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Peer-support suicide prevention in a non-metropolitan U.S. community.

Suicide is the third leading cause of death for 15- 19-year-olds and exceeds all natural causes of death for youth in this age group (National Center for Health Statistics, 2007). Each year, countless adolescents require medical attention for self-inflicted injuries (CDC See Control Data, century date change and Back Orifice.

CDC - Control Data Corporation
, 2006). The impact of these deaths and potential years of life lost led to the Garrett Lee Smith Memorial Act to develop, implement, and evaluate prevention programs for youth (Youth Suicide Early Intervention ear·ly intervention
n. Abbr. EI
A process of assessment and therapy provided to children, especially those younger than age 6, to facilitate normal cognitive and emotional development and to prevent developmental disability or delay.
 and Prevention Act of 2004). Given added resources, suicide prevention Suicide prevention is an umbrella term for the collective efforts of mental health practitioners and related professionals to reduce the incidence of suicide through proactive preventive measures.  has become an important focus for children, adolescents, and college students. Nevertheless, suicide risk assessment is a daunting task that is sometimes considered to be unachievable (Hallfors et al., 2006).

In prevention studies, measurement of suicidal behaviors can be challenging due to low base rates for suicide deaths. Rodgers, Sudak, Silverman, and Litts (2007) characterized the conflicting need for outcomes studies as a "measurement conundrum" in which programming effectiveness should be determined by decrease in deaths, but unattainable in the absence of vast sample sizes. As a result, intermediate factors in prevention such as increased knowledge and perceived efficacy are potential mediating factors in primary prevention and important constructs for measurement in prevention studies.

Mental health problems that are detected later in life often begin in youth (age 12-24 years) (Patel, Flisher, Hetrick, & McGorry, 2007). Thus, primary prevention efforts that minimize the burden of depression, anxiety, and other possible precipitates (e.g., poor impulse control impulse control Psychology The degree to which a person can control the desire for immediate gratification or other; IC may be the single most important indicator of a person's future adaptation in terms of number of friends, school performance and future , maladaptive Maladaptive
Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.

Mentioned in: Cognitive-Behavioral Therapy
 problem-solving) to self-harm behavior are critical. Here, we briefly outline the status of youth suicide risk and prevention and the necessity for non-metropolitan and rural efforts. Finally, we provide evaluative data for the LifeSavers' peer support, suicide, and crisis prevention program.

Though the path to a suicide attempt suicide attempt, suicide bid nintento de suicidio

suicide attempt, suicide bid ntentative f de suicide

 varies, studies have suggested that low self-esteem and hopelessness are key factors in youth suicide risk (Overholser, Adams, Lehnert, & Brinkman, 1995; Roberts, Roberts, & Chen, 1998). Other factors include negative life events (Rudd, Joiner join·er  
n.
1. A carpenter, especially a cabinetmaker.

2. Informal A person given to joining groups, organizations, or causes.
, Jobes, & King, 1999; Shaffer et al., 2001), psychopathology psychopathology /psy·cho·pa·thol·o·gy/ (-pah-thol´ah-je)
1. the branch of medicine dealing with the causes and processes of mental disorders.

2. abnormal, maladaptive behavior or mental activity.
 (Apter et al., 1998), and impulsivity (Apter et al., 1995) in addition to disrupted familial environment, low economic status, sense of isolation, presence of mood disorder mood disorder 
n.
Any of a group of psychiatric disorders, including depression and bipolar disorder, characterized by a pervasive disturbance of mood that is not caused by an organic abnormality. Also called affective disorder.
, interpersonal conflict, and availability of drugs/alcohol and lethal means (Maris, Berman, & Silverman, 2000). These are all important targets for prevention efforts. Untreated problems may escalate in college settings where suicide has been identified as the second leading cause of death (CDC, 1997). One objective outlined in the National Strategy for Suicide Prevention was to "increase the proportion of school districts and private school associations with evidence-based programs ... designed to prevent suicide" (U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS
, 2001, p. 64). Unfortunately, investigations of youth suicide prevention programs are either nonexistent non·ex·is·tence  
n.
1. The condition of not existing.

2. Something that does not exist.



non
 or are plagued by methodological problems (see Lewis & Lewis, 1996) yielding very few evidence-based programs for any age group (see Rodgers, Sudak, Silverman, & Litts, 2007 for review).

Though available studies typically omit theoretical mechanisms for youth suicide prevention programs, peer gatekeeper programs are said to be successful because peers are more "in touch" (Konet, 1990; Lewis & Lewis, 1996). Social ties, interdependence, and trust occur more readily among similar, in-group others and foster an environment that is more prepared to intervene in the event of emerging crisis. According to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 youth who participated in the Signs of Suicide (SOS SOS, code letters of the international distress signal. The signal is expressed in International Morse code as … — — — … (three dots, three dashes, three dots). ) training, participants' fear of reporting concerns to adults was a primary complaint of the program (Aseltine & DeMartino, 2004). Gould (2003) posited that teens are simply more likely to discuss problems with other teens. In sum, peer helper programs, whereby trained teens help others who are troubled by difficulties (e.g., parent conflict, isolation) that could lead to a suicide attempt if unaddressed, may be beneficial.

Naturally, prevention efforts should be implemented in those settings for which the need is greatest. It is notable that suicide deaths occur more frequently in non-metropolitan, rural, less densely populated areas (cf.Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Still, relatively few studies have explored prevention efforts in rural, non-metropolitan U.S. subgroups including youth in rural communities. In a study of rural high school students, suicide risk was associated with parental physical abuse, parent-related stressors, poor adult support outside the home, running away from home, pressure to have sex, separation from parents, and acquaintance with a suicide death victim (Wagner, Cole, & Schwartzman, 1995). Unfortunately, residents of rural America experience limited access to mental health care and insurmountable mental health-related stigma ("Lost in Rural America," 2000). Adcock, Nagy, and Simpson (1991) observed that, nationally, rural high school students are less informed on common signs of suicide than students in urban areas. Mann et al. (2005) identified physical education, means restriction, and gatekeeper education as the most promising interventions. However, some attention to the limited resources in rural communities in particular warrants some effort to take advantage of community (including peer) resources.

Note also that while suicide prevention activities often occur in school settings, less than 1% of suicide deaths occur in schools (DeVoe et al., 2005). Thus, the need to promote peer support in and outside school settings is both logical and practical. The current study explores youth peer support via the LifeSavers program in a non-metropolitan, rural setting to contribute to the scientific evidence of suicide prevention. We hypothesized that youth who participated in the LifeSavers Training program would increase in (1) knowledge and positive attitudes, (2) self-esteem, and (3) self-acceptance.

METHOD

Intervention Training

The LifeSavers training program was implemented by LifeSavers Training Corporation, a not-for-profit corporation and registered charitable organization This article is about charitable organizations. For other uses of the word charity, see Charity.
A charitable organization (also known as a charity) is an organization with charitable purposes only.
. Training "retreats," which began in 1987, have been conducted for youth at a retreat camp site in rural Illinois. The three-day manualized, weekend retreats consist of small and large group activities organized to train high school students how to (1) work together as a team, (2) listen without judgment to others' concerns, (3) recognize the signs of a peer who may be depressed and suicidal, and (4) enlist the aid of a professional counseling resource or other adult as needed as needed prn. See prn order. . In the course of the retreat, youth participate in "listening circles" in which trainees learn to express thoughts and feelings, maintain confidentiality, and demonstrate sensitivity to others. The "listening circles" are led by past LifeSavers' trainees who have volunteered as such in their respective schools and have undergone advanced training to become group leaders.

Potential trainees are identified via current school LifeSavers, teachers, school counselors, school coaches, and other adult LifeSavers' advisors. The process of selection is semi-random in that any student who is perceived to demonstrate or have the capacity for good listening skills and empathy toward others is recruited to participate in LifeSavers training. At present, there are no exclusion criteria exclusion criteria AIDS Donor exclusion criteria, see there  for students who are interested in the LifeSavers' training program.

Participants

Participants for the current study were 63 high school students who attended the LifeSavers training program in the rural southern Illinois region. The students were enrolled in 10 schools in non-metropolitan communities. In this sample, eight of the ten counties in which participants were enrolled were designated non-metropolitan. The two schools that were located in countries labeled "metropolitan" were located near metropolitan areas, but reported populations of less than 10,000. Appropriate parental consent and youth assent were obtained before students voluntarily participated in the study. They were told the study would assist in the development of the training program.

Measures

LifeSavers Attitudes and Knowledge Scale (LAKS LAKS Landelijk Actie Komitee Scholieren ). Knowledge and attitudes toward helping someone who experiences suicide risk were assessed via the LAKS (Snep, 1992), a 25-item self-report inventory. Each item was rated on a Likert scale Likert scale A subjective scoring system that allows a person being surveyed to quantify likes and preferences on a 5-point scale, with 1 being the least important, relevant, interesting, most ho-hum, or other, and 5 being most excellent, yeehah important, etc  ranging from 1 (strongly agree) to 5 (strongly disagree); reverse coding was required for 22 of the 25 items. Thus, possible inventory scores ranged from 25 to 125 whereby higher scores were indicative of positive responses in the direction of the construct being assessed. Higher scores reflected increased knowledge and attitudes about everyday life events and social issues that face adolescents. Example items include "I can see when kids are having a hard time with other kids" and "If I respond properly, I can help someone who is thinking about suicide." Although Snep (1992) did not report reliability data, alpha = .80 for both the pretest and posttest post·test  
n.
A test given after a lesson or a period of instruction to determine what the students have learned.
 scales in the current sample.

Rosenberg Self-Esteem scale (RSE). Self-esteem was measured via the RSE (Rosenberg, 1965) which assessed responses to statements of self-worth and distinguished among individuals with low and high esteem. The RSE is a 10-item instrument rated on a Likert scale that ranges from 1 (strongly agree) to 4 (strongly disagree); 5 items were reverse coded. Higher scores are indicative of higher self-esteem with possible scores ranging from 10 to 40. Example items include "On the whole, I am satisfied with myself" (reverse scored" and "I feel I do not have much to be proud of." This scale was originally normed on 5,024 high school juniors and seniors with reported scalability of .72. In this sample, for the pretest and posttests, alpha = .90 and .86, respectively.

Self Acceptance Scale (SCS). Self-acceptance or a sense of self-reliance on one's values and faith in one's capacity to cope with life was assessed via the SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System.  (Berger, 1952, 1955). It is a 36-item Likert scale in which scores range from 1 (completely true) to 5 (completely false) which yields a total score range of 36 to 180; 8 items were reverse coded. Respondents are asked to indicate how true or how false a statement is for them. Example items include "I'm afraid for people to find out what I'm really like for fear they'd be disappointed in me" and "I don't question my worth as a person, even if I think others do." Higher scores indicate strong beliefs of self-acceptance. In this sample, alpha = .94 on the prestest data and .91 on the posttest data.

Procedure

The university's Institutional Review Board approved the present study. Students attending the LifeSavers weekend training program were administered the pre-test packet immediately upon arrival at the training site (T1). To insure confidentiality, participants determined a 4-digit number associated with the telephone number of their choice (i.e., home, mobile) as an identifier for all materials. At the end of the LifeSavers weekend training program (T2), students were given the posttest packet, which replicated the pre-test instruments, and asked to complete the packet on site. Approximately 30 minutes were required to complete the questionnaire. Students were informed that participation in the study was voluntary and that participation did not affect their training or status in the LifeSavers program. All trainees agreed to participate in the current study.

RESULTS

All participants completed T1 and T2 measures. The majority of participants (78%) were female; see Table 1. Mean age for the sample was 15.05 years (SD = .83; range 14-17). Though participants were enrolled in grades 9-12, most of them reported 10th grade status. The majority (65.1%) of participants' parents were said to be married.

A paired-samples t test was conducted to evaluate participants' pretest (T1) scores relative to post-training (T2) performance on measures of attitudes and knowledge, self-esteem, and self-acceptance. All pretest and post-test means, standard deviations, and effect sizes are presented in Table 2. Results indicated that attitudes and knowledge and self-esteem increased significantly with a large effect observed for the increase in self-reported attitudes and knowledge. However, the increase in scores from T1 to T2 was not significant for self-acceptance.

DISCUSSION

Fatal suicide attempts are a leading cause of death among youth age 13-19 years. Opportunities to intervene early are important and discourage the development of "suicidal careers" in which individuals at risk experience multiple suicide attempts, parasuicidal behavior, and persistent suicide ideation ideation /ide·a·tion/ (i?de-a´shun) the formation of ideas or images.idea´tional

i·de·a·tion
n.
The formation of ideas or mental images.
. Unfortunately, empirical support for teenage suicide prevention has not evolved much across U.S. communities. In the current study, we assessed knowledge and attitudes, self-acceptance, and self-esteem for high school students who participated in LifeSavers training, a suicide and crisis prevention program that has been implemented in several non-metropolitan communities. We found that youth who participated in the LifeSavers program increased in two of the three areas of measure--attitudes and knowledge and also self-esteem. This study makes an important contribution to the suicide literature in that it explores prevention for youth in non-metropolitan communities where suicide deaths are most rampant. This study also addresses the need for prevention research to go beyond death rates to address quality of life for troubled youth in rural environments.

Emphasis on mediating factors is worthwhile for the overall prevention of emotional crises among high school youth. The impact of LifeSavers training may speak to, at least in part, Durkheim's anomie anomie, a social condition characterized by instability, the breakdown of social norms, institutional disorganization, and a divorce between socially valid goals and available means for achieving them.  such that LifeSavers trainees experience an increased sense of social cohesion and an atmosphere that discourages hopelessness and promotes a positive affect overall. Future studies should continue to consider mediating factors to understand the mechanism by which prevention programming functions. In this sample, we found that the LifeSavers training program seems to be efficacious for high school youth, particularly young women, in rural communities. Studies have indicated that those who report more proficiency for an activity are more likely to engage in that activity. Thus, increased self-esteem and also self-acceptance are important intermediate factors along with relevant knowledge associated with suicide risk. Future studies might consider other intermediate factors such as personality (extroversion extroversion /ex·tro·ver·sion/ (eks?tro-ver´zhun)
1. a turning inside out.

2. direction of one's energies and attention outward from the self.
 v. introversion introversion: see extroversion and introversion. ) and verbal acuity in suicide prevention that might facilitate peer support and helping behavior.

Though this study makes an important contribution to the suicide prevention literature, it is not without limitations. There was no random assignment to a control group to account for maturation or other effects of the retreat setting. Unfortunately, such studies are not often feasible in naturalistic conditions. Also, given the relatively short pre- and post-training interval, we do not know if the training effect was maintained. It is notable that most participants received some level of "booster" or continued training in their respective high schools and at varying rates. Some trainees participated in weekly activities that were led by an adult advisor. However, training activities were less frequent in some schools and individual LifeSavers trainees participated to varying degrees. Future studies would benefit from a waitlisted control group and statistical control for the wide range of continued training to which participants are exposed post-training. Another limitation of the study is the under-representation of male participants. Though adolescent girls are more likely to engage in self-harm behavior, boys are more likely to die by suicide. Thus, balanced attention to the needs of both boys and girls boys and girls

mercurialisannua.
 is warranted and recruitment of adolescent boys for ongoing peer support training is essential. Finally, there is no current evidence of behavior change that is associated with increase in knowledge or self-esteem. However, we posit that youth who are more knowledgeable about suicide risk and who are equipped to be good listeners are also more likely to provide more informed peer support in the event of a potential crisis.

In all, this study has important implications for adolescents and the communities in which they reside. Youth who are at risk for mental health problems typically do not get help until later in life (Patel, Fisher, Hetrick, & McGorry, 2007). However, peer support can have direct and indirect effects on potentially high-risk suicidal persons. Thus, primary prevention efforts, which dissuade generation of self-harm behavior, are critical and should be implemented in communities and after-school settings. Universal crisis prevention programs create a normative environment in which youth who have relatively little access to psychiatric services develop a sense of belonging that is reinforced with a readiness to seek help if needed. A climate that normalizes asking questions and listening to a distressed other can provide a welcome alternative to acting out in response to interpersonal problems with family and romantic relationships.

To our knowledge, this is the first empirical study to address youth suicide prevention in non-metropolitan communities. Programs such as LifeSavers potentially circumvent the critique that rural students are less informed about suicide (Adcock, Nagy, & Simpson, 1991).

Though school gatekeeping efforts have received some attention in the literature, added efforts toward creating a cultural milieu of peer support particularly in underresourced communities will significantly advance suicide prevention.

REFERENCES

Adcock, A. G., Nagy, S., & Simpson, J. A. (1991). Selected risk factors in adolescent suicide attempts. Adolescence, 26 817-828.

Apter, A., Bleich, A., Plutchik, R., Mendelsohn, S., & Tyano, S. (1988). Suicidal behavior, depression, and conduct disorder Conduct Disorder Definition

Conduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of
 in hospitalized adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 37(9), 915-923.

Apter, A., Gothelf, D., & Orbach, I., Weizman, R., Ratzoni, G., Har-even, D., & Tyano, S. (1995). Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. Journal of the American Academy of Child & Adolescent Psychiatry, 34, 912-918.

Aseltine, R. H., & DeMartino, R. (2004). An outcome evaluation of the SOS suicide prevention program. American Journal of Public Health, 94(3), 446-451.

Aseltine, R. H., James, A., Schilling, E. A., & Glanovsky, J. (2007). Evaluating the SOS suicide prevention program: A replication and extension. BMC (BMC Software, Inc., Houston, TX, www.bmc.com) A leading supplier of software that supports and improves the availability, performance, and recovery of applications in complex computing environments.  Public Health, 7, 161-167.

Berger, E. M. (1952). The relationship between expressed acceptance of self and expressed acceptance of others. The Journal of Abnormal and Social Psychology, 47(4), 778-782.

Berger, E. M. (1955). Relationships among acceptance of self, acceptance of others, and MMPI MMPI
abbr.
Minnesota Multiphasic Personality Inventory


MMPI Child psychiatry A personality assessment tool widely used in making psychologic evaluations, which is normally given at age 16 and older. Personality testing
 scores. Journal of Counseling Psychology, 2(4), 279-284.

Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center.  (CDC). (1997). Youth risk behavior surveillance: National College Health Risk Behavior Survey--United States, 1995. Morbidity and Mortality Weekly Report Morbidity and Mortality Weekly Report (MMWR) is a weekly epidemiological digest for the United States published by the Centers for Disease Control and Prevention. The 5 June 1981 issue of the MMWR published the cases of five men in what turned out to be the first report of AIDS. , 46(SS-6), 1-54.

Centers for Disease Control and Prevention. (2006). Youth risk behavior surveillance--United States, 2005. Morbidity and Mortality Weekly Report, 55 (SS-5, 1-112.

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Goldsmith, S., Pellmar, T., Kleinman, A., & Bunney, W. (Eds.). (2002). Reducing suicide: A national imperative. Washington, D.C.: The National Academies Press.

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An important antecedent to the specialty of child psychiatry was the social recognition of childhood as a special phase of life with its own developmental stages, starting with
, 42 386-405.

Hallfors, D., Brodish, P. H., Khatapoush, S., Sanchez, V., Hyunsan, C., & Steckler, A., (2006). Feasibility of screening adolescents for suicide risk in "real world" high school settings. American Journal of Public Health, 96(2), 282-287.

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NASSP North American Society of Social Philosophy
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New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
: Guilford Press.

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U.S. Office of Management and Budget The Office of Management and Budget (OMB), formerly the Bureau of the Budget, is an agency of the federal government that evaluates, formulates, and coordinates management procedures and program objectives within and among departments and agencies of the Executive Branch.  (2000). Final report and recommendations from the Metropolitan Area Standards Review Committee to the Office of the Management and Budget concerning changes to the standards for defining metropolitan areas. Retrieved October 10, 2007 from http://www.whitehouse.gov/omb/inforeg/mtro2000.pdf

Wagner, B. M., Cole, R. E., & Schwartzman, P. (1995). Psychosocial correlates of suicide attempts among junior and senior high school youth. Suicide and Life-Threatening Behavior, 25(3), 358-372.

Youth Suicide Early Intervention and Prevention Expansion Act of 2004, S. 2175, 108th Cong.

Rheeda L. Walker and Olivia D. Hoskins, Department of Psychology, Southern Illinois University.

Judy Ashby, LifeSavers Training Corporation.

Farrah N. Greene, Department of Psychology, University of Hawaii (body, education) University of Hawaii - A University spread over 10 campuses on 4 islands throughout the state.

http://hawaii.edu/uhinfo.html.

See also Aloha, Aloha Net.
 at Manoa.

(1) The U.S. Office of Management and Budget (2000), which is responsible for urban and rural (now known as metropolitan and non-metropolitan) classification, assesses "degree of urbanization and adjacency to a metropolitan area". Groupings 1-9 were assessed by the OMB OMB
abbr.
Office of Management and Budget

Noun 1. OMB - the executive agency that advises the President on the federal budget
Office of Management and Budget
 as of 2003 such that 1-3 are metropolitan and 4-9 are non-metropolitan. A code description of one describes counties in metropolitan areas with a population of one million or more whereas a code of nine describes a county that is completely rural or less than 2,500 people in an urban population that is not adjacent to a metropolitan area. The U.S. Department of Agriculture (2004) only codes urban and rural areas on the county level for population, urbanization and proximity to metropolitan areas and not by the characteristics of an individual city or town.

Requests for reprints should be sent to Dr. Rheeda Walker, Department of Psychology, University of Georgia Organization
The President of the University of Georgia (as of 2007, Michael F. Adams) is the head administrator and is appointed and overseen by the Georgia Board of Regents.
, Athens, GA 30602-8048. E-mail: rlwo@uga.edu
Table 1. Demographic characteristics of participants.

Characteristic            n     %

Sex
        Female            49   77.8
         Male             14   22.2

Grade
           9              24   38.1
          10              34   54.0
          11               4    6.3
          12               1    1.6

Parent's marital status
        Married           41   65.1
       Separated           4    6.0
       Divorced            3    4.8
       Remarried          11   17.5
       Deceased            2    3.2

Table 2. Pre-test and post training comparisons and effect sizes.

                       Pre-test       Post-test      t(df)      Cohen's
                          M(SD)           M(SD)                       d

Attitudes and
Knowledge          97.44 (7.32)   103.72 (7.58)   6.13(53) **       .85

Self-acceptance   128.47 (21.93)  130.74 (23.21)  1.21 (52)         .10

Self-esteem        29.65 (5.03)    31.38 (5.30)   3.76 (59) **      .34

** p<.001
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Author:Walker, Rheeda L.; Ashby, Judy; Hoskins, Olivia D.; Greene, Farrah N.
Publication:Adolescence
Article Type:Report
Geographic Code:1USA
Date:Jun 22, 2009
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