Frank J. Zenere, Ed.S.School Psychologist, Crisis Management Specialist

Miami-Dade County Public SchoolsMiami, Florida U.S.A.

RVTS Conference 2014

“Creating a School Culture of Prevention”

June 3, 2014

Kristiansand, Norway

Greetings from Miami

Miami-Dade County Public Schools

Fourth largest school district in the U.S.A. (350,000 students)

73% of students eligible for free and reduced price lunch

91% of all Miami-Dade students are minority children

50% of all families are foreign born

More than 12% of households are headed by a family member with less than a

9th grade education

75% of families speak a language other than English at home

Miami-Dade entered the 21st century with graduation rates barely 55%

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A CHANGING WORLD … CHANGING NEEDS

M-DCPS meets these changing needs.

Student Safety & Health Priority Areas

HIV/AIDS, and STI’s

Substance Abuse

Teen Dating Violence

Youth Suicide

At-Risk Cyber BehaviorsChild Abuse/Neglect

Human Trafficking

School Violence/Bullying

Homelessness

School Safety

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DID YOU KNOW?

Tragic incidents and large scale acts of violence in schools anywhere in the United States are

EXTREMELY RARE.

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Homicides on school grounds during the school day are VERY RARE

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U.S. Department of Justice, 2012

What does research say about the most serious incidences of school violence?

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Safe School Initiative Findings

Incidents of targeted violence at school rarely were sudden, impulsive acts.

Prior to most incidents, other people knew about the attacker’s idea and/or plan to attack.

There is no accurate or useful “profile” of students who engaged in targeted school violence.

Most attackers engaged in some behavior prior to the incident that caused others concern or indicated a need for help.

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United States Secret Service and the United States Department of Education, 2002

Safe School Initiative Findings

• Most attackers had difficulty coping with losses or personal failures.

• Many had considered or attempted suicide. • Many attackers felt bullied, persecuted or

injured by others prior to the attack. • Most attackers had access to and had used

weapons prior to the attack. • In many cases, other students were

involved in some capacity.

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United States Secret Service and the United States Department of Education, 2002

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Bullying Statistics, 2010, U.S.A.

Approximately, 70-80% of school age students have been involved in bullying during their school years, as a bully, victim or bystander (Graham, 2011).

Children identified as bullies often experience significant mental health problems such as depression (Swearer, Song, Cary. Eagler & Mickelson, 2001).

Victims of chronic bullying suffer severe and profound consequences including; depression, anxiety and are at incresed risk of dropping out of school.

Cyberbulling victims are twice as likely to attempt suicide as others who are bullied (Hinduja & Patchin, 2010).

90% of bullying takes place between 4th and 8th grades (makebeatsnotbeatdowns.org ).

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DID YOU KNOW?

There were 6,477 homeless students identified in Miami-Dade County Public Schools in 2012-2013.

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DID YOU KNOW?

• Florida reported 117,612 AIDS cases to CDC, cumulatively, from the beginning of the epidemic through December 2008.

• Florida ranked 3rd highest among the 50 states in cumulative reported AIDS cases.

• Miami ranks as the top city in the nation with the most reported cases.

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Drug use by 12th grade students in the U.S.A. over the last year.

•Alcohol: 70.6%•Marijuana: 34.3%•Stimulants: 10%•Other Opiates: 9.5%•Tranquilizers: 7.3%•Sedatives: 6.5%•Hallucinogens: 6.2%•Cocaine: 5.3%•Inhalants: 4.2%•Steroids:2.5%•Heroin: 0.9%

United States Department of Justice, 2012

DID YOU KNOW?

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DID YOU KNOW?

• Currently there are approximately 27 million people enslaved throughout the world with 2.5 million located in the USA.

• Florida, with one of the highest incidences of human trafficking in the country, has been identified as a hub for human trafficking.

• Trafficking can involve school-age children—particularly those not living with their parents—who are most vulnerable.

At least 1 in 5 children and adolescents has a mental health disorder

1 in 10 has a serious disorder

90% of people who develop a mental disorder show warning signs during their teen years

Mental Health in the U.S.A.

Youth Suicide Data, U.S.A., 2010

Suicide was the third leading cause of death for 15-24 year olds.

For youth aged 15-19, the suicide rate was 13.62 per 100,000; for children 10-14, the rate was 1.29 per 100,000.

Male youth die by suicide four times more frequently than female youth.

The majority of youth who died by suicide used firearms (44.5% of deaths). Suffocation was the second most common method (39.7% of deaths).

American Association of Suicidology

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Why Schools Should Address Suicide

Maintaining a safe school environment is part of a school’s overall mission. Other prevention activities (e.g., violence,

bullying, substance abuse, etc.) can also reduce suicide risk (Epstein & Spirito, 2009).

Programs that improve school climate and promote connectedness help reduce suicide risk (Blum, McNeely & Rinehart, 2002).

Activities designed to prevent suicide and promote student mental health reinforce the benefits of other student wellness programs.

Preventing Suicide: A Toolkit for High Schools, 2012

Why Schools Should Address Suicide

26.1% of high school students, grade 9-12, felt sad or hopeless for two or more weeks

16 % of high school students, grade 9-12, seriously considered suicide in the previous 12 months

8% of students, grade 9-12, reported making at least one suicide attempt in the previous 12 months

30%-40% of teens who die by suicide have made a prior attempt

USA, Youth Risk Behavior Survey, 2011, CDC, 2012

Why Schools Should Address Suicide

Approximately 90% of youth suicide victims suffer from some form of mental illness, the majority of which have a mood disorder. Mental illness can impact student performance in the following ways: Difficulty concentrating Academic difficulties Disruptive behavior Problems with peers Increased irritability and aggression Poor judgment Excessive sleeping

Why Schools Should Address Suicide

A student suicide can significantly impact other students and the entire school community. Taking appropriate and timely actions

following a suicide is critical in helping students cope with the loss and preventing additional tragedies.

Preventing Suicide: A Toolkit for High Schools, 2012

Why Schools Should Address Suicide

Schools have been sued for negligence for the following reasons: Failure to notify parents if their child

appears to be suicidal Failure to get assistance for a student at

risk of suicide Failure to adequately supervise a student

at riskPreventing Suicide: A Toolkit for High Schools, 2012

Components of Comprehensive School Suicide Prevention

Plans

Policy and procedures Universal, targeted and indicated

prevention Gatekeeper training Screening Risk assessment protocol Resource identification Case management Postvention plan

Miller, D., SUNY

Suicide Prevention Components

Tier 3: Intensive,Individual Interventions

1-5% individual students

Tier 2: Targeted, classroom, group

Interventions5-10% students

Tier 1: Universal, Prevention

and Interventions80-90%% individual

students

Tier III

Tier II

Tier I

Suicide Prevention: Universal Program

Perspectives

Focus upon reduction of risk factors – intrapersonal and interpersonal.

Enhance protective factors - intrapersonal and interpersonal (family, school, community)

Risk Factors and Protective Factors

Suicide prevention efforts seek to reduce risk factors and increase protective factors.

Risk Factors are characteristics that make it more likely that a person will think about suicide or engage in suicidal behaviors - could create the impetus for a suicidal act.

Protective Factors are not just the opposite or lack of risk factors. They are conditions that promote strength and resilience and ensure that vulnerable individuals are supported and connected with others during difficult times, thereby making suicidal behaviors less likely.

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Risk Factors

Previous suicide attempt/ gestureFeelings of hopelessness or isolationPsychopathology (depressive disorders/mood disorders)Parental psychopathologySubstance abuse disorderFamily history of suicidal behaviorLife stressors such as interpersonal losses (relationship, social, work) and legal or disciplinary problemsAccess to firearmsPhysical abuse/Sexual Abuse

Conduct disorders or disruptive behaviorsSexual orientation (homosexual, bisexual, and trans-gendered youth)Juvenile delinquencySchool and/or work problemsContagion or imitation exposure to media accounts of suicidal behavior in friends/acquaintances)Living alone and/or runawaysChronic physical illnessAggressive-impulsive behaviors

Protective Factors

Family cohesion (family with mutual involvement, shared interests, and emotional support Academic achievement Good coping skills Perceived connectedness to school Good relationships with peers Lack of access to means for suicidal behavior Help-seeking behavior/advice seeking Impulse control

Problem solving/conflict resolution abilities

Social integration/opportunities to participate

Sense of worth/confidence Stable environment Access to and care for mental/physical/substance disorders Responsibilities for others/pets Religiosity (a controversial topic currently)

Universal Prevention Components

Universal Prevention Components

Skill building lessons for students Suicide awareness education, including

knowledge of warning signs (Middle and Senior High Schools)

Promote help-seeking Screening of all students Gatekeeper training for caregivers

Suicide Prevention Curricula

Purpose Provide information about suicide

prevention Promote positive attitudes Increase students’ ability to recognize if

they or their peers are at risk of suicide Encourage students to seek help for

themselves and their peers.

Preventing Suicide: A Toolkit for High Schools, 2012

Suicide Prevention Curricula

Content Basic information about depression and

suicide Warning signs that indicate a student may

be in imminent danger of suicide Underlying factors that place a student at

higher risk of suicide Appropriate responses when someone is

depressed or suicidal Help-seeking skills and resources

Preventing Suicide: A Toolkit for High Schools, 2012

WHAT WE DO KNOW…

Presenting information to students can increase knowledge, positively affect referral practices and change their negative attitudes toward suicidal youth

Talking about suicide with youth, including warning signs, does NOT result in negative, unintended side effects

Reliable and valid screening and assessment measures and methods are available

Miller, D., SUNY

WHAT WE DO KNOW

The following have lead to reductions in self- reported suicidal behavior

Providing information to students regarding suicide awareness and intervention

Teaching students problem solving and coping skills

Reinforcing protective factors, while addressing risk factors

Miller, D., SUNY

MIAMI-DADE COUNTY PUBLIC SCHOOLS SUICIDE PREVENTION COMPONENTS

Universal Level Comprehensive Student Services

Program PK-12:Meets the academic, personal/social, career/community awareness and health needs of all students. This program provides students with non-academic skills that promote and support student achievement and individual growth.

Philosophical Basis Program Content Program Modes of Delivery Resources

COMPREHENSIVE STUDENT SERVICES PROGRAM

Philosophical Basis

Our Vision- The Division of Student Services provides the necessary resources and services for students to be successful in school, work, and in life.

School Counselin

g Profession

als

SchoolCounselor

s

TRUST Specialist

s

School Psycholog

ists

School Social

Workers

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Individual CounselingGroup CounselingFamily CounselingCrisis Prevention

Crisis InterventionCommunity Resources

College AssistanceCareer/Goal ExplorationEvaluation

ConsultationAcademic Advisement

Youth Empowerment

Promoting Healthy

Relationships

Student

Support

Student Development Framework (standards and benchmarks)

Four (4) Areas of skill development Academic Personal/Social Career/Community Awareness Health and Wellness

Program Content

The program modes of delivery organize the work of student services personnel into direct and indirect activities and services. They include the direct services to students, parents, teachers, and administrators through curriculum, planning, responsive services, and indirect services of system support.

Program Modes of Delivery

Resources

The Comprehensive Student Services Program PK-Adult is supported by resources in the form of personnel, funding, policies and procedures, and the community.

Goals

Eliminate or reduce barriers to student achievement

Maximize student personal, emotional and social growth

Promote and enhance a healthy and safe learning environment

Provide support to teachers, administrators and staff

Miami-Dade County Public Schools Suicide Prevention Components

Universal Level Curricula to Promote Healthy

Relationships/Youth Empowerment: provides developmental and transitional strategies to promote physical and psychological health, and the social-emotional well-being of all students (e.g., teen dating violence, sexting).

TRUST PROGRAM

“To Reach Ultimate Success

Together”

What Is TRUST?

This is a comprehensive student assistance program designed to provide prevention, intervention,

referral, and follow-up services to students and their families who may be experiencing problems in the area of substance abuse and other self-defeating

behaviors.

The TRUST Focus

Minimizes student risk factors. Promotes protective factors. Creates a research-based approach to substance abuse.

Who Are Our TRUST Specialists?

Master’s or doctoral level professionals with degrees in counseling, psychology, social work, or related field.

Certification in guidance and counseling, school social work, school psychology.

TRUST Specialist’s Role

Implement substance education curriculum Implement staff in-service trainings Assist administrators and other Student Services staff

in working with drug involved youths Provide individual, group and family counseling Provide community resources

TRUST Curriculum Focus

Substance Abuse Education Substance Abuse and Risk –Taking Behaviors Identify The Media’s Influence on Social Culture Science/Social Studies Curriculum Infusion

Managing Your Emotions Skills for Developing Healthy Relationships and Responsible

Behavior Components of Solving Conflicts Developing Good Decision-Making/Assertive Refusal Skills Methods To Change Unwanted Behavior Developing Peer Leaders

Typical or Troubled

Typical or Troubled: program developed by the American Psychiatric Foundation aimed at training school personnel to recognize signs of potential student mental health concerns and seek assistance from appropriate staff. The program will be adapted for parents and students.

A program of the American Psychiatric Foundation

Brought to you via the Office of Exceptional Student Education

and the Division of Student Services

Typical or Troubled?Know the Difference, Make a Difference

Typical or Troubled: School Mental Health Education

NOTICE TALK ACT

Everyone Can Make a Difference

Every Adult

ParentsSchoolStaff

Treatment

Steps to take

Warning signs

Normal teen development

Types of mental health problems

Referral process

Talking to parents

Managing the Classroom

State of the problem

Main Components of Presentation

Typical? or Troubled?

62 • Typical or Troubled?TM

• Complex period of rapid change,

transition

• Challenges: fitting in, defining identity, competing demands (school, home)

• Sometimes - other home issues (divorce, violence or substance abuse)

Bottom line: May display alterations of mood, distressing thoughts, anxiety, and impulsive behavior.

Typical Teens

• Experiencing more than normal developmental challenges

• Without treatment, more likely to have serious problems:

• Academic• Relationships• Employment

Signs ofTrouble

• Typical or Troubled?TM

Mood disorders

Anxiety disorders

Psychotic disorders

Behavioral/disruptive disorders

Teen Mental Health Disorders

• Typical or Troubled?TM

Gatekeeper Training

Universal level Staff Webinar: recorded suicide

prevention webinar for school personnel. Webinar builds knowledge in the areas of suicide awareness, risk and protective factors, warning signs, myths and help-seeking.

Early Warning Signs

Withdrawal from friends and family Preoccupation with death Marked personality change and serious mood

changes Difficulty concentrating Difficulties in school (decline in quality of

work) Change in eating and sleeping habits Loss of interest in pleasurable activities Frequent complaints about physical

symptoms, often related to emotions, such as stomachaches, headaches, fatigue, etc.

Persistent boredom Loss of interest in things one cares about

Late Warning Signs

Actually talking about suicide or a plan Exhibiting impulsivity such as violent actions, rebellious behavior, or running

away Refusing help, feeling “beyond help” Complaining of being a bad person or feeling “rotten inside” Making statements about hopelessness, helplessness, or worthlessness. Not tolerating praise or rewards Giving verbal hints with statements such as: “I won’t be a problem for you

much longer,” “Nothing matters,” “It’s no use,” and “I won’t see you again” Becoming suddenly cheerful after a period of depression-this may mean that

the student has already made the decision to escape all problems by ending

his/her life Giving away favorite possessions Making a last will and testament Saying other things like: “I’m going to kill myself,” “I wish I were dead,” “or “I

shouldn’t have been born.”

Myths About Suicide

Talking to someone about suicide may give him or her the idea.

Anyone who tries to kill him or herself is irrational or insane.

People who talk about suicide don’t usually do it, they just want attention.

If someone is determined to take his or her own life there is nothing you can do about it.

The Samaritans, 2014

BeSafe Anonymous Reporting System: students are made aware of multiple methods of contacting school police to report knowledge of individuals planning to self-harm or harm others; reinforced by campus posters.

WHAT WE DO KNOW…

Screening tools have been used effectively at school-wide, class-wide and individual levels

Screening assessment measures can accurately and effectively identify at-risk and high-risk youth

The use of screening procedures does NOT lead to an increased level of self-reported distress or suicidal behavior

Miller, D., SUNY

Targeted Prevention Components

Suicide Prevention Components

Targeted level Student Assistance Profile: At the end of each

grading period, counselors receive a printout on each student that reviews major areas of functioning including academic performance, attendance and behavioral concerns. Students demonstrating difficulty in several areas meet with a school counselor.

Suicide Prevention Components

Targeted level Student Support Team: multidisciplinary team that

discusses at-risk students and determines best course of intervention.

Group Counseling Services: school-based small group interventions exploring grief issues, GLBTQ student support, dropout prevention, anger management and other areas of concern.

Suicide Prevention Components

Targeted level Health Connect in Our Schools: program that

addresses health needs of children through health promotion, education and care. These school-based teams are located in at-risk communities and consist of one nurse, two health aides, and a clinical social worker.

Postvention: peer survivors of student suicide are provided services focused upon addressing grief responses, prevention of contagion effects, and maintaining a safe, secure and positive school climate.

Skill-Building Programs for Students at Risk of Suicide

Purpose Build coping, problem-solving and cognitive skills Address related problems such as depression and

other mental health issues and substance abuse

Content Problem- solving and coping skills exercises Activities to improve resilience and interpersonal

relationships Focus on the prevention or reduction of self-

destructive behavior

Indicated Prevention Components

YOUTH SUICIDAL BEHAVIOR: ASSESSMENT AND INTERVENTION

Conduct mental health status examination Conduct suicide risk behavior assessment Involve law enforcement, if necessary Contact parent/guardian Provide supervision Provide recommendations for community-

based mental health resources Provide follow-up support Document the process

Crisis Hotline Reporting

The crisis hotline is used to report select student risk behaviors that have come to the attention of a school staff member, whether the behavior occurred on campus or in the community.

The school mental health professional that is working with the student is responsible for reporting the risk behavior, after the crisis situation has been stabilized.

How and What to Report?

Contact the Crisis Hotline at 305-995-CARE (2273)

Identify if you are calling to complete a report or if you require immediate consultation

Report knowledge of the following behaviors: Suicidal ideation, threat or gesture Suicide attempt Homicidal ideation, threat or gesture Self-injurious behavior

Consultation

Consultation may include discussion of District response procedures, risk assessment guidelines and intervention strategies.

Crisis Team members may also assist schools in identifying and locating appropriate resources for individuals and families.

It is sometimes just helpful to have a colleague listen and reflect upon your concerns.

Treatment and Case Management

Barriers to Treatment of At-Risk Youth

Neither teens nor the adults who are close to them recognize symptoms as a treatable illness

Fear of what treatment might involve Belief that nothing can help Perception that seeking help is a

weakness or a failure-stigma Feeling too embarrassed to seek help

American Foundation for Suicide Prevention, 2011

Facts About Treatment

Some depressed teens show improvement in 4-6 weeks with structured psychotherapy alone

Most others experience significant reduction of depressive symptoms with antidepressant medication

Supplementary interventions (exercise, yoga, breathing exercises, changes in diet) improve mood, relieve anxiety and reduce stress that contributes to depressionAmerican Foundation for Suicide Prevention, 2011

Facts About Antidepressant Medications

Medications work by restoring brain chemistry back to normal

A small percentage of youth show agitation and abnormal behavior that may include increased suicidal thoughts and behavior

Since 2004, FDA warning recommends close monitoring of youth taking antidepressants for worsening of symptoms, suicidal thoughts or behavior, or other changesAmerican Foundation for Suicide Prevention, 2011

School Actions Following Treatment/Hospitalization

Schedule a Student Support Team meeting upon return to school

Ask parent/guardian to sign the Mutual Consent for Release of Information form

Discuss who, if any, staff member(s) they would like to inform about the suicidal behavior event

Adjust classroom schedule and work load to accommodate the student’s needs

Designate school support person(s) Be aware of any medications student is taking along with

potential side effects Provide assistance in preparing responses to potential

questions from peers Check on the student regularly following his/her return to

school

SUICIDAL BEHAVIOR AMONG AT-RISK STUDENT POPULATIONS

Suicide and Bullying, is there a Connection?

Nearly 25% of 10th grade students who reported being bullied also reported having made a suicide attempt in the past 12 months( Youth Suicide Prevention Program, 2010-2011).

Half of 12th grade students who reported being bullied also reported feeling sad and hopeless almost everyday for two consecutive weeks ( Youth Suicide Prevention Program, 2010-2011).

In one study, researchers found a clear relationship between cyberbullying and suicide; 78% of suicide victims had been subjected to bullying at school and online (American Academy of Pediatrics, 2012).

Suicide and Bullying, is there a connection?

A study conducted by Klomek, et al.,2011 found that exposure to bullying had relatively few outcomes for the majority of youth. The only group that showed suicidal ideation and behavior following high school was youth who suffered from depression at the time they were bullied.

Another longitudinal study links exposure to prolonged bullying to the development of serious mental disorders (depression and anxiety) in later life. 25 % of this group reported suicidal ideation or behavior as an adult (Copeland et al., 2013).

Suicide and Bullying:Limits to Research Findings

Although involvement in bullying is related to a greater likelihood of suicidal thoughts and behavior, one cannot conclude that bullying causes suicidal thoughts and behaviors

Most studies have looked at the correlation between bullying and suicide at one point in time; more longitudinal studies are needed

Other factors, such as mental health problems and family history of suicide, play a much larger role in predicting suicidal thoughts and behaviors than bullying (stopbullying.gov, Suicide Prevention Resource Center, 2011)

Suicidal Behavior among LGBTQ Students

LGB high school students and students unsure of their sexual orientation were 3.4 times more likely to have attempted suicide in the last year than their straight peers (Garafalo et al., 1999).

30.1 percent of transgender individuals reported they have attempted suicide (Kenagy, 2005).

Numerous studies cite that LGB youth have higher rates of suicide ideation than their straight peers (Massachusetts Dept. Of Education, 2006).

Suicidal Behavior Among LGBTQ Students

Being LGBT is not in isolation a risk factor for suicidal behavior; however, stressors that they face, including discrimination and harassment- are directly associated with suicidal behavior

American Association of Suicidology

Suicidal Behavior Among LGBTQ Youth: Implications for Prevention

Provide professional development for school staff about issues faced by LGBTQ youth, including the elevated risk for suicidal behavior, victimization, and family rejection

Develop policies and procedures for responding to youth suicidal behavior and self-injury

Create and enforce non-discrimination polices that extend equal rights to all sexual orientations and gender identities

Develop school-based support groups for LGBTQ youth and their families

Suicide Prevention Resource Center, 2008

YOUTH SUICIDE PREVENTION:CULTURAL IMPLICATIONS

It is estimated that by the year 2030, minority children will outnumber white children in the United States. Therefore, the availability of quality mental health services for minorities is critical to the future of our nation (CDC, 2005).

Youth Suicide Prevention:Cultural implications

Be aware of cultural protective factors Understand the role of acculturation Determine the impact of religion and spirituality Understand the interpretations of distress across

cultures Be aware of attitudes toward help-seeking, especially

mental health services Understand the role of family in treatment Dispel cultural myths Be aware of the battle between collectivism vs.

independence Goldston et al., 2008

Suicide Prevention in M-DCPS:Historical Perspective

1980-1988 : Student Suicide Rate 5.5/100,000

1989: Program Implementation 1989-2006: Student Suicide Rate

1.4/100,000

1990-2005: Suicide Rates for Youth 5-19 years

M-DCPS Suicide Rate 1.3/100,000 Florida Suicide Rate 3.0/100,000 USA Suicide Rate 3.5/100,000

Risk Behavior

2008-09

2009-10

2010-11

2011-12 2012-13

Suicides 4 2 4 1 7

Suicide Attempts 35 38 39 31 67

Suicidal Gestures 39 36 28 17 26

Suicidal Threats 279 237 202 90 207

Suicidal Ideations

288 357 346 271 310

Self- Injury 133 182 149 65 242

Homicidal Threats

4 86 118 84 103

Homicidal Ideations

106 82 42 11 27

Homicidal Gestures

0 0 0 5 2

Misc. Risk Behaviors

96 49 33 118 255

Missing Persons 364 342 400 285 220

Total 1,348 1,411 1,301 978 1,488

Student Risk Behavior: Five Year Review

2008-09 2009-10 2010-11 2011-12 2012-130

0.5

1

1.5

2

2.5

Suicide Rate

2008-09 2009-10 2010-11 2011-12 2012-13

1.2 0.6 1.2 0.3 2.0

Student Suicide Data, Rate per 100,000

2008-09 2009-10 2010-11 2011-12 2012-1310.1 11.0 11.2 8.9 19.1

Student Suicide Attempt Data, Rate per 100,000

2008-09

2009-10

2010-11

2011-12

2012-13

0

5

10

15

20

25

Suicide Attempts

“We really need to put more resources in prevention. No matter how well we plan, you can’t plan for everything. The big lesson is that there are limits to our response.” - James Steinberg

QUESTIONS