1. Resilience and Coping in Middle and High School: The Roles of Parents, School staff, Peers & Community Shashank V. Joshi, MD, FAAP Jeremy Wilkinson, MD Lucile Packard Children’s Hospital at Stanford svjoshi@stanford.edu Shashank V. Joshi, MD, FAAP Jeremy Wilkinson, MD Lucile Packard Children’s Hospital at Stanford svjoshi@stanford.edu

2. 2 Outline 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

3. 3 Primary therapeutic relationships Parents Teachers / School staff Doctors/ Therapists Student peers

4. 4 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

5. 5 Other 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

6. Risks & Vulnerabilities Assets & Protective Factors Frances J Wren MD

7. Developmental Developmental Thoughts: Hopeless Self-critical Glass half-full Brooding Relationships: Withdrawn Irritable Pessimistic Emotions: Sad Bored Joyless Anxious Easily upset Body : Disturbed sleep Disturbed appetite Poor concentration Low energy Less fun Fewer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

8. Pathways to adolescent depression GeneticsBrain How easily upset? How intensely? How long? Capacity for joy, humor? Emotional regulation Anxiety/ Arousal Anxiety/ Arousal 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

9. Risks & Vulnerabilities Assets & Protective Factors Community, Family, Teen RESILIENCE Frances J Wren MD

10. 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

11. Protective 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

12. Buffer zones (Riera, 2004) Stress buffer zone Stress tolerance level Sedimented Stress via Traumatic Events: Divorce, Death of a loved one, Prolonged Illness, Financial Stress, Poverty, or other factors Girlfriend/b oyfriend rejection Exam s College Apps Graduation Girlfriend/boyfr iend rejection Exam s College Apps Graduatio n

13. Safe, effective communities Safe Responsive Opportunities to develop talents and skills Connections with caring competent adults Connections with competent peers Loving, effective families Love, joy, humor Communication, responsiveness, flexibility Consistent, rational discipline Realistic expectations Resources to obtain services and opportunities Emotionally skilled kids Managing negative feelings Problem-solving Making and keeping relationships Recognizing and valuing own talents and skills Finding opportunities for fun and joy Frances J Wren MD

14. What about the vulnerable teen? Challenging temperament Exposed to trauma Family troubles - including parental depression Frances J Wren MD

15. 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

16. 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

17. 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

18. 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

19. Resources Please see the Project Safety Net website for books and Internet resources related to coping and resilience Frances J Wren MD

20. 20 Primary therapeutic relationships Parents Teachers / School staff Doctors/ Therapists Student peers

21. 21 Primary therapeutic relationships Parents Teachers / School staff Doctors/ Therapists Student peers Adapted with permission from Feinstein, Fielding, Udvari-Solner, & Joshi: Amer Jnl of Psychotherapy, 63(4) 2009, in press

22. 22

23. 23 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

24. 24 You can help... / Know warning signs / Conduct intervention / Know warning signs / Conduct intervention

25. 25 You can help...  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.

26. 26 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 You can help...

27. 27 Intervention / Three Basic Steps 1. Show you care 2. Ask about suicide 3. Get help Intervention / Three Basic Steps 1. Show you care 2. Ask about suicide 3. Get help You can help...

28. 28 Intervention Step One / Show You Care / Be Genuine Intervention Step One / Show You Care / Be Genuine You can help...

29. 29 / 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. You can help...

30. 30 / 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." You can help...

31. 31 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 You can help...

32. 32 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. You can help...

33. 33  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?  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? You can help...

34. 34  You do not need to solve all of the person's problems; 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?  You do not need to solve all of the person's problems; 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? You can help...

35. 35 / Ask about treatment  Do you have a therapist/doctor?  Are you seeing him/her?  Are you taking your medications? You can help...

36. 36 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 You can help...

37. 37 You can help... Know Referral Resources / Resource sheet / Hotlines Know Referral Resources / Resource sheet / Hotlines

38. 38 Hotlines / National Suicide Prevention Lifeline / 1-800-273-TALK / www.suicidepreventionlifeline.org / 911  In an acute crisis call 911 Hotlines / National Suicide Prevention Lifeline / 1-800-273-TALK / www.suicidepreventionlifeline.org / 911  In an acute crisis call 911 You can help...

39. 39 / 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 You can help...

40. 40 / 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. You can help...

41. 41 Primary therapeutic relationships Parents Teachers / School staff Doctors/ Therapists Student peers