SPECIAL REPORT

Developing an Educational Workshop on Teen Depression and Suicide: A Proactive Community Intervention
Ebba W. McArt, Donald A. Shulman, and Elizabeth Gajary Community outreach activities showed that adolescents and parents in Monroe County, New York, had difficulty identifying and accessing mental health crisis services for youths. The need to address this deficit led to the development of an educational workshop on teen depression and suicide. Local, national, and international trends in teen suicide led the authors to suggest a proactive, preventive educational approach that includes both primary and secondary prevention modalities, made directly available to teens, parents, and youth professionals. Additionally, the program developed new partnerships between mental health agencies and schools through workshops and workshop presenter training.

Ebba W. McArt, Ph.D., is Performance Improvement Manager, Hillside Behavioral Health System, Rochester, NY, and former Coordinator, YES Program. Donald A. Shulman, CSW, is Emergency Services Coordinator and YES Crisis Specialist, 0009-4021/99/060793-14 $3.00 1999 Child Welfare League of America 793

794

CHILD WELFARE VoL LXXVIII, #6 November/December

he workshop described in this article informs and educates adolescents, adults working with adolescents, and parents about child and adolescent depression and suicide. The workshop is part of a preventive approach to two serious problems that affect a limited but growing segment of the adolescent population. In this case, it fits well within the mission of the Youth Emergency Services (YES) consortium, which includes increasing the community's awareness of serious child and youth mental health problems. Comprehensive, collaborative community programs offering child and youth emergency mental health services are still relatively new, and much remains to be learned about the population in need of these services. The initial experience of Youth Emergency Services was one of coming to terms with the severity and complexity of the needs presented by families seeking services. Many adolescents, however, do not obtain the services they need because the services are not known to them or to their families, or are not perceived to be readily accessible. Since 1991, the YES consortium has offered immediate access and a comprehensive array of emergency services to children and adolescents under 18 years of age who have serious emotional problems and who reside in Monroe County in upstate New York [Shulman & Ahey 1993]. Families and youths are assisted in a team-based program involving the collaboration of six community agencies, including four hospital-based community mental health centers in Rochester, New York: Crestwood Children's Center, Park Ridge Mental Health Center, Rochester Mental Health Center, and The Genesee Hospital Department of Psychiatry and Mental Health Center. Hillside Children's Center and the Strong Memorial HosCrestwood Children's Center, Rochester, NY. Elizabeth Gajary, M.A., is Project Coordinator, Department of Preventive Medicine, University of Rochester, Rochester, NY. This project was made possible through the 1995 Gottschalk Mental Health Research Award, funded by the Mental Health Association of Rochester/Monroe County. This article explicates a program initially projected in the March/April 1993

issue o/Child Welfare.

Ebba W. McArt / Donald A. Shulman / Elizabeth Gajary

795

pital Division of Child and Adolescent Psychiatry are also part of the consortium. Coordinated outpatient, respite, mobile, and home-based services are available to families as a means of maintairxing children in their homes. The rationale for developing an educational workshop emerged from information gathered in previous program outreach activities. For example, 97 African American and Latino parents and youths participated in one outreach project. Divided into 10 small groups, they brainstormed about help-seeking difficulties, spec^cally, impediments to obtaining mental health care services and accessing child and youth crisis services [McArt 1994]. Five community agencies serving African American and Latino clients collaborated on the project. The outcomes clearly showed that there was a need in minority communities for good public information about crisis resources, and for a better understanding of the services available. One goal of the grant project described here was the development of an educational workshop for adolescents on depression and suicide, and on help-seeking strategies in an emotional crisis. The use of an educational workshop approach was expected to improve access to appropriate mental health crisis services for families and youths who live in the commvmity. The project's second goal was to leam more about the help-seeking behaviors of adolescents in relation to depression and suicide, including predisposing factors (e.g., demographics) and enabling factors (e.g., knowledge about help resources, financial factors) [Aday & Anderson 1974; Anderson & Newman 1973]. Within this framework, the workshop was intended to document how a diverse adolescent population would seek help in a crisis, while at the same time disseminating information about crisis services available to that population in Monroe County. Trends in Teen Suicide Suicide has been defined as "any death that is the direct or indirect result of a positive or negative act accomplished by the vie-

796

CHILD WELFARE Vol. LXXVIII, #6 November/December

tim, knowing or believing the act will produce this result" [Maris 1991]. Indirect suicide is a common but neglected form of suicide. For example, it has been postulated that many road traffic fatalities in young males are actually suicides [Farberow 1980]. Also, self-neglecting behavior, such as a hunger strike or a refusal to take life-preserving medication, if it results in death, is also considered suicide [Diekstra 1995]. Intemationai and national data banks, as well as the literature, indicate an increase in suicide mortality and morbidity in the U.S. and in Europe over the past century. Of the published suicide rates in countries reporting such statistics to the World Health Organization, the range in suicide rates span from nearly zero per million (among females in Malta), to a high of over 600 per million (airiong males in Hungary) [World Health Organization 1992]. Suicide rates in the Statistics Annual published by the World Health Organization over several decades [World Health Organization 1972,1982,1992] show a clear increase in suicides for children between the ages of 5 and 14, and also in the 15 to 24 age category. Interestingly, the trend is reversed for the 45 and older age groups. Between 1950 and 1990, there were notable national increases in youth suicide rates in the United States, especially for persons between 10 and 19 years of age [Hodgman & McAnamey 1992]. Studies presented at an American Public Health Association meeting [1995] found that the risk of suicide attempts appears to be highest among girls and young women, college students, and adolescents with difficult family relationships. Beautrais et al. [1996] found correlations between risks of serious suicide attempts among youths and the extent of exposure to childhood adversity, social disadvantage, and psychiatric morbidity. The authors pointed out that the stresses related to these chronic problems are generally outside an individual's control. According to the Centers for Disease Control, potential reasons for increases in the rate of adolescent suicide are many. Among the risk factors they

Ebba W. McArt / Donald A. Shulman / Elizabeth Gajary

797

list are substance abuse; mental illness; impulsive, aggressive, and antisocial behavior; a variety of family factors; severe stress in school or social life; and increased access to firearms by the atrisk population [Centers for Disease Control 1995]. The same risk factors are cited by others [Harvard Mental Health Letter 1996]. Diekstra [1995] suggests a correlation between earlier onset of puberty, heightened familial and social changes and pressures upon adolescents, and rising alcohol and drug abuse as possible explanations of the increase in the suicide rate among teens. Although the number of youth suicides remained relatively stable in Monroe County during the 1980s and 1990s, the suicide rate among 15- to 19-year-olds remains above the county's Year 2000 Goal [Monroe County Department of Health 1994,1995]. A seven-year review of 32 suicides by adolescents ages 10 to 19 that occurred in Moruroe County during the period 1990 through 1996 revealed that 92% were ages 15 to 19, and 8% were ages 12 to 14; 81% were male and 19% were female; and 75% were Caucasian, 19% were African American, and 6% were of other ethnic origin [McArt & Kellenberger 1997]. One-third of the adolescents had a documented history of mental health problems, but only onequarter had a history of receiving mental health services. Twelve percent had made at least one previous suicide attempt. None of the youths were intoxicated at the time of the suicide. Even taking into account this small population base, the findings give credence to Hartmarm's suggestion [1997] that large numbers of children are being left out of mental health care services. National surveys on adolescent suicide consistently show that up to 10% of American high school students report that they attempted suicide in the previous year, and one-quarter or more report that they have thought about it seriously [Centers for Disease Control 1995]. A representative sample of high school students in Monroe County who were asked in 1995 and 1997 whether they had thought about or attempted suicide reported rates of about 10% and 25%, respectively [Monroe County Health

798

CHILD WELFARE Vol. LXXVIII, #6 November/December

Department 1995,1997]. These findings, and the experiences of the Youth Emergency Services (YES) program, are consistent with the research results of Rotheram-Borus et al. [1996], which assessed suicidal behavior and risk factors among 1,616 predominantly middle-class students who sought residential or nonresidential crisis services. They found that 22% reported a past suicide attempt, and that this and other patterns appeared to be similar to the patterns found among minority youths in Los Angeles and New York City. Suicide attempts clearly take place across all economic, social, and ethnic boundaries. Compared to the above data, national mental health estimates appear corwervative when they indicate that about 5% of the child and adolescent population are seriously emotionally disturbed (for example, exhibiting symptoms of severe depression, or suicidal or psychotic behaviors) [Rosenthal 1992]. The YES program assists up to 1,500 families and youths per year, a majority of whom are suicidal and/or depressed. Although this figure represerits more than 1% of the coimty's children and adolescents between the ages of 5 and 17, it is well below the estimated need, and again, suggests that a significant number of children and adolescents are going without services. Given the increasing problems and negative trends of the target population in Monroe County and elsewhere, it seems essential that child and adolescent service programs adopt a proactive approach to the delivery of youth crisis services. A preventive approach to suicide during adolescence through education and counseling is vital. The Centers for Disease Control [1995] list several effective strategies being used by programs throughout the U.S. for preventing suicide among young persons, including educating young persons about suicide, risk factors, and interventions; and training parents, school personnel, and commuruty professionals to identify young persons at highest risk for suicidal thoughts, threats, and attempts. YES staff members are frequently contacted by schools and community agencies to provide educational activities on a vari-

Ebba W. McArt / Donald A. Shulman / Elizabeth Gajary

799

ety of topics related to child and adolescent behaviors and crisis services. The workshop serves as a vehicle to formalize some of these activities. For adolescents, the workshop offers an opporturuty to discuss depression and suicide within or after the workshop with experienced professional clinicians. The workshop also enables youths to assist peers who are depressed and suicidal by providing firsthand support and by linking them with appropriate professional resources.

Workshop Development, Pilot Process, and Outcomes

A diverse community planning team was formed during the summer of 1995, comprising child and youth professionals, health professionals, youth representatives, and a research assistant. Team members included four individuals with extensive experience in presenting teen workshops on depression and suicide. Three youth representatives were recruited, all high school students from urban and suburban school districts.' The planning team met regularly for several months. The team's objectives were to develop a workshop in which one could leam how teens feel about the issues, how to teach teens problem-solving methods, and how to provide teens with iriformation regarding where to tum for help. Information about obstacles to obtaining mental health crisis services was reviewed. The workshop's goals and objectives were formulated and strategies for obtaining optimal youth participation in workshop presentations were discussed. Plairming team members agreed that twoway communication was vital to a successful workshop. At first, meetings were devoted to discussions concerning primary audiences, target age groups, and the workshop format. Although it soon became clear that both middle school and high school students could benefit from the workshop, the team decided to focus on high school students, since age-appropriate content would differ based on age group, and only one work-

800

CHILD WELFARE Vol. LXXVIII, #6 November/December

shop could be developed during the grant period. The experiences derived from formats used by others was reviewed, and the team agreed that a mixed method format should be used, including discussion, a brief video, slides, a workshop survey, and an evaluation. Handouts would also be included, but they would be limited to emergency phone niunbers, signs and symptoms of depression, and fundamental help strategies. The team decided to use a wallet card used by a local hotline as a model for the handouts. Staff members responsible for teen workshops previously offered through the hotline contributed useful materials and experience for planning. Progress reviews by clinical staff members and a thorough literature review enhanced the discussion of the clinical content for the workshop. The team reviewed the current guidelines of the American Medical Association concerning adolescent depression and suicide [American Medical Association 1992], and consulted the 1996 New York State syllabus, health curriculum, and proposed leaming standards. These resources did not mention depression and suicide specifically, but instead, stressed emotional health and discussed related topics (e.g., diet, exercise, stress management, problem-solving skills, alcohol and drug abuse, importance of friends, family and community support, commuruty resources to deal with problems) [New York State Education Department 1995,1996]. At the same time, the team discovered that some of the subjects being taught to high school youths might also address the topics of depression and suicide (i.e., government, humanities). For example, a conversation with an English teacher in a large suburban school district revealed that, in her writing class, she asked students to write about depression and suicide as a way to explore this topic with adolescents. She felt that a preventive, educational activity was needed, and gave her strong support for the workshop. The workshop team found that most of the materials that referred to adolescent depression and suicide were similar, setting

Ebba W. McArt / Donald A. Shulman / Elizabeth Gajary

801

forth concepts, indicators, and risk factors. The challenge was to integrate such essential content into the overall design of the workshop sections. The team consulted with a medical expert, who recommehded that a preventive approach be incorporated, so that suicide would be treated as an illness. When the workshop plan and contents were completed, two high school health teachers on the workshop team were approached and asked to pilot test the workshop with their students. School administrators were also contacted; they facilitated the commurucation with health teaching staff. Approvals were obtained to conduct workshop pilot programs at both schools (one a large urban school, the other a large suburban school). In addition, the team was invited to present the workshop at a summer youth conference. The initial workshop pilot experience was very useful. Following presentations to a total of nine groups of students, and constructive feedback from students as well as the health teaching staff, the contents, format, and presentation styles of the workshop were fine-timed. The team determined that the presentation was well suited to a high school audience, and that the format could be accommodated to fit either a single or a double class period. In addition to the hands-on evaluations elicited at the two schools, the evaluation process also included a thorough review of the outline by members of the workshop team, by clinical staff members who presented pilot workshops, and by the youth coriference staff members, all of whom strongly endorsed the workshop as a commuruty prevention activity. The early workshops helped refine the final product. To date, the workshop has been presented to urban, suburban, and mral high school health classes; school administrators; juvenile justice detention center residents; youth conferences; school wellness center staff members; parents, agency boards; and human service agencies. The experience gained through the workshop presentations

802

CHILD WELFARE Vol. LXXVIII, #6 November/December

was shared with the pilot sites and with the Youth Emergency Services program consortium. In general, the workshop has been very well received. Most participants feel that they are better informed about depression and suicide following the workshop than before. It should be noted, however, that many of the older high school students who attended the workshops had previously used mental health or counseling services for emotional problems or were familiar with someone who received such services, and they were well iriformed about the topics discussed. Results of the workshop's pre-post opinions survey showed that opinions changed most frequently on two questions: "People who are thinking about committing suicide often make statements about wanting to die" (true); and on a statement exploring whether it is best to ask a suicidal person if he or she is thinking of suicide (true). Other statements showed only minor changes in opinion.

Discussion and Implications

From the outset. Youth Emergency Services has successfully provided community-based emergency services, including case-finding activities. The consortium provides professional and intensive crisis intervention to families experiencing extremely complex and severe crises, often with life-threatening implications. More often than not, the crises are a result of physical abuse or neglect, sexual abuse, major mental illness, repeated suicidal ideation, and actual suicide attempts. Despite systematic intervention, many families received treatment after situations were out of control and highly traumatic. Family and client recovery was often slow and emotionally painful despite comprehensive delivery of integrated services and interagency collaboration and communication. It became evident that a tertiary approach, while needed and at times lifesaving, was insufficient and that a need existed to emphasize primary and secondary preventive modalities.

Ebba W. McArt / Donald A. Shulman / Elizabeth Gajary

803

If the Youth Emergency Services consortium is to maximize its efforts, preventive services are needed that confront the sociocultural norms of contemporary society that contribute to the selfdestructive behaviors of many adolescents. The workshop provides a primary preventive service that seeks to identify suicidal precursors and interventions before individual situations spiral out of control. Thus, the workshop represents a primary approach to enabling teens, educators, and family members to identify the signs, sjonptoms, and risk factors of youth suicide before the severity and complexity of the case situations increase. It will become an ongoing part of YES program outreach and community education activities. Priority will be given to high school students enrolled in health or other classes covering depression and suicide. Other suitable audiences include community youth groups, parent groups, school health and wellness staff members, and student support staff members. Trairiing partnerships are being developed with schools, community organizations, and with a local university to meet future workshop requests. The authors' experience to date, as well as recent trends in adolescent suicide, indicate a need for community-based programs to emphasize a preventive approach in providing crisis intervention services. Local, national, and intemationai trends support the importance of creating educational programs to increase community awareness about the signs, symptoms, and risk factors related to youth depression and suicide. Crisis service providers are in a unique position to stress the importance of always taking a teen's statements about suicide seriously, and of limiting access to firearms for youths, given the high correlation between such access and completed suicides. The YES experience also highlights the need for reliable methods for documenting adolescent suicide attempts, and for designing effective interventions following attempts. The current psychiatric codes of the Diagnostic and Statistical Manual of Mental Disorders do not adequately identify and describe adolescent sui-

804

CHILD WELFARE Vol. LXXVIII, #6 November/December

cide attempts [American Psychiatric Association 1994]. Professionals have difficulty following up on these serious incidents systematically and comprehensively. Yet, where post-attempt interventions have been implemented, results have shown that they can be effective [Rotheram-Borus et al. 1996]. Summary Eight years into the YES emergency services collaboration, a comprehensive Youth Emergency Services model has emerged, one that incorporates a proactive approach to cliiucal and prevention strategies. In addition to direct service provision, these strategies include: (1) workshop trairung of school and commuruty professionals so that they can identify yoimg persorts at highest risk for suicidal thoughts, threats, and attempts; (2) prevention education for both adolescents and parents about suicide, risk factors, and interventions; (3) a partnership with the local hotline to facilitate community screerung and referral to appropriate crisis services for families and youths; (4) collaboration with a large primary care provider network to streamline the after-hours crisis referral process, using the hotline; and (5) the use of a website to inform individuals about services and resources. It is proposed that this is a contemporary model that can meet the present primary and secondary intervention needs for children, adolescents, and their families.^ References
Aday, L,, & Anderson, R, (1974), A framework for the study of access to medical care. Health Services Research, 9, 208-220. American Medical Association. (1992), Guidelines for adolescent preventive services. Recommendations 20,21. Chicago: Author. American Psychiatric Association, (1994), Diagnostic and statistical manual of mental disorders (4th ed.), Washington, DC: Author. .

Ebba W. McArt / Donald A. Shulman / Elizabeth Gajary

805

American Public Health Association, (1995), Annual meeting "Decision making in public health: Prerogatives, power and ethics," San Diego, California, October 29-November 2, Anderson, R,, & Newman, J, (1973), Societal and individual determinants of medical care utilization in the United States. Milbank Quarterly, 51,95-124, Beautrais, A. L., Joyce, P, R,, & Mulder, R, (1996), Risk factors for serious suicide attempts among youths aged 13 through 24 years. Journal ofthe American Academy of Child and Adolescent Psychiatry, 9,1174-1182, Centers for Disease Control. (1995), Suicide among children, adolescents, and young adultsUnited States, 1980-1992, Morbidity and Mortality Weekly Report, 44,289-291, Diekstra, R, R, & Gamefiski, N, (1995), On the nature, magnitude and causality of suicidal behaviors: An intemationai perspective. In Suicide and Life-Threatening Behavior (vol. 25) (pp. 36-57), New York: The American Association of Suicidology, Guilford Press, Diekstra, R. R (1995), Preventive strategies on suicide. New York: E,J, Brill, Rarberow, N, L, (Ed,), (1980), The many faces of suicide: Indirect self-destructive behavior. New York: McGraw-Hill. Hartmann, L. (1997), Children are left out. Psychiatric Services, 48, 943-954, Harvard Mental Health Letter, (1996), Suicide- Part 1, 13(5),l-6. Grinspoon, L, (Ed,), Boston, MA: Harvard Medical School, Hodgman, C, H,, & McAnamey, E, R, (1992), Adolescent depression and suicide: Rising problems. Hospital Practice; 73-96, McArt, E, W, (1994), Multicultural perspectives on barriers to mental health services and access to child & youth crisis services. Unpublished research report. Youth Emergency Services, Rochester, NY, ' . McArt, E. W, & Kellenberger, A, (1997), Adolescent deaths from suicide in Monroe County, 1990-96. Unpublished research report. Youth Emergency Services, Rochester, NY, Maris, R, W, (1991). Suicide. In Encyclopedia of Human Biology (Vol.7) (pp, 372-385), New York: Academic Press, Monroe County Health Department. (1997), Adolescent health report card 1997. Rochester, NY: Monroe County Health Department, Monroe County Health Department! (1995), Monroe County youth risk behavior survey report. Rochester, NY: Author, New York State Department of Education, (1996), Learning standards for health, physical education, and home economics (rev,), Albany, NY: University of the State of New York,

806

CHILD WELFARE VoL LXXVIM, #6 November/December

New York State Department of Education. (1995). Curriculum, instruction and assessment: Preliminary draft framework. Health, physical education, and home economics. Albany, NY: University of the State of New York (unpublished report). New York State Department of Education. (1986). Health education syllabus: Grades K-12. Albany, NY: University of the State of New York. Pathways to a coordinated system of health care and human services for children and families in Rochester, New York. (1997). Report by the Monroe County Child Health InitiaHve: Rochester General Hospital Department of Pediatrics, University of Rochester School of Medicine Department of Pediatrics and Monroe County Health Department, Rochester, NY. Rosenthal, H. (1992). Children's mental health services: Closing the gap. Albany, NY: Mental Health Action Network report. Rotheram-Borus, M. J., Piacentini, J., Can Roosem, R., Graae, F., Cantwell, C, CastroBianco, D., Miller, S., & J. Feldman. (1996). Enhancing treatinent adherence with a specialized emergency room program for adolescent suicide attempters. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 654-663. Shulman, D. A., & Athey, M. (1993). Youth Emergency Services: Total community effort, a multisystem approach. Child Welfare, 71,171-179. World Health Organization. (1993). World health statistics annual. Geneva, Switzerland: Author. World Health Organization. (1982). World health statistics annual. Geneva, Switzerland: Author. World Health Organization. (1976). World health statistics annual Geneva, Switzerland: Author. (Address requests for a reprint to Ebba McArt, Performance Improvement Manager, Hillside Behavioral Health System, 1183 Monroe Avenue, Rochester, NY 14620.)

Call For Papers

"Children First in the New Millenniam: A New Commitment to Children & Young People"

ANNUAL WORLD CONFERENCE

Sydney, Australia 7 - 1 1 August 2000
Contact: W'oikl lTel +(n 2 4; Fiix +ttl 2 4
Worid Forum 2000

lyn l.iiw - Hrochiire.'i iirdilubli' noir!

www.a twa.a.sn.auAvt 2 ()()() Email .shai-\Mi@zeta.()ri.au