Is teaching problem solving to young people a way of preventing teenage suicide?

158 Practice Development in Health Care, 3(3) 158-178, 2004 © Whurr Publishers Ltd

Research and review

Is teaching problemsolving to young people away of preventingteenage suicide?Patricia Day—Lecturer in Primary Care Nursing, Sheffield Hallam University, UK

Suicide and the youngIn a Panorama programme called ‘Boys don’t cry’ Juliet Morris talked about how heryounger brother, who was 24, had taken his own life (BBC1 1999). ‘No one thought hewould ever do anything like that’ she commented. Ed McCabe’s parents used exactly thesame words to describe their son’s suicide. He was 22, football and clothes mad. He gave uphis job, fell into debt and lost his girlfriend. His father describes how the police came totell him his son had hung himself. This parent’s sense of loss and regret represents the focalpoint for the author’s work as a school nurse in the prevention of young male suicide.

Male suicides in the 15–24 age group have increased by 60% inthe past 20 years.

Every week 12 young men kill themselves (Samaritans 1999); men are fourtimes more likely to kill themselves than girls (Garland and Zigler 1993) and they aremore likely to hang themselves while girls typically overdose (Madge and Harvey1999). Male suicides in the 15–24 age group have increased by 60% in the past 20years. The Samaritans estimate that 19,000 adolescents attempt suicide every year and700 succeed (Kenny 2002). Few young people convey their intention to take their ownlife (Hill 1995).

Suicide is now the second biggest killer of young men after accidents (Laurent2000). The most recent available figures for Sheffield reflect this trend. In 1995–1998there were 172 deaths from suicide; 140 men and 32 women (Sheffield Health 1999).No age breakdown is given but even if this was included, it is unlikely to be accurate.Coroners are reluctant to label adolescent deaths as suicide because of the impulsivenature of adolescence and to spare the feelings of families (Madge and Harvey 1999).

This belittles the significance of suicidal behaviour among this age group

which may, in turn, be accorded less priority by policy makers than it

deserves (Madge and Harvey 1999 p146)

3(3) 8/25/04 1:39 AM Page 158

159Problem solving in the prevention of suicide

In order to assess the extent of underestimated suicides a study ofnon-accidental deaths among under 20-year-olds was carried out (Madgeand Harvey 1999). All records over a 17-year period from a Londoncoroner’s office were examined. It seems that the real rate of suicide amongthis group may be three times the official recorded level. In addition, thesocial cost of adolescent suicide is disproportionately high. Suicide resultsin immeasurable grief for families and friends (Bloch 1999). It also results ina significant number of years of potential life lost which represents a highcost to society (Bloch 1999). This national concern has recently beenreflected in Government targets to reduce suicide (Department of Health1999). The aim is to reduce the death rate from suicide and undeterminedinjury by at least one fifth by 2010, saving up to 4,000 lives in total(Department of Health 1999).

The reasons for the increase in young male suicide are difficult topinpoint (Laurent 2000). However, an extensive literature review hasrevealed causative strands that have informed the preventative approach tothis major health problem. Adolescence is a time of rapid emotional,cognitive and social change (Hendricks 1999). The sheer number ofchanges, particularly in early to mid adolescence, can have an impact onemotional well-being (Seiffge-Krenke 2000). Sometimes the risk-takingnature of adolescence results in life-threatening behaviour.

There is a marked gender difference in the coping style of adoles-cents. Young women are much better at using social support when theyhave problems and accepting therapeutic help (Seiffge-Krenke 2000). Inadolescents the act of suicide is usually impulsive (Bloch 1999).

Post-mortem psychological profiles of completers depict them as

impulse ridden people who act out of feelings of inner worth-

lessness or hopelessness. (Bloch 1999 p.28)

In a study investigating levels of hopelessness and reasons for takingoverdoses, one of the reasons most frequently given was that people felt thesituation was so unbearable they did not know what else to do (Williams1986 p.271). A sense of control over one’s life and destiny is cited as areason for living by clients suffering from depression (Malone et al. 2000).

Deficits in problem solving skills are an important risk factor insuicidal behaviour (Pollock and Williams 1998) and effective problemsolving skills help people to cope with difficult situations (Carris et al. 1998).

Cognitive rigidity and inflexibility has been described in suicidal

adults and involves dichotomous or all-or-nothing thinking, a lack of

divergent thinking and the inability to use innovative or creative

ways to solve problems. (Carlton and Deane 2000 p.41)

3(3) 8/25/04 1:39 AM Page 159

160 Day

A study of 77 suicide attempters found that they had poor problem solvingskills compared to psychiatrically disturbed ‘non-attempters’ and were more likely touse a wishful thinking style to solve their problems (Carlton and Deane 2000).

When individuals with poor problem solving skills are faced with a crisisthey are unable to generate solutions, they become overwhelmed and progressivelymore hopeless. As their hopelessness increases, they are more at risk of depressionand, ultimately, suicide (Pollock and Williams 1998). Suicide can be seen as the‘ultimate step in the escape from self and world’ and ‘problem solving forhopelessness’ (Sandin et al. 1998 p.422). Hope enables individuals to overcomestressful situations by reinforcing the feeling that there is a way out of a difficultsituation (Hendricks 1999).

Low self-esteem also discriminates suicidal adolescents (Tomori and Zalar2000). Self-esteem influences one’s actions (Hendricks 1999) and an adequate level ofself-esteem is associated with the ability to control impulsive behaviour and cope withstress. High self-esteem is seen as a factor in resilience (Sandin et al. 1999 p.423).

Low self-esteem interferes with constructive self-confirmation and

adversely affects the chances for establishing the supportive interpersonal

relations that can be highly protective in stress. (Tomori and Zalar 2000 p.232)

A study of 45 teenagers in Oxford who had taken overdoses distinguished themas feeling depressed, hopeless and angry and having low self-esteem (Kingsbury et al.1999). Doubts about one’s abilities can result in the teenager giving up when there aredifficulties rather than persisting and overcoming them (Hendricks 1999).

Prevention of suicideSchool-based programmes to address these issues have been popular in the US.However, concerns regarding the efficacy of these programmes have been raised.Several reviews have concluded that suicide education programmes are not effectiveand can even have negative effects (Garland and Ziger 1993, Ploeg et al. 1996). Afterthe delivery of a suicide awareness programme in one school, male students were foundto display an increase in hopelessness and an increase in ‘maladaptive coping responses’(Overholser et al. 1989 p.925). One study of a suicide education initiative identified anincrease in suicide rates in the intervention group (Lester 1992). Programmes aimed atenhancing problem solving appear to be more effective (Petersen 1995). Evidenceexists that problem solving training reduces suicidal ideation (Carris et al. 1998). In astudy of self-harming teenagers in Oxford, the best treatment appeared to be ‘problemorientated therapy’ (Hawton et al. 2000).

The development of social competence is seen as a vital component of theseprogrammes (Petersen 1995). Competence is having the ability to adapt to one’senvironment (Van Slyck et al. 1996). It infers a degree of resilience in coping with life’sstresses and managing challenging circumstances ‘without being debilitated’ (VanSlyck et al. 1996 p.436). Instead of avoiding the negative consequences of stress, theindividual shows the ability to cope with the situation in such a way that he or she does

3(3) 8/25/04 1:39 AM Page 160


not suffer potentially devastating effects. These individuals manage ‘to bounce backfrom adversity’ (Van Slyck et al. 1996 p.436).

The most effective ways of enhancing these protective mechanisms in childrenand adolescents is to increase the capacity to cope. This can be a learned response (VanSlyck et al. 1996). Programmes which incorporate cognitive-behavioural therapy in thisway have demonstrated positive outcomes. After one intensive course, the decision-making capacity of 12-year-olds equalled that of a control group of 15-year-olds (Mann etal. 1991). An increase in self-esteem and sensitivity to others has been reported as aresult of school-based programmes (Elias and Weissberg 1990). Children also displayedbetter adjustment in terms of other stress in their lives. This included transition tosecondary school, peer pressure and conflict, drug abuse, and relationships with teachers.

The stop, think, do programmeThe stop, think, do programme from Australia has demonstrated effective outcomes(Petersen 1995). In one study children who received the programme made significantgains in social competence and acceptability by peers (Nimmo 1993). Children,teachers and parents noted changes in terms of making and keeping friends, copingwith teasing, being less attention seeking and less shy. After delivery of the programmein a special school, children were said to be less likely to act without thinking and lesslikely to fight with others (Beck and Horne 1992).

This programme was devised by Lindy Petersen, a clinical psychologist whofirst used her ideas with children referred for behavioural problems to an Adelaideclinic (Petersen 1995). She used the universal symbol of traffic lights to teach childrenhow to problem solve. Children are taught how to think about, evaluate and choosesolutions to their problems before they act. The emphasis is on learning how to think,not what to think. The red light cues children to stop before they act impulsively, andwork out what is actually happening, how those involved feel and what they want tohappen. The yellow light is a sign to think about what they could do to solve theproblem, and the likely consequences of their actions. The green light means choosinga solution with the best consequences, and if that does not work out, trying an alter-native. The use of traffic lights provided an invaluable tool for delivering thisprogramme in a classroom setting (Day et al. 1999).

The clinic programme was adapted in Adelaide for use as a classroom strategy(Petersen and Gannoni 1992). This strategy has been shown to be cost-effective(Forman 1993). It also represents a shift in focus from a therapeutic treatment to apreventative model, which benefits all children (Petersen 1995).

The pilot projectIn response to the increase in suicide rates among young people, a proposal to developan education package was funded by a quality improvement group within the Trentregion called SIGMA (Day et al. 1999). The original pilot was conducted in a largecomprehensive school on a major council housing estate in Sheffield. The school’scatchment area is high in unemployment and deprivation. It has an adult suicide rate 12

3(3) 8/25/04 1:39 AM Page 161

162 Day

times that of Walkley, a more affluent area (Sheffield First 1999). It also has the largestnumber of reported self-harm incidents for school-age children in Sheffield (Day et al.1999). After consulting the literature, the stop, think, do programme was adapted foruse in this school. The programme was randomly delivered to three Year 8 classes(12–13-year-olds) and evaluated through questionnaires and systematic reflection.

Positive outcomes were demonstrated after the intervention in terms ofattitudes to problem solving. Teachers and pupils also received it enthusiastically.However, the original project lacked breadth and depth in terms of research method-ology and more evidence was required for the programme to be widely disseminated.

Stop, think, do as action researchThe philosophy of action research aligns itself closely to an investigation aboutteaching problem solving skills. Action research is especially appropriate whereproblem solving and improvement are on the agenda (Hart and Bond 1995). Actionresearch is ‘problem sensing and problem focused’ and involves the researcher immedi-ately in the problem situation (Hart and Bond 1995 p.52). The idea is for theresearcher to act as a catalyst to help participants define a problem or think in adifferent way about an existing one.

While there is no specific methodology related to action research, the conceptimplies a questioning and participatory approach (Meyer 1993). It is ‘research donewith and for people rather than on people’ (Meyer 1993 p.1067). Participants are seenas vital players in the change process (Hart and Bond 1995). They are involved atevery phase of the action research process and are seen as equals in the relationshipwith the researcher (Le May and Lathlean 2001). This includes recognizing the rightsof children to have a say in services that affect them (Neill 1998). In fact, the processof assessing the needs of vulnerable groups, responding to them, and measuringprogress, fits within the action research cycle. The combination of enquiry, inter-vention and evaluation underpins this style of research (Hart and Bond 1995).

Kurt Lewin, who coined the phrase ‘action research’, was a Marxist interestedin social change (Carr and Kemmis 1986). He viewed the principles of action researchas independence, equality and co-operation. Through this process, policies, whichexploited individuals, would be changed. Recent social scientists have changed thisemphasis. Rather than bringing about democracy, it is seen as encompassing its values.

The action research cycleThe process is seen as a series of activities or steps (Ainley et al. 2000).

1. Lewin described the first phase as planning a general idea (Carr and Kemmis1986). In the stop, think, do programme the general idea is to improvechildren’s ability to cope by giving them a framework.

2. From this planning a general objective is formulated. In this case, the aim wasto tackle the problems of risk-taking behaviour through problem solvingstrategies.

3(3) 8/25/04 1:39 AM Page 162


3. Fact finding about the situation is necessary. An extensive literature reviewwas carried out. The author and colleague also travelled to Australia to inves-tigate the stop, think, do programme. They met Lindy Petersen, the clinicalpsychologist who wrote the framework and talked to teachers, parents andchildren about their experiences of the programme. This informed bestpractice.

4. The first step of action is taken. The programme was written to include theauthors’ own ideas as well as the stop, think, do framework. It was piloted in acomprehensive school with 12–13-year-old children.

5. Reconnaissance takes place after execution of the plan. This involves factfinding about what has been achieved, what has been learnt and what shouldbe changed. After the pilot, children seemed to develop better problem solvingstrategies but the evidence for this was not sufficiently robust. The plan was toapply more rigorous methodology and use a wider group of children.

6. The next step consists of a circle of planning, executing and fact-finding toevaluate the results of the second step. After collating the evidence from thepilot programme, the structure is modified. More emphasis is placed on drama.

7. Modification of the overall plan takes place. The project shows areas forimprovement. It is too short and too busy. The evidence points to the benefitsof a longer intervention.

The action research process is shown in Figure 1.

The first phase

Mental health affects how a person feels, thinks and communicates (Department ofHealth 1999). Without good mental health individuals are unable to fulfil their fullpotential or lead an active life. Children living in poverty are three times more likely tosuffer mental ill health than children from affluent areas (Department of Health 1999).The adults in poor communities also have a higher prevalence of mental illness. Morecontemplate and actually commit suicide than people who are better off (Departmentof Health 1999).

The Manor in Sheffield ranks within the 1% most deprived wards nationally(Stead et al. 2001). This has been calculated according to the most up-to-date depri-vation score, the Index of Multiple Deprivation. In this score six domains are assessed:income; employment; health deprivation and disability; education, skills and training;housing; and access to services (Stead et al. 2001). Depression has been found to behighly correlated to deprivation. The incidence of depression among those living onthe Manor is reported at 12%, three times that of the affluent areas of the city. Thisarea of the city also has one of the highest suicide rates (Stead et al. 2001).

Prevention of suicide and self-harm is relevant to mental health strategy inprimary care (Stead et al. 2001). This preventative stance is reflected in the dissemi-nation of the stop, think, do programme in Sheffield. Funding from the Manor andCastle Health Action Zone enabled the project to be sustained. The aim of the Health

3(3) 8/25/04 1:39 AM Page 163

164

Action Zone is to increase health and well-being in areas of poverty (Sheffield HealthAction Zone 1999). This is an attempt by the Government to address the unacceptablehealth inequalities which exist in deprived parts of the city.

Delivery of the projectMyrtle Springs School was chosen for delivery of the project. This school is in theManor/Castle area of the city and has among the worst educational attainment of anyschool in the city. According to figures collected from hospital accident andemergency departments in Sheffield in 1996, it is also in the ward with the highestnumber of reported incidences of self-harm among 11–16-year-olds (SheffieldChildren’s Hospital 1996).

Day

Figure 1. Action research process (Ainley et al. 2000)

Reconnaissance or preliminary investigation

Research question or problem formulation

Plan for action

Reflection

Take action andcollect data on action

Analyse data

Replan

Replan

ReflectionTake action andcollect data on action

3(3) 8/25/04 1:39 AM Page 164


The programme has been delivered to Year 7 children (aged 11–12 years)during the academic year. This age group was chosen because of the increase in self-harm in older children (Day et al. 1999). After the pilot project at Waltheof School,children were asked about the best age to receive the programme. At a focus group theconsensus was that Year 7 would be better than Year 8 because of the transition fromprimary to secondary school. Many children experienced problems in the compre-hensive school and felt the stop, think, do framework might help them.

You should teach it to kids in junior school so that when they come up here

they know how to deal with stuff.

Ethical considerationsThe vulnerability of children is a major consideration when undertaking research (Politand Hungler 1997). Legally and ethically, children do not have the competence to giveinformed consent. Permission of parents must be sought for them to take part. Letters weresent to parents of Year 7 children at Myrtle Springs School advising them of the project.

In addition, those who work with children have a duty of care towards them(South Yorkshire Area Child Protection Committee 2001). This was made explicit atthe start of the project.

During this time together we will be talking about some things that are difficult.

This is our special time together and we all need to know that things we say will

be private, but if you say something which makes us feel you are not safe, we

would need to share this with someone else. We would talk to you about this,

as your safety is really important to us. Do you understand this?

Ethical approval was not considered necessary. The department of clinical effec-tiveness in Sheffield gave advice on this issue. The original pilot was directed by a clinicalpsychologist, a children’s mental health worker, a school nurse and user representativefrom MIND. As a result, the emotional well-being of children was a primary consideration.

The cycles of action researchThree cycles in the delivery of stop, think, do have been examined in detail. This datahave been collated to give a complete picture. In order to strengthen validity, multiplesources of data have been used. This research methodology is described as triangulation(Redfern and Norman 1994).

The greater the convergence attained through the triangulation of multiple

data sources, methods, investigators, or theories, the greater the confidence

in the observed findings. (Redfern and Norman 1994 p.46)

In addition to confirmation of the research findings, triangulation has alsobeen used to give a sense of holism. This holistic quality reflects the philosophy of

3(3) 8/25/04 1:39 AM Page 165

166

action research as rooted in the real world (Le May 2001). Each source of datacontributes a varied dimension to the study and thus adds a piece to the jigsaw (Shih1998). The jigsaw does not always fit together perfectly. Sometimes the results can becontradictory because of the complex and unpredictable nature of behaviour (Parahoo1997). However, this is likely to enhance and enrich understanding and avoids thereductionist stance of purely quantitative research (Parahoo 1997).

In the case of stop, think, do a combination of quantitative and qualitativeapproaches were used to assess the impact of the intervention. These included:

1. Quantitative methodology: the Locus of Control Scale for Children (LCSC;Nowicki and Strickland 1973) was administered to children before and afterthe intervention.

2. Qualitative methodology: Questionnaires were administered to teachers andschool nurses, and focus groups were held with children who also completedhomework diaries.

Locus of Control Scale for ChildrenThe concept of locus of control was developed by Rotter (1966) and is based on sociallearning theory. It is used to explain individual differences in the impact ofreinforcement on learning and behavioural change (Furnham and Steele 1993). Rotterdefined locus of control as:

When a reinforcement is perceived by the subject as not being entirely

contingent upon his action, then, in our culture, it is typically perceived as the

result of luck, chance, fate, as under the control of powerful others, or as

unpredictable because of the great complexity of the forces surrounding

him. When the event is interpreted in this way by an individual, we have

labelled this a belief in external control. If the person perceives that the event

is contingent upon his own behaviour or his own relatively permanent charac-

teristics, we have termed this a belief in internal control. (Rotter 1966 p.1)

A high internal locus of control is associated with healthy and adaptivebehaviour, high self-esteem and self-acceptance (Furnham and Steele 1993). Incontrast, a high external score has been shown to be related to maladjustment, afeeling of powerlessness, low academic achievement and poor physical health(Furnham and Steele 1993). A feeling of despondency is engendered by the inability toinfluence events or overcome difficulties (Bandura 1982). Personal self-efficacy enablesindividuals to master challenges and achieve highly (Bandura 1982).

The most widely used measurement of locus of control in children is theNowicki and Strickland 40-item scale (Nowicki and Strickland 1973). It has beenconstructed for, and validated on, children from 8 to 16 years (Furnham and Steele1993). The test has been shown to have satisfactory reliability. High internal scores,particularly for boys, have been related to independence, social maturity, academicconfidence, and self-motivated behaviour (Nowicki and Strickland 1973). The test

Day

3(3) 8/25/04 1:39 AM Page 166

167

provides a score of the degree of external/internal locus of control expressed as a singlefigure. Each of the 40 questions elicits a ‘yes’ or ‘no’ answer. Some ‘yes’ responses areregarded as indicating external locus of control and some as indicating internalization.These are randomly ordered, and are marked using a scorecard, which identifies which‘yes’ and ‘no’ responses score 1.

Students who received the programme at Myrtle Springs School were asked tocomplete the questionnaire before starting the programme and after the last lesson.This was done to measure the impact of the programme on the participants. The aim ofa quantitative method is to collect objective data from a large number of individuals(Parahoo 1997). Teachers administered questionnaires in class time. Due to literacyproblems, they were asked to read out the questions to many of the children. Forty-tworesponses were returned before and after the intervention. One teacher commentedthat ‘quite a lot of children found the questionnaires difficult to assess’.

Descriptive statisticsThe results of the questionnaires taken before and after the programme have beenanalysed using SPSS. In interpreting the results, it should be borne in mind that thehigher the score the higher the externalization of the locus of control. The results areshown in Table 1. The means and standard deviations are well within the boundariesthat could be expected of this age group for a normal population when compared withthe original standardization sample on which this method is based (Nowiki andStrickland 1973), see Table 2.

In order to see whether there was a significant difference between the locus ofcontrol scores at time 1 and time 2 a paired samples t-test was carried out. The resultsshow that there was no significant difference in the scores (t = 0.556, df = 41, p =0.581). The mean score for time 1 was 16.31 and the mean score for time 2 was 16.67.The results show that the externalization of the locus of control actually increasedslightly after intervention. However this difference is well within the standard

Problem solving in the prevention of suicide

Table 1. Locus of control before and after the programme

N Minimum Maximum Mean (SD)

Before programme

LCSC (valid n listwise) 42 2 24 16.31 (4.53)

Sex of Participant

Male 24 15.54 (5.15)

Female 18 17.33 (3.41)

After programme

LCSC (valid n listwise) 42 9 26 16.67 (4.77)

Sex of Participant

Male 24 16.58 (5.06)

Female 18 16.78 (4.51)

3(3) 8/25/04 1:39 AM Page 167

168

deviation. The guidance notes to the LCSC suggest that significant scores would bethose that were

One or two standard deviations away from the mean for their age and sex

group in either the internalizing or externalizing direction. (Nowicki 1993 p.33)

Therefore one reason why there was not a significant shift in the scores as aresult of the programme may be that most of the children in the study were alreadywithin the norms for their peer group. In addition, the programme may not have beenlong enough for significant shifts to be recorded. One of the published findings of thepilot exercise at Waltheof School was that:

Acquisition of problem-solving skills takes longer than four sessions and

should be integral to a more long-term strategy. (Day et al. 1999 p.324)

When the sex of the participant is taken into account we see that there areslight differences in the way males appear to have reacted to the programme in thattheir mean externalization has increased slightly from 15.54 to 16.58, while forfemales there has actually been a decrease in mean externalization from 17.33 to16.78. While both these movements are greater than that of the total group theyare still small variations, although it is interesting to note that the girls’ startingpoint was actually at the upper end of the normal scale for their age group, whilethe boys were starting well within the norm. This could lend further credence tothe tentative hypothesis expressed above that the programme has more impact onthose who start with a higher than normal external locus of control. These findingscould also imply that girls respond more readily to the programme than boys.Clearly however, the overall movements and numbers of participants involved aretoo small to form the basis for any firm assertions. What they do provide arepotential indicators for further research about which groups respond most to thisprogramme and why.

Questionnaires to teachers and school nursesQuestionnaires were sent to teachers and school nurses after the delivery of theprogramme. They were deliberately short. Lengthy and boring questionnaires cause

Day

Table 2. Locus of control by age and sex

Age group Males: Mean (SD) Females: Mean (SD)

9 17.97 (4.67) 17.38 (3.06)

11 18.32 (4.38) 17.00 (4.03)

13 13.15 (4.87) 13.94 (4.23)

15 13.81 (4.06) 12.25 (3.75)

17 12.48 (4.81) 12.01 (5.15)

3(3) 8/25/04 1:39 AM Page 168

169

‘fatigue and lack of concentration’ (Parahoo 1997 p.269). It was felt unlikely thatteachers would fill in a time-consuming questionnaire due to their workload. Stampedaddressed envelopes were enclosed for ease of return. Unambiguous language was usedto ensure reliability (Parahoo 1997). The use of plain English is recommended to elicitrelevant information (Bell 1993). Questions were brief, to the point and spaced outevenly. Open-ended questions were used because they give respondents freedom inexpressing themselves (Parahoo 1997 p.256). They were contained within one page ofA4 paper.

Participants were asked what they knew about the programme before delivery,what they thought of it, what they thought was good, what could be done better, andhow relevant the programme was to their work. The anonymous style of questionnaireswas used to reduce bias and because the presence of an interviewer can affect responsesto questions (Polit and Hungler 1997).

In order to ensure consistency, the same questionnaire was given to teachersand school nurses. Positive comments were received from all the participants. Usefulsuggestions were also made about improving the programme. These suggestions wereintegrated into the design of the project as it evolved.

Focus groups with childrenIn order to collect information about the programme, focus groups were held in theschool. They provide a platform for dealing with complex issues (Twinn 2000). Focusgroups bring individuals together to answer questions on a particular topic (McDougall1999) and they are useful in gathering different individual perspectives in a short spaceof time (Harvey-Jordan and Long 2002). Interaction within the group allows opinionsand ideas to be generated. This is especially true with children who generally find iteasier to articulate their feelings than write them down. As a result, focus groups canprovide rich data, which can be used in triangulation with other research methods(McDougall 1999).

In the case of the stop, think, do programme two focus groups were heldwith children. A children’s mental health worker who is highly skilled in groupwork facilitated them. Pupils were interviewed in small groups, without theirteacher or anyone involved in delivering the programme being present.Confidentiality was emphasized. This was essential in order to avoid the ‘inhibitingeffect on some group members who may conform to group opinion or withholdinformation’ (McDougall 1999 p.49).

The groups were formatted to ask them what they liked and did not like aboutthe programme, what they found helpful and unhelpful, what they remembered themost, if they understood the ideas of problem solving and if they thought other youngpeople would find them helpful.

The groups were self-selecting. This may mean that those who attended werethe ones who had strong feelings about the programme. Subsequently their views maynot be a reflection of the whole. However, there were consistent positive commentsfrom children as to the usefulness of the programme.


3(3) 8/25/04 1:39 AM Page 169

170

Homework diariesAt the start of the programme children were given an orange booklet to complete eachweek. The colour used was deliberate to fit in with the amber light of the problem-solving framework, which involves thinking about solutions to a problem and workingout their consequences. The booklet was divided into three sections to fit with deliveryof the programme.

Week one consisted of choosing a day and ticking how you felt in the morning,afternoon and evening. Words used to describe feelings were: buzzing, excited, happy,sad, down, wound-up, irritable, angry, worried, proud, afraid, scared, content, nervousand anxious. An important part of the programme was for children to recognize howthey feel and how this can impact on their behaviour. Week two involved recordinghow many decisions they made in a day. Week three was the problem-solvingframework. Children were asked to choose a problem and try and work it out with astop, think, do approach.

One teacher commented on the sense of ownership the orange booklets gavethe children. The ways in which children described their problems has provided aninvaluable insight into their world. It has also demonstrated how meaningful theteaching programme was to them.

FindingsData from questionnaires, focus groups and diaries have been grouped in themes.Patterns and concepts have emerged (Parahoo 1997). These findings are reportedtextually, supported by quotes from the participants. Thus the project is described fromthe points of view of children, teachers and school nurses.

Feelings

Emotional literacy is increasingly part of the language used by educationalists, mentalhealth workers and others in promoting the emotional well-being of children (Sharp2001). Effective education is part of the stop, think, do programme. Children brain-storm feelings. They then play a card game about feelings. They mime the feeling andothers guess what it is. Next time they put words to the feeling.

Many children in the three groups were inarticulate about feelings and tendedto lump feelings together. When they described being ‘mad’ it could mean angry, upset,fed up or lonely. During the stop, think, do programme children learn about the widerange of emotion words and are encouraged to use them. One child commented in afocus group, ‘I liked the bit about feelings because you don’t get a chance to talk aboutthings like that’.

Feelings played an important part in some scenarios in the diaries.

My nan died. I felt sad. I can help myself by not crying. I don’t like school. I

felt terrible.

What could I do?

Day

3(3) 8/25/04 1:39 AM Page 170

171

I could tell someone how I feel. Tell a teacher. Tell my mum.

What will happen if I do?

They might knock it down, tell me never to come to school again. Give me

detention. They might sought [sic] it out.

One child became empowered by his action.

I want to get better at drawing. I felt very upset and stressed. I want me to

practise and get better at drawing.

What could I do?

I could practise more often. Look how they got all the details in. Take tips

from people. Go to art club.


I might get better at drawing different things, not drawing from a cartoon

show. It worked out very good. I’m that good people buy them off me for 50p’.

This empowerment is seen as part of a process of self-efficacy and mastery overall areas of life (Sturt, 1999).

Bullying

Bullying was a major concern for the children at Myrtle Springs School. After theprogramme one child said, ‘I used to get bullied a lot and didn’t tell anyone, now I’vetold my teacher and she has sorted it out and now I don’t get bullied’.

Hidden in the homework diary, another child told his poignant story:

This is true: I am being bullid [sic] by two boys in the same year. I am angry

and upset. I want it to stop. I also want to hammer them.

What can I do?

Hit them. Tell my mum and dad. Tell the teacher or a good friend. Tell my

older brother.


I will hit them. They will go up to school and sort it out. They will listen to me

and try to sort it out. He will go and hit them hiself.

Choose an option

Well he hit one of them. And then we went home. Then the next day they

had a gang after him (my brother).

PS This was not long ago but it was sorted out.

The child’s teacher followed up this incident. He seemed shocked that thechild had not come to him. The reality of life for many children on this estate is that‘you stick up for yourself ’. The general feeling is if you tell it makes things worse.

Another child’s experience reiterates this.

Two boys are going to beat me up. I feel scarried, terrified, horrofied. I tell

them to stop.


3(3) 8/25/04 1:39 AM Page 171

172

What can I do?

Tell my mum. Fight them myself. Get my friends. Tell a teacher.


They might stop. They will get done. They might hit me for telling. They say

sorry.

Choose an option

Get my friends. They got beat up!

Two children did feel referral to others would work.

Somebody calls me a name. I feel angrey. I would tell the teachers, my mum,

a friend or my dad. It will get sorted.

Someone is getting bullied. It makes me sad. I want it to stop happening.

What can I do?

Tell a teacher. Say to the bullies stop. Take the boy away. Ask parent what

to do.


They might give them detension. Start to pick on me. Might follow us. Tell

me what to do.

Choose an option

Tell the teacher. The bully could get excluded. The boy would not get bullied

any more.

Relationships with teachers

An interesting finding has been that children themselves noticed a change in relation-ships with teachers.

I liked the lessons because you can work things out instead of the teacher

telling you what to do all the time.

I liked it ’cos you can talk to your teacher differently and about things you

can’t normally, like they’re your friend.

Relationships with family

Family problems were documented more than any other in the homework diaries.

My sister makes my bedroom messy. I feel mad, angery. I want it to stop.

What can I do?

Tell my mum. Tell her myself. Get a lock. Beat her up.


She will tell her to tiedy it up. She will ignor me. I will not be aloud one.

Choose an option

Tell my mum.

How did it work out?

It worked.

Fighting with my brother. I feel angry

What can I do?

Day

3(3) 8/25/04 1:39 AM Page 172

173

Hit him. Tell on him. Egnore him.


If I hit him I will get done. If I tell on him noting might not happen. Egnore

him. He stoped hitting me.

I had eten my sister’s chocolate. I felt sad/scared

What can I do?

Tell the truth. Don’t say enething. Act normal. Don’t tell her.


She might forgive me. Tell me to buy her a new bar. Tell me off.

Choose an option

I told the truth. It was OK.

One child worked out a reciprocal arrangement with her sister.

My sister keeps pinching my CDs.

What can I do?

Hide them. Tell her to ask me first. Tell mum on her. Lock them up.


I might forget where I hid them. She might not listen. Mum might not do

enything. I might lose the key.

Choose an option

Tell her to ask me first. She asks me and I say yes and borrow one of hers.

Some children felt that the programme had a beneficial effect on their familyrelationships.

The lessons helped me to get on with my kid sister better, she used to really

wind me up and it helps me when I want to really shout at her, now I don’t

mind her really.

It helped me to talk to my dad and to know that he will help me.

It helped me a lot and I think you should teach it to parents so that they can

help us, yeah and teachers.

Teaching methods

Children enjoyed the sessions.

Can we have them lessons again?

Teachers appreciated how structured the programme was.

It is easy to follow, clearly explained.

They liked the variety of teaching methods.

An interesting programme.


3(3) 8/25/04 1:39 AM Page 173

174

Discussions and group work were good.

Video discussions were good.

The use of weighing scales to balance negatives and positives helped

children visualize the process.

Liked the role plays.

Drama good.

Drama reinforces theory.

The programme was seen as encouraging a high level of child participation.

Pupils involved at many levels – as a class, in small groups and individually.

Relevance

The programme aimed to establish an intervention that would address the mentalhealth and well-being of young people. It is also a framework that could be used inother areas of health promotion including sex education, drug and alcohol use, andlifestyle issues that involve making choices. However, its wider dissemination isdependent on perceptions of its relevance.

Teachers and school nurses considered it highly relevant to their work.

Important concept for students to take on board and apply regularly.

Relevant, as always trying to reinforce good decision making.

Good for resolving problems.

Useful tool for health promotion as well as basic decision making techniques

for children and parents.

Relevant in comprehensive which has lots of children with problems.

Would be good in primary schools too.

Mostly relevant. Some less able pupils struggled with written tasks and did

no work or lost their orange booklets.

One child felt strongly that he wanted to discuss other issues.

It was good to talk about problems but you should talk about other stuff, like

you know sex and that.

Improvements

The stop, think, do programme is seen as continually evolving and capable ofadaptation to many different settings. As a result, evaluation is integrated into themodel. The programme has been adapted to include the recommendations of teachersand school nurses.

Pace needed to be quicker in places.

Objective not always clear to all students.

Day

3(3) 8/25/04 1:39 AM Page 174


Improve status of homework/orange booklets.

Give samples of work and tasks expected for orange booklets.

Let pupils know what is expected of them and what is to be delivered

throughout the sessions, i.e. a programme or agenda with tick boxes

showing progress.

ConclusionAction research involves a change process (Le May and Lathlean 2001). Change isapparent at many levels in the stop, think, do programme. The project brought togetherprofessionals from very different backgrounds. A children’s mental health worker and aschool nurse designed the original pilot. This work has been recognized as highlyinnovative as it brings mental health promotion to a classroom setting. It has involvedteachers and school nurses in different ways of working. This collaboration is seen as animportant part of action research (Le May and Lathlean 2001).

The original programme has been reviewed and amended following the initialpilot. For instance, the age of the participants has been lowered. The cyclical nature ofaction research has also impacted on the delivery of the lessons. The active partici-pation of children has been evident throughout the sessions. Children have enjoyed thegroup work, games, videos and drama. The work has been inclusive in its approach andsome children with severe difficulties have been able to join in. This collaboration hasfostered a feeling of equality and empowerment (Le May and Lathlean 2001).

The project has been evaluated in several ways. After the programme, thechildren, taken as a whole group, showed little difference in their locus of control,although girls tended to move more towards internalization and boys towards external-ization. The assumption is that this may be because of the relatively brief nature of theprogramme. A longer programme is necessary for a change in perception (Mann et al.1991). The three sessions in the course are brief and very busy. In line with theprinciples of action research it is suggested that a further study be undertaken concen-trating on a group of children over a longer time frame to identify the optimum lengthfor the programme. There may also be some value in exploring further the reasons forthe perceived difference in effect on girls and boys.

The qualitative results show how children have used the programme todevelop strategies to cope with bullying and their relationships with other children athome and school.

Another issue that needs to be clarified is the dilemma of whether to target afew children or to offer a universal programme. It has been shown in the locus ofcontrol test that the results were within the norm for this age group (11–12-year-olds),although again, the girls started from a higher mean score and moved to a lower score.It would be a useful study to identify at the initial questionnaire those whose external-ization exceeded the mean plus one standard deviation, and then to do a concentratedprogramme with them. One implication of this would be that school nurses andclassroom teachers might not be the best vehicle for delivering such a concentratedprogramme since their main focus is on the whole school population.

3(3) 8/25/04 1:39 AM Page 175

However, the quantitative results of the study are only one aspect of the whole.The qualitative results give a much more positive aspect to the findings of theprogramme. This shows how children have used the programme to develop strategiesto cope with bullying and their relationships with other children at home and school.This shows the importance of combining both sorts of measures in action research.Taken in isolation the quantitative results would suggest a conclusion that theprogramme was ineffective but the qualitative results suggest that raw measurementsmay lack the subtlety to fully evaluate the programme.

One issue with the use of locus of control in the area of bullying is thatbullying requires bullies as well as victims, both are members of the same schoolcommunity. Stop and think applies to the bully as much as the bullied. It may be thatthe group of children with an internalized locus of control may contain theaggressors and that it may be valuable for some children to lessen their internal-ization. After all just because a high level of internalization is considered to indicate‘independence, social maturity, academic confidence, and self-motivated behaviour’,does not rule out the bullying of those who lack these qualities. In any event, forpotential bullies to reflect on the consequences of their actions is probably equallyvaluable, although possibly more difficult to measure. This suggests that in lookingfor quantitative measurement there may be a need for a more sophisticated tool toprovide meaningful results.

Children, teachers and school nurses have provided rich data to support theuse of the strategy in schools. Further work is needed to assess the long-term impact ofthe programme. In addition, the whole school community would benefit from learningand reinforcing the strategy. Work is continuing in Sheffield schools to help youngpeople make the most of their lives, to promote their emotional well-being and enablethem to make healthy choices. It is hoped that the stop, think, do programme willbecome embedded in the culture of schools so that all young people benefit from itsuse. By stopping and thinking, teenagers are encouraged to reflect on their options,consider the consequences and seek help. The stop, think, do programme cannotprovide all the answers to the self-harming and suicidal behaviour of the young.However, it is workable and has provided a meaningful framework for the Year 7children at Myrtle Springs School. Children themselves found it useful, saying ‘can wehave them lessons again?’.

ReferencesAinley B, Barlow P, Houldin R, Miller J, Potter K, Reypert A, Wilson S. Primary care: action research in

the implementation process. Community Practitioner 2000; 73(2): 470–2. Bandura A. Self-efficacy mechanism in human agency American Psychologist 1982; 37(2): 122–47.Beck J, Horne D. A whole school implementation of the Stop Think Do social skills training program at

Minerva special school. In B Willis, J Izard (eds) Student Behaviour Problems : Directions,Perspectives and Expectations. Australian Council for Educational Research, 1992.

Bell,J. Doing Your Research Project. 2nd Edn. Open University Press, 1993. Bloch D. Adolescent suicide as a public health threat. Journal of Child and Adolescent Psychiatric Nursing

1999; 13(1): 26–38.Carlton P, Deane F. Impact of attitudes and suicidal ideation on adolescents’ intentions to seek professional

Day176

3(3) 8/25/04 1:39 AM Page 176

177

psychological help. Journal of Adolescence 2000; 23: 35–45.Carr W, Kemmis S. Becoming Critical. Education, Knowledge and Action Research Deakin University

Press, 1986.Carris M, Sheeber L, Howe S. Family rigidity, adolescent problem solving deficits and suicidal ideation: A

mediational model. Journal of Adolescence 1998; 21: 459–72.Day P, Murphy A, Cooke J. Traffic light lessons; problem solving skills with adolescents. Community

Practitioner 1999; 72(10): 322–4.Department of Health. Saving Lives. London: Stationery Office, 1999.Elias M, Weissberg R. School based social competence promotion as a primary prevention strategy: A tale

of two projects. In R Lorian (ed) Protecting the Children: Strategies for Optimising Emotional andBehavioural Development. Haworth, 1990.

Fisher R. Teaching Juniors. Stanley Thornes, 1991.Forman G. Coping Skills: Interventions for Children and Adolescents. Jossey-Bass, 1993.Furnham A, Steele H. Measuring locus of control: A critique of general children’s health and work-related

locus of control questionnaires. British Journal of Psychology 1993; 84: 443–79.Garland AF, Zigler E. Adolescent suicide prevention. Current research and social policy implications.

American Psychologist 1993; 48: 169–82.Hart E, Bond M. Action Research for Health and Social Care. A guide to practice. Open University Press,

1995.Harvey-Jordan S, Long S. Focus groups for community practitioners: A practical guide. Community

Practitioner 2002; 75(1): 19–21. Hawton K, Fagg J, Simkin S, Bale F, Bond A. Deliberate self-harm in adolescents in Oxford 1985-1995.

Journal of Adolescence 2000; 23: 47–55.Hendricks C. (1999). Perpetual determinants of early adolescent health promoting behaviours: Model

development. Journal of Theory Construction and Testing 1999; 2(1): 13–22.Hill K. The Long Sleep: Young People and Suicide. Virago, 1995.Kenny C. Its good to talk. Nursing Times 2002; 98(1): 14.Kingsbury S, Hawton K, Steinhardt K, James A. Do adolescents who take overdoses have specific psycho-

logical characteristics? A comparative study with psychiatric and community controls. Journal of theAmerican Academy of Child and Adolescent Psychiatry 1999; 38(9): 1125–31.

Laurent C. Holding on. Health Service Journal 2000; 5 October: 6–7.Le May A, Lathlean J. Action research: A design with potential. NT Research 2001; 6(1): 502–9.Lester D. State initiatives in addressing youth suicide: Evidence for their effectiveness. Social Psychiatry

and Psychiatric Epidemiology 1992; 27: 75–7. Madge N, Harvey,J. Suicide among the young – the size of the problem. Journal of Adolescence 1999; 22:

145–55. Malone KM, Oquendo MA, Haas GL, Ellis SP, Li S, Mann J. Protective factors against suicidal acts in

major depression: Reasons for living. American Journal of Psychiatry 2000; 157(7): 1084–8.Mann L, Harmoni R, Power C. The GOFFER course in decision making. In J Baron, RV Brown (eds.)

Teaching Decision Making to Adolescents. Hove: Lawrence Erlbaum Associates, 1991.McDougall P. Focus groups: An overview of their use as a research method. Community Practitioner 1999;

72(3): 48–9.Meyer J. New paradigm research in practice:The trials and tribulations of action research. Journal of

Advanced Nursing, 1993; 18: 1066–72.Meyer J. Using qualitative methods in health related action research. British Medical Journal 2000; 320:

178–81.Neill S. Developing children’s nursing through action research. Journal of Child Health Care 1992; 2(1):

11–15.Nimmo J. Social competence: A pilot study of a cognitive behavioural social skills programme with compar-

isons of outcomes for in-class and withdrawal groups. Unpublished Master Ed. Thesis, QueenslandUniversity, 1993.

Nowicki S, Strickland BR. A locus of control scale for children. Journal of Consulting and Clinical Psychology1973; 40: 148–51.


3(3) 8/25/04 1:39 AM Page 177

Overholser J, Hemstreet Spirit B, Vyse S. Suicide awareness programmes in the schools: Effects of gender andpersonal experience. Journal of the American Academy of Child and Adolescent Psychology 1989; 28:925–30.

Parahoo K Nursing Research: Principles, Process and Issues. Basingstoke, Hants: MacMillan, 1997.Petersen L. Stop, think, do: Improving social and learning skills for children in clinics and schools. In PJG Henck

(ed.) Behavioural Approaches for Children and Adolescents: Challenges for the Next Century. PlenumPress, 1995.

Petersen L, Gannoni AF. Teachers’ Manual for Managing Student Behaviour Skills while Managing StudentBehaviour. Australian Council for Educational Research, Hawthorn, Victoria, 1992.

Ploeg J, Ciliska D, Dobbins M. A systematic overview of adolescent suicide prevention programmes. CanadianJournal of Public Health 1996; 87(5): 319–24.

Polit D, Hungler B. Essentials of Nursing Research Methods, Appraisal and Utilization. 4th Edn. Lippincott-Raven, 1997.

Pollock LR, Williams JMG. Problem solving and suicidal behaviour. Suicide and Life-Threatening Behaviour1998; 28(4): 375–87.

Redfern S, Norman I. Validity through triangulation. Nurse Researcher 1994; 2(2): 40–56.Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychological

Monographs: General and Applied 1966; 80(1): 1–28.The Samaritans. Young Men Speak Out. Samaritans, 1999.Sandin B, Chorot P, Santed MA, Valiente M, Joiner TE. Negative life events and adolescent suicidal behaviour:

A critical analysis from the stress process perspective. Journal of Adolescence 1998; 21: 415–26. Seiffge-Krenke I. Causal links between stressful events, coping style and adolescent symptomatology. Journal of

Adolescence 2000; 23: 47–55.Sharp P. Nurturing Emotional Literacy. A Practical Guide for Teachers, Parents and those in the Caring

Professions. David Fulton, 2001.Sheffield Childrens Hospital Accident and Emergency Department. Reported incidences of self-harm in 11–16

year olds in Sheffield. Unpublished manuscript, 1996.Sheffield First. Sheffield Trends. Produced by a partnership of public private and not-for-profit organisations in

Sheffield, 1999.Sheffield Health Action Zone. Cutting Edge Equity Pledge. Sheffield Health Authority, 1999.Sheffield Health Information and Research Department. Death Tapes 1995–1998. OPCS, 1999.Shih F. Triangulation in nursing research: Issues of conceptual clarity and purpose. Journal of Adolescent

Nursing 1998; 28(3): 631–41.South Yorkshire Area Child Protection Committee. Child protection prcedures. South Yorkshire Services, 2001.Stead M, Pitt F, Clegg D. Severe mental illness in Sheffield. A population heath needs assessment. Sheffield

Health Authority, 2001.Sturt J. Placing empowerment research within an action research typology. Journal of Advanced Nursing 1999;

30(5): 1057–63.Tomori M, Zalar B. Characteristics of suicide attempters in a Slovenian high school population. Suicide and Life

Threatening Behaviour 2000; 30: 3. Twinn S. The analysis of focus group data. A challenge to the rigour of qualitative research. NT Research 2000;

5(2): 140–6.Van Slyck M, Stern M, Zak-Place J. Promoting optimal adolescent development through conflict resolution,

education, training and practice: An innovative approach for counselling psychologists. CounsellingPsychologist 1996; July: 433–61.

Williams JMG. Different reasons for taking overdoses in high and low hopelessness groups. British Journal ofMedical Psychology 1986; 59: 269–77.

Address for correspondence: Patricia Day, School of Health and Social Care, SheffieldHallam University, 33 Collegiate Crescent, Sheffield S10 2BP. (E-mail [email protected])

Day178

3(3) 8/25/04 1:39 AM Page 178

Documents

Is teaching problem solving to young people a way of preventing teenage suicide?