the past year.

Any one of these behaviors would on their own indicate the need for immediate intervention and referral to a psychiatrist, other mental health professional, or mental health facility:

· Excessive preoccupation with death, loss, and violence (may indicate this in poetry, drawings, messages, phone conversations).

· Discusses plans/wishes for suicide.

· Has a suicide plan.

· Leaves suicidal-type notes for others to see.

SUICIDE RISK IN CHILDREN (ages 5 to 12)

Three or more of these behaviors lasting over a one month period of time would signal the need to refer the child to a family physician, pediatrician, child psychologist or psychiatrist for possible intervention:

· Sudden and dramatic changes in eating or sleeping patterns lasting over one month.

· Frequent (2-3 per week) night terrors causing child to have extreme anxiety, which persist for over one month.

· Sudden increase in bedwetting or bedsoiling, when this had not been a problem, and when this persists for over one month.

· Child’s sudden change in mood resulting in severe crying spells, extreme sadness, rageful outbursts, or complete withdrawal, that do not seem related to any external event (such as a death of a family member, or a pet), and which last over one month in duration.

· Artwork, pretend play, or peer play that depict consistent themes of death, violence, loss, and which persist over a one month duration of time.

Any one of these behaviors would on their own indicate need for immediate referral to a family physician, child psychologist, psychiatrist, or mental health facility:

· Child’s displaying extreme sexualized behavior, beyond what a child of that developmental stage would normally display or have knowledge about.

· Child’s obssessional talk about death, mutilation, or violence (several times per day), lasting for over one month.

· Child’s acting out mutilating behaviors towards self, others, or animals.

WHAT TO DO IF YOU THINK SOMEONE IS SUICIDAL

While not all of us are trained to know how to professionally intervene if someone is suicidal, there are several basic steps that can help.

First, if you have reasonable concerns, do not hesitate to ask the person if he or she is thinking of harming him or herself. You can say: “You seem very down and upset – are you thinking of harming yourself?” Bringing up the subject will not plant the idea if not already there, or necessarily anger or upset the person. In fact, the suicidal individual may feel that the question gives permission for them to admit to their suicidal feelings, which may be a relief.

Second, if the individual admits to suicidal thoughts or feelings, always assume the threat is serious, even if you’re not sure. It is better to be too cautious then to miss a legitimate suicidal threat.

Third, if you do not feel the person is in immediate danger (they do not possess a weapon, or do not have in their possession medication available for an overdose), take the following steps:

· ask if they have thought of a plan.

· if the answer is no (they have not thought of a plan) continue talking to them about how they feel – what the problem areas are, without trying to judge, deny the importance, or fix the problems. Just listen! When appropriate, let the person know you will do whatever possible to help get them connected to a source of help – and then follow through to make certain this happens.

· if the answer is “yes,” (they have thought of a plan) ask them to tell you what the plan is. As the person is talking, think of resources you may need to call at this time – family members or others nearby, who can help with immediate intervention. You may need to excuse yourself very briefly, to enlist others to make the telephone calls for help, while you sit with the person who is suicidal. Try to stay with the person until back-up resources are available (an immediate appointment with a mental health professional, taking the individual to a mental health facility or hospital).

If the person with an active suicide plan resists all offers for help, do not hesitate to call the EMS (Emergency Medical Services) or the police if the plan seems imminent, even if the individual becomes angry with you about this. At the very least, notify immediate family members or significant others about the individual’s plan. Confidentiality is not a consideration when a person’s life is at stake.

Often, suicidal individuals will protest getting professional help yet be remarkably compliant when they are taken for help. It is important for someone to remain with the suicidal person through this process. The helper can reduce fears about treatment, can reassure the person they “are not going crazy,” and can calmly but emphatically state that there is another way to resolve their problems, other than suicide. The ambivalence/confusion of the suicidal individual works to the advantage of the helper because most often the individual is looking for a strong, authoritarian figure to direct his/her emotions and feelings. Making emphatic statements to the suicidal individual is important (such as “I am here to help you. This can get better. We will get help”.).

THE “NO-HARM” CONTRACT

One of the most useful interventions that all helpers including family members can use with a suicidal individual is the “no-harm” contract. This is a simple statement that the suicidal individual is asked to make either verbally or in writing in which that person agrees not to harm themselves for a specified length of time (hours, days, weeks). An example might be: “I agree to not harm myself in any manner during the next two days, until my appointment with Dr. Smith.” The statement may have more impact if written (and witnessed), though if the suicidal person resists a written statement but is willing to verbally agree to a “no-

harm” contract, this is much preferred over no contract at all.

If the suicidal individual is not willing to agree to either a verbal or written “no-harm” contract, this would be a strong indication that the person is in the high risk category for suicide, and immediate intervention should take place. For those who do agree to the contract, the act of contracting not to harm themselves can be very calming and effective, setting a limit in place they could not provide for themselves. However, in all circumstances professional assistance should be obtained as soon as possible.

CONCLUSION

Suicide has been described as a permanent solution to a temporary problem – yet there were 31,000 individuals in the United States this past year who chose the permanent solution and no longer have the opportunity to change their minds and live. Awareness of the risk of suicide, the outlined factors, and the suggested immediate interventions are presented to help decrease the tragic but preventable outcome among school age population who are contemplating suicide by providing that critical time to seek help, reduce the feelings of depression and helplessness, and renew hope.

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