Shashank V. Joshi, MD, FAAP Jeremy Wilkinson, MD Lucile Packard Children’s Hospital at Stanford

Resilience and Coping in Middle and High School:

The Roles of Parents, School staff, Peers

& Community

Resilience and Coping in Middle and High School:

The Roles of Parents, School staff, Peers

& Community

Shashank V. Joshi, MD, FAAPJeremy Wilkinson, MD

Lucile Packard Children’s Hospital at Stanford

[email protected]

Shashank V. Joshi, MD, FAAPJeremy Wilkinson, MD

Lucile Packard Children’s Hospital at Stanford

[email protected]

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Outline of this sessionOutline of this session

Present current barriers to identification and support of students

Propose strategies for collaboration

Describe coping and resiliency factors which may help to buffer stress

Present current barriers to identification and support of students

Propose strategies for collaboration

Describe coping and resiliency factors which may help to buffer stress

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Primary therapeutic relationshipsPrimary therapeutic relationships

peers

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When Normal Stress Becomes Unmanageable

When Normal Stress Becomes Unmanageable

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

Students may find it hard to ask for help

Peers may be unaware of signs and symptoms of depression

Parents may be afraid to ask about depression and self-harm

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

Students may find it hard to ask for help

Peers may be unaware of signs and symptoms of depression

Parents may be afraid to ask about depression and self-harm

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Other challengesOther challenges

School personnel may experience parents and doctors as barriers to health, rather than as partners

Parents and Doctors may hold similar views of school personnel

Psychiatrists and other mental health providers are often difficult to reach

School personnel may experience parents and doctors as barriers to health, rather than as partners

Parents and Doctors may hold similar views of school personnel

Psychiatrists and other mental health providers are often difficult to reach

Risks &Vulnerabilities

Assets &Protective Factors

Frances J Wren MD

DevelopmentalDevelopmental

Thoughts:Hopeless

Self-criticalGlass half-full

Brooding

Relationships:

WithdrawnIrritable

Pessimistic

Emotions:Sad

BoredJoylessAnxious

Easily upset

Body:Disturbed sleep

Disturbed appetitePoor concentration

Low energy

Less fun

Fewer successes

Missed opportunities

Less social support

Withdrawal from activities

Loss of relationships

Hard to start, finish, learn

Frances J Wren MD

Pathways to adolescent depression

Genetics Brain

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

Emotional regulationEmotional regulation

Anxiety/ArousalAnxiety/Arousal

Cognitive style

Cognitive style

How easily worried? How fearful?

Body stress/arousal? Sleep?

Life Experience

How flexible?How positive?

Easily discouraged?Believes can change things?

Frances J Wren MD

Risks &Vulnerabilities

Assets &Protective Factors

Community, Family, Teen

RESILIENCE

Frances J Wren MD

Protective factors for Kids:Protective factors for Kids:

Positive emotions: optimism, joy, humor

Flexible thinking

Sense of meaning & value

Active coping style

Social support

Positive emotions: optimism, joy, humor

Flexible thinking

Sense of meaning & value

Active coping style

Social support

Frances J Wren MD

Protective Factors for TeensProtective Factors for Teens

Effective parenting, with mutual respect between teen/parent

Connections to other competent and caring adults

Connections to pro-social and competent peers

Problem-solving skills

Positive self-perceptions & Talents valued by self and society

Beliefs that life has meaning/hopefulness

Community/School safety and effectiveness Frances J Wren MD

Buffer zones (Riera, 2004)Buffer zones (Riera, 2004)

Stress buffer zone

Stress tolerance level

Sedimented Stressvia Traumatic Events:

Divorce, Death of a loved one, Prolonged Illness,

Financial Stress, Poverty, or other factors

Girlfriend/boyfriend rejection

Exams College Apps Graduatio

n

Girlfriend/boyfriend rejection

Exams

College Apps

Graduation

Safe, effective

communities

Safe Responsive

Opportunities to develop talents and skills Connections with caring

competent adultsConnections with competent peers

Loving, effective families

Love, joy, humorCommunication, responsiveness, flexibility

Consistent, rational disciplineRealistic expectations

Resources to obtain services and opportunities

Emotionally skilled kidsManaging negative feelings

Problem-solvingMaking and keeping relationships

Recognizing and valuing own talents and skills

Finding opportunities for fun and joy

Frances J Wren MD

What about the vulnerable teen?What about the vulnerable teen?Challenging temperament

Exposed to trauma

Family troubles - including parental depression

Frances J Wren MD

The teen with a challenging temperament

The teen with a challenging temperament

Active teaching of skills

Early intervention: if interfering with life, if exposed to trauma

Planning: finding strengths and talents

Attend in particular to: anxiety, sleep, social skills

Take care of ourselves as friends and parents

Frances J Wren MD

Resilience in the face of trauma or loss

Resilience in the face of trauma or loss

Putting the experience into words:naming, education, putting together the story

Learning skills and strategies

Becoming active in reality and in memory

Early intervention

Frances J Wren MD

Resilience in the face of family troubles

Resilience in the face of family troubles

Putting the experience into words:naming, education,

putting together the story as an individual and as a family

Able to see things from others’ points of view

Realistic about the troubles; Active problem-solver

Not alone in the midst of the trouble or afterwards

Parental self-care

Frances J Wren MD

Resilient children are not super children; resilience comes from hard slow growth, mastering obstacles and developmental

challenges

William Beardslee: Out of a Darkened Room

Frances J Wren MD

ResourcesResources

Please see the Project Safety Net website for books and Internet resources related to coping and resilience

Frances J Wren MD

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peers

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peers

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

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You Can Help!Adapted with permission

from the Washington Youth Suicide Prevention Program

You Can Help!Adapted with permission

from the Washington Youth Suicide Prevention Program

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You can help. . . You can help. . .

Know warning signs

Conduct intervention

Know warning signs

Conduct intervention

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Most suicidal people don't really want to die – they just want their pain to end.

About 80% of the time people who kill themselves have given definite signals or talked about suicide.

Most suicidal people don't really want to die – they just want their pain to end.

About 80% of the time people who kill themselves have given definite signals or talked about suicide.

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Warning Signs

Observable signs of serious depression Unrelenting low mood Pessimism Hopelessness Desperation Anxiety, psychic pain, inner tension Withdrawal Sleep problems

Increased alcohol and/or other drug use

Recent impulsiveness and taking unnecessary risks

Threatening suicide or expressing strong wish to die

Making a plan Giving away prized possessions Purchasing a firearm Obtaining other means of killing oneself Unexpected rage or anger

Warning Signs

Observable signs of serious depression Unrelenting low mood Pessimism Hopelessness Desperation Anxiety, psychic pain, inner tension Withdrawal Sleep problems

Increased alcohol and/or other drug use

Recent impulsiveness and taking unnecessary risks

Threatening suicide or expressing strong wish to die

Making a plan Giving away prized possessions Purchasing a firearm Obtaining other means of killing oneself Unexpected rage or anger


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Intervention Three Basic Steps

1. Show you care2. Ask about suicide3. Get help

Intervention Three Basic Steps

1. Show you care2. Ask about suicide3. Get help


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Intervention Step One

Show You Care

Be Genuine

Intervention Step One

Show You Care

Be Genuine


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Show you care Take ALL talk of suicide seriously

If you are concerned that someone may take their life, trust your judgment!

Listen Carefully Reflect what you hear Use language appropriate for age

of person involved Do not worry about doing or saying exactly the

"right" thing. Your genuine interest is what is most important.

Show you care Take ALL talk of suicide seriously

If you are concerned that someone may take their life, trust your judgment!

Listen Carefully Reflect what you hear Use language appropriate for age

of person involved Do not worry about doing or saying exactly the

"right" thing. Your genuine interest is what is most important.


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Be Genuine Let the person know you really

care. Talk about your feelings and ask about his or hers.

"I'm concerned about you…about how you feel." "Tell me about your pain." "You mean a lot to me and I want to help." "I care about you, about how you're holding up." "I don't want you to kill yourself." "I'm on your side…we'll get through this."

Be Genuine Let the person know you really

care. Talk about your feelings and ask about his or hers.

"I'm concerned about you…about how you feel." "Tell me about your pain." "You mean a lot to me and I want to help." "I care about you, about how you're holding up." "I don't want you to kill yourself." "I'm on your side…we'll get through this."


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Intervention Step Two:Ask About Self-harm and Suicide

Be direct but non-confrontational

Intervention Step Two:Ask About Self-harm and Suicide

Be direct but non-confrontational


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Ask about self-harm and suicide

Don't hesitate to raise the subject.

Talking with people about suicide won't put the idea in their heads

Chances are, if you've observed any of the warning signs, they're already thinking about it

Be direct in a caring, non-confrontational way. Get the conversation started.

Ask about self-harm and suicide

Don't hesitate to raise the subject.

Talking with people about suicide won't put the idea in their heads

Chances are, if you've observed any of the warning signs, they're already thinking about it

Be direct in a caring, non-confrontational way. Get the conversation started.


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You do not need to solve all of the person's problems;

Just engage them

Are you thinking about harming yourself or suicide?

Do you have a plan for harming yourself, ending your life?

What thoughts or plans do you have?

How long have you been thinking about suicide?


Just engage them

Are you thinking about harming yourself or suicide?

Do you have a plan for harming yourself, ending your life?

What thoughts or plans do you have?

How long have you been thinking about suicide?


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Just engage them

Have you thought about how you would do it?

Do you have __? (Insert the lethal means they have mentioned.)

Do you really want to die? Or do you mainly want the pain to go away?


Just engage them

Have you thought about how you would do it?

Do you have __? (Insert the lethal means they have mentioned.)

Do you really want to die? Or do you mainly want the pain to go away?


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Ask about treatment

Do you have a therapist/doctor?

Are you seeing him/her?

Are you taking your medications?

Ask about treatment

Do you have a therapist/doctor?

Are you seeing him/her?

Are you taking your medications?


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Intervention Step Three:Get help but do NOT leave the student alone

Know referral resources Reassure the student Encourage the student to

participate in helping process Outline safety plan

Intervention Step Three:Get help but do NOT leave the student alone

Know referral resources Reassure the student Encourage the student to

participate in helping process Outline safety plan


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Know Referral Resources

Resource sheet

Hotlines

Know Referral Resources

Resource sheet

Hotlines

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Hotlines National Suicide Prevention Lifeline

1-800-273-TALKwww.suicidepreventionlifeline.org

911 In an acute crisis call 911

Hotlines National Suicide Prevention Lifeline

1-800-273-TALKwww.suicidepreventionlifeline.org

911 In an acute crisis call 911


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Reassure the person that help is available and that you will help them get help. Together I know we can figure something out to

make you feel better. I know where we can get some help. I can go with you to where we can get help. Let's talk to someone who can help . . . Let's

call the crisis line now.

Encourage the suicidal person to identify other people in their lives who can also help. Parent/Family Members Favorite Teacher School Counselor School Nurse Religious Leader Pediatrician/ Family doctor

Reassure the person that help is available and that you will help them get help. Together I know we can figure something out to

make you feel better. I know where we can get some help. I can go with you to where we can get help. Let's talk to someone who can help . . . Let's

call the crisis line now.

Encourage the suicidal person to identify other people in their lives who can also help. Parent/Family Members Favorite Teacher School Counselor School Nurse Religious Leader Pediatrician/ Family doctor


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Outline a safety plan Make arrangements for the helper(s) to

come to you OR take the person directly to the source of help - do NOT leave them alone!

Once therapy (or hospitalization) is initiated be sure the suicidal person is following through with appointments and medications.

Outline a safety plan Make arrangements for the helper(s) to

come to you OR take the person directly to the source of help - do NOT leave them alone!

Once therapy (or hospitalization) is initiated be sure the suicidal person is following through with appointments and medications.


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peers

Documents

Shashank V. Joshi, MD, FAAP Jeremy Wilkinson, MD Lucile Packard Children’s Hospital at Stanford