Suicidality and Self-Injury
in Middle School
SOS Signs of Suicide® Program
Screening for Mental Health, Inc.
“One young person contemplating suicide grips
our hearts. Nine hundred thousand young
people contemplating suicide grips our
collective conscious.”
-Charles Curie, Administrator,
Substance Abuse and Mental Health Services
Administration
Screening for Mental Health, Inc.
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1991: Pioneered the concept of large scale
mental health screening with National
Depression Screening Day.
SMH Programs include:
SOS Signs of Suicide® High School Program
 National Alcohol Screening Day®
 CollegeResponse®
 WorkplaceResponse®
 HealthcareResponse®

The Problem:
Youth Suicide and
Related Risk Factors
Prevalence of Suicide in Youth
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While child suicide is very uncommon, mortality from suicide
increases steadily through the teens.
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Suicide is the sixth leading cause of death among 5-14 year olds
and the third leading cause of death among those 15-24.
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American Foundation for Suicide Prevention
Adolescent suicidal behavior is deemed underreported because
many deaths of this type are classified as unintentional or
accidental.
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NIMH, In Harms Way, Suicide in America, 2003
World Health Organization, 2000
Over 90% of children and adolescents that die by suicide have a
mental health disorder at the time of their death, most often
depression.
Prevalence of Suicide-Related
Phenomena in Middle School Age Group
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Seriously thought about killing themselves
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Made a plan about how to kill themselves
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18% of 6th graders
19% of 7th graders
24% of 8th graders
11% of 6th graders
12% of 7th graders
12% of 8th graders
Made a suicide attempt
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7% of 6th graders
9% of seventh graders
11% of eighth graders
CDC Middle School Youth
Risk Behavior Survey, 2003
What Are Risk Factors?
•Suicide is a complex behavior that is usually caused by a
combination of risk factors in the context of negative life
events
•A risk factor is anything that increases the likelihood that
persons will harm themselves.
•Risk factors are not necessarily causes.
•The first step in preventing suicide is to identify and
understand the risk factors.
-Adapted from the National Youth Violence Prevention
Resource Center
SUICIDE: A MULTI-FACTORIAL EVENT
Psychiatric Illness
Co-morbidity
Personality
Disorder/Traits
Neurobiology
Impulsiveness
Substance
Use/Abuse
Hopelessness
Suicide
Severe Medical
Illness
Family History
Access To Weapons
Life Stressors
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
Depression and Youth

In 2004, 9% of adolescents aged 12 to 17 (an
estimated 2.2 million adolescents) experienced at
least one major depressive episode in the past year
-SAMHSA, 2005
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In children and adolescents, an untreated depressive
episode may last between 7 to 9 months (Birmaher et
al., 1996a, 1996b) —potentially, an entire academic
year!
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Depression has been linked to suicide, poor school
performance, substance abuse, running away, and
feelings of worthlessness and hopelessness
-National Institute for Mental Health, 2005
Symptoms of
Adolescent Depression
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Frequent sadness, tearfulness, crying
Hopelessness
Decreased interest in activities; or inability to
enjoy previously favorite activities
Persistent boredom; low energy
Social isolation, poor communication
Low self esteem and guilt
Extreme sensitivity to rejection or failure
Symptoms of
Adolescent Depression (cont.)
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Increased irritability, anger, or hostility
Difficulty with relationships
Frequent complaints of physical illnesses such as
headaches and stomachaches
Frequent absences from school or poor performance in
school
Poor concentration
A major change in eating and/or sleeping patterns
Talk of or efforts to run away from home
Thoughts or expressions of suicide or self destructive
behavior
-AACAP, The Depressed Child
Signs of Suicide
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Talking, reading, or writing about suicide or death
(including online communication)
Talking about feeling worthless or hopeless
Saying things like “I wish I were dead.”
Visiting or calling people to say goodbye.
Giving things away.
A sudden interest in drinking alcohol.
Purposefully putting oneself in danger.
Obsessed with death, violence, and guns or knives.
Previous suicidal thoughts or attempts.
-http://pbskids.org/itsmylife
Suicidality and Substance Abuse

Youths aged 12-17 who reported past year
alcohol use (19.6%) were more likely than
youths who did not use alcohol (8.6%) to be at
risk for suicide.
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SAMHSA, NHSDA Report, Substance use and the Risk of Suicide
Among Youths, 2002
1/3 to ½ of teenagers were under the influence
of drugs or alcohol shortly before they killed
themselves.
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National Strategy for Suicide Prevention, DHHS
Self-injury in Youth
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In the pediatric population, self-injury is defined
as deliberate non-lethal harming of oneself
Self-injury is a maladaptive coping skill
employed by youth experiencing painful
emotions
Is generally NOT an attempt to die by suicide.
Between 150,000 and 360,000 adolescents in the
U.S. self-injure
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Walsh, Lieberman, 2004.
Self-injury Comes in Several Forms
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Behaviors include:
Cutting – the most common form
 Burning
 Hitting
 Poking
 Picking
 Hair pulling
 Putting oneself in harms way
 Head banging
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Relationship Between Suicide
and Self-injury
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Death can occur, even if unintentionally
Those who self-injure may become suicidal in
the future.
The student is experiencing a mental health
disorder that should be treated professionally
and stands the best chance of recovery if caught
early.
If handled inappropriately or not at all, there is a
potential for contagion.
Why Focus on Youth Prevention
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Many adult mental disorders have related antecedent
problems in childhood
Children who first become depressed before
puberty are at risk for some form of mental disorder
in adulthood
Suicide rates increase dramatically from early
adolescence to young adulthood
A previous suicide attempt is the leading risk factor
for adult suicide
Introducing prevention early may help promote
prevention throughout the lifecycle
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NIMH, 2005
Developmental Stages of
Younger Children
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Early adolescence is a time of emotional transition
when individuals transfer their sense of interpersonal
closeness from parents to peers.
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Rothbaum et. al., Child Development, 2000
Due to this transition, addressing the peer group is
developmentally appropriate for those youth who have
begun to confide in friends.
Since younger students are more apt to share concerns
with adults it is also important to encourage helpseeking from adults.
In other words, you have to address both the role
of peers and the role of adults.
Adolescent Cognition
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Transition from the period of concrete operations (7-11
years) to period of formal operations (11-15 years)
Concrete thinking and problem-solving– performed in
the presence of the objects thought about.
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Begins to reason logically and organize thoughts coherently.
However, they can only think about actual physical objects,
they cannot handle abstract reasoning
Period of formal operations – Less tied to concrete
reality
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Thought becomes more abstract, incorporating the principals
of formal logic. Includes the ability to formulate hypotheses,
think abstractly, reason.
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Due to this shift – a middle school program must
include materials that foster both
Integrated Prevention Strategies

Integrated prevention strategies that address multiple
associated factors are likely to be more effective in
reducing suicidal behavior that programs that focus on
a single risk factor.
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Grunbaum et al., Surveillance Summaries, 2004
Risk factors for youth include:
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Depression
Conduct disorder
Suicidal ideation
Alcohol use
Self-injury
The SOS Middle School Program
SOS Middle School Program
Components
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Video/DVD – “SOS: Get Into the ACT” with Discussion
Guide
Posters
Stickers -- “ACT”
Parent newsletter
Student newsletter
Classroom Games
Self-injury packet
Procedure Manual
Screening Forms for staff use
SOS Middle School Video/DVD
With Discussion Guide
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The SOS: Get Into The Act video is the main teaching
tool of the middle school program.
Help students recognize the signs of suicide, depression
and self-injury in a friend or within themselves and
respond to them as they would in any type of health
emergency.
Aim is to create a supportive and responsive
atmosphere for those youth who may be at-risk for
depression, suicide, or self-injury by empowering them
to know how to recognize the warning signs and seek
help.
Action Message -- ACT
 Acknowledge: Acknowledge that your friend
has a problem and it is serious
 Care: Let the person know you are concerned
and want to help
 Tell: Tell a trusted adult
The ACT Message
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The message is primarily directed to peers to encourage
them to help a friend but it emphasizes the need to tell
a trusted adult
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ACT can be generalized to use with any social problem
Goals of the Program
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Decrease the incidence of self-injury, suicide attempts,
unrecognized depression, and the number of youth
who die by suicide
Encourage individual help seeking, as well as help
seeking on behalf of a friend
Increase knowledge and adaptive attitudes about
depression, suicidality, and self-injury
Reduce stigma associated with mental health problems
by communicating that these problems are treatable
Student Materials
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Student newsletter
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ACT stickers promote peer-to-peer
communication by making the ACT message
popular, personal and powerful.
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ACT posters to reinforce the ACT message
Interactive Classroom Games
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Classroom games serve as a way of increasing
both knowledge and skills in students
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Games that have learning complexity and are
successfully infused into the curriculum are an
effective strategy to move the knowledge and
skills students receive into long-term memory
and result in positive behaviors
Parent Materials
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Parent materials are provided to actively engage parents
in a school’s prevention efforts, to:
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Gain their support
Provide information about mental health resources available
in the school and community
Encourage parents to discuss the problems of depression,
suicide, and self-injury with their children.
By raising awareness, schools can partner with parents
to watch for the signs of problems in their children and
instill confidence in parents to seek help for their
children if necessary.
Staff Materials
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Staff in-service lecture
Guidelines for teachers and school clinicians for
responding to youth who self-injure (Self-injury
Packet)
Parent Newsletter for staff who are parents
Center for Epidemiological Studies Depression
Scale for Children (CES-DC) for school staff to
use with individual students seeking help
Accessing Treatment
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Encourages student help-seeking
Based on the SOS: Get Into the ACT Program, I feel…
I need to talk to someone about myself or a friend.
I do not need to talk to someone about myself or a friend.
Name (Print)______________________________________________
Teacher_________________________________________________
If you wish to speak with someone, you will be contacted (indicate time
frame). If you need to speak with someone sooner, please ask for
help immediately.
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Encourages collaboration with local mental health facilities and
individual professionals for increased access to treatment
Implementation Overview
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School personnel implement the program with
materials provided
Can be implemented in one or two classroom
periods
Students view and discuss video in classroom.
 Students are assigned Student Newsletter to read
 Students participate in classroom game
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Implementation Overview (cont.)
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Entire student body or a select portion of
student body may participate in the program.
Parent newsletter assists in the identification of
depression, self-injury, and suicidality and helps
initiate family discussion
Active or passive parental permission
Parent Night
Staff Training
Staff Training
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Training faculty and staff is universally
advocated and essential to a suicide prevention
program.
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Research indicates that training faculty and staff
can produce positive effects on an educator’s
knowledge, attitudes and referral practice.
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Smith, T & Smith V., Lazear, K, Roggenbaum, S., & Doan, J., 2003.
Staff Training (cont.)
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Schools must prepare staff as students may
disclose to any adult.
Train to increase school staff’s knowledge about:
SOS program: why, when, where, how
 Warning signs
 School and community based mental health
resources
 School protocol for providing help for at-risk youth
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Staff Training Suggestions
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Show the “Get Into the ACT” video and facilitate a
discussion
Review the signs of suicide and depression.
Answer questions, dispel myths
Review the school policy for handling students who
disclose suicidal intent
Review school and community resources.
Distribute protocol for what to do when approached by
students asking for help
“Feed them and they will come.”
Parents as Partners
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Studies have shown that a many as 86% of
parents were unaware of their child’s suicidal
behavior.
The percentage of parents who are involved in a
student’s activities is very small.
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Smith, T & Smith V., Lazear, K, Roggenbaum, S., & Doan, J., 2003.
Engaging Parents/Guardians
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Sends parents a letter stating the goals of the program
(template provided), referral resources, and Parent
Newsletter.
Decide between active and passive consent.
Combine permission form collection with other activities
(sports forms, next year’s schedule).
Host a parent night event:
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Show video, facilitate discussion
Distribute the Parent Newsletter
Answer questions, dispel myths
Review warning signs, protective factors, and limiting access to
lethal means
Provide referral resources in the school and community
Plan for Referrals
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Contact local mental health facilities and advise
them of your program dates and times
Verify referral procedures, wait lists, insurance
details, etc.
Create a Referral Resource list or send with
parent packet
Use SAMHSA’s Find Treatment Locator to
identify additional referral resources
SAMHSA’s Find Treatment Locator
http://www.mentalhealth.samhsa.gov/DATABASES/DEFAULT.ASP
Help-Seeking and Follow Up
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Use Response Card
Brainstorm ways to encourage students to seek help,
involve students in this planning
Respond to requests for help
Set expectations about when follow-up can be expected
Provide referral information
Track students using the Student Follow-Up Form
Involve peer leaders in encouraging help seeking
Other Suggestions
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Demonstrate the program to administration to
get their support
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Start small, pilot test
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Involve students in the program planning
Get Teacher Buy-In
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Involve teachers from the start
Change requires growth
Change is a process
Speak to teachers’ needs
Speak their language
Keep change small and simple
Everyone is different (process of change)
Change is reversible
Maintain change
Minimize the risks
-Prevention that Works! Knowles, Cynthia, 2001.
Why Partner?
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If a school does not have adequate staff
Students may feel more comfortable speaking with an
outsider
As an introduction to community-based mental health
resources
Enhance referral network for the school
“Allowing these agencies into the building educates and familiarizes
students with their services and how to access them.”
Common Objections
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“Suicide is not a problem in our school.”
“Schools are not appropriate for suicide prevention
programs.”
“The program may introduce the idea to students.”
“I don’t have enough staff or time.”
“We have problems making referrals.”
“I don’t agree with labeling youth.”
“We already have a suicide prevention program.”
Responses to Common Objections
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No school is immune to adolescent suicide.
Depression has been linked to poor school performance, substance abuse,
running away, and feelings of worthlessness and hopelessness. Student
problems with academics, peers, and others are more apt to be evident in
schools.
The majority of parents are unaware of their child’s suicidality.
Integrating the topics of depression and suicide in a health curriculum can
reduce stigma associated with these problems and can create a supportive
atmosphere in which at-risk youth may talk about their feelings and get the
help that they need.
The program can be used flexibly using existing resources and partnering with
community providers.
Identifying needs can justify funding. Share resources within school districts.
Establish relationship with existing providers.
Implementing the SOS program does not result in diagnosis. Decisions about
diagnosis and treatment are made between a doctor and a patient, and, in the
case of minors, the parent/guardian(s).
Clinical Advisors
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William Beardslee, MD
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Jon Hisgen, MS, CHES
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NOVA Southeastern University, Ft. Lauderdale, FL
Jefferson Prince, MD
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Los Angeles Unified School District, Los Angeles, CA
Scott Poland, NCSP
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University of Michigan Depression Center, Ann Arbor, MI
Rich Lieberman, NCSP
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Wisconsin Department of Public Instruction, Madison, WI
Cheryl King, PhD
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Children’s Hospital, Boston, MA
Massachusetts General Hospital, Boston, MA
Barent (Barry) Walsh, PhD
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The Bridge of Central MA, Worcester, MA
School Based Professionals
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Cynthia Bucken, Nipmuc Regional Middle/High School, Upton, MA
Ellen Courshene, Wellesley Middle School, Wellesley, MA
Laurie Curley, Ph.D., JFK Middle School, Hudson, MA
Deborah Hardy, Ed.D., Ed.M., M.S., Irvington Middle School, Irvington, NY
Kay Hurley, Sarah W. Gibbons Middle School, Westborough, MA
Karen Ingerman, Remington Middle School, Franklin, MA
Joann Kenney, Dover Sherborn Regional Middle School, Dover, MA
Tara Manke, Ph.D., Stacy Middle School and Middle School East, Milford, MA
Elaine Mitsocke, Robert H. Adams Middle School, Holliston, MA
Julie Phipps, Robert E. Melican Middle School, Northborough, MA
For more information about the SOS
Middle School or the SOS High School
program, please reach us at:
781-239-0071
[email protected]
Or visit:
www.MentalHealthScreening.org/schools
Screening for Mental Health, Inc.
One Washington Street, Suite 304 Wellesley Hills, MA 02481
Phone: 781.239.0071 Fax: 781.431.7447
www.mentalhealthscreening.org
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Suicidality and Self-Injury in Middle School