Teaching Suicide Prevention Is Positive Youth Development

Introduction

Since 1999, suicide rates have increased by 24% nationwide (Curtin, Warner, & Hedegaard, 2016). Additionally, the country has experienced an upward trend in youth suicidal ideation and attempts since 2009 (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of Adolescent and School Health, 2015).

Extension professionals have grappled with the need to provide suicide prevention programming to teens in the past (Jacobs & Beam, 2008). More recently, a local community coalition with which I was involved decided to teach suicide intervention skills using positive youth development. When youths learn suicide intervention skills, they improve their ability to recognize the signs of suicide ideation in someone and to question the individual about it. By taking on the meaningful role of suicide gatekeeper, they increase their own resiliency and their ability to help others (Search Institute, 2018).

Why Incorporate Youth Development in Suicide Prevention Efforts?

Following a series of teen suicide deaths in 2010, our community coalition identified suicide prevention education as an emerging need. Ten facilitators became certified to teach the Question Persuade Refer (QPR) program, a 1-hr suicide intervention course designed for adults. QPR program participants learn to recognize suicide warning signs, ask "the suicide question," persuade the person to live, and refer him or her for professional help (QPR Institute, n.d.).

The 2010 county Youth Risk Behavior Survey (YRBS) of 285 youths in grades 9 and 11 reinforced the need for suicide prevention. However, it showed that only 20% of the teen respondents would tell an adult if they were "feeling sad, empty, hopeless, angry or anxious" but more than 50% would tell a friend or sibling (Wisconsin Department of Public Instruction, 2009). These data made it clear that area teens, as well as adults, needed suicide intervention skills.

A Youth-Adapted Educational Approach

In response to the need for teens to have suicide intervention skills, our coalition initiated the Youth QPR program, an adaptation of the original QPR program made appropriate for students in grades 9–12. Youth QPR's goals are the same as those of the adult program. Development of communication skills and empathy are additional focuses of the youth-adapted program.

The original QPR training for adults involves the use of direct instruction almost exclusively. For teens, selected teaching tools and strategies needed to be engaging, age-appropriate, and directly applicable. For example, instead of instruction about myths, we provided cards youths could use to indicate whether a statement was a myth or fact, followed by discussion. In another part of the lesson, small student groups educated their peers about six categories of warning signs indicating that someone might be contemplating suicide. After this peer education, a short video of a teenager in crisis allowed the students to practice recognizing the signs.

QPR's core intervention principles—question, persuade, and refer—remained unchanged from the adult version, except for one detail. At the referral step, facilitators emphasized teens' responsibility to tell an adult. This recommendation simplified the helping process for teens; adults, who in a school setting also had been QPR trained, took on the direct referral role.

After learning to question, persuade, and refer, teen participants watched facilitators demonstrate an intervention. Then they took part in one-on-one role plays. Everyone asked the most important prevention question—"Are you thinking about killing yourself?"—at least once.

Evaluation Methods

To assess Youth QPR outcomes, we used a retrospective survey. The survey (see appendix) included a 5-point Likert scale, which Youth QPR participants used to rate their understanding of how to talk with someone about suicide, where 1 = no understanding and 5 = very high understanding. For a question about preparedness to ask "the suicide question," youths rated themselves from 1 = not prepared at all to 5 = very prepared.

Results

In the first year of Youth QPR, all students in grades 9–12 in two high schools were trained. Since then, ninth-grade students have been trained early in each school year. From 2011 to 2017, 13 adult facilitators trained 373 community-based adults, including 151 school district staff members. Youth QPR has been taught to 1,175 youths.

When asked to rate their understanding of how to talk to someone about suicide, students reported an average understanding of 2.79 before the training and 4.12 after, indicating an increase (+1.33) in understanding. With respect to students' preparedness to ask "the suicide question," the average rating was 3.83. Females reported feeling more prepared than males; averages were 3.95 and 3.72, respectively.

Beyond youth responses to QPR training, county-level YRBS results show the program's impact. Although depression and suicidal ideation increased from 2010 to 2016, suicide planning and attempts decreased (see Table 1), suggesting that Youth QPR is having the desired effect of preventiveness during a mental health crisis.

Table 1.
Comparison of Select Items from County-Level Youth Risk Behavior Survey of Grade 9–11 Students in 2010 and 2016

During the past 12 months . . .	2010	2016
did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?	Yes = 26.0%	Yes = 29.1%
did you ever seriously consider attempting suicide?	Yes = 14.1%	Yes = 14.3%
did you make a plan about how you would attempt suicide?	Yes = 11.9%	Yes = 11.4%
how many times did you actually attempt suicide?	1 or more times = 9.9%	1 or more times = 7.2%
Note. Data used with permission from participating school districts.

Implications for Extension Professionals

On our county's 2018 YRBS survey, the percentage of teens who would tell a peer, rather than an adult, if they were feeling depressed or sad remained consistent with the 2010 results, confirming that we must continue providing training in suicide intervention skills for teens. Yet how do other communities identify teens as a target audience for suicide intervention skills? The national survey still does not include questions about who a teen in crisis would turn to (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of Adolescent and School Health, 2017). Our state YRBS included such a question for the first time in 2017 (Wisconsin Department of Public Instruction, 2017). Given increasing suicide rates among youths and adults over the last 20 years (American Foundation for Suicide Prevention, 2015), local, state, and national youth surveys should ask who youths would turn to if in need. The collected data would undoubtedly direct suicide intervention skills training toward youths, who need it most. Extension can advocate for such research.

Our county's QPR facilitators have shared the Youth QPR adaptation with new facilitators in partnership with QPR master trainers. As a result, Youth QPR is now being implemented in 10 counties in our state and in communities of three other states. Extension units elsewhere could implement this train-the-trainer approach to expand the program's reach.

Teaching suicide intervention skills to youths is a positive youth development strategy for advancing life skills, including communication skills and empathy. Youths who learn these skills become community assets who recognize a suicide crisis and can take action.

Acknowledgments

I acknowledge the core group of Youth QPR facilitation team members who conduct trainings each year for youths and adults—Alex Galston, Kristi Hanson, Kelly Labar, Lisa Listle, and Kathy Rumsey. I also acknowledge the significant contributions and partnership of the local school districts in collecting data and supporting suicide intervention skills education.

References

American Foundation for Suicide Prevention. (2015). Suicide statistics. Retrieved from https://afsp.org/about-suicide/suicide-statistics/

Curtin, S. C., Warner, M., & Hedegaard, H. (2016). Increase in suicide in the United States, 1999–2014. Retrieved from the National Center for Health Statistics website: https://www.cdc.gov/nchs/products/databriefs/db241.htm

Jacobs, B., & Beam, L. (2008). Mobilizing Extension for youth suicide prevention using the signs of suicide (SOS) program. Journal of Extension, 46(1), Article 1TOT7. Available at: https://www.joe.org/joe/2008february/tt7.php

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of Adolescent and School Health. (2015). Trends in the prevalence of suicide-related behavior National YRBS: 1991–2015. Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trends/2015_us_suicide_trend_yrbs.pdf

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of Adolescent and School Health. (2017). Questionnaires. Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/questionnaires.htm

QPR Institute. (n.d.). What is QPR? Retrieved from https://qprinstitute.com/about-qpr

Search Institute. (2018). The developmental assets framework. Retrieved from https://www.search-institute.org/our-research/development-assets/developmental-assets-framework/

Wisconsin Department of Public Instruction. (2009). YRBS 2009: Wisconsin high school YRBS survey. Retrieved from https://dpi.wi.gov/sspw/yrbs

Wisconsin Department of Public Instruction. (2017). 2017 Wisconsin Youth Risk Behavior Survey. Retrieved from https://dpi.wi.gov/sites/default/files/imce/sspw/pdf/yrbs2017hsquestionnaire.pdf

Appendix

Youth QPR Evaluation

Please complete the following Youth QPR Evaluation. Your responses will be combined with those of the other participants and will be used to evaluate and make improvements on future classes. If you have questions, please contact Monica Lobenstein, Jackson County 4-H Youth Development Agent at 715-284-4257. Filling out the evaluation indicates that you are willing to have your responses compiled and shared with other professionals who may learn from the results.

1) What is your gender? ____ Male ____ Female

2) Please rate your understanding of the concepts listed below (circle best number):

1 = no understanding, 2 = I understand a little, 3 = I somewhat understand,
4 = I mostly understand it, 5 = I have a very high understanding

	Before Training					After Training
Myths & facts about suicide	1	2	3	4	5	1	2	3	4	5
Clues and warning signs of suicide	1	2	3	4	5	1	2	3	4	5
How you can help stop a suicide	1	2	3	4	5	1	2	3	4	5
How to talk to someone about suicide	1	2	3	4	5	1	2	3	4	5
Where to get help if you are worried about someone	1	2	3	4	5	1	2	3	4	5

3) After this class, do you feel prepared you to ask "the suicide question" if needed? (circle one)

Not prepared at all 1

A little prepared 2

Somewhat prepared 3

Quite a bit prepared 4

Very prepared 5

4) Would you tell an adult if someone you knew were considering suicide even if you believed he or she would be angry with you? (circle one)

a. Yes b. No c. Not sure

5) Would you recommend this training for other teens? (circle one)

a. Yes b. No c. Not sure

6) What was most useful about the training?

7) What was least useful about the training?

8) What suggestions do you have to help improve the training?

9) Other comments?