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School-based Strategies for Building Resilience and Promoting Adolescent Mental

Health: Lessons Learned from a Community Suicide Cluster

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Shashank V. Joshi, MD, FAAP svjoshi@stanford.edu

School-based Mental Health Services

✏ Background

✏ Schools are the primary providers of mental health services for children (Hoagwood, 2007) ✏ 1st line providers by default ✏ Better if by design

✏ Among children who do receive services, 70-75% report school as the primary source of care 25% get treated in the general medical sector (Burns, et al., 1995; Hoagwood, 2007; Bagnell, 2007)

✏  > 10% of U.S. children are not progressing

academically due to mental health disorders

And how many depressed teenagers have a parent with depression?

10-14% Major Depression 20-25% Depression of some type

Major  Depression  in  Teenagers  

Average age of onset 15 years

By the age of 18 years how many have had an episode?

20-50%

Frances  J  Wren,  MD  

Pathways  to  adolescent  depression  

Gene<cs   Brain  

How  easily  upset?  How  intensely?  How  long?  Capacity  for  joy,  humor?  

Emotional regulation

Anxiety/ Arousal

Cognitive style

How  easily  worried?    How  fearful?  Body  stress/arousal?    Sleep?  

Life  Experience  

 How  flexible?  How  posi<ve?  

Easily  discouraged?  Believes  can  change  things?  

Frances J Wren, MD

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The Problem Counselors, psychologists, teachers and other personnel may be unsure of their roles

Developmental challenges to symptom reporting by child / young teen

Peers may be unaware of signs and symptoms of depression (in self or others)

Barriers to help-seeking must be understood and overcome, and sociocultural factors are key

The Tragedy of Teen Suicide

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q  Palo Alto, California

q  66,500+ residents

q  12,500 students

q  An exceptional community to live, work and visit

q  A community shaken by teen suicide 2009 - 2010 and again 2014 - 2015

Protec<ve  Factors  in  Youth  Suicide  

Protective Factors

Family Connectedness -Positive Parent/Child relations - Parental involvement/ spvsn

Religiosity Beliefs against suicide

Social support/connectedness -Opportunities to engage in supportive social environments (sports teams, extracurriculars, youth groups)

Positive School Connections -School climate -Prosocial peer connections -Perceived availability of trusted adults

Borowsky, I.W., Ireland, M., & Resnick, M.D. (2001). Adolescent suicide attempts: Risks and protectors. Pediatrics, 107, 485–493. Bridge, J.A., Goldstein, T.R., & Brent, D.A. (2006). Adolescent suicide and suicidal behavior. Journal of Child Psychology and Psychiatry 47, 372–394 Gould, M.S., Greenberg, T., Velting, D.M., Shaffer, D. (2003). Youth suicide risk and preventative intervention: A review of the past 10 years, J Am Acad Child Adolesc Psychiatry 42-4, 42:4, 286-405. Wyman (2014): Developmental Approach to Prevent Adolescent Suicides; Am J Prev Med 2014;47(3S2):S251–S256

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EDUCATION PREVENTION INTERVENTION

E-1 Mental Health Curriculum in Schools

P-1 Youth Outreach I-1 Adopted Suicide Prevention Policies

E-2 Community Education P-2 Mental Health Support for Students

I-2 Screening

E-3 Media Education P-3 Character Education & Resilience Skill Building

Programs

I-3 Peer to Peer Support

E-4 Mental Health Training for Teachers

P-4 Reduction of Lethal Means to Self Harm

I-4 Surveys/Assessment of Risk

P-5 Crisis Manual and Safety Plan

I-5 Gatekeeper Programs

P-6 Accessible Resources on Suicide Prevention and

Depression

I-6 Affordable and Expanded mental Health Care

P-7 Reduction of Harassment and Social Cruelty

I-7 Crisis Hotlines

P-8 Supportive School Environment

I-8 Support for Highest Risk Youth

I-9 Grief Counseling for those Impacted by Suicide

I-10 Organized Health Care Provider Network

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Primary therapeutic relationships & The Supporting Alliance

Parents Teachers / School staff

Doctors/ Therapists

Student

peers

Adapted with permission from Feinstein, Fielding, Udvari-Solner, & Joshi: Amer Jnl of Psychotherapy, 63(4) 2009

The role of collaboration

Mainstreaming increases Classroom heterogeneity

necessitates

New relationships with doctors and parents

Instructional tolerance mediates

Teacher stress, leading to attrition, frustration, and poor student outcomes

Poor collaboration taxes resources, reducing

Good collaboration builds capacity, increasing

Figure 1 – Influence of collaboration on instructional tolerance.

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Partners and Stakeholders

Adapted with permission from Feinstein, Fielding, Udvari-Solner, & Joshi: Amer Jnl of Psychotherapy, 63(4) 2009

Examples of School Policy Reforms

✏ The Academic, Social, and Emotional Learning Act of 2015 (Rep. Tim Ryan, Ohio)

✏ California Student Mental Health Policy Workgroup Rec #4: Teacher and Administrator training for mental health in the classroom

✏ Palo Alto Unified School District (PAUSD) BP/AR for Suicide Prevention and Wellness Promotion