A Case Study. Dr. Brown described a study designed to prevent aggression involving approximately 1000 children in Baltimore. Data from this study revealed some significant differences in characteristics and behaviors of individuals with suicidal behaviors (suicide completion, attempts or ideation), compared to children who did not engage in these behaviors. This was a universal prevention study (interventions given to all children), including ages 6 through early their 20’s. Five percent of these children attempted suicide, and 70 percent of the attempts occurred before age 15. About 15 percent had suicidal ideation at age 21. A number of factors were associated with the increased likelihood of suicidal behavior (suicide completion, attempts or ideation). Poverty status was about twice as common in individuals who committed suicide. Females were approximately three times as likely to attempt suicide than males. Psychiatric diagnoses were noteworthy; for example, anxiety and depression were associated with three to four times the risk of suicide as people without these disorders. “Acting out behaviors,” (e.g., attention deficit hyperactivity disorder, antisocial personality disorder) or a substance abuse disorder were associated with two to three times the associated risk.” Having multiple diagnoses increased the risk for suicide. Dr. Brown highlighted that a substantial proportion of children who had suicidal behaviors did not have any psychiatric diagnosis.

…about one-third of the people who attempted to commit suicide were without a diagnosis

C.Hendricks Brown

Dr. Brown described two other noteworthy observations on suicide in this study. First, there was a striking lack of services. Sixty percent of attempters never used mental health services. And 75 percent had no mental health services in the year of the attempt, although 50 percent of the latter group stated that they needed them. Second, “the onset of [substance] dependence and abuse actually occurred most often after the first suicide attempt.” This obviously puts the status as an antecedent of this risk factor into question for this sub-group. Dr. Brown’s study revealed different developmental trajectories with important implications for prevention. They found that the subset of children who were aggressive at an early age, the high risk individuals, showed a much greater impact of the intervention.

A SYSTEMS APPROACH TO YOUTH SUICIDE PREVENTION

Dr. John Kalafat discussed a systems approach to suicide prevention in schools. He defined systems interventions and their rationale, and described evaluation and implementation for systems interventions. He also described the results for two systems school-based suicide intervention programs in two different states.

Dr. Kalafat identified a conceptual issue in suicide prevention. He stated that suicide prevention experts often make a distinction between reducing risk factors and increasing protective factors. Dr. Kalafat expressed that this distinction is “meaningless.” He explained that models relying on such a distinction assume that causal factors work in too simple a manner to be realis-



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Suicide Prevention and Intervention: Summary of a Workshop A Case Study. Dr. Brown described a study designed to prevent aggression involving approximately 1000 children in Baltimore. Data from this study revealed some significant differences in characteristics and behaviors of individuals with suicidal behaviors (suicide completion, attempts or ideation), compared to children who did not engage in these behaviors. This was a universal prevention study (interventions given to all children), including ages 6 through early their 20’s. Five percent of these children attempted suicide, and 70 percent of the attempts occurred before age 15. About 15 percent had suicidal ideation at age 21. A number of factors were associated with the increased likelihood of suicidal behavior (suicide completion, attempts or ideation). Poverty status was about twice as common in individuals who committed suicide. Females were approximately three times as likely to attempt suicide than males. Psychiatric diagnoses were noteworthy; for example, anxiety and depression were associated with three to four times the risk of suicide as people without these disorders. “Acting out behaviors,” (e.g., attention deficit hyperactivity disorder, antisocial personality disorder) or a substance abuse disorder were associated with two to three times the associated risk.” Having multiple diagnoses increased the risk for suicide. Dr. Brown highlighted that a substantial proportion of children who had suicidal behaviors did not have any psychiatric diagnosis. …about one-third of the people who attempted to commit suicide were without a diagnosis C.Hendricks Brown Dr. Brown described two other noteworthy observations on suicide in this study. First, there was a striking lack of services. Sixty percent of attempters never used mental health services. And 75 percent had no mental health services in the year of the attempt, although 50 percent of the latter group stated that they needed them. Second, “the onset of [substance] dependence and abuse actually occurred most often after the first suicide attempt.” This obviously puts the status as an antecedent of this risk factor into question for this sub-group. Dr. Brown’s study revealed different developmental trajectories with important implications for prevention. They found that the subset of children who were aggressive at an early age, the high risk individuals, showed a much greater impact of the intervention. A SYSTEMS APPROACH TO YOUTH SUICIDE PREVENTION Dr. John Kalafat discussed a systems approach to suicide prevention in schools. He defined systems interventions and their rationale, and described evaluation and implementation for systems interventions. He also described the results for two systems school-based suicide intervention programs in two different states. Dr. Kalafat identified a conceptual issue in suicide prevention. He stated that suicide prevention experts often make a distinction between reducing risk factors and increasing protective factors. Dr. Kalafat expressed that this distinction is “meaningless.” He explained that models relying on such a distinction assume that causal factors work in too simple a manner to be realis-

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Suicide Prevention and Intervention: Summary of a Workshop tic. Dr. Kalafat prefers a “mediational model.” In mediational models, an additional, or mediating factor is involved in the causal relationship between the two factors under study. Community competence does not exist in most places in this country. John Kalafat The Systems Intervention: Building a Competent Community. The premise of the systems approach is that only by addressing the entire community’s interactions can a complex behavioral problem such as suicide be reduced. This includes interventions at the individual, classroom, school, and community levels, as well as changes in interactions among levels. Through his work in implementing and evaluating school-based suicide prevention programs, Dr. Kalafat found problems in communication and oppositional relationships between different groups (e.g., school administration, staff, parents, children, and community agencies). Important issues may be neglected because different community stakeholders have limited time and scopes of responsibility, according to Dr. Kalafat. As a consequence, communities suffer in numerous ways, including increased suicide rates. Dr. Kalafat stated that “systemic prevention change norms; an effective prevention intervention will go beyond affecting individuals.” Evaluation of System Needs. Starting in approximately 1980, schools started seeking outside help to deal with increasing suicide rates. Gate-keeper training was often specifically requested to provide training so that school counselors could more effectively identify students at risk. Upon evaluation of the schools, Dr. Kalafat identified the following six interrelated problems. (1) All staff and faculty need training including bus drivers, cafeteria workers, and coaches who often have developed relationships with students. (2) Students are often the first to be aware of other students having problems. Therefore, training only adults will not suffice. (3) Students are hesitant to seek help from adults. (4) Coordination is lacking between community treatment facilities and schools. (5) There are few clinicians with training in suicide and youth suicide prevention in the community. (6) There are problems with treatment compliance and follow-up. …our mental health services are not culturally or psychologically accessible to males. John Kalafat Thus, a comprehensive evaluation of the problem reveals a need for broad solutions including improved accessibility and delivery of services. Dr. Kalafat noted that services need to be culturally, psychologically, temporally, geographically, and financially accessible. Cultural and psychological accessibility is critical with adolescents according to Dr. Kalafat, and are most critical for adolescent males.

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Suicide Prevention and Intervention: Summary of a Workshop Implementation of a Systems Anti-Suicide Intervention. Dr. Kalafat highlighted the need for those working in prevention to help institutions overcome their preference for short-term and isolated prevention programs. After evaluating the needs of the system, Dr. Kalafat implements a set of complementary measures to reduce suicide. These are described below. Meet with the administration, to make sure there are written policies and procedures for responding to at-risk students. Develop linkages to the community. These need to be in place prior to onset of an emergency need on the part of the school. Develop parental involvement and awareness. Train all faculty and staff including bus drivers, cafeteria workers, coaches. Educate students about help-seeking. Implement screening measures. Screening presents four particular challenges. First, screening is especially important in identifying the population of students who are “quietly disturbed,” as Dr. Kalafat described. He said research shows that these children are often self-isolating and may not come to the attention of others, thereby increasing their risk. Second, policy constraints and financial responsibilities for schools create political difficulties. According to Dr. Kalafat, “schools are bound by legislation to provide treatment or pay for treatment for anybody that they identify as having a concern or problem, so they are not interested in case finding.” Third, parental consent is needed for screening, and “the rates of compliance with active parental consent run about 50 percent in schools.” Fourth, suicidality fluctuates significantly in adolescents, Dr. Kalafat reported, making repeated screening necessary. Train community gate-keepers including law enforcement and emergency personnel, and clinicians. Reduce access to means. The parents are likely the best avenue to reduce access to means according to Dr. Kalafat. Case Studies. Dr. Kalafat discussed two school-based systems prevention efforts: Bergen County, New Jersey, and Dade County, Florida. Both of these counties are populous, with about a quarter of a million adolescents in each. A 10-year follow up in Bergen County found that the programs were continuing with good fidelity in 30 of the 32 public schools. In New Jersey, Dr. Kalafat and his colleagues looked at suicide rates for the 5 years pre-implementation, 5 years during the “roll out,” and 5 years after the implementation had been completed. They compared county, state and national suicide rates to control for general trends. The suicide rate in Bergen county was reduced by half, with no such change in state or national rates during the same time period. In Florida, data from 10 years prior and 10 years post-implementation were examined. Again, there was about a 50 percent reduction in suicide rate in the county, but not the state or the nation. The Dade County study occurred some years after the Bergen County program, providing replication at two different times. The workshop attendees discussed the promise of this approach and its similarity to the program used in the Air Force to reduce suicide. The workshop attendees listed the necessary factors of effective systems interventions.

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Suicide Prevention and Intervention: Summary of a Workshop Concurrent complementary universal, selected and indicated interventions. Collaboration among all parties. Fidelity of program implementation. The program must be designed to be sustained over a long period of time in order to evaluate its effectiveness. Program evaluation must be mandatory, planned at the outset including proximal and distal outcome measures, and sufficiently funded. A “Program Champion” is essential. A paid, dedicated staff position works best. Everyone is trained to be competent to provide appropriate initial response, at minimum. The workshop attendees asked Dr. Kalafat if there is any evidence of additional benefits from suicide prevention programs. He stated that they also show promise in reducing interpersonal violence. No single type of intervention is likely to be universally effective, we can turn our attention to a more appropriate question: which combination of the many poten tial interventions is likely to be the most effective as well as feasible in prevent ing violent injuries? John Kalafat In a discussion of dissemination of successful models, Dr. Brown suggested three stages of development and dissemination. First, efficacy and effectiveness studies must be done, followed by small-scale implementation studies, and finally broad dissemination can start, with continued evaluations at each step. Dr. Kalafat listed 10 priorities for effective prevention of suicide. (1) Suicide assessment and intervention training in graduate programs in all clinical disciplines. (2) Study of individual treatment efficacy, since it remains unproven. (3) Program efficacy assessment to formulate data-based methods for all groups. (4) Improved continuity of care from hospital and/or emergency settings to outpatient treatment. (5) Enhanced case identification and referral of at risk individuals. (6) Improved accessibility and delivery of services, as exemplified by the “full service school” movement. (7) Decreased access to means. (8) Improved media reporting to reduce imitation and contagion. (9) Promotion of protective factors. (10) Complementary approaches incorporating universal, selected, and indicated interventions are paramount.