Youth Prevention Priority Area: Intervention Evidence

A Preliminary Review, November 2018

Introduction One of AMB West Philanthropies’ 2019 priority giving areas is prevention. In support of this priority, Child Trends reviewed the evidence base for interventions that address youth suicide. We focused primarily on interventions that appear to be feasible and supported in Park County, Montana based on our discussions to date with AMB West Philanthropies and community stakeholders. This review is intended to serve as a starting place for understanding the evidence and information available for these potential interventions, as opposed to a comprehensive list of effective youth strategies. As a preliminary review, this document may have additional evidence and types of interventions added in a future version. It is important to note that there is little research on effective interventions or strategies for preventing suicide, especially youth suicide. This research gap is due, in part, to the fact that despite recent rises in nationally, death by suicide is still relatively rare and can have multiple and disparate causes. These circumstances make broad-based interventions and research challenging. Applicants planning to submit for the youth suicide prevention priority area are encouraged to build on the information here and consider how this evidence aligns with the context of Park County and their work. For each type of intervention, we present a brief description, program example(s), potential indicators of success, and evidence of links to reductions in suicidal thoughts, ideation, or attempts. To make as many resources as possible available, we used footnotes for useful websites and parenthetical references for research citations. The interventions are organized into three categories, based on the work of Silverman and Maris (1995) and aligned with the identification of target groups. Universal preventive interventions are those that aim to reduce risk and increase protective factors for the entire community or population, without identifying individuals in need of additional support. Selective interventions are those that target individuals who seem to be at risk for suicide, based on other behaviors, but have not demonstrated suicidal behavior per se. Indicated interventions are narrowly aimed at those who have expressed or made a . Because suicide is multi-faceted, a comprehensive, community-wide approach to suicide prevention should include all three types of interventions.

Preliminary Youth Suicide Prevention Evidence Review 1

Table of Contents

Universal Preventive Interventions ...... 3 Community Center ...... 3 General Awareness and Knowledge Initiatives ...... 3 Restriction of Access to Lethal Means ...... 4 Social-Emotional Learning & Skills Programs ...... 5 Selective Interventions ...... 6 Bullying Prevention Programs ...... 6 Family-based Programs ...... 7 Mentorship Programs ...... 8 Service Coordination ...... 8 Training Teachers and Schools on ACEs ...... 8 Indicated Interventions ...... 9 Increase Access To and Use of Mental Health Services ...... 9 References ...... 11

Preliminary Youth Suicide Prevention Evidence Review 2

Universal Preventive Interventions Interventions in this category aim to reduce risk and increase protective factors for the entire community or population, without identifying individuals in need of additional support.

Community Center • Background: Building and maintaining a center for the community or county that could host adult and youth programming, including recreation or mental health services. • Sample programs: The Youth Clubs of Park County (Cody, WY) provides after-school and summer activities for youth, focusing on “positive self-identity, good health and well-being, positive values, a commitment to learning, social competency and community involvement.” 1 The Clubs are staffed by trained adults and cost $50 per month per youth. • Indicators of success: These would depend on the goals established for the center. If the goals are similar to Cody’s Youth Clubs, examples of indicators could be youth feeling connected to their community and endorsing positive values. • Evidence: Youth centers that offer programming informed by positive youth development principles, have evidence of improving suicide-related factors such as decreasing risk behaviors, improving health outcomes, and increasing community engagement.2 For example Chicago Youth Centers provide out-of-school-time youth development programs, and have found participants have stronger academic performance, improved confidence in problem solving, and more interest in taking on difficult tasks.3

General Awareness and Knowledge Initiatives • Background: These interventions target a whole population, with the goal of providing information to reduce risk factors and increase protective factors. They can be school- based or community-based and include public awareness campaigns. • Sample programs: Signs of Suicide (SoS)4, Raising Awareness of Personal Power (Larimer County, CO)5. • Indicators of success: Improved knowledge about the signs of suicide and appropriate response steps. o Note: Indicators should also include assessment of unintended outcomes, including potential increases in suicide ideation, increases in perceptions of the pervasiveness of suicide, and increases in suicide attempts.

1 https://www.facebook.com/codyclub/ 2 https://youth.gov/youth-topics/effectiveness-positive-youth-development-programs 3 https://www.chicagoyouthcenters.org/results 4 https://www.sprc.org/resources-programs/sos-signs-suicide 5 http://allianceforsuicideprevention.org/education-programs/school-based-education-rapp/

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• Evidence: Entities such as the American Foundation for Suicide Prevention6 and the Substance Abuse and Mental Health Services Administration (SAMHSA)7 prioritize community mobilization and raising awareness, however, systematic studies of these efforts have not been conducted (Decker, Wilcox, Holliday, & Webster, 2018). A review of studies of school-based awareness programs found they were significantly associated with decreased suicide attempts and ideation (Zalsman et al., 2016). Other programs have been shown to increase knowledge about the warning signs of suicide and action steps for a responder, and some programs have also been shown to increase self-reported likelihood of help-seeking behavior (Robinson et al., 2013). However, these programs may have unintended negative consequences, (Robinson et al., 2013) by normalizing suicidal ideation or suggesting that considering suicide is common among youth. Such unintended consequences were found in some, but not all, anti-drug media campaigns (Allara, Ferri, Bo, Gasparrini, & Faggiano, 2015).

Restriction of Access to Lethal Means • Background: These interventions restrict access to the most lethal means for suicide (e.g., sites frequently used for jumping, lethal medications, toxic substances, and firearms). • Sample programs: Distribution of gun locks (kits available for free from MT Department of Health8 and others), policies that limit acquisition of firearms (Everytown for Gun Safety, 2018), and gun-safety training; use of blister packs or small packs for lethal medications; controlling access to toxic pesticides (Zalsman et al., 2016); policies that limit youth access to alcohol (Decker et al., 2018). • Indicators of success: More people storing their firearms safely (e.g., locked, unloaded, separate from ammunition); increased use of gun locks; fewer youth reporting access to lethal medications, toxic pesticides, alcohol, and/or firearms. • Evidence: Restricting access to lethal means has been shown to be an effective deterrent to suicide. Examples include barricading jump sites, using blister packets for medications, and removing or limiting gun access (Mann et al., 2005; Zalsman et al., 2016; Grossman et al., 2005). These methods may be especially effective for youth, who may act impulsively. Policies that limit youth access to alcohol, such as changes in taxes, price, or store operating hours have been linked to reduced underage drinking and suicide (Decker et al., 2018). Moreover, having guns in the home, even guns that are locked up, is linked to increase in suicides (National Research Council, 2005). Laws designed to restrict child access to firearms by allowing charges of negligent storage, or both negligent storage and reckless provision, are associated with a reduction of 66–69 percent in self-inflicted firearm injuries among those under age 18 (RAND, n.d.- a). Providing gun safety training in combination with gun locks or other locking mechanisms has been shown to be effective at encouraging safe storage of firearms (Rowhani-Rahbar, Simonetti, & Rivara, 2016). However, providing training only is not consistently effective and significant proportions of those with gun locks report not using them (e.g., see Who stores guns safely?9).

6 https://afsp.org/ 7 https://www.samhsa.gov/ 8 https://dphhs.mt.gov/aboutus/news/2017/5-31-17suicide 9 https://journalistsresource.org/studies/society/public-health/safe-gun-storage-research

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Social-Emotional Learning & Skills Programs • Background: According to the Collaborative for Academic, Social, and Emotional Learning (CASEL),10 social-emotional learning (SEL) is the process through which children and adults acquire and effectively apply the knowledge, attitudes, and skills necessary to understand and manage emotions, set and achieve positive goals, feel and show empathy for others, establish and maintain positive relationships, and make responsible decisions. • Sample programs: o Positive Action,11 a classroom curriculum that engages family members and offers professional development to teachers, has been implemented successfully in rural and low-income school districts (Grant et al., 2017). Positive Action will provide staff development for $3,000 per day, plus travel expenses for the trainer. Positive Action is associated with improved academic performance, self-control, decreased aggression, decreased verbal and less physical harassment and bullying in school (Grant et al., 2017). o Wyman’s Teen Outreach Program (TOP),12 according to CASEL, “uses free- standing SEL lessons and community service to promote students' social and emotional development.” Lessons address content on adolescent development, skill-building, connections with others, and learning about one's self. Additionally, a community service component has four phases: preparation, action, reflection, and celebration. TOP has been linked to improved grades, decreases in behavioral referrals in school and decreases in skipping class. o Additional programs include The Good Behavior Game,13 which focuses on youth in primary school, and Youth Aware of Mental Health, which has been offered in Montana14 and focuses on youth in secondary school. • Indicators of success: Emotional regulation, resilience, social problem-solving skills (Grant et al., 2017); reduced suicidal ideation, attempts, and depression (Decker et al., 2018). • Evidence: In general, SEL interventions have been associated with protective factors thought to decrease suicidality, such as improved interpersonal skills (e.g., prosocial behaviors, interpersonal communication) and intrapersonal skills (e.g., coping, attention) (Grant et al., 2017). Additionally, they have been linked to decreases in suicide risk factors such as conduct problems, emotional distress, and drug use (Taylor, Oberle, Durlka, & Weissberg, 2017). The Good Behavior Game and Youth Aware of Mental Health programs have been associated with decreased suicidal ideation and attempt (Decker et al., 2018).

10 https://casel.org 11 https://www.positiveaction.net/ 12 http://wymancenter.org/top/ 13 https://www.goodbehaviorgame.org/ 14 http://www.montana.edu/cmhrr/yam/index.html

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Selective Interventions Interventions in this category target individuals who seem to be at risk for suicide, based on other behaviors, but have not demonstrated suicidal behavior per se.

Bullying Prevention Programs • Background: Definitions of bullying vary. To coordinate terminology used, the Centers for Disease Control and Prevention (CDC) employed a consensus building process with a panel of researchers and practitioners. This group defined bullying as behavior that is: 1) directly or indirectly verbally, physically, or socially aggressive, 2) repeated or has the potential to be repeated over time; and 3) carried out in the context of a real or perceived power imbalance.15 However, when students are asked to describe bullying, they focus on the hurt and harm it causes, not on repetition nor power imbalances (Hellström, Persson, & Hagquist, 2015). This discrepancy can explain why students often report their schools are not doing enough to prevent bullying (Evans, Cotter, & Smokowski, 2017). • Sample programs: The federal bullying prevention website StopBullying.gov provides a database of public resources on bullying.16 o Most programs that are designed to specifically target bullying behaviors follow a model from the Olweus Bullying Prevention Program (Ttofi & Farrington, 2011). The program has three components: 1) training students and school staff on what bullying is and its consequences; 2) establishing bullying policies; and 3) creating spaces for students to talk about bullying (Olweus, Limber, & Mihalic, 1999). The Olweus Bullying Prevention Program17 estimates the first-year costs for implementing their program at roughly $3,000, with most costs related to a one-time expense for printed guides. Evaluations of this program in the U.S. have not shown consistent or sustained reductions in bullying perpetration and victimization (Espelage, 2013; Temkin, n.d.; Ttofi & Farrington, 2011). o Other programs that are not specifically focused on bullying also appear to hold promise. For example, social-emotional learning (SEL) programs, mentioned in the Universal Preventive Intervention section above, may play a role in bullying prevention as they help youth regulate their own emotions. SEL programs are linked to decreases in bullying perpetration and victimization (Gaffney, Ttofi, & Farrington, 2018). Examples include: ▪ Take the Lead—a SEL and positive youth development program for middle school students (Domino, 2013), and

15 https://www.stopbullying.gov/what-is-bullying/index.html 16 https://www.stopbullying.gov/ 17 https://www.blueprintsprograms.org/program-costs/olweus-bullying-prevention-program

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▪ Youth Matters18—a program designed to shift school and peer norms among middle school students regarding anti-social behaviors like bullying (Jenson, Brisson, Bender, & Williford, 2013). o Other programs focus on helping schools with implementation. For example, the Safe Schools Certification Program is a technical assistance model that certifies schools after they demonstrate efforts on each of eight key components of school climate. • Indicators of success: Youth understanding of what bullying is, youth report of changes in bullying intensity/frequency, youth report of positive adult/school relationships and response to bullying, youth comfort in intervening when they see bullying. • Evidence: A recent meta-analysis indicated that bullying prevention can significantly reduce bullying perpetration and victimization (Gaffney et al., 2018); however, most bullying prevention programs have not been evaluated (National Academies of Sciences Engineering and Medicine, 2016). Of those that have been evaluated, decreases in bullying behavior are generally small (Gaffney et al., 2018; Ttofi & Farrington, 2011), and effectiveness fades as students get older (Yeager, Fong, Lee, & Espelage, 2015). Both Take the Lead and Youth Matters are associated with significant decreases in bullying perpetration and victimization (Gaffney et al., 2018). However, evidence of the effectiveness of bullying prevention programs on youth suicide remains thin, and bullying is one among many contributors to youth suicide.19

Family-based Programs • Background: Youth experiencing emotional and behavioral health crises often exist in families that may also benefit from support. Programs that serve the family unit acknowledge the interpersonal dynamics within families that can present barriers and opportunities for addressing youth outcomes. • Sample programs: Multisystemic Therapy,20 Family Bereavement Program,21 the HOPE Family Project22. • Indicators of success: Decreased suicidal ideation, increased family communication, increased use of positive parenting practices, decreased out-of-home placement. • Evidence: Multisystemic Therapy has been shown to reduce suicide attempts among youth with psychiatric concerns (Decker et al., 2018; Huey et al., 2004). Additionally, reductions in suicidal thoughts and behaviors have been demonstrated among youth who have received the Family Bereavement Program following to the death of a parent (Sandler, Tein, Wolchik & Ayers, 2016) and for youth whose families have received the HOPE Family Project while living in homeless shelters (Lynn, Acri, Goldstein, Bannon, Beharie & McKay, 2014).

18 https://www.childtrends.org/programs/youth-matters 19 https://www.childtrends.org/prevent-youth-suicide-must-address-bullying 20 http://www.mstservices.com/ 21 https://reachinstitute.asu.edu/programs/resilientparent 22 https://www.childtrends.org/programs/the-hope-family-project

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Mentorship Programs • Background: These programs link at-risk students to adult or peer mentors in the community. Although some programs may require year-round in-person mentors, other programs are more flexible. • Sample programs: Check and Connect,23 Big Brothers/Big Sisters,24 Sources of Strength25. • Indicators of success: Increased connection to adults or peers, perception of adult support, referrals of suicidal youth, acceptability of help-seeking. • Evidence: Specific programs, such as Sources of Strength (a peer mentoring program), have been found to have positive effects in both urban and rural schools (Wyman et al., 2010). Peer mentoring programs can increase a youth’s sense of being connected to their school, and higher levels of school connectedness are associated with lower levels of suicidal thoughts and behaviors (Marraccini & Brier, 2017).

Service Coordination • Background: The goal of service coordination is to ensure a maximally efficient system in which no youth or family falls through the cracks. This system could include a means for following-up when a service referral has been made, a way for service-providing organizations to ensure their efforts are complimentary and not duplicative, and/or a means to evaluate community needs and identify service gaps. • Sample programs: Montana’s CONNECT Referral program is a means to increase communication and overall care coordination.26 It is already operating in Park County but may be expanded. For instance, the CONNECT Referral system might include all referrals made during the newborn home visit of all Park County families. An individual who has time and capacity to follow-up with clients could then ensure that the referral resulted in receipt of the specified service. • Indicators of success: Increased follow-up after a referral, service use after a referral, collaboration among service providers, less redundancy, increased awareness of what others are doing, decreased sense of competition, increased interagency referrals. • Evidence: Few studies have been conducted linking service coordination in general to suicide prevention. There is strong evidence, however, that follow-up after a suicide attempt to ensure that mental health services are received is a means for reducing subsequent suicide attempts (Zalsman et al., 2016). Improved service coordination is one mechanism for ensuring that such follow-up takes place.

Training Teachers and Schools on ACEs • Background: Adverse childhood experiences (ACEs), such as abuse or neglect, parental substance use or mental health issues, and parental incarceration or death, have been linked to serious social, emotional, physical, and cognitive impairments in

23 http://checkandconnect.umn.edu/ 24 https://www.bbbs.org/ 25 https://sourcesofstrength.org/ 26 https://connectmontana.org/

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development.27 Recent research suggests that ACEs are linked to suicide attempts in adults (Choi, Dinitto, Marti, & Segal, 2017) and suicidal ideation in adolescents (Soleimanpour, Geierstanger, & Brindis, 2017). Trauma is a broader term that captures any experiences an individual has had—not just in childhood—that were physically or emotionally harmful and had lasting adverse effects.28 Program services are now becoming trauma-informed, meaning they are committed to realizing, recognizing, and responding to trauma, as well as resisting re-traumatizing the people they serve.29 • Sample programs: Though there are many guidelines available regarding teachers and ACEs,30,31,32,33 few programs have been evaluated. One that does have research support is Support for Students Exposed to Trauma, which trains teachers to deliver a program to students who have been exposed to potentially traumatic events. Support for Students Exposed to Trauma provides online free resources, including teacher training. Research on this model indicates it is associated with reductions in trauma symptoms, improved student behavior, and high student and parent satisfaction with the program.34 • Indicators of success: Youth understanding of trauma, emotional regulation, resilience, social problem-solving skills (Grant et al., 2017). • Evidence: Given that ACEs and trauma have been linked to suicide attempts and ideation, training teachers and others in schools to effectively address the needs of their students who have been exposed to trauma makes sense. Further, the limited research on these models seems to indicate that they can lessen trauma symptoms and improve student behavior. However, we have not yet identified studies that directly link ACEs or trauma training to reduction in suicidal thoughts or ideation among youth. Indicated Interventions Interventions in this category are narrowly aimed at those who have expressed suicidal ideation or made a suicide attempt.

Increase Access To and Use of Mental Health Services • Background: The school system lists many child and family mental health providers in Park County,35 but access may be limited for low income or uninsured families, and

27 https://www.cdc.gov/violenceprevention/acestudy/about.html 28 https://www.samhsa.gov/trauma-violence 29 https://www.samhsa.gov/nctic/trauma-interventions 30 https://www.nctsn.org/resources/child-trauma-toolkit-educators 31 https://www.nctsn.org/resources/creating-supporting-and-sustaining-trauma-informed- schools-system-framework 32 https://safesupportivelearning.ed.gov/trauma-sensitive-schools-training-package 33 https://schooljusticepartnership.org/component/mtree/search-by/resource- topic.html?value=trauma%20informed%20classrooms 34 https://ssetprogram.org/learn-more 35http://www.livingston.k12.mt.us/uploads/7/0/7/1/70715519/mental_health_resource_list _updated_december_2016__2_.pdf

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stigma and other barriers (e.g., transportation) may prevent some youth from accessing services even in cases where the need is evident. • Sample programs: Services can range in size and complexity from an online program that refers people to supports,36 to school-based health centers that offer mental health care to those who seek it, to school-wide initiatives. An example of a school- wide initiative is one where teachers and administrators work with law enforcement and mental health providers for universal screening, identifying students at risk, crisis response in an attempt or completed suicide situation, and response post-suicide. The SAFETY Program is an example of a brief intervention designed for integration with emergency services for youth who attempt suicide (Decker et al., 2018). • Indicators of success: Decreased stigma associated with mental health issues, increase in number of youth (especially high-risk youth) accessing services, decreased depressive symptoms, fewer suicide attempts, decreased suicidal ideation, decrease in proportion of students reporting an unmet need for mental health care. • Evidence: Psychotherapy alone or with antidepressant medication can be an effective treatment for depression, suicidal ideation, and suicide attempts (Mann et al., 2005). Though antidepressants can increase suicidal ideation in youth, reviews have concluded the benefits of the antidepressant treatment outweigh the risks (National Institute of Mental Health, n.d.). However, simply increasing the availability of mental health services is not sufficient for improving mental health or decreasing suicides (RAND, n.d.-b). Mechanisms need to be in place to ensure that the services reach those who need them most. A study in Utah, for example, found that the most common barrier to accessing mental health services was a belief that such services would not help (Moskos, Halbern, & Gray, 2007). Another reason cited was an inability to afford care. In 2008, a federal parity law was passed37 to ensure that insurance plans cover mental and physical health equally, but many who need mental health services may lack health insurance or not know how to access it through their coverage. Evaluations of school-based health centers that provide mental health services indicate youth are much more likely to use services available in school than they are to use services in the community and that these services are also associated with decreased mental health stigma (School Based Health Alliance, n.d.). Additionally, there is research supporting the efficacy of family-based interventions with suicidal youth (Zalsman et al., 2016). One specific example is the SAFETY Program, which provides cognitive-behavioral family treatment following a youth suicide attempt and has shown improvements in both youth and parental behavioral health indicators, including reductions in subsequent youth suicidal behavior (Asarnow, Berk, Hughes & Anderson, 2015).

36 https://socialworkerconnect.com/about/ 37 https://www.cms.gov/cciio/programs-and-initiatives/other-insurance- protections/mhpaea_factsheet.html

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