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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%
5
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
7
DID YOU KNOW?
Tragic incidents and large scale acts of violence in schools anywhere in the United States are
EXTREMELY RARE.
8
Homicides on school grounds during the school day are VERY RARE
9
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.
11
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.
12
United States Secret Service and the United States Department of Education, 2002
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 ).
.
DID YOU KNOW?
There were 6,477 homeless students identified in Miami-Dade County Public Schools in 2012-2013.
16
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.
17
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?
18
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
Youth Suicide Data in NorwayAge 15-24, Male and Female
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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.
33
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
45
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