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1. As discussed in the book and in the powerpoint presentation, there is the myth of adolescence being a time of strife and turmoil,. Do you agree? What was your adolescent period like?2. Additionally, review the information below as well as the powerpoints. Share your thoughts on identity crisis, parental involvement, substance use, eating disorder, and suicide. How would you address these issues with teens and parents, especially now during COVID-19 restrictions? How useful was the information in the twelvetalks link (review the wheels and gender identity sections? How would you use those resources to talk to teens, parents, and your family members?
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Whitepaper December 2020
Transforming Suicide
prevention through Education,
Innovation and Technology
Five Suicide Experts Discuss the Challenges and Opportunities
Precision Guided Behavioral Health
3025 SW 1st Ave, Portland, Oregon 97201
800.910.6769
owlinsights.com
Rising suicide rates represent a public health crisis.1 According to CDC data, rates of suicide increased 35%
from 1999 to 2018. A statistic that forces us, as a country, to evaluate the efficacy of our nation’s suicide
prevention efforts. Despite this sobering fact, there is good news. Advances in technology and access,
some spurred by the pandemic, are creating new opportunities to address this problem.
A panel of suicide prevention experts gathered in November of 2020 to discuss those opportunities via webinar.
The expert panel included:
–
Dr. Christine Moutier, Chief Medical Officer, American Foundation for Suicide Prevention
–
Dr. Tony Pisani, Associate Professor of Psychiatry and Pediatrics at the Center for the Study and Prevention of
Suicide at the University of Rochester, New York
–
Dr. Tom Insel, Mental Health Czar for the State of California and CEO of Humanest
–
Dr. Christy Esposito-Smythers, Professor and Licensed Clinical Psychologist George Mason University and
Inova Health System
–
Dr. Whitney Black, Psychiatrist and Quality Medical Director for the Department of Psychiatry at Oregon
Health & Science University (OHSU), and Clinical Advisor for Owl Insights, moderated the panel.
Understanding the Data and Current
State Strategies
Additional Risks Identified During the
COVID-19 Pandemic
Understanding suicide prevention during the
COVID-19 pandemic requires evaluation of the
dynamic between pre-pandemic risk factors
and more specific pandemic risk factors (e.g.,
isolation, economic loss). Recent surveys by the
CDC indicate increased rates of stress, anxiety, and
depression triggered by the COVID-19 pandemic.2
Their recent report indicates that between
10% -11% of respondents reported experiencing
suicidal ideation within the previous 30 days.
For contrast, rates of suicidal ideation in primary
care populations are commonly estimated to be
between 2.4-3.3%.3 This speaks to the need for a
national public health strategy to address this crisis.
During the webinar, Dr. Tom Insel suggested we
need to create a system of care that meets people
where they are. “Rather than waiting until there’s
a crisis, where someone has already arrived in the
emergency room, if we had been able to get there
in a moment of need, at the time and place where
they were willing to engage…we may have been
able to manage the situation – before there was a
crisis.” This situation acknowledges the reactionary
nature of our current system and the need to
develop a more proactive system.
How to identify the warning signs of a
developing crisis and ensure access to resources
is a complicated problem to solve, but the
science around suicide risk and prevention is
evolving. Dr. Christine Moutier commented on
her research in this area – describing how the
COVID-19 pandemic may increase risk through
its effects on a number of well-established prepandemic suicide risk factors.4
Identifying risk starts with establishing a
framework. Webinar participants were polled with
the following question:
“Does your organization have a standard process
and/or policies in place to systematically identify
people at risk for suicide through screening and
assessment?”
Yes
76%
No
24%
Citing challenges such as the economy, the
opioid crisis, and social media, she noted it
is important to ask, “’Where is the evidence
for strategies that could be employed and
need to be scaled at state and national levels
to mitigate the risk that COVID is very likely
pressing upon mental health distress and the
other socioeconomic factors?’ Even the rise in
alcohol sales and gun sales – these things say to
us, in the suicide prevention field – that there is
a moment of heightened risk, but there’s also
incredible opportunity, now that the dialogue
has opened up on a national scale to start
talking about how everybody is feeling because
we’re all feeling stress and strain.”
Pointing out that suicide is complex, but also
a preventable cause of death, Moutier said
“clinicians and health systems have a pivotal role
to play. Even for all the very important suicide
prevention roles played at the community
level, ultimately when someone is detected as
at risk, everyone is instructed to do the same
thing, which is to connect the at-risk person
with their primary care provider, emergency
department, or mental health professional.”
Indeed, healthcare visits represent a significant
opportunity to detect suicide risk and
provide interventions.
N = 109
Precision Guided Behavioral Health
3025 SW 1st Ave, Portland, Oregon 97201
800.910.6769
owlinsights.com
A Need to Bridge Gaps Between Touchpoints
Meeting patients where they are was a common theme during the webinar. Approximately 38% of individuals
make a health care visit within one week prior to a suicide attempt, with the majority of these visits occurring
primary care.5 These visits represent an opportunity to intervene just as one would for those at risk for stroke or
other health conditions. Yet, access to care and evidence-based treatments remains challenging. Insel stated,
“Where we’ve really failed is on the continuity piece, and this is what other countries do much better. We don’t
have a kind of active, continuous, comprehensive care system for people who have made an attempt to ensure
that they’ll never make another attempt.” Creating this type of system would require numerous shifts including
improving access to care, training providers in suicide prevention and culturally responsive care, and scaling to
meet the needs of our communities.6
Providers need more suicide prevention education to effectively detect and treat risk. Pointing out the gaps in
our system and provider education, Black asked, “How do we train providers across the healthcare spectrum in
order to close the research-to-practice gap and create a more efficient, effective system for suicide prevention in
healthcare? And does technology play a role?”
Identifying risk starts with establishing a
framework. Webinar participants were polled with
the following question:
“Does your organization provide standardized
suicide prevention education to all providers,
including non-behavioral health providers?”
Yes
61%
No
39%
N = 109
Precision Guided Behavioral Health
Dr. Anthony R. Pisani’s work spans the prevention
continuum and his observation has been that
education creates paradigm shifts – like the one
that dramatically decreased deaths in automobile
accidents starting in the 1970s. People had to shift
their attitude toward safety and accept measures
such as seat belts and safer roads. Community
organizations like Mothers Against Drunk Driving
(MADD) changed attitudes and influenced policy. We
need a national, scalable strategy to address the key
components of suicide prevention.
“As we improve our measurements, as we make them
more real time, how do we then prepare ourselves to
cooperate with the data?” he asked. “We are moving
into an era where we will get better predictive
models and improved screening that doesn’t just
depend upon one person’s report but will pull in
other variables as well. But we really need to be
thinking about how we cooperate with that data.
How do we work alongside the robots essentially
to provide that human connection? What you do
matters, but how we do it matters more. I think a lot
of the education can focus there.”
3025 SW 1st Ave, Portland, Oregon 97201
800.910.6769
owlinsights.com
Democratizing Mental Health
Continuously engaging people even when it’s
logistically challenging – and even when it takes care
providers out of their usual brick and mortar clinic –
will be key to reversing suicide trends. Insel described
his hopes for a system “where people can get pulled
into care and stay in care rather than having a crisisdriven care system, which is what we have today. It’s
really hard to bend the [suicide rates] curve with that
kind of a system.”
Dr. Whitney Black agreed: “We all want this for our
patients – this democratizing of mental health – but
it’s been hard to do, getting people access that works
for them via telehealth or new applications. I think
about how very important it is that patients get peer
support or group support because our clinics are open
from 8:00 to 5:00 but life keeps going and so do the
stressors.”
The Veterans Administration’s REACH VET program
is doing good work in this area, Dr. Anthony Pisani
said. The program employs predictive modeling and
The Anxiety and Depression Association of America
reports more than 90% of American adults say that
mental health is as, or more important than physical
health. However, this has not translated into the
majority of people with a mental health condition
actually receiving the care that they need.9
“The great news is that through technology,
measurement-based care can be delivered using
measurement feedback systems that are cloudbased and allow for assessments to be completed
electronically via smartphones, tablets, or even
computers, which makes the job of the clinician and
the implementation of measurement-based care
that much easier,” Esposito-Smithers said. “The Owl
is a prime example of this. From our perspective at
the Inova Kellar Center and the research at large, it’s
well worth the investment. There’s clear research to
suggest that measurement-based care does improve
client outcomes when integrated with an evidencebased practice.”
medical record data to identify Veterans at highest
risk for suicide.7 “And they use that to provide
outreach,” he said, “instead of waiting for people to
come in. In first efforts, they don’t yet see that it’s had
an effect. But as a health system, the VA has tons of
data that might be informative…. There’s still a firm
boundary right now between something that is in
the health system, in healthcare provision, and then
people’s health outside of that system. I really like the
idea of ‘Can we blur that a little bit?’ so that health
is what we’re really focused on – not whether it’s
happening in a healthcare system or elsewhere.”
Technology-Enabled Solutions and
Measurement-based Care
Technology offers a variety of solutions that may help
providers meet patients where they are and improve
continuity. For example, a technology enabled
measurement-based solution, facilitates tracking of
patient symptoms both at and in between visits, while
also reducing burden on providers. Measurementbased care is an evidence-based practice that involves
the systematic administration of symptom rating
scales and the use of the results to drive clinical
decision.8
Further, merging the practice of measurementbased care with technology facilitates ongoing use
of this evidence-based practice in the telehealth
environment while collecting data for future analysis
to inform population health strategies. In essence,
these platforms allow the collection of patientreported outcome measures (PROMs) as well as
feedback from families, parents, and teachers via a
cloud based application. Some providers are using
measurement-based care as a proactive tool to
monitor patients’ symptoms severity and suicidal
ideation between appointments, allowing them to
provide more proactive than reactive care.
“There’s clear research to suggest that
measurement-based care does improve
client outcomes when integrated with an
evidence-based practice.”
Christianne Esposito-Smythers, chief medical officer
of the American Foundation for Suicide Prevention
Precision Guided Behavioral Health
3025 SW 1st Ave, Portland, Oregon 97201
800.910.6769
owlinsights.com
Supporting Care and Connection
Reducing Reactivity in the System
In her work at OHSU, Dr. Whitney Black has
experienced the practical application of this idea.
“Through our application of measurement-based
care, through the Owl at OHSU, we developed a
suicide care pathway in several of our outpatient
clinics. We’re continuously monitoring our patients
through measurement-based care, through the
administration of specific measures like the C-SSRS,
PHQ-9, PHQ-A, even in between appointments.”
In her work at OHSU, Dr. Whitney Black has
experienced the practical application of this idea.
“Through our Referring again to her institution’s
work, Black explains that at OHSU, a social worker
is consistently monitoring the system, so that
when a patient is flagged as potentially having
increased risk, someone reaches out to checkin with the patient. “The social worker then
contacts that patient to check-in with them and
say, ‘Hey, what’s going on? Are you doing okay?
Any new stressors? Do we need to move up your
appointment? Do we need to get somewhere
for some crisis care? Let’s do some brief safety
planning,’” she said.
Dr. Christianne Esposito-Smythers shared her
experience with how tech-enabled MBC facilitates
data integration into the clinical encounter by
automating the collection, tracking, and monitoring
of PROMs for patients and sharing results with the
care team.
“For example, if a kid comes in and you see a
significant increase in suicide risk, as a result of one
of the assessments she completed, the treatment
planning team can know it’s time to focus more
closely and decide if a higher level of care is needed,
more frequent sessions perhaps, which would
significantly improve the quality of care for that
child,” Esposito-Smythers said.
“The really beautiful thing about that,” she
continued, “is that it also serves as a caring
contact, which I think might be the most
important part. If someone’s home and alone,
especially during the pandemic, they know that
someone is thinking about them, that within the
same day of completing an assessment, they got a
call back because someone’s worried and thinking
about them.”
Research shows that suicidal thinking can fluctuate
significantly from moment to moment, indicating a
need for ongoing assessment outside of the
clinic visit.
Finding New Ways to Make Connections
Suicide Prevention is about procedures and policies and setting a framework but it’s also about helping
patients feel connected with providers and the community. A key goal is to avoid creating in them
the feeling that they’re only feeding information into a system, merely “ticking a box,” as Pisani put it.
Accessibility is important from a logistical and an emotional standpoint. Moutier said she’d like to see
more ways our system is “almost in your face, in terms of incorporating connection into our daily lives.
Cognitive retraining, distress tolerance, mindfulness techniques, and treatment for psychiatric conditions
are packed with evidence and promise for reducing suicide risk. But our issue has been the actual
implementation in a way that’s based in the tools that we have across and through our lives.”
1 https://www.cdc.gov/nchs/products/databriefs/db362.htm#:~:text=From%201999%20through%202018%2C%20the%20age%2Dadjusted%20
suicide%20rate%20increased,year%20from%202006%20through%202018.
2 https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6932a1-H.pdf
3 https://www.ncbi.nlm.nih.gov/books/NBK137739/
4 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2772135
5 Ahmedani BK, Stewart C, Simon GE, et al. Racial/ethnic differences in health care visits made before suicide attempt across the United States.
Med Care. 2015;53(5):430–5.
6 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2772135
7 https://www.research.va.gov/currents/0918-Study-evaluates-VA-program-that-identifies-Vets-at-highest-risk-for-suicide.cfm
8 https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201500439
9 https://adaa.org/survey-finds-americans-value-mental-health-and-physical-health-equally
Precision Guided Behavioral Health
3025 SW 1st Ave, Portland, Oregon 97201
800.910.6769
owlinsights.com
RESEARCH
f
s and
FINDINGS
ACT for Youth Upstate Center of Excellence
A collaboration of Cornell University, University of Rochester, and the New York State Center for School Safety • May, 2004
Stages of Adolescent
Development
by Sedra Spano
Adolescence is a time of great change for young people.
It is a time when physical changes are happening at an
accelerated rate. But adolescence is not just marked by
physical changes—young people are also experiencing
cognitive, social/emotional and interpersonal changes as
well. As they grow and develop, young people are influenced by outside factors such as: parents, peers, community, culture, religion, school, world events and the
media. There are a number of different theories or ways
of looking at adolescent development (see chart). Each
theory has a unique focus, but across theories there
are many similar elements. While it is true that each
teenager is an individual with a unique personality and
interests, there are also numerous developmental issues
that just about every teen faces during the early, middle
and late adolescent years (AACAP, 2003).
The feelings and behaviors of middle and high school
adolescents can be categorized into five broad areas:
1.) moving toward independence; 2.) future interests
and cognitive development; 3.) sexuality; 4.) physical
changes; and 5.) ethics and self-direction. Specific
characteristics of adolescent behavior within each area
are described in the following material. Teenagers do
vary slightly from the following descriptions, but the
feelings and behaviors are, in general, considered typical for each stage of adolescence.
Early Adolescence (approximately
10-14 years of age)
Movement Toward Independence: emerging identity
shaped over time by internal and external influences;
moodiness; improved abilities to use speech to express
oneself; more likely to express feelings by action than
by words (may be more true for males); close friendships gain importance; less attention shown to parents,
with occasional rudeness; realization that parents are not
perfect; identification of their own faults; search for new
people to love in addition to parents; tendency to return
to childish behavior during times of stress; peer group
influence on personal interests and clothing styles.
Future Interests and Cognitive Development:
increasing career interests; mostly interested in present
and near future; greater ability to work.
Sexuality: girls physically mature faster than boys; shyness, blushing, and modesty; more showing off; greater
interest in privacy; experimentation with body (masturbation); worries about being normal.
Physical Changes: gains in height and weight; growth
of pubic and underarm hair; increased perspiration body odor develops; increased oil production of hair
and skin; breast development and menstruation in girls;
growth of testicles and penis, nocturnal emissions (wet
dreams), deepening of voice, growth of hair on face in
boys.
Ethics and Self-Direction: rule and limit testing; occasional experimentation with cigarettes, marijuana, and
alcohol; capacity for abstract thought.
Middle Adolescence (approximately
15-16 years of age)
Movement Toward Independence: self-involvement,
alternating between unrealistically high expectations and
worries about failure; complaints that parents interfere
with independence; extremely concerned with appearance and with one’s own body; feelings of strangeness
about one’s self and body; lowered opinion of and withdrawal from parents; effort to make new friends; strong
emphasis on the new peer group; periods of sadness as
the psychological loss of parents takes place; examination of inner experiences, which may include writing a
diary.
Future Interests and Cognitive Development:
intellectual interests gain importance; some sexual and
aggressive energies directed into creative and career
interests; anxiety can emerge related to school and academic performance.
Sexuality: concerns about sexual attractiveness; frequently changing relationships; more clearly defined
Theories of Adolescence
(Muuss, R., et.al., 1996; Rice and Dolgin, 2002)
2
Developmental Area
Primary Theorist
Main Focus
Biological
G. Stanley Hall, Arnold Gesell,
James Tanner
Focus of the period is physical
and sexual development
determined by genes and biology.
Psychological
Sigmund Freud, Anna Freud
Focus on adolescence as a period of
sexual excitement and anxiety.
Psychosocial
Erik Erikson
Focus is on identity formation;
adolescents struggle between
achieving identity and identity diffusion.
Cognitive
Jean Piaget
Focus is on formal operational thought;
moving beyond concrete, actual
experiences and beginning to think in
logical and abstract terms.
Ecological (interaction
between individual
and environment)
Urie Bronfenbrenner
Focus is on the context in which
adolescents develop; adolescents are
inuenced by family, peers, religion,
schools, the media, community, and
world events.
Social Cognitive
Learning
Albert Bandura
Focus is on the relationship between
social and environmental factors and
their inuence on behavior. Children
learn through modeling.
Cultural
Margaret Mead, Carol Gilligan
Focus is on the culture in which the
child grows up.
sexual orientation, with internal conflict often experienced by those who are not heterosexual; tenderness and
fears shown toward opposite sex; feelings of love and
passion.
Physical Changes: males show continued height and
weight gains while female growth slows down (females
grow only 1-2 inches after their first menstrual period).
Ethics and Self-Direction: development of ideals and
selection of role models; more consistent evidence of
conscience; greater goal setting capacity; interest in
moral reasoning.
Late Adolescence (approximately
17-21 years of age)
Movement Toward Independence: firmer identity;
ability to delay gratification; ability to think through
ideas; ability to express ideas in words; more developed
sense of humor; interests become more stable; greater
emotional stability; ability to make independent decisions; ability to compromise; pride in one’s work; selfreliance; greater concern for others.
Future Interests and Cognitive Development: more
defined work habits; higher level of concern for the
future; thoughts about one’s role in life.
Sexuality: concerned with serious relationships; clear
sexual identity; capacities for tender and sensual love.
Physical Changes: most young women are fully developed; young men continue to gain height, weight,
muscle mass, body hair.
Ethics and Self-Direction: capable of useful insight;
focus on personal dignity and self-esteem; ability to
set goals and follow through; acceptance of social institutions and cultural traditions; self-regulation of self
esteem.
What Parents Can Do
When young people feel connected to home, family,
and school, they are less likely to become involved
in activities that put their health at risk. Parental
warmth and strong, positive communication helps
young people establish individual values and make
healthy life decisions.
ACT
ION ITEMS
Nurture a positive relationship with your
teen and listen to him/her. When parent-teen interactions are characterized by
warmth, kindness, consistency, respect, and
love, the relationship will flourish, as will
self-esteem, mental health, and social skills.
Active or engaged listening is probably the
skill parents need to practice the most.
Encourage independent thought and
expression in your teen; allow him/her
to make and learn from mistakes. Teens
who are competent, responsible, and have
high self-esteem have parents who encourage
them to express their opinions and who
include them in family decision making and
rule setting. Healthy development requires
that parents allow adolescents to make mistakes, within limits. Parents can help their
teen by not doing everything for their adolescent as they develop; adolescent development
is sometimes a series of “three steps forward
and two steps back.”
Show genuine interest in your teen’s
activities. Having interest in the day-to-day
“comings and goings” of teenagers lives
allows parents to monitor their adolescents’
behavior in positive ways. Parents who,
together with their teens, set firm boundaries
and high expectations may find that their
teen’s abilities to live up to those expectations grows and grows.
3
Bibliography
American Academy of Child and Adolescent Psychiatry
(AACAP). Retrieved 2003, from http://
www.aacap.org/publications/factsfam/
develop.htm
Focus Adolescent Services. Retrieved 2003, from http://
www.focusas.com/Parenting.html
Muuss, R., Velder, E., & Porton, H. (1996). Theories of
adolescence. New York: McGraw-Hill.
Resnick, M.D., et al. (1997). Protecting adolescents
from harm: Findings from the national longitudinal study on adolescent health. JAMA, 278,
823-832.
Rice, P. and Dolgin, K. (2002). Adolescents in theoretical context. In The adolescent: Development,
relationships and culture (10th ed.). Boston:
Allyn and Bacon.
Steinberg, L. (2001). We know some things: Parentadolescent relationships in retrospect and prospect. Journal of Research in Adolescence, 11,
1-19.
The Upstate Center of Excellence invites you to visit the ACT
for Youth website where additional copies of this newsletter
and many other youth development resources are available.
http://www.actforyouth.net
Cornell University
Family Life Development Center
Surge 1
Ithaca, NY 14853
TEL: 607.255.7736
FAX: 607.255.8562
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Thank you!
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